Biomedical subjects

Michael S Klinkman

Publications and source records attributed to Michael S Klinkman.

7 recordsLinked to original sources

PubMed2006

The economics of integrated depression care: the University of Michigan study.

A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care.

Delivery of Health Care, Integrated↗

PubMed2006

Depression case finding in primary care: a method for the mandates.

The current mandates for depression screening in primary care create a dilemma for clinicians. How should screening be implemented in the face of limited evidence for sustainable strategies for effective depression monitoring and management in primary care. In this article we review the issues surrounding primary care depression screening, and develop the argument for a case-finding strategy that includes careful choice of a single instrument, focused identification of high-risk patients, and systematic monitoring of outcomes. We believe this is a sustainable method that primary care clinicians can implement to address the spirit of current depression screening mandates.

Cross-Sectional Studies↗

PubMed2005

Severity and criteria based prompting for treatment of depressed patients.

PURPOSE: Primary care physicians (PCPs) often do not respond to prompts based upon criteria-based depression screens, perhaps because these prompts do not account for depression severity. We conducted this pilot study to determine the feasibility of prompting for both diagnostic criteria and severity and to assess whether depression would be more attended to with positive "dual prompts" than prompts based on either criteria or symptom severity alone. METHODS: Immediately prior to a routine care appointment, 87 adults from three primary care practices completed the PRIME-MD Clinician Evaluation Guide Mood Module (PRIME-MD; assesses depression criteria) and the Brief Depression Rating (BDR; assesses depressive symptom severity), and their results were issued in a salient PCP prompt on the chart. Immediately afterwards, patients reported the impact of the screening results upon treatment decisions during the encounter. Data were analyzed by X2, analysis of variance, and binomial regression. RESULTS: Compared to subjects screening positive on either depression criteria or severity alone (n = 10), those patients on both (n = 17) were more likely to report discussing depression, and agreement that the physician and patient decided treatment was needed and initiated or continued. There were no differences in patient satisfaction based on screening results. After accounting for PRIME-MD results, BDR scores predicted agreement with the physician and patient decided treatment was needed (OR = 22.03; 95% CI: 2.05-236.46). CONCLUSIONS: Supplementary severity-based depression screening is feasible, and might overcome the limitations of criteria-based screening alone. Future research could test this hypothesis in a large randomized trial.

Adolescent↗

PubMed2003

The role of algorithms in the detection and treatment of depression in primary care.

Many depressed patients present to primary care physicians instead of psychiatrists, and several studies have found that primary care physicians underdiagnose and undertreat depression. Primary care physicians may fail to diagnose and treat depression for many reasons: depression as it appears in primary care is in many ways a different disease than that seen in the psychiatric setting, and the process of detecting and treating it is different as well. Primary care clinicians face 2 main tasks when addressing depression in routine practice: to accurately identify those patients who are most likely to benefit from antidepressant treatment and to provide the best treatment options possible in the limited time available per visit. Treatment algorithms can be useful, but they are often difficult to apply in primary care. This article reviews the evidence about the detection and treatment of depression in primary care, examines current research on the differences between the primary and specialty care environments, and discusses aspects of treatment guidelines and algorithms that are important to primary care physicians.

Algorithms↗

PubMed2002

Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues.

Humans↗

PubMed2002

Improved detection of depression in primary care through severity evaluation.

OBJECTIVES: To determine whether the use of a symptom severity measure to augment an existing Diagnostic and Statistical Manual of Mental Disorders-Third Edition, Revised (DSM-III-R) criteria-based depression screener (PRIME-MD) would decrease the difficulties associated with depression screening in primary care by filtering out patients with minimal impairment. STUDY DESIGN: The study design was secondary data analysis. POPULATION: The study sample comprised 1317 patients, with intentional oversampling by ethnicity and sex, presenting for routine care at a university family practice center in Galveston, Texas. OUTCOMES MEASURED: The primary outcomes were cross-sectional, health-related quality-of-life outcomes of subjects who met symptom severity criteria as well as criteria for a DSM-III-R mood disorder. Health care utilization outcomes were examined as secondary outcomes. RESULTS: The combination of a 6-item depression severity instrument and the PRIME-MD resulted in 71% of depressed subjects being categorized as severely symptomatic and 29% as minimally symptomatic. Severely symptomatic subjects had significantly worse SF-36 Mental Health Component Summary scale (MCS) scores than did minimally symptomatic subjects (32.8 vs 43.5, P <.05). Minimally symptomatic subjects had MCS scores similar to those of a third group of subjects who did not meet DSM-III-R "threshold" criteria for mood disorder but who were severely symptomatic. Adjusted health care utilization was higher for the initial 3-month charge period in the severely symptomatic depressed subjects compared with minimally symptomatic depressed subjects ($679.20 vs $462.38, P <.05). CONCLUSIONS: The 6-item depression severity measure effectively separated patients meeting DSM-III-R "threshold" depression criteria into 2 groups: one presenting with severe symptoms and impairment and the other presenting with mild symptoms and significantly less impairment. A strategy of initial screening using a brief depression severity instrument, followed with a DSM criteria-based instrument, could decrease the immediate clinician workload by one third and focus treatment on those most likely to benefit.

Adult↗

PubMedDate not supplied

Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication.

PURPOSE: This study aimed to identify the demographic, psychiatric, and attitudinal predictors of treatment adherence during the maintenance phase of antidepressant treatment, ie, after symptoms and regimen are stabilized. METHODS: We surveyed 81 primary care patients given maintenance antidepressant medications regarding general adherence, recent missed doses, depression and treatment features, medication beliefs (necessity, concerns, harmfulness, and overprescription), and other variables. Additional data were collected from medical and payer records. RESULTS: Median treatment duration was 75 weeks. Adherence and beliefs were broadly dispersed and unrelated to treatment duration and type, physical functioning, and demographics. Multivariate analysis adjusting for social desirability, depression severity, and treatment duration indicated that an antidepressant-specific "necessity-minus-concerns" composite was strongly associated with both adherence outcomes. Specifically, adherence was highest when necessity exceeded concerns and lowest when concerns exceeded necessity. We crossed these 2 dimensions to characterize 4 patient attitudes toward antidepressants: skepticism, indifference, ambivalence, and acceptance. CONCLUSIONS: Patients given maintenance antidepressants vary widely in adherence. This variation is primarily explained by the balance between their perceptions of need and harmfulness of antidepressant medication, in that adherence is lowest when perceived harm exceeds perceived need, and highest when perceived need exceeds perceived harm. We speculate on ways to tailor adherence strategies to patient beliefs. Subsequent research should determine whether patients' perceptions about medication predict depression outcomes, can be used to improve clinical management, and respond to behavioral intervention.

Adult↗