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Biomedical subjects

M L Bruce

Publications and source records attributed to M L Bruce.

At least 19 recordsLinked to original sources
PubMed2002

Primary care physicians attitude toward diagnosis and treatment of late-life depression.

Underdiagnosis and undertreatment of late-life depression is common, especially in primary care settings. To help assess whether physicians attitude and confidence in diagnosing and managing depression serve as barriers to care, a total of 176 physicians employed in 18 primary care groups were administered surveys to assess attitudes towards diagnosis, treatment, and management of depression in elderly patients, (individuals over 65 years of age). Logistic regression was performed to assess the association of physician characteristics on attitudes. Nearly all of the physicians surveyed felt that depression in the elderly was a primary care problem, and 41% reported late-life depression as the most common problem seen in older patients. Physicians were confident in their ability to diagnose and manage depression, yet 45% had no medical education on depression in the previous three years. Physicians confidence in their ability to diagnose, treat, and manage depression, and their reported adequacy of training, do not appear to correspond to the amount of continuing medical education in depression, suggesting that physician overconfidence may potentially be serving as a barrier to care.

Journal Article↗
PubMed2001

Validity of self-reported cancer history: a comparison of health interview data and cancer registry records.

Few studies have addressed the accuracy of self-reported cancer history, although epidemiologic studies routinely use self-reported information as the sole source of exposure or outcome data or as a criterion for exclusion from study participation. In this paper, false-negative reporting of cancer history is examined in a community-based sample by comparing interview data with tumor registry records. Subjects were participants in the 1980 New Haven Epidemiologic Catchment Area study; in 1995, cancer records (from 1935 onward) were obtained by linking the sample to the Connecticut Tumor Registry. Analyses focused on 263 individuals who had at least one tumor reported to the Connecticut Tumor Registry prior to participation in the Epidemiologic Catchment Area study. The overall rate of false-negative reporting was 39.2%. Logistic regression analysis revealed that false-negative reporting was significantly associated with non-White race, older age, increased time since cancer diagnosis, number of previous tumors, and type of cancer treatment received. In addition, false-negative reporting varied widely by cancer site, ranging from 0% for melanoma skin cancer to 83.3% for central nervous system cancers. The false-negative rate for breast cancer was 20.8%, that for colon and prostate cancers was 42.1%, and that for bladder cancer was 61.5%. Implications of these findings for prevalence estimation and future epidemiologic studies are discussed.

Adolescent↗
PubMed2001

The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study.

The PROSPECT (Prevention of Suicide in Primary Care Elderly - Collaborative Trial) Study evaluates collaborative care for the treatment of current depressive disorders in older primary care patients. Using screening data, we evaluate implications of expanding the focus to additional patients who report taking psychotropic medication or having a history of depression. Some 13.8% of the patients screened were taking a psychotropic medication and 7.3% were both taking an antidepressant and had a Center for Epidemiologic Studies - Depression Scale (CES-D) score of > 15. Patients who reported current antidepressant use and those with a history of depression also had elevated CES-D scores. Conversely, most patients having an elevated CES-D score also reported taking an antidepressant or having a history of depression. These latter criteria for potential caseness yielded a larger number of patients than those identified by the CES-D alone. More comprehensive approaches to the management of depression should attend to patients already taking psychotropic medication and symptomatic patients with a history of depression, as well as those with current syndromal depression.

Aged↗
PubMed2001

High-risk management guidelines for elderly suicidal patients in primary care settings.

Older adults, especially older white men, are more likely to commit suicide than other age-groups. The assessment and management of suicide ideation and behavior for the elderly is especially relevant for primary care physicians because many patients visit their physician shortly before committing suicide. In 1993, the Agency for Health Care Policy and Research (AHCPR) released clinical practice guidelines for the treatment of depression in primary care settings. The AHCPR guidelines offered some assistance with respect to detecting and treating patients who are suicidal. However, these guidelines lacked detailed and specific instructions for managing high-risk patients within the context of intervention research. The current set of guidelines builds upon this previous work by describing (1) a general approach for interacting with suicidal patients; (2) structured assessments for determining the degree of risk for suicide; (3) crisis intervention strategies; and (4) ongoing management procedures for working with suicidal patients in primary care settings.

Aged↗
PubMed2001

The systematic assessment of depressed elderly primary care patients.

Studies of the primary care treatment of depressed elderly patients are constrained by limited time and space and by subject burden. Research assessments must balance these constraints with the need for obtaining clinically meaningful information. Due to the wide-ranging impact of depression, assessments should also focus on suicidality, hopelessness, substance abuse, anxiety, cognitive functioning, medical comorbidity, functional disability, social support, personality, service use and satisfaction with services. This paper describes considerations concerning the assessment selection process for primary care studies, using the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study as an example. Strategies are discussed for ensuring that data are complete, valid and reliable.

Activities of Daily Living↗
PubMed2001

Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression.

OBJECTIVE: The authors' goal was to examine the extent to which perceived stigma affected treatment discontinuation in young and older adults with major depression. METHOD: A two-stage sampling design identified 92 new admissions of outpatients with major depression. Perceived stigma was assessed at admission. Discontinuation of treatment was recorded at 3-month follow-up. RESULTS: Although younger patients reported perceiving more stigma than older patients, stigma predicted treatment discontinuation only among the older patients. CONCLUSIONS: Patients' perceptions of stigma at the start of treatment influence their subsequent treatment behavior. Stigma is an appropriate target for intervention aimed at improving treatment adherence and outcomes.

Adolescent↗
PubMed2001

Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence.

OBJECTIVE: Major depression is undertreated despite the availability of effective treatments. Psychological barriers to treatment, such as perceived stigma and minimization of the need for care, may be important obstacles to adherence to the pharmacologic treatment of major depression. The authors examined the impact of barriers that were present at the initiation of antidepressant drug therapy on medication adherence in a mixed-age sample of outpatients with major depression. METHODS: A two-stage sampling design was used to identify adults with a diagnosis of major depressive disorder, as determined by the Structured Clinical Interview for Diagnosis, who sought mental health treatment at outpatient clinics. Additional instruments were administered to 134 newly admitted adults who had been taking a prescribed antidepressant medication for at least a week to assess perceived stigma, self-rated severity of illness, and views about treatment. The patients were reinterviewed three months later and were classified as adherent or nonadherent on the basis of self-reported estimates of the number and frequency of missed doses. RESULTS: Medication adherence was associated with lower perceived stigma, higher self-rated severity of illness, age over 60 years, and absence of personality pathology. No other characteristics of treatment or illness were significantly related to medication adherence. CONCLUSIONS: Perceived stigma associated with mental illness and individuals' views about the illness play an important role in adherence to treatment for depression. Clinicians' attention to psychological barriers early in treatment may improve medication adherence and ultimately affect the course of illness.

Adaptation, Psychological↗
PubMed2001

Depression and disability in late life: directions for future research.

The author reviews evidence from epidemiologic and clinical studies suggesting a reciprocal, potentially spiraling, relationship between depression and disability in older adults. The discussion outlines possible methodological and conceptual explanations for this evidence and poses avenues for future research. An underlying theme is the impact of how disability and depression are measured on the nature of empirical evidence and its interpretation. Measures and corresponding analytic strategies that capture the complexity of depression, disability, and their relationship are expected to lead to the most fruitful approaches to reducing the burden of depression and disability in the lives of older adults.

Aged↗
PubMed2001

The prevalence and correlates of untreated serious mental illness.

OBJECTIVE: To identify the number of people in the United States with untreated serious mental illness (SMI) and the reasons for their lack of treatment. DATA SOURCE/STUDY DESIGN: The National Comorbidity Survey; cross-sectional, nationally representative household survey. DATA COLLECTION: An operationalization of the SMI definition set forth in the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act identified individuals with SMI in the 12 months prior to the interview. The presence of SMI then was related to the use of mental health services in the past 12 months. PRINCIPAL FINDINGS: Of the 6.2 percent of respondents who had SMI in the year prior to interview, fewer than 40 percent received stable treatment. Young adults and those living in nonrural areas were more likely to have unmet needs for treatment. The majority of those who received no treatment felt that they did not have an emotional problem requiring treatment. Among those who did recognize this need, 52 percent reported situational barriers, 46 percent reported financial barriers, and 45 percent reported perceived lack of effectiveness as reasons for not seeking treatment. The most commonly reported reason both for failing to seek treatment (72 percent) and for treatment dropout (58 percent) was wanting to solve the problem on their own. CONCLUSIONS: Although changes in the financing of services are important, they are unlikely by themselves to eradicate unmet need for treatment of SMI. Efforts to increase both self-recognition of need for treatment and the patient centeredness of care also are needed.

Adolescent↗
PubMed2000

Assessing problems with religious content: a comparison of rabbis and psychologists.

This study measured distinctions made by a sample of clergy and mental health professionals in response to three categories of presenting problems with religious content: mental disorder, religious or spiritual problem, and "pure" religious problem. A national, random sample of rabbis (N = 111) and clinical psychologists (N = 90) provided evaluations of three vignettes: schizophrenia, mystical experience, and mourning. The participants evaluated the religious etiology, helpfulness of psychiatric medication, and seriousness of the presenting problems. The rabbis and psychologists distinguished between the three diverse categories of presenting problems and concurred in their distinctions. The results provide empirical evidence for the construct validity of the new DSM-IV category religious or spiritual problem (V62.89). Use of the V code allows for more subtle distinctions among the variety of problems that persons bring to clergy and mental health professionals. These distinctions may also provide a foundation for the initiation of co-professional consultation.

Attitude of Health Personnel↗
PubMed2000

Adverse life events and cognitive-personality characteristics in the prediction of major depression and antidepressant response.

OBJECTIVE: Stressful life events are known to precipitate major depression. However, it remains unclear why some individuals who experience adverse events develop depression whereas others do not, and how the occurrence of life events affects treatment outcome. Emerging models posit that the effect of adverse life events varies by cognitive-personality style. This study examines the direct and interactive effects of stressful life events and cognitive-personality style in predicting 1) episode onset in patients with DSM-IV unipolar depression versus community comparison subjects and 2) depressive symptom severity at the completion of a 6-week standard antidepressant regimen. METHOD: Multivariate models were used to test the effects of adverse life events, cognitive-personality style, and the congruence of event type (interpersonal versus achievement) with cognitive-personality style on depressive onset and treatment outcome in 43 patients with major depression and 43 healthy comparison subjects. Cognitive-personality characteristics were assessed by using Beck's measures of sociotropy (interpersonal dependency) and autonomy (need for independence and control). RESULTS: Adverse life events, sociotropy, and an autonomy factor need for control were each significantly related to depressive onset and predicted group status for 88% of the subjects. Event types affected outcome differently, and specific life event types interacted with cognitive-personality styles in predicting response to treatment. A multivariate model accounted for 65% of the variance in predicting outcome. CONCLUSIONS: Adverse life events are a potent factor in predicting depression. However, cognitive-personality characteristics also confer susceptibility to depression. Better outcome is associated with occurrence of adverse interpersonal events (e.g., death of a loved one) rather than adverse achievement events (e.g., loss of job) and occurs when the event type is congruent with cognitive-personality style.

Adult↗
PubMed1999

Clinical determinants of suicidal ideation and behavior in geriatric depression.

BACKGROUND: The aim of this study was to find clinical characteristics that can identify elderly patients with depression at risk for suicidal ideation and to determine their prognosis. METHOD: Suicidal ideation, past suicidal behavior, severity of depression, cognitive impairment, medical burden, disability, and social support were studied in 354 patients with depression aged 61 to 93 years. The patients had in-person evaluations every 6 months and telephone evaluations for a mean of 1.8 years (SD, 2.2). RESULTS: During the index episode, suicidal ideation was predicted by previous suicide attempts with serious intent (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.37-5.80), severity of depression (OR, 1.09; 95% CI, 1.03-1.16), and poor social support (OR, 1.77; 95% CI, 1.18-2.65). Suicide attempts during the year prior to entry were reported by patients with a severe index episode (OR, 1.05; 95% CI, 1.00-1.11), impaired instrumental activities of daily living (OR, 0.78; 95% CI, 0.67-0.93), and limited impairment in activities of daily living (OR, 1.53; 95% CI, 1.10-2.14). At the initial evaluation, severity of depression, previous attempts, and seriousness of suicidal intent during previous attempts predicted the course of suicidal ideation (concordance correlation, 0.78). During follow-up, contemporaneous severity of depression was the most important determinant of suicidal ideation over time (concordance correlation, 0.88). CONCLUSIONS: Elderly individuals with severe depression, history of suicide attempts with serious intent, and poor social support are most likely to have suicidal ideation and should be targeted for appropriate interventions. Severity of depression is the strongest predictor of the course of suicidal ideation.

Age Factors↗
PubMed1999

Marital dissatisfaction and incidence of major depressive episode in a community sample.

The association between marital dissatisfaction at baseline and 12-month incidence of major depressive episode (MDE) was examined in a community sample of married individuals from the New Haven Epidemiologic Catchment Area program (N = 904) who did not meet criteria for MDE at baseline. Results indicate that marital dissatisfaction was associated with increased incidence of MDE, with a significant risk ratio of 2.7 and an attributable risk of 29.5%. Thus, dissatisfied spouses were nearly 3 times more likely than nondissatisfied spouses to develop an MDE during the year, and nearly 30% of the new occurrences of MDE were associated with marital dissatisfaction. The association between marital dissatisfaction and risk of MDE (a) remained significant when controlling for demographics and depression history and (b) was not moderated by sex or by depression history. Findings suggest that marital dissatisfaction may be etiologically related to major depression.

Adult↗
PubMed1999

Variation in the impact of social network characteristics on physical functioning in elderly persons: MacArthur Studies of Successful Aging.

OBJECTIVES: Social support and social networks have been shown to exert significant effects on health and functioning among elderly persons. Although theorists have speculated that the strength of these effects may differ as a function of sociodemographic characteristics and prior health status, few studies have directly tested the moderating effects of these variables. METHODS: Longitudinal data from the MacArthur Study of Successful Aging were used to examine the effects of structural and functional social support on changes in physical functioning over a 7-year period, measured by the Nagi scale, in a sample of initially high-functioning men and women aged 70 to 79 years. Multiple regression analyses were used to test the main effects of social support and social network variables, as well as their interactions with gender, income, and baseline physical performance. RESULTS: After controlling for potential confounding effects, respondents with more social ties showed less functional decline. The beneficial effects of social ties were stronger for respondents who were male or had lower levels of baseline physical performance. DISCUSSION: The effects of social support and social networks may vary according to the individual's gender and baseline physical capabilities. Studies of functional decline among elderly persons should not ignore this population variation in the effects of social networks.

Activities of Daily Living↗
PubMed1999

Predictors of antidepressant prescription and early use among depressed outpatients.

OBJECTIVE: The rates of antidepressant recommendation and use were determined in outpatients with major depression receiving services in mental health clinics. Site of service and the patients' sociodemographic and clinical characteristics were investigated as possible predictors. METHOD: Patients admitted to six outpatient clinics were recruited through a two-stage sampling procedure. Patients with major depressive disorder (N = 124) according to the Structured Clinical Interview for DSM-IV--Patient Edition were assessed at admission and 3 months later. RESULTS: Drug therapy was recommended for most patients (71%), and minimal use (at least 1 week) was recorded for 59% of the subjects. White patients were nearly three times as likely to receive a recommendation for antidepressants. Antidepressant recommendation was also associated with severity of depressed mood, recent medication use, and clinic type. Recent antidepressant use was the only variable that predicted whether the patient actually took the recommended medication. CONCLUSIONS: Many patients with depression seeking treatment at community mental health clinics do not receive antidepressant drug therapy. The offer of medication is predicted by patient ethnicity, clinic type, and symptom severity. Minority patients are less likely to be offered antidepressant treatment.

Adolescent↗
PubMed1999

The effects of major depression and phobia on stage at diagnosis of breast cancer.

OBJECTIVE: To examine the longitudinal effects of major depression and phobia on stage at diagnosis of subsequent breast cancer. METHOD: Data from the New Haven Epidemiologic Catchment Area (ECA) study were linked to the Connecticut Tumor Registry (CTR). The sample comprised of seventy-two women with a first primary breast cancer diagnosed sometime after their baseline ECA study interview. In the ECA study, lifetime psychiatric history was assessed using the Diagnostic Interview Schedule based on DSM-III criteria. Stage at diagnosis of breast cancer was taken from CTR records and dichotomized into early stage (in situ and localized tumors) versus late stage (regional and distant tumors). RESULTS: A positive history of major depression was associated with an increased likelihood of late-stage diagnosis of breast cancer (odds ratio [OR] = 9.81, p = 0.039), whereas a positive history of phobic disorders was associated with a decreased likelihood of late-stage diagnosis (OR = 0.01, p = 0.021), controlling for sociodemographic characteristics of the sample. CONCLUSIONS: These analyses revealed a longitudinal association between reported lifetime psychiatric history and stage at diagnosis of subsequent breast cancer. Phobia may motivate women to adhere to breast cancer screening recommendations and to report suspicious symptoms to a physician without delay. Major depression, on the other hand, was identified as an important predictor of late-stage diagnosis; proper recognition and management of depression in the primary care setting may have important implications for breast cancer detection and survival.

Adolescent↗