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Biomedical subjects

Bruce L Rollman

Publications and source records attributed to Bruce L Rollman.

At least 19 recordsLinked to original sources
PubMed2006

Generalized anxiety disorder severity scale (GADSS): a preliminary validation study.

To assist researchers and clinicians in primary care with assessment and treatment of generalized anxiety disorder (GAD), we developed a simple standardized instrument, similar to the Panic Disorder Severity Scale. Independent evaluators used the six-item Generalized Anxiety Disorder Severity Scale (GADSS) to conduct telephone assessments of 330 patients from four primary care facilities with DSM-IV diagnoses of GAD and/or panic disorder who were participating in a study of the effectiveness of collaborative care treatment. Participants were also evaluated at a 12-month follow-up. Internal consistency, convergent and discriminant validity, and sensitivity to change were determined. The GADSS had high internal consistency, and showed good validity and sensitivity to change. Change in GADSS scores discriminated between two different treatment strategies. GADSS is a simple, efficient way to rate severity over the telephone in patients with established diagnoses of GAD.

Anxiety Disorders↗
PubMed2006

Implementation of guideline-based care for depression in primary care.

Evidence-based clinical practice guidelines for treating depression in primary care settings were developed, in part, to ensure that health services are provided in a consistent, high-quality, and cost-effective manner. Yet for a variety of reasons, guideline-based primary care for depression remains the exception rather than the rule. This work provides a brief review of effective strategies used to customize and then deliver evidence-based treatment for depression in primary care settings; describes two representative case studies that illustrate locally customized collaborative care strategies for treatment delivery; and concludes with principles and implications for policy and practice based on our practical experiences.

Depression↗
PubMed2006

Challenges of implementing depression care management in the primary care setting.

Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.

Depression↗
PubMed2005

A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care.

CONTEXT: Panic disorder and generalized anxiety disorder are prevalent in primary care, associated with poor functional outcomes, and are often unrecognized and ineffectively treated by primary care physicians. OBJECTIVE: To examine whether telephone-based collaborative care for panic and generalized anxiety disorders improves clinical and functional outcomes more than the usual care provided by primary care physicians. DESIGN: Randomized controlled trial. SETTING: Four Pittsburgh area primary care practices linked by a common electronic medical record system. Patients A total of 191 adults aged 18 to 64 years with panic and/or generalized anxiety disorder who were recruited from July 2000 to April 2002. Intervention Patients were randomly assigned to a telephone-based care management intervention (n = 116) or to notification alone of the anxiety disorder to patients and their physicians (usual care, n = 75). The intervention involved non-mental health professionals who provided patients with psychoeducation, assessed preferences for guideline-based care, monitored treatment responses, and informed physicians of their patients' care preferences and progress via an electronic medical record system under the direction of study investigators. MAIN OUTCOME MEASURES: Independent blinded assessments of anxiety and depressive symptoms, mental health-related quality of life, and employment status at baseline, 2-, 4-, 8-, and 12-month follow-up. RESULTS: At 12-month follow-up, intervention patients reported reduced anxiety (effect size [ES], 0.33-0.38; 95% confidence interval [CI], 0.04 to 0.67; P</=.02) and depressive symptoms (ES, 0.35; 95% CI, 0.25-0.46; P = .03); improved mental health-related quality of life (ES, 0.39; 95% CI, 0.10 to 0.68; P = .01); and larger improvements relative to baseline in hours worked per week (5.7; 95% CI, 0.1 to 11.3; P = .05) and fewer work days absent in the past month (-2.6; 95% CI, - 4.8 to -0.3; P = .03) than usual care patients. If working at baseline, more intervention patients than usual care patients remained working at 12-month follow-up (94% vs 79% [15% absolute difference, 0.7%-28.6%]; P = .04). CONCLUSIONS: Telephone-based collaborative care for panic disorder and generalized anxiety disorder is more effective than usual care at improving anxiety symptoms, health-related quality of life, and work-related outcomes.

Adult↗
PubMed2005

Somatic symptoms of depression in elderly patients with medical comorbidities.

OBJECTIVE: Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression. DESIGN: Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures. PARTICIPANTS: Two hundred and forty eight primary care and psychiatric patients aged >or= 60 years. METHODS: Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling. RESULTS: Two somatization measures, the Asberg Side Effects Rating Scale and the Utvalg for Kliniske Undersogelser (UKU), were significantly associated with psychological symptoms of depression (r = 0.73 and r = 0.76, p < 0.0001) but not with medical comorbidities (r = 0.02, p = 0.16 and r = 0.10, p = 0.78). In multiple regression models, psychological symptoms of depression remained significant predictors of somatization (p < 0.0001) after controlling for age, gender, and medical comorbidities. CONCLUSIONS: In older patients with medical disorders and multiple somatic complaints, clinicians should consider the possibility of depression. Rating scales emphasizing somatic symptoms associated with depression may provide a more accurate measure of depression severity than those excluding such symptoms.

Aged↗
PubMed2005

Symptomatic severity of PRIME-MD diagnosed episodes of panic and generalized anxiety disorder in primary care.

BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial. OBJECTIVE: To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses. DESIGN: Cross-sectional interview. PATIENTS: Individuals aged 18 to 64 who presented for care at 4 primary care practices. MEASUREMENTS: The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS). RESULTS: Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients. CONCLUSIONS: The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis.

Adult↗
PubMed2004

Translating evidence-based depression management services to community-based primary care practices.

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.

Community Health Services↗
PubMed2003

Emerging models of depression care: multi-level ('6 P') strategies.

Depression is a prevalent, often chronic condition that has enormous personal, social, and financial consequences. Although technologies for treating depression have advanced notably over the past 20 years, many people continue to suffer needlessly, due in part to the lack of evidence-based treatment applied in primary care settings. Substantial public and private efforts have been devoted to encouraging individuals to seek care, improving recognition and diagnosis by primary care physicians, and implementing evidence-based treatment practices. From these efforts have come new models of care as well as an awareness of the critical barriers impeding clinical, organizational, economic, and policy implementation of effective care strategies. In this paper, we describe these clinical and systems barriers and consider the perspectives of various stakeholder groups; present emerging clinical models for providing evidence-based care as well as economic strategies for overcoming barriers to their implementation; and propose community-based approaches that will need to be tested. To achieve maximum benefits from current knowledge, we will need to implement a multi-level strategy employing focused efforts involving patients, providers, practice settings, health plans, purchasers (public and private), and populations (or communities): the '6 P' strategy.

Chronic Disease↗
PubMed2003

Cardiovascular health and depression.

Research has shown that depression increases the likelihood that otherwise healthy people will develop ischemic heart disease (IHD) and worsens the prognosis of patients who already have IHD. Moreover, concerns about safety (e.g., cardiac side effects, drug-drug interactions) have caused physicians to be hesitant about using antidepressant agents in patients with IHD. This article is based on a recent roundtable of experts who met to discuss risk, diagnosis, and treatment options for depression in patients with IHD. This article reviews clinical and epidemiological studies that have described a link between depression and the subsequent development of IHD and have examined the role of depression as a predictor of cardiac events in patients with existing IHD. The article addresses the issue of whether depression can be safely and efficaciously treated both in patients with stable IHD and in those with acute coronary syndromes. The authors discuss safety issues related to the potential for interactions between antidepressants and cardiovascular medications, the use of nonpharmacologic treatment options such as psychosocial interventions, and the effect of antidepressant therapy on quality of life in patients with IHD. The article concludes with practical clinical guidance concerning the management of depression in patients who have recently experienced myocardial infarction.

Journal Article↗
PubMed2002

Depression as a risk factor for non-suicide mortality in the elderly.

Depression can be a consequence of medical illness and disability, yet recent literature suggests it may also influence morbidity and mortality through a variety of behavioral and biological mediators. Relatively little is known about the complex temporal relations among behavior, affect, motivation, and pathophysiology to account for the association between depression and mortality. We performed a systematic review of the recent literature (1997-2001) examining the evidence linking depression to non-suicide mortality, describe possible mediators of the depression mortality effect, and identify important next steps in this area of research, including: a) the development of well-specified a-priory mediator models that articulate how depression leads to mortality; b) the conduct of longitudinal studies in which depression and behavioral and pathophyisological mediators are assessed simultaneously; c) treatment studies for depression that include assessments of associated changes in health-related quality of life, medical morbidity, and mortality; and d) treatment studies for behavioral risk factors and medical conditions that include assessment of depressive symptoms.

Aged↗
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

Clinical importance of HIV and depressive symptoms among veterans with HIV infection.

OBJECTIVE: To compare the clinical importance (association with illness severity and survival) of depressive and HIV symptoms among veterans with HIV infection. DESIGN: Cross-sectional study; survival analysis. SETTING: Infectious Disease Clinics at 3 VA Medical Centers. PARTICIPANTS: HIV-infected patients (N = 881) and their health care providers from June 1999 through July 2000. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms were assessed using the 10-item Centers for Epidemiologic Studies Depression Scale (CES-D). Patient baseline survey included an HIV Symptom Index measuring the frequency and bother of 20 common symptoms. Providers were surveyed on patients' illness severity, and survival data were obtained from VA death records. Of 881 patients, 46% had significant depressive symptoms (CES-D >/=10). Increasing depression symptom severity was associated with increasing HIV symptom frequency (P <.001) and bother (P <.001). Multiple regression results revealed that having moderate or severe depressive symptoms was not associated with provider-reported illness severity or survival. However, HIV symptoms were significantly associated with provider-reported illness severity (P <.01) and survival (P =.05), after adjusting for moderate and severe depressive symptoms, CD4 cell count/mm3, viral load, age, race, and antiretroviral use. CONCLUSIONS: Depression, while common in this sample, was not associated with illness severity or mortality after adjusting for HIV symptoms. HIV symptoms are associated with severity of illness and survival regardless of patients' severity of depressive symptoms. This suggests that equal medical consideration should be given to HIV symptoms presented by HIV-infected patients regardless of their depression status, rather than automatically attributing medical complaints to depression.

Adult↗
PubMedDate not supplied

Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk.

BACKGROUND: Depression is often underrecognized in patients with end-stage renal disease. We interviewed outpatients at an urban dialysis facility using a criterion-based case-finding instrument to assess the rates, clinical correlates and outcomes of depression. METHODS: The Primary Care Evaluation of Mental Disorders Mood Module and the nine-item Patient Health Questionnaire were used to assess depression. We measured health-related quality of life using the Kidney Disease and Quality of Life Short Form, and medical comorbidities were measured using the Charlson Comorbidity Index. We compared the sociodemographic and clinical characteristics and health-related quality of life of depressed and nondepressed patients using t tests and the chi-square test, and we used a Cox regression model to test the relationship between depression and mortality. RESULTS: We interviewed 62 patients and followed them for a mean of 29 months (range, 0.1-36). Seventeen (28%) had major or minor depression. Depressed patients were younger and had lower health-related quality of life than did nondepressed patients. Depression predicted mortality (HR=4.1, 95% CI=1.5-32.2, P<.05) after adjusting for age, gender, race, medical comorbidities, albumin, kt/V and/or the presence of diabetes. CONCLUSIONS: Depression is common and associated with decreased health-related quality of life and increased mortality in hemodialysis patients. Clinical trials are necessary to examine whether treatment of depression can improve these outcomes.

Adolescent↗
PubMedDate not supplied

The effectiveness of psychotherapy in treating depressive disorders in primary care practice: clinical and cost perspectives.

This paper reviews the clinical and cost effectiveness of psychotherapy for treating major and minor depression in primary care practice. Conclusions drawn from psychotherapy studies completed prior to 1995 were constrained by methodological deficiencies such as ambiguity regarding patient diagnostic status, use of non-specific psychotherapies, and lack of treatment manuals. More recent studies have addressed these flaws by shifting from efficacy to effectiveness designs, using standard diagnostic assessment procedures and appropriate follow-up time periods, using empirically evaluated treatment manuals, and selecting appropriate comparison conditions. Twelve primary care studies meeting these design criteria were analyzed, and the following conclusions were drawn: When used to treat major depression, a depression-specific psychotherapy produces better clinical outcomes than a primary care physician's usual care and outcomes similar to those produced by pharmacotherapy. When used to treat minor depression or dysthymia, the effectiveness of psychotherapy in comparison to usual care remains more equivocal. A review of the sparse data on cost effectiveness suggests that while psychotherapy has a higher fiscal cost than a physician's usual care, psychotherapy's higher value in treating patients with major depression may justify its use.

Antidepressive Agents↗
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↗