Index by author
The Issue in Brief
Mark D. Sullivan , and colleagues
Background Opioid medications are commonly used to treat chronic noncancer pain, but they can be misused. This study examines whether there is an association between depression and misuse of opioids by patients with no history of substance abuse who are receiving chronic opioid therapy.
What This Study Found Patients are much more likely to misuse opioids if they are depressed. This study surveyed 1,334 patients with no history of substance abuse who were on long-term opioid therapy for chronic pain. Patients with moderate and severe depression were more likely to misuse their opioid pain medications for nonpain symptoms compared with patients who were not depressed. Patients with mild, moderate, and severe depression were 1.9, 2.9, and 3.1 times more likely, respectively, than patients who were not depressed to misuse their opioid medications by self-increasing their dose. Other risk factors for misuse include male sex, lower average daily dose, less education, younger age, higher pain severity, and white race.
Implications
- Clinicians should be alert to the risk of patients using opioids to relieve symptoms of depression.
- The authors call for future research to examine whether treatment of depression decreases the risk of opioid misuse.
Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial
Alex H. Krist , and colleagues
Background Americans receive only one-half of recommended preventive services, in part because of poor access to reliable information. This study develops and tests an interactive preventive health record (IPHR), a health information system that provides patients with direct access to their electronic medical record.
What This Study Found An interactive preventive health record that explains information in lay language and provides individualized recommendations, resources, and reminders is associated with a greater rate of being up-to-date on recommended preventive services. In a study of 4,500 patients in 8 primary care practices, patients received either usual care or a mailed invitation to use an interactive preventive health record. Despite fairly low rates of use, the proportion of patients up-to-date with all preventive services increased by 3.8 percent among intervention patients and by 1.5 percent among control patients. Greater increases were observed among patients who used the IPHR. At 16 months, 25 percent of users were up-to-date with all services, double the rate among nonusers. Moreover, at 4 months, delivery of colorectal, breast and cervical cancer screening increased by 19 percent, 15 percent, and 13 percent, respectively, among users.
Implications
- Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery.
Barbara P. Yawn , and colleagues
Background Postpartum depression is common but often unrecognized. This study reports on the effectiveness of a program of screening, evaluation, and management of postpartum depression in family medicine offices, with referral outside the practice for complicated or unresponsive cases.
What This Study Found Primary care physicians given screening tools and education are more likely to diagnose and treat postpartum depression, and their patients have lower depressive symptoms at 6 and 12 months of follow-up. In a study of 28 practices that received either education and tools for postpartum depression screening or usual care, rates of diagnosis, treatment initiation, and referral for psychiatric evaluation were higher in the intervention group, indicating the program effectively raised awareness. Specifically, of the 1,897 patients in the analysis, 654 had elevated screening scores indicating depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis and therapy for postpartum depression. They also had lower depressive symptom levels at 6 and 12 months' postpartum.
Implications
- The authors call for dissemination efforts and continued evaluation of similar practical primary care-based programs that have minimal requirements for referrals to outside mental health services.
How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
Franca Warmenhoven , and colleagues
Background Depression is common in palliative care patients. In clinical practice there is concern about both under- and overdiagnosis and treatment of depression. This study explores the opinions of 22 family physicians in The Netherlands about the recognition, diagnosis, and management of depression in palliative care patients.
What This Study Found Family physicians in The Netherlands perceive the diagnosis and management of depression in palliative care patients as challenging but generally feel competent to address the issue. Focus group discussions found that physicians do not strictly apply criteria of depressive disorder when evaluating patients but rather rely on their clinical judgment and strongly considered patients' context and background factors. The participants acknowledged difficulty in discerning depression from normal sadness and identified a lack of knowledge, time, and additional support sources as challenges.
Implications
- The authors recommend improving family physician education by building on the elements the study participants identified as key in diagnosing depression and distinguishing it from normal sadness: strengthening continuity of care and relationship-building with patients and their families through the course of palliative care, and explicitly addressing sadness as part of the normal process of coming to terms with the prospect of end of life.
- Guidelines, criteria, and other tools will provide valuable support only when applied in the context of such a patient-centered approach, according to the authors.
Meditation or Exercise for Preventing Acute Respiratory Infection: A Randomized Controlled Trial
Bruce Barrett , and colleagues
Background Treatments for acute respiratory infection (ARI), such as influenza, are not highly effective. Some evidence suggests that strengthening general physical and mental health may reduce the burden of ARI. There is also evidence that mindfulness meditation can reduce stress and negative emotion. This study tests whether training in meditation or exercise can reduce susceptibility to ARI illness.
What This Study Found Training in mindfulness meditation and sustained moderate-intensity exercise are associated with reduced illness severity and fewer days of missed work from acute respiratory infections. In this study, 149 patients were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, 8-week training in moderate intensity sustained exercise, or observational control. There were substantial reductions in ARI illness among those randomized to exercise training and even greater benefits among those receiving mindfulness meditation training. Implications for the workplace, the authors note, may be especially important. Compared with the control group, all-cause absenteeism was 31 percent lower in both intervention groups. Looking at ARI-related absenteeism in particular, there were 48 percent fewer days missed in the exercise group, and 76 percent fewer in the meditation group.
Implications
- The authors suggest that these findings, if confirmed in future studies, will have important implications for public and private health policy and practice, and for scientific research into maintaining health and preventing disease.
Osvaldo P. Almeida , and colleagues
Background Although programs exist to help general practitioners reduce the prevalence of depression and suicide behavior among patients, evidence of effectiveness is inconclusive. This study set out to determine whether an educational intervention for general practitioners in Australia reduces the prevalence of depression and self-harm among their older patients.
What This Study Found An educational program for general practitioners reduces the 2-year prevalence of depression and self-harm behavior in older patients. The study of 373 physicians and 21,762 patients aged 60 years and older tested a program of practice audit with personalized feedback and printed educational material about screening, diagnosis, and management of depression and suicide behavior in later life. Those in the intervention group experienced a 10 percent reduction in the odds of depression and self-harm behavior over 2 years of follow-up. The beneficial effect was primarily due to reduced self-harm behavior among patients who did not report symptoms at baseline; the study did not reduce the prevalence of depression or self-harm behavior in patients who had symptoms at baseline.
Implications
- In this study, the intervention had no effect on recovery from depression or self-harm behavior, but prevented the onset of new cases of self-harm. The authors call for future research to replicate these results.
Chemical Intolerance in Primary Care Settings: Prevalence, Comorbidity, and Outcomes
David A. Katerndahl , and colleagues
Background As many as one-third of people report that they are highly sensitive to certain common environmental chemicals such as cleaning products, tobacco smoke, and perfumes. Patients with chemical intolerance use health care services at increased rates. This study assesses the prevalence of chemical intolerance and accompanying medical and mental disorders among primary care patients, and evaluates the patients' functional status and health care utilization.
What This Study Found In a sample of 400 primary care patients, chemical intolerance was prevalent, often in conjunction with a range of medical and psychiatric conditions. Overall, 20 percent of the sample met criteria for chemical intolerance. They had significantly higher rates of allergies and possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. Patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with other patients.
Implications
- Although chemical intolerance is common in primary care, it often goes unrecognized and requires active investigation by primary care physicians.
Objective Evidence of Severe Disease: Opioid Use in Chronic Pain
John A. Zweifler
What This Study Found Chronic pain is difficult to treat. Clinicians aim to reduce or eliminate pain, but opioid pain medications are frequently abused, with overdoses and deaths on the rise. In addition, there are no measures of pain to guide prescribing of medications. Until we have measures of pain itself, we should insist on objective evidence of severe disease before prescribing opioids for chronic pain.