Biomedical subjects

Barbara H Hanusa

Publications and source records attributed to Barbara H Hanusa.

26 records · Page 2Linked to original sources

PubMed2002

Verapamil treatment for women with bipolar disorder.

BACKGROUND: Additional pharmacological treatments are needed for patients with bipolar disorder. We describe our experience with verapamil in an inclusive, sequential series of outpatient women (some pregnant) with bipolar disorder. METHODS: All women who were prescribed verapamil for bipolar disorder (n = 37) were included. We used the criterion of 50% reduction in scores on the Mania Rating Scale or the Hamilton Rating Scale for Depression to define response for women who were treated for an acute episode of bipolar hypomania/mania or depression, respectively. For euthymic women who chose verapamil maintenance treatment, we evaluated whether they met criteria for a recurrent episode during therapy. RESULTS: Treatment for acute episodes was initiated in 28 women. Of women with depression and mania, 39% and 100% responded, respectively. Seven of the nine patients (77%) with mixed states responded: all seven improved to response criterion on the mania scale, and two responded on the depression scales as well. Six of eight patients who received continuation therapy remained well. CONCLUSIONS: These data provide evidence that verapamil is effective for mania. The response rate for mania compares favorably to that for other mood stabilizers. After decades of case reports and underpowered clinical trials, we must definitively study verapamil for efficacy and gender specificity in bipolar disorder.

Anti-Arrhythmia Agents↗

PubMed2002

Physician office visits of adults for anxiety disorders in the United States, 1985-1998.

OBJECTIVE: To determine the number of physician office visits by adults in which an anxiety disorder diagnosis was recorded and rates of treatment during these visits. DESIGN: We used data from the 1985, 1993, 1994, 1997, and 1998 National Ambulatory Medical Care Surveys, which is a nationally representative series of surveys of office-based practice employing clustered sampling. SETTING: Office-based physician practices in the United States. PARTICIPANTS: A systematically sampled group of office-based physicians. RESULTS: The number of office visits with a recorded anxiety disorder diagnosis increased from 9.5 million in 1985 to 11.2 million per year in 1993-1994 and 12.3 million per year in 1997-1998, representing 1.9%, 1.6%, and 1.5% of all office visits in 1985, 1993-1994, and 1997-1998, respectively. The majority of recorded anxiety disorder diagnoses were not for specific disorders, with 70% of anxiety disorder visits to primary care physicians coded as "anxiety state, unspecified." Visits to primary care physicians accounted for 48% of all anxiety disorder visits in 1985 and 1997-1998. Treatment for anxiety was offered in over 95% of visits to psychiatrists but in only 60% of visits to primary care physicians. Primary care physicians were less likely to offer treatment for anxiety when specific anxiety disorders were diagnosed than when "anxiety state, unspecified" was diagnosed (54% vs 62% in 1997-1998). Prescriptions for medications to treat anxiety disorders increased between 1985 and 1997-1998 while use of psychotherapy decreased over the same time period in visits to both primary care physicians and psychiatrists. CONCLUSIONS: Although there is a large number of office visits with a recorded anxiety disorder diagnosis, under-recognition and under-treatment appear to be a continuing problem, especially in the primary care sector. Medication is being substituted for psychotherapy in visits to both psychiatrists and primary care physicians over time.

Adolescent↗

PubMed2002

A randomized trial using computerized decision support to improve treatment of major depression in primary care.

OBJECTIVE: To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression. DESIGN: Randomized controlled trial. SETTING: Academically affiliated primary care practice in Pittsburgh, PA. PATIENTS: Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria. INTERVENTION: PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: "active care" (AC), "passive care" (PC), or "usual care" (UC). MEASUREMENTS AND MAIN RESULTS: Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D </=7). Patients' mean HRS-D score decreased regardless of their PCPs' guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P <.001). However, neither continuous (HRS-D </=7: 22% AC, 23% PC, 22% UC; P =.8) nor categorical measures of recovery (P =.2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in >/=3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P =.09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P =.3). CONCLUSIONS: Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.

Adult↗

PubMed2002

Advance care planning.

BACKGROUND: Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated. OBJECTIVE: To compare patient reactions to values-based and treatment-based advance directive forms. SETTING: Two academic general medicine outpatient clinics in Pittsburgh, Pa. METHODS: Outpatients age 55 or older who did not have an AD and were not demented were randomly assigned to complete either Emanuel's Medical Directive (EMD) or Pearlman's values history (PVH) form. MEASUREMENTS: Length of time to complete and number of questions asked about the AD forms; proportions of patients discussing the AD with family, designating a surrogate, returning the AD by mail, and desiring to have the AD in the medical record; patient ratings of AD by telephone interview; physician report of patient-initiated AD discussions. RESULTS: Of the 275 patients approached, 143 refused, 69 already had an AD, 63 patients were enrolled, and 25 in each group completed the telephone interview. A majority of individuals in both groups had conversations with others about the AD (60% EMD, 56% PVH; P = .77). All PVH forms designated a surrogate, whereas 79% of EMD forms did so (P = .02). One patient in each group initiated a conversation with his or her physician about AD following study completion. Both forms were thought to be a good first step in planning care at the end of life (92% EMD vs 84% PVH totally or mostly agree; P = .06). Patients completing the EMD thought it would give them control over the way their doctor cared for them at the end of their lives more than did the PVH group (84% EMD vs 48% PVH totally or mostly agree; P = .02). More patients completing the EMD form worried that it would be difficult to change answers on the form if they later changed their minds (20% EMD vs 4% PVH totally or mostly agree; P = .02). CONCLUSIONS: Both the values-based and treatment-based AD forms were rated favorably overall. Patients thought the treatment-based directive would give them more control over their care. Patients completing the values history form were more likely to designate a surrogate. Patients are likely to discuss both types of AD with family, but neither form alone is likely to lead to AD conversations with physicians.

Advance Directives↗

PubMed2002

Black-white differences in severity of coronary artery disease among individuals with acute coronary syndromes.

OBJECTIVE: To determine whether the extent of coronary obstructive disease is similar among black and white patients with acute coronary syndromes. DESIGN: Retrospective chart review. PATIENTS: We used administrative discharge data to identify white and black male patients, 30 years of age or older, who were discharged between October 1, 1989 and September 30, 1995 from 1 of 6 Department of Veterans Affairs (VA) hospitals with a primary diagnosis of acute myocardial infarction (AMI) or unstable angina (UnA) and who underwent coronary angiography during the admission. We excluded patients if they did not meet standard clinical criteria for AMI or UnA or if they had had prior percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: Physician reviewers classified the degree of coronary obstruction from blinded coronary angiography reports. Obstruction was considered significant if there was at least 50% obstruction of the left main coronary artery, or if there was 70% obstruction in 1 of the 3 major epicardial vessels or their main branches. Of the 628 eligible patients, 300 (48%) had AMI. Among patients with AMI, blacks were more likely than whites to have no significant coronary obstructions (28/145, or 19%, vs 10/155 or 7%, P =.001). Similarly, among patients with UnA, 33% (56/168) of blacks but just 17% (27/160) of whites had no significant stenoses (P =.012). There were no racial differences in severity of coronary disease among veterans with at least 1 significant obstruction. Racial differences in coronary obstructions remained after correcting for coronary disease risk factors and characteristics of the AMI. CONCLUSIONS: Black veterans who present with acute coronary insufficiency are less likely than whites to have significant coronary obstruction. Current understanding of coronary disease does not provide an explanation for these differences.

Angina Pectoris↗

PubMed2002

Urban homelessness and poverty during economic prosperity and welfare reform: changes in self-reported comorbidities, insurance, and sources for usual care, 1995-1997.

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P <.001) and mental health comorbidity (44.9% vs. 36.9%, P =.04) and required more chronic medication (52.1% vs. 30.3%, P <.001). More respondents in 1997 than 1995 reported having no health insurance (41.4% vs. 29.4%, P <.001). While there was no difference in the overall proportion reporting a source for usual care (78.3% in 1997 vs. 80.2% in 1995, P =.55), fewer persons reported use of the emergency department and more persons reported using a shelterbased clinic for usual care in 1997 compared with 1995. These findings suggest more need for medical care among homeless and urban poor persons in 1997 compared with 1995 and support the continued need for outreach and support services despite a vigorous economy.

Adolescent↗

PubMedDate not supplied

Race, quality of depression care, and recovery from major depression in a primary care setting.

Racial variations in the use of effective medical care and subsequent clinical outcomes have been identified for many medical conditions. Still, it is unclear whether racial variations in care and clinical outcomes exist for depressed primary care patients. Primary care patients presenting for routine treatment were screened for major depression as part of a study to disseminate a depression treatment guideline. Primary care physicians (PCPs) were informed of their patients' depression via an electronic medical record system and asked whether they agreed with the diagnosis. Treatment patterns and depressive symptoms over the following six-months were assessed by chart review and the Hamilton Rating Scale for Depression, respectively. Over a 20-month period, 8,944 African-American and Caucasian patients aged 18-64 were approached for screening. African-Americans were less likely to agree to undergo screening than Caucasians (83% vs. 88%; P<.0001), but those doing so were more likely to report mood symptoms (26% vs. 15%; P<.001). 204 patients, including 52 African-Americans (25%), met protocol-eligibility criteria and completed a baseline interview. Baseline sociodemographic and clinical characteristics, and PCPs' agreement rate with the depression diagnosis were similar. Although PCPs were less likely to counsel their African-American than Caucasian patients for depression (P=.03), this difference resolved after adjusting for education level, employment, and insurance status and we found no other variations in the depression care provided or in clinical outcomes by race. We found little racial variation in either process measures or clinical outcomes for depression in our sample of African-American and Caucasian primary care patients.

Adolescent↗

PubMedDate not supplied

Addressing depression in obstetrics/gynecology practice.

Efforts to improve the care of depression in primary care patients have largely ignored the potential of obstetrics/gynecology (OB/GYN) practices. We describe feasibility studies of a depression screening and care management intervention in three diverse OB/GYN practices. Patients were screened using the Patient Health Questionnaire. A depression care manager offered education and referral assistance to women who screened positive for depression. The prevalence of depression was higher in the hospital clinic (20.2%, 47/233) than the suburban clinic (10.7%, 8/75) or the office practice (8.2%, 48/583). Seventy-two women participated in the care management intervention. Patient satisfaction with the intervention was high and at 1-month follow-up, 31.9% of patients had kept or scheduled a new mental health appointment. Depression interventions developed in primary care can be successfully adapted for use with patients in OB/GYN practices. Additional modifications, particularly efforts to improve coordination of care with both general medical and mental health providers, are needed.

Adolescent↗