 |
|
The Role of Competing Demands in the Treatment Provided Primary Care Patients With Major Depression
Kathryn Rost, PhD;
Paul Nutting, MD;
Jeffrey Smith, BS;
James C. Coyne, PhD;
Lisa Cooper-Patrick, MD;
Lisa Rubenstein, MD
Arch Fam Med. 2000;9:150-154.
ABSTRACT
| |
Objective To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit.
Design A cross-sectional patient survey.
Participants and Setting Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders.
Main Outcome Measures In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients.
Results Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05).
Conclusions The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.
INTRODUCTION
PROVIDING comprehensive care requires that patients and their primary care physicians establish priorities among many health issues that could potentially be addressed at any given visit. Studies that examine the adequacy of primary care for a specific problem will necessarily observe gaps in performance when patients have multiple problems because the specific problem under investigation may not have a high priority for that particular visit. This "competing demands" phenomenon has been described previously for primary care health promotion1-2 and more recently for mental health care.3-4 In primary care treatment of mental health problems, the detection and management of major depression represents an active choice from multiple physician-patient priorities including the treatment of acute physical illness, the monitoring of chronic physical illnesses, and the provision of preventive services. Figure 1 provides the study's conceptual framework adapted from the competing demands literature3 identifying potentially key provider, patient, and practice variables that influence whether depression is addressed during a primary care visit. This study investigates the influence of key patient characteristics.
|
|
|
|
Conceptual framework showing potential patient, physician, and practice determinants of attention to depression during a primary care visit.
|
|
|
PATIENTS AND METHODS
STUDY DESIGN
Data for this article were collected for a study examining the effect of a primary care–based intervention to increase the proportion of depressed patients who completed guideline-concordant care. The parent study used stratified randomization to assign 12 primary care practices in the Ambulatory Sentinel Practice Network to an enhanced or usual care condition. Two physicians in each of the 6 primary care practices randomized to the usual care condition used a 2-stage screening process to recruit 20 depressed patients from a consecutively identified cohort (77.4% participation rate of eligible identified patients). An extensive description of the parent study's methods is available from one of us (K.R.) (K. Rost, PhD, P. Nutting, MD, J. Smith, BS, and J. Werner, MS, unpublished data, July 22, 1999). Two hundred forty patients participating in the usual care condition (2 physicians x 6 practices x 20 patients) provided the subjects for this analysis. Eligible patients (1) reported 5 or more of the 9 criteria for major depression in the past 2 weeks on the Inventory to Diagnose Depression5; (2) screened negative for lifetime mania; (3) screened negative for alcohol dependence with current drinking6; and (4) did not meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for bereavement-related depression. We excluded patients who were pregnant, postpartum, or breastfeeding because the parent study tested an intervention addressing antidepressant medication management. In addition, practical considerations forced us to exclude a few patients with severe cognitive impairment, patients whose physical illness was too severe to complete screening, patients who could not read the screening materials, patients with no telephone in the home, and patients who planned to seek most of their health care elsewhere during the next year. Immediately after patients were identified as eligible, the administrative staff invited them to participate in a longitudinal study seeking to understand more about what people who feel sad or uninterested in things decide to do about their condition. Study enrollment procedures, including management of suicidal intent, were approved by the Human Research Advisory Committee of the University of Arkansas for Medical Sciences, Little Rock, and the University of Colorado Multi-institutional Review Board, Denver.
Virtually all subjects in the study were recruited before the patient's visit with the physician, who in most cases provided their ongoing care. Study personnel did not inform physicians in the usual care condition when their patients met criteria for major depression but, in some cases, patients asked their physician questions about the study. All data reported in this article were collected from patients using a structured telephone interview conducted an average (SD) of 8.4 (8.7) days after the index visit.
OPERATIONAL DEFINITION OF MAJOR VARIABLES IN THE STUDY
Dependent Variables
Two outcome variables were defined for this study—one for untreated patients and the other for treated patients who remained symptomatic.
Discussing Depression in Untreated Patients
Depression was characterized as being discussed as a possible diagnosis during the visit if untreated patients reported that during the index visit a doctor or other health care provider asked them about depressive symptoms or previous depression treatment, told them that they had depression, or recommended depression treatment during the visit. Untreated patients were defined as patients who did not take antidepressant medication or receive specialty care counseling during the 6 months before the index visit. Untreated patients included undetected patients and detected patients electing watchful waiting, both groups whose depressive symptoms require monitoring.7
Changing Depression Management in Treated Patients
Depression management was characterized as being changed if treated patients reported that during the index visit a doctor or other health care provider recommended that they go for counseling to another doctor or therapist (referral), gave them a prescription for medication to help their personal or emotional problems, or changed medication that they were already taking for personal or emotional problems. Treated patients were defined as patients who took antidepressant medication or received specialty care counseling during the 6 months before the index visit. All treated patients reported 5 or more of the 9 criteria for major depression at the index visit.
INDEPENDENT VARIABLES
Competing Demands
We characterized competing demands on patients' agendas (yes/no) if patients reported that their reason for the index visit was a new problem, rather than an old problem or a checkup. We also characterized the degree of competing demands on the patient's and/or physician's agenda by summing the number of physical comorbidities the patient reported from a list including diabetes, high blood pressure, arthritis, respiratory conditions, recent cancer, neurological conditions, stroke, congestive heart disease, coronary artery disease, back problems, irritable bowel syndrome, thyroid disease, kidney failure, or eye disease.
Covariates
We tested the hypothesized relationship controlling for other conceptually relevant influences on primary care depression treatment shown in Figure 1. These variables were operationalized as follows:
Patient Attitudes.
This construct was measured by assessing the acceptability of specialty care counseling and the acceptability of antidepressant medication to patients. Patients were asked to rate how acceptable each of these 2 approaches were for helping them feel better by noting whether each approach was definitely acceptable, probably acceptable, probably unacceptable, or definitely unacceptable. Patient responses were dichotomized into probably not/definitely not acceptable and probably/definitely acceptable. Values for these variables were imputed in 6 subjects who failed to answer the questions by assigning these subjects the most prevalent response.
Depression Severity.
This construct was measured using a 23-item version of the Center for Epidemiological Studies–Depression5 which was modified to measure DSM-IV8 symptoms for major depression during the past week.
Sociodemographic Characteristics.
The model included continuous measures of age and education, and dichotomous measures of gender, minority status, and marital status.
DATA ANALYSIS
The research team used a hierarchical approach to test the relationship of patient characteristics to whether depression was attended to during the visit in clustered hierarchical linear models nesting patients within physicians and physicians within practices. These models indicated that no significant differences were noted among physicians or practices, most likely a result of the limited variation among 12 physicians in 6 practices. The insignificant clustering effects allowed us to employ regression models to test the hypothesized relationships.
RESULTS
The 240 patients in the study were on average (SD) 43.9 (12.8) years old, 84.2% were female, 79.2% were high school educated, and 15.8% were minority. One hundred forty-four patients reported taking antidepressant medication and/or seeing a specialty care provider during the 6 months before baseline. Patients reported an average (SD) of 6.7 (1.4) symptoms of major depression and 2.2 (1.8) physical comorbidities. Following the index visit, 68.4% of the 240 subjects reported that antidepressant medication was probably or definitely acceptable; 77.9% reported that specialty care counseling was probably or definitely acceptable; 28.7% of patients reported that the main reason for the visit was a new problem. The 12 board-certified family physicians participating in the study were on average (SD) 43.3 (5.9) years old, 66.7% were male, and 91.7% were nonminority.
Physicians and patients discussed depression as a possible diagnosis in 46 (47.9%) of the 96 untreated patients in the sample. Physicians adjusted treatment recommendations in 87 (60.4%) of the 144 treated patients in the sample. As listed in Table 1, logistic regression models found that physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients had fewer physical comorbidities (odds ratio [OR] = 0.66, P = .01), if patients reported antidepressant medication was acceptable (OR = 4.57, P = .01), if patients reported specialty care counseling was unacceptable (OR = 0.33, P = .05), and if patients had less education (OR = 0.77, P = .02). Logistic regression models found that physicians were more likely to adjust treatment recommendations in treated patients if patients reported a new problem was not the reason for the visit (OR = 0.39, P = .05) and if patients were currently married (OR = 4.22, P<.001). No other variables were statistically significant.
|
|
|
|
Logistic Regression Models Examining Predictors of Depression Activity During the Visit
|
|
|
COMMENT
In the patient population we studied, the attention depression gets during the visit is less associated with the severity of the patient's emotional symptoms than with the number or recency of other problems the patient has. In untreated patients, each chronic physical problem reduces the odds that the physician discusses depression as a possible diagnosis (OR = 0.66, P = .01). In treated patients, a new problem reduces the odds that the physician changes depression recommendations (OR = 0.39, P = .05). Besides these indicators of competing demands, attitudinal and sociodemographic variables are associated with whether depression gets addressed during the visit. Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (OR = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (OR = 0.33, P = .05). A lower level of education is positively associated with discussing depression as a possible diagnosis with untreated patients; current marital status is positively associated with changing depression recommendations in treated patients.
Our results indicate that chronic physical problems potentially disrupt initiating (but not adjusting) depression treatment. Thus, one would expect longitudinal cohort studies to observe that physical comorbidity negatively predicts the probability of initiating care but is unrelated to the course of care depressed patients receive over time. Such findings would contradict preventive medicine studies9 that show that physical comorbidity negatively predicts the course of preventive care patients receive over time. If physical comorbidity is unrelated to the course of depression care patients receive over time, these data support the idea that physicians and patients successfully prioritize the problems they address over multiple visits so that emotional problems receive high-quality treatment in the primary care setting, even when facing competing demands. In contrast, new problems potentially disrupt adjusting (but not initiating) depression treatment. Previous studies have found that new problems predict lower rates of health habit counseling.10
Subsequent research efforts to address how competing demands affect depression treatment over the long term should be encouraged to investigate a broader array of variables. Patient variables should be expanded to include actual visit length and familiarity with the primary care physician, which has been shown to be an important predictor of primary care physicians' detection of depression and other psychosocial problems in pediatric and adult populations.11-12 Conceptually relevant primary care physician and practice characteristics noted in Figure 1 should also be investigated for their influence on depression treatment in data sets that have more physicians and practices than we had available to study.
To our knowledge, this study provides the first evidence that patient attitudes toward antidepressant medication and specialty care counseling are associated with the probability that an untreated patient's depression gets addressed. The finding is consistent with an accumulating literature13-20 which argues that trying to improve the outcomes of primary care depression treatment by improving physician detection vastly oversimplifies a complex problem. As deliberate participants in the visit, patients will reveal or conceal information about their emotional problems to achieve goals that are important to them21-23 according to their psychological readiness.24 Perhaps recognizing that their primary care physician is likely to suggest pharmacotherapy,25 patients who do not want antidepressant medication decide to "go it on their own" to avoid being pressured into accepting a prescription or feeling guilty for refusing help. Going it on one's own may be a constructive choice for some patients with mild to moderate depression who improve on their own.26 But going it on one's own may not be a constructive choice for the 50% of undetected patients who remain depressed 1 year later, many of whom fail to return when their symptoms become more severe.27 Conversely, untreated depressed patients who find specialty care counseling an acceptable treatment report reduced odds of discussing depression during the index visit. While this decision may be an efficient use of time for patients who do not rely on primary care physicians to be gatekeepers to the mental health system, patients who accept specialty care counseling as an acceptable treatment have not yet started specialty care counseling and might do so more quickly with the support and encouragement of their primary care physicians if depression were discussed. This finding also suggests that primary care physicians may underestimate their patients' interest in specialty care counseling because they are more likely to discuss depression with the subgroup of depressed patients who find specialty care counseling unacceptable.
The strengths of this study include the use of newly emerging methods that allow us to distinguish between untreated and treated cases of depression20 in examining the relationship of competing demands on the initiation and ongoing provision of high-quality depression treatment; however, we do acknowledge the study's limitations. First, because our cross-sectional design cannot establish causality, we cannot conclude that competing demands negatively influence depression treatment. Longitudinal studies are needed to strengthen inference about this question because experimental studies on this relationship cannot be readily conducted. Second, we also cannot draw any conclusions about competing priorities and detection because our database did not allow us to ascertain whether physicians recognized depression symptoms without addressing them at that particular visit. Third, we suspect new problems reduce the probability that physicians address depression in untreated and treated patients; however, we may not have observed the relationship in untreated patients because the question in the database did not allow us to distinguish whether the new problem the untreated patient presented with was a physical or emotional problem. A new emotional problem probably increases the likelihood that depression will be addressed. A new physical problem probably decreases the likelihood. Fourth, we note that because untreated patients may have inadvertently cued their physician that they were depressed by asking questions about the study, our estimate of the proportion of patients who discussed depression with their physician may be high. The resulting measurement error reduces the study's ability to estimate accurately the relationship between competing demands and the 2 outcomes of interest. Fifth, while our cohort resembles depressed primary care populations that are predominantly female subjects,27 our findings are less generalizable to male patients, minorities and poorly educated individuals who did not constitute a large proportion of the sample, and to patients without telephone access, pregnant or postpartum patients, illiterate and cognitively impaired patients who were excluded from the parent study.
Even with these limitations, this study provides the first empirical evidence that competing demands from other problems predict whether depression is discussed and treatment recommendations are adjusted to a much greater degree than the severity of the depression symptoms. A better understanding of the effect of competing demands over time is needed to ensure that depressed patients get high-quality mental health care as initial and continuing treatment for the disorder is increasingly concentrated in the primary care setting.
AUTHOR INFORMATION
Accepted for publication March 26, 1999.
This research was supported by grants MH49116 (Dr Rost, principal investigator), MH54444 (Dr Rost, principal investigator), and P50 MH48197 (Mr Smith, principal investigator) from the National Institue of Mental Health, Rockville, Md, and the MacArthur Foundation, Chicago, Ill.
We acknowledge Marcia Blake, Nancy Burris, Byron Burton, Naihua Duan, Carl Elliott, Linda Freeman, Debbie Hodges, Barbara Howard, Joylyn Humphrey, JoAnn Kirchner, Kathryn Magruder, Susan Moore, Cynthia Moton, Jody Rath, Becky Saddler, Melonie Shelton, and Margaret White for their excellent advice and assistance with the study. We also acknowledge the physicians, nurses, office staff, and patients of the participating primary care practices: Chatham Primary Care, Siler City, NC; Dunes Family Health Care, Reedsport, Ore; Eau Claire Family Medicine, Eau Claire, Wis; Enid Family Medicine Clinic, Enid, Okla; Fergus Falls Medical Group, Fergus Falls, Minn; Health East Eastside Medical Center, St Paul, Minn; Lynchburg Family Practice, Lynchburg, Va; Mile Bluff Clinic, Mauston, Wis; Mountain Area Family Health, Asheville, NC; Northern Colorado Family Medicine, Greeley; Oakwood Health Care Center–Westland Family Practice, Westland, Mich; Somerset Family Practice, Somerville, NJ; and University of North Dakota Center for Family Medicine, Minot.
Corresponding author: Kathryn Rost, PhD, Centers for Mental Healthcare Research, 5800 W 10th St, Suite 605, Little Rock, AR 72204 (e-mail: kmrost{at}stlnet.com).
From the Centers for Mental Healthcare Research, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Dr Rost and Mr Smith); Ambulatory Sentinel Practice Network, Denver, Colo (Dr Nutting); Department of Family Medicine, University of Michigan, Ann Arbor (Dr Coyne); Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md (Dr Cooper-Patrick); and Sepulveda Veterans Administration, Sepulveda, Calif, RAND, Santa Monica, Calif, and University of California at Los Angeles (Dr Rubenstein).
REFERENCES
| |
1. Jaen CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38:166-171.
ISI
| PUBMED
2. Stange KC, Fedirko T, Zyzanski SJ, Jaen CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract. 1994;38:231-237.
ISI
| PUBMED
3. Klinkman MS. Competing demands in psychosocial care—a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19:98-111.
FULL TEXT
|
ISI
| PUBMED
4. Williams JW. Competing demands—does care for depression fit in primary care? J Gen Intern Med. 1998;13:137-139.
FULL TEXT
|
ISI
| PUBMED
5. Zimmerman M, Coryell W, Corenthal C, Wilson S. A self-report scale to diagnose major depressive disorder. Arch Gen Psychiatry. 1986;43:1076-1081.
FREE FULL TEXT
6. Rost KM, Burnam MA, Smith GR. Development of screeners for depressive disorders and substance disorder history. Med Care. 1993;31:189-200.
ISI
| PUBMED
7. Depression Guideline Panel. Depression in Primary Care: Volume 2: Treatment of Major Depression: Clinical Practice Guideline, Number 5. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services, Public Health Service; 1993. AHCPR publication 93-0551.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
9. Fontana SA, Love RR, Helberg C, Baumann LC. The delivery of preventive services in primary care practices according to chronic disease status. Am J Public Health. 1997;87:1190-1196.
FREE FULL TEXT
10. Chernof BA, Sherman SE, Lanto AB, Lee ML, Yano EM, Rubenstein LV. Health habit counseling amidst competing demands: effects of patient health habits and visit characteristics. Med Care. In press.
11. Klinkman MS, Coyne JC, Gallo S, Schwenk TL. False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Arch Fam Med. 1998;7:451-461.
FREE FULL TEXT
12. Kelleher KJ, Childs GE, Wasserman RC, McInerny TK, Nutting PA, Gardner WP. Insurance status and recognition of psychosocial problems: a report from the pediatric research in office settings and the ambulatory sentinel practice networks. Arch Pediatr Adolesc Med. 1997;151:1109-1115.
FREE FULL TEXT
13. Dowrick D, Buchan I. Twelve-month outcome of depression in general practice: does detection or disclosure make a difference? BMJ. 1995;311:1274-1276.
FREE FULL TEXT
14. Linn LS, Yager J. The effect of screening, sensitization, and feedback on notation of depression. J Med Educ. 1980;55:942-949.
ISI
| PUBMED
15. Coryell W, Endicott J, Winokur G, et al. Characteristics and significance of untreated major depressive disorder. Am J Psychiatry. 1995;152:1124-1129.
FREE FULL TEXT
16. Coryell W, Akiskal HS, Leon AC, et al. The time course of nonchronic major depressive disorder. Arch Gen Psychiatry. 1994;51:405-410.
FREE FULL TEXT
17. Simon GE, Von Korff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105.
FREE FULL TEXT
18. Callahan CM, Hendrie HC, Dittus RS, Brater DC, Hui SL, Tierney WM. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42:839-846.
ISI
| PUBMED
19. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153:636-644.
FREE FULL TEXT
20. Coyne JC, Klinkman MS, Gallo SM, Schwenk TL. Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. Gen Hosp Psychiatry. 1997;19:333-343.
FULL TEXT
|
ISI
| PUBMED
21. Freeling P, Rao BM, Paykel ES, Sireling LI, Burton RH. Unrecognized depression in general practice. Br Med J (Clin Res Ed). 1985;290:1880-1883.
22. Barrett JE. Practice-based mental health research in primary care: Directions for the 1990s. In: Hibbard H, Nutting PA, eds. Primary Care Research: Theory and Methods. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services, Public Health Service; 1998:315-321.
23. Susman JL, Crabtree BF, Essink G. Depression in rural family practice: easy to recognize, difficult to diagnose. Arch Fam Med. 1995;4:427-31.
FREE FULL TEXT
24. Leaf PJ, Livingston MM, Tischler GL, Weissman MM, Holzer CE, Myers JK. Contact with health professionals for the treatment of psychiatric and emotional problems. Med Care. 1985;23:1322-1337.
FULL TEXT
|
ISI
| PUBMED
25. Meredith LS, Rubenstein LV, Rost KM, et al. Treating depression in staff-model versus network-model managed care organizations. J Gen Intern Med. 1999; 14:39-48.
26. Elkin I, Parloff MB, Hadley SW, Autry JH. NIMH Treatment of Depression Collaborative Research Program. Arch Gen Psychiatry. 1985;42:305-316.
FREE FULL TEXT
27. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR Jr. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20:12-20.
FULL TEXT
|
ISI
| PUBMED
RELATED ARTICLE
The Archives of Family Medicine Continuing Medical Education Program
Arch Fam Med. 2000;9(2):175-177.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Does Diabetes Double the Risk of Depression?
O'Connor et al.
Ann Fam Med 2009;7:328-335.
ABSTRACT
| FULL TEXT
Will Hypertension Performance Measures Used for Pay-for-Performance Programs Penalize Those Who Care for Medically Complex Patients?
Petersen et al.
Circulation 2009;119:2978-2985.
ABSTRACT
| FULL TEXT
Mental Health Service Use Among Hurricane Katrina Survivors in the Eight Months After the Disaster
Wang et al.
Focus 2009;7:243-253.
ABSTRACT
| FULL TEXT
Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings
Ani et al.
J Am Board Fam Med 2009;22:123-135.
ABSTRACT
| FULL TEXT
Premature Mortality From General Medical Illnesses Among Persons With Bipolar Disorder: A Review
Roshanaei-Moghaddam and Katon
Psychiatr. Serv. 2009;60:147-156.
ABSTRACT
| FULL TEXT
Disagreement in Parent and Primary Care Provider Reports of Mental Health Counseling
Brown and Wissow
Pediatrics 2008;122:1204-1211.
ABSTRACT
| FULL TEXT
Psychiatric Rehospitalization Among Elderly Persons in the United States
Prince et al.
Psychiatr. Serv. 2008;59:1038-1045.
ABSTRACT
| FULL TEXT
Perceptions About Competing Psychosocial Problems and Treatment Priorities Among Older Adults With Depression
Proctor et al.
Psychiatr. Serv. 2008;59:670-675.
ABSTRACT
| FULL TEXT
Care Management for Depression in Primary Care Practice: Findings From the RESPECT-Depression Trial
Nutting et al.
Ann Fam Med 2008;6:30-37.
ABSTRACT
| FULL TEXT
Physician and Patient Characteristics Associated With Discussion of Psychosocial Health During Pediatric Primary Care Visits
Brown et al.
CLIN PEDIATR 2007;46:812-820.
ABSTRACT
Mental Health Service Use Among Hurricane Katrina Survivors in the Eight Months After the Disaster
Wang et al.
Psychiatr. Serv. 2007;58:1403-1411.
ABSTRACT
| FULL TEXT
Supporting self-management for patients with complex medical needs: recommendations of a working group
Bayliss et al.
Chronic Illness 2007;3:167-175.
ABSTRACT
Relationship Between Patient Medication Adherence and Subsequent Clinical Inertia in Type 2 Diabetes Glycemic Management
Grant et al.
Diabetes Care 2007;30:807-812.
ABSTRACT
| FULL TEXT
Practice-based Assessment of Tobacco Usage in Southwestern Primary Care Patients: A Research Involving Outpatient Settings Network (RIOS Net) Study
Ralston et al.
J Am Board Fam Med 2007;20:174-180.
ABSTRACT
| FULL TEXT
The Triple Threat for Chronic Disease: Obesity, Race, and Depression
Stecker et al.
Psychosomatics 2006;47:513-518.
ABSTRACT
| FULL TEXT
Depression decision support in primary care: a cluster randomized trial.
Dobscha et al.
ANN INTERN MED 2006;145:477-487.
ABSTRACT
| FULL TEXT
Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals
Okonofua et al.
Hypertension 2006;47:345-351.
ABSTRACT
| FULL TEXT
Effects of Enhanced Depression Treatment on Diabetes Self-Care
Lin et al.
Ann Fam Med 2006;4:46-53.
ABSTRACT
| FULL TEXT
A Randomized Trial to Improve the Quality of Treatment for Panic and Generalized Anxiety Disorders in Primary Care
Rollman et al.
Arch Gen Psychiatry 2005;62:1332-1341.
ABSTRACT
| FULL TEXT
Screening for Alcohol Use Disorders Among Medical Outpatients: The Influence of Individual and Facility Characteristics
Desai et al.
Am. J. Psychiatry 2005;162:1521-1526.
ABSTRACT
| FULL TEXT
Clinical Determinants of Health-Related Quality of Life in Patients With Irritable Bowel Syndrome
Spiegel et al.
Arch Intern Med 2004;164:1773-1780.
ABSTRACT
| FULL TEXT
How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study
Beasley et al.
Ann Fam Med 2004;2:405-410.
ABSTRACT
| FULL TEXT
How and Why to Study the Practice Content of a Practice-Based Research Network
Pearce et al.
Ann Fam Med 2004;2:425-428.
ABSTRACT
| FULL TEXT
Pharmacological Treatment of Depression in Older Primary Care Patients: The PROSPECT Algorithm
Mulsant et al.
Focus 2004;2:253-259.
ABSTRACT
| FULL TEXT
Depression Management in Medical Clinics: Does Healthcare Sector Make a Difference?
Frayne et al.
American Journal of Medical Quality 2004;19:28-36.
ABSTRACT
Blending Specialist and Practitioner Roles in Psychiatric Nursing: Experiences of Graduates
Scharer et al.
J Am Psychiatr Nurses Assoc 2003;9:136-144.
ABSTRACT
Mental Health Services Received by Depressed Persons Who Visited General Practitioners and Family Doctors
Wang et al.
Psychiatr. Serv. 2003;54:878-883.
ABSTRACT
| FULL TEXT
Descriptions of Barriers to Self-Care by Persons with Comorbid Chronic Diseases
Bayliss et al.
Ann Fam Med 2003;1:15-21.
ABSTRACT
| FULL TEXT
ClinfoTracker: A Generalizable Prompting Tool for Primary Care
Nease and Green
J Am Board Fam Med 2003;16:115-123.
ABSTRACT
| FULL TEXT
Patient Beliefs Predict Response to Paroxetine Among Primary Care Patients with Dysthymia and Minor Depression
Sullivan et al.
J Am Board Fam Med 2003;16:22-31.
ABSTRACT
| FULL TEXT
Use, Quality, and Outcomes of Care for Mental Health: The Rural Perspective
Rost et al.
Med Care Res Rev 2002;59:231-265.
ABSTRACT
Associations of Symptoms and Health-Related Quality of Life: Findings from a National Study of Persons with HIV Infection
Lorenz et al.
ANN INTERN MED 2001;134:854-860.
ABSTRACT
| FULL TEXT
Social Support and Treatment Response in Older Depressed Primary Care Patients
Oxman and Hull
Journals of Gerontology Series B: Psychological Sciences and Social Science 2001;56:35P-45.
ABSTRACT
| FULL TEXT
Competing Demands From Physical Problems: Effect on Initiating and Completing Depression Care Over 6 Months
Nutting et al.
Arch Fam Med 2000;9:1059-1064.
ABSTRACT
| FULL TEXT
The Challenge of Depression in Late Life: Bridging Science and Service in Primary Care
Gallo and Coyne
JAMA 2000;284:1570-1572.
FULL TEXT
|
