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Biomedical subjects

Michael Von Korff

Publications and source records attributed to Michael Von Korff.

At least 19 recordsLinked to original sources
PubMed2007

Cost-effectiveness of systematic depression treatment among people with diabetes mellitus.

CONTEXT: Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. OBJECTIVE: To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. DESIGN: Randomized controlled trial comparing systematic depression treatment program with care as usual. SETTING: Primary care clinics of group-model prepaid health plan. PATIENTS: A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. INTERVENTION: Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. MAIN OUTCOME MEASURES: Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. RESULTS: Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). CONCLUSIONS: For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

Ambulatory Care↗
PubMed2006

Predictors of onset of facial pain and temporomandibular disorders in early adolescence.

There are few prospective studies assessing risk factors for onset of temporomandibular (TMD) pain disorders in any age group. The aim of this prospective cohort study was to identify risk factors for onset of clinically significant TMD pain (i.e., pain meeting research diagnostic criteria for myofascial pain and/or arthralgia) during early adolescence. Subjects were 1,996 boys and girls, initially 11 years old, randomly selected from a large nonprofit health care system. Subjects completed a baseline telephone interview and were followed up with mailed questionnaires every 3 months for 3 years. At baseline and all follow ups, subjects were asked to report the presence of facial pain in the past 3 months. Subjects reporting a first onset of facial pain received a standardized clinical examination. In multivariate analyses, baseline predictors of clinically significant pain included female gender [Odds Ratio (OR)=2.0, 95% Confidence Interval (CI)=1.2-3.3] and negative somatic and psychological symptoms including somatization (OR=1.8, CI=1.1-2.8), number of other pain complaints (OR=3.2, CI=1.7-6.1) and life dissatisfaction (OR=4.1, CI=1.9-9.0). Many of the risk factors for onset of clinically significant TMD pain in adolescents are similar to risk factors for onset of TMD and other pain problems in adults, as well as risk factors for onset of other pain conditions in adolescents. These findings suggest that the development of TMD pain in adolescence may reflect an underlying vulnerability to musculoskeletal pain that is not unique to the orofacial region.

Adolescent↗
PubMed2006

Improving depression care in patients with diabetes and multiple complications.

BACKGROUND: Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications. OBJECTIVE: To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications. DESIGN: The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications. PATIENTS: Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan. MEASUREMENTS: Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records. RESULTS: The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care. CONCLUSION: Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.

Adult↗
PubMed2006

Cost-effectiveness of two self-care interventions to reduce disability associated with back pain.

STUDY DESIGN: Two randomized, controlled trials. OBJECTIVE: To evaluate the incremental cost-effectiveness of psychologist-led and lay-led interventions in reducing disability in 2 cohorts of primary care patients with back pain. SUMMARY OF BACKGROUND DATA: Although activating self-care interventions have been advanced as effective tools to reduce back pain-related activity limitations, few studies have evaluated the added costs of these programs relative to their added benefits. METHODS: We estimated the incremental benefits and incremental costs associated with 2 self-care interventions for primary care patients with back pain. Effectiveness was measured as the number of low-impact back pain days (i.e., days when patients were satisfied with their level of back pain) over a 1-year follow-up. Costs of back-pain related services were estimated from health plan cost data. Incremental cost-effectiveness ratios were calculated for each intervention to determine the costs associated with an additional low-impact back pain day. RESULTS: Patients assigned to the lay and psychologist interventions had a mean of 14.3 (95% confidence interval [CI] -2.7 to 30.9) and 26.2 (95% CI 9.1-44.4) additional low-impact back pain days, respectively, compared with patients receiving usual care. The incremental per-person costs of the lay-led and psychologist-led interventions were dollar 139 (95% CI - dollar 62.13 to dollar 321.76) and dollar 161 (95% CI dollar 51.18 to dollar 275.93), respectively. The mean cost of an additional low-impact back pain day was dollar 9.70 for the lay-led intervention and dollar 6.13 for the psychologist-led intervention. CONCLUSIONS: Both the lay and psychologist interventions were associated with modest improvements in outcomes but with somewhat higher costs compared to usual care.

Adult↗
PubMed2006

Association between obesity and psychiatric disorders in the US adult population.

BACKGROUND: Epidemiologic data suggest an association between obesity and depression, but findings vary across studies and suggest a stronger relationship in women than men. OBJECTIVE: To evaluate the relationship between obesity and a range of mood, anxiety, and substance use disorders in the US general population. DESIGN: Cross-sectional epidemiologic survey. SETTING: Nationally representative sample of US adults. PARTICIPANTS: A total of 9125 respondents who provided complete data on psychiatric disorder, height, and weight. Response rate was 70.9%. MAIN OUTCOME MEASURES: Participants completed an in-person interview, including assessment of a range of mental disorders (assessed using the World Health Organization Composite International Diagnostic Interview) and height and weight (by self-report). RESULTS: Obesity (defined as body mass index [calculated as weight in kilograms divided by the square of height in meters] of > or =30) was associated with significant increases in lifetime diagnosis of major depression (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09-1.35), bipolar disorder (OR, 1.47; 95% CI, 1.12-1.93), and panic disorder or agoraphobia (OR, 1.27; 95% CI, 1.01-1.60). Obesity was associated with significantly lower lifetime risk of substance use disorder (OR, 0.78; 95% CI, 0.65-0.93). Subgroup analyses found no difference in these associations between men and women, but the association between obesity and mood disorder was strongest in non-Hispanic whites (OR, 1.38; 95% CI, 1.20-1.59) and college graduates (OR, 1.44; 95% CI, 1.14-1.81). CONCLUSIONS: Obesity is associated with an approximately 25% increase in odds of mood and anxiety disorders and an approximately 25% decrease in odds of substance use disorders. Variation across demographic groups suggests that social or cultural factors may moderate or mediate the association between obesity and mood disorder.

Adult↗
PubMed2006

Men with pelvic pain: perceived helpfulness of medical and self-management strategies.

OBJECTIVE: To assess the frequency of use of different treatments and pain management strategies and their perceived helpfulness in male patients with pelvic pain. METHODS: Approximately 1 month after a health maintenance organization visit for pelvic pain, 286 men (mean age 46.7 years) completed telephone interviews about their symptoms and treatments and pain management strategies used in the past year. Participants rated the helpfulness of each treatment and strategy used on 0 to 10 scales. RESULTS: Even though men with identified bacterial etiology were excluded from the study, antibiotic medication was the most commonly reported treatment (67% of patients) and rated as the second most helpful treatment [mean (SD)=6.3 (3.6)]. Opiates were rated as the most helpful treatment on average [mean (SD)=7.9 (2.1)], but were used by only 12% of patients. Substantial minorities of patients reported several behaviors as helpful, including urinating (reported as helpful by 26%), taking warm baths (23%), and drinking water (23%), although patterns of effects differed for men with versus without urinary symptoms. Activities most commonly reported as worsening symptoms were sitting (42%), walking/jogging (27%), and sexual activity (25%). DISCUSSION: Patients with male pelvic pain syndrome are commonly prescribed antibiotics, which they perceive as moderately helpful, despite the lack of scientific evidence of efficacy. Clinicians may find it useful to support patient use of safe, inexpensive, self-management approaches, especially warm baths, increased water intake, and avoidance of prolonged sitting.

Activities of Daily Living↗
PubMed2006

The association of patient relationship style and outcomes in collaborative care treatment for depression in patients with diabetes.

PURPOSE: We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes. METHODS: From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes. RESULTS: Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style. CONCLUSION: Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style.

Aged↗
PubMed2005

Relationship of pain and symptoms to pubertal development in adolescents.

Temporomandibular disorder (TMD) pain, abdominal pain, migraine and tension-type headache are more prevalent in women than in men. This study assessed the relationship of back pain, headache, abdominal pain, TMD pain, and the presence of multiple pain conditions to gender and pubertal development in a cross-sectional, population-based survey of adolescents. We also examined the association between pubertal development and depressive and somatic symptoms, factors often associated with pain in adults. We hypothesized that prevalence of all pain conditions, as well as rates of other symptoms, would increase as puberty progresses in females, but not males. Subjects (3,101 boys and girls, 11-17 years old, selected from an HMO population) reported on the presence of each pain condition in the prior 3 months and completed scales assessing pubertal development, and depressive and somatic symptoms. Data were analyzed using descriptive statistics and multivariate logistic regression. Prevalence rates were weighted for factors affecting response. Prevalence of back pain, headache and TMD pain increased significantly (odds ratios, OR=1.4-2.0, P<0.001) and stomach pain increased marginally with increasing pubertal development in girls. Rates of somatization, depression and probability of experiencing multiple pains also increased with pubertal development in girls (P<0.0001). For boys, prevalence of back (OR=1.9, P<0.0001) and facial pain (OR=1.5, P<0.01) increased, stomach pain decreased somewhat and headache prevalence was virtually unchanged with increasing maturity. For both sexes, pubertal development was a better predictor of pain than was age. Thus it appears that pain, other somatic symptoms and depression increase systematically with pubertal development in girls.

Adolescent↗
PubMed2005

Medical co-morbidity and validity of DSM-IV depression criteria.

BACKGROUND: Clinicians have questioned the validity of depression criteria in patients with chronic medical illness, but few empirical data address this question. METHOD: Computerized records identified two samples of managed care patients beginning depression treatment: 235 with diabetes, ischemic heart disease, or chronic obstructive lung disease and 204 without those conditions. Telephone assessments at baseline, 2 months, and 6 months included the Structured Clinical Interview for DSM-IV and other measures of depression severity and functional status. Item Response Theory analyses compared patterns of depressive symptoms across groups and specifically evaluated somatic symptoms (fatigue, change in weight or appetite, psychomotor agitation/retardation, and sleep disturbance) as indicators of depression. Logistic regression examined how change in somatic symptoms during treatment varied between patient groups. RESULTS: Overall item response analysis indicated differential item functioning between groups (chi2=33.7, df=18, p=0.017). Two of eight item-level comparisons were statistically significant; one in the predicted direction (patients with co-morbidity reported more fatigue at low levels of depression: chi2=17.9, df=1, p<0.001) and one in the opposite direction from predicted (patients with co-morbidity reported less psychomotor agitation/retardation at low levels of depression: chi2=8.0, df=1, p=0.005). Observed differences were modest: at the midpoint of the depression severity scale, patients with medical co-morbidity had a 54% probability of reporting fatigue compared to 45% in those without co-morbidity. All four somatic symptoms showed robust improvement with treatment, and this improvement did not differ significantly between patients with and without medical co-morbidity. CONCLUSIONS: We find only limited evidence that fatigue, changes in weight or appetite, psychomotor agitation/retardation, and sleep disturbance are less valid indicators of depression in patients with chronic medical illness. DSM-IV criteria for diagnosis of depression do not require significant modification for patients with medical co-morbidity.

Adult↗
PubMed2005

Health concerns of patients with nonbacterial prostatitis/pelvic pain.

BACKGROUND: Heightened awareness of patients' reasons for physician visits for male pelvic pain (nonbacterial prostatitis) and symptom concerns may increase patient satisfaction with care and help guide better management of this syndrome, for which evidence-based treatment is lacking. METHODS: We interviewed men with recent health maintenance organization visits for new episodes of nonbacterial prostatitis (N = 286; mean age, 46.7 years) and again 3, 6, and 12 months later. We inquired about their reasons for the visit and, at each interview, symptom concerns. We used Poisson regression to examine the association between baseline symptom worry and health care utilization during the 14 months after the index visit. RESULTS: Most patients reported concern at the index visit that they might have an infection (73%) or cancer (68%). One year later, 43% reported prostatitis symptoms in the past month. Among these, many were still concerned that their symptoms would worsen if untreated (71%), that they had cancer (46%) or an infection (45%), and that they might need surgery (44%). Controlling for patient age and baseline symptom severity, we found that baseline symptom worry predicted prostatitis-related health care visits over the 14 months after the index visit (P = .005). CONCLUSIONS: Despite symptom improvement following a health care visit for a new episode of pelvic pain/nonbacterial prostatitis, continued patient concerns about cancer, infection, and symptom worsening without treatment were common, even 1 year later. Patient worry may be associated with increased health care utilization.

Adult↗
PubMed2005

A trial of an activating intervention for chronic back pain in primary care and physical therapy settings.

In primary care and physical therapy settings, we evaluated an intervention for chronic back pain patients which incorporated fear reducing and activating techniques. Primary care patients seen for back pain in primary care were screened to identify persons with significant activity limitations 8-10 weeks after their visit. Eligible and willing patients were randomized (N=240). A brief, individualized program to reduce fear and increase activity levels was delivered by a psychologist and physical therapists. Over a 2 year follow-up period, intervention patients reported greater reductions in pain-related fear (P<0.01), average pain (P<0.01) and activity limitations due to back pain (P<0.01) relative to control patients. The percent with greater than a one-third reduction in Roland Disability Questionnaire scores at 6 months was 42% among Intervention patients and 24% among control patients (P<0.01). Over the 2 year follow-up, fewer intervention patients reported 30 or more days unable to carry out usual activities in the prior 3 months (P<0.01). The adjusted mean difference in activity limitation days was 4.5 days at 6 months, 2.8 days at 12 months, and 6.9 days at 24 months. No differences were observed in the percent unemployed or the percent receiving worker's compensation or disability benefits, but these outcomes were relatively uncommon. We conclude that an intervention integrating fear reducing and activating interventions into care for chronic back pain patients produced sustained reductions in patient fears, common activity limitations related to back pain, and days missed from usual activities due to back pain.

Activities of Daily Living↗
PubMed2005

Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication.

This paper investigates comorbidity between chronic back and neck pain and other physical and mental disorders in the US population, and assesses the contributions of chronic spinal pain and comorbid conditions to role disability. A probability sample of US adults (n=5692) was interviewed. Chronic spinal pain, other chronic pain conditions and selected chronic physical conditions were ascertained by self-report. Mood, anxiety and substance use disorders were ascertained with the Composite International Diagnostic Interview (CIDI). Role disability was assessed with questions about days out of role and with impaired role functioning. The 1 year prevalence of chronic spinal pain was 19.0%. The vast majority (87.1%) of people with chronic spinal pain reported at least one other comorbid condition, including other chronic pain conditions (68.6%), chronic physical conditions (55.3%), and mental disorders (35.0%). Anxiety disorders showed as strong an association with chronic spinal pain as did mood disorders. Common conditions not significantly comorbid with chronic spinal pain were diabetes, heart disease, cancer, and drug abuse. Chronic spinal pain was significantly associated with role disability after controlling for demographic variables and for comorbidities. However, comorbid conditions explained about one-third of the gross association of chronic spinal pain with role disability. We conclude that chronic spinal pain is highly comorbid with other pain conditions, chronic diseases, and mental disorders, and that comorbidity plays a significant role in role disability associated with chronic spinal pain. The societal burdens of chronic spinal pain need to be understood and managed within the context of comorbid conditions.

Adolescent↗
PubMed2005

A longitudinal study on the predictive validity of the fear-avoidance model in low back pain.

Recently, fear-avoidance models have been quite influential in understanding the transition from acute to chronic low back pain (LBP). Not only has pain-related fear been found to be associated with disability and increased pain severity, but also treatment focused at reducing pain-related fear has shown to successfully reduce disability levels. In spite of these developments, there is still a lack in well-designed prospective studies examining the role of pain-related fear in acute back pain. The aim of the current study was to prospectively test the assumption that pain-related fear in acute stages successfully predicts future disability. Subjects were primary care acute LBP patients consulting because of a new episode of LBP (<or=3 weeks). They completed questionnaires on background variables, fear-avoidance model variables and LBP outcome (Graded Chronic Pain Scale, GCPS) at baseline, 3, 6, and 12 months follow-up and at the end of the study. Two-hundred and twenty-two acute LBP patients were included, of whom 174 provided full follow-up information (78.4%). A backward ordinal regression analysis showed previous LBP history and pain intensity to be the most important predictors of end of study GCPS. Of the fear-avoidance model variables, only negative affect added to this model. Our results do not really support the longitudinal validity of the fear-avoidance model, but they do feed the discussion on the role of pain-related fear in early stages of LBP.

Adolescent↗
PubMed2005

A prognostic approach to defining chronic pain.

This paper develops a prognostic approach to defining chronic back pain. Possible and probable chronic back pain were defined, respectively, by a 50% and an 80% (or greater) probability of future clinically significant back pain. We assessed whether an empirically derived chronic pain classification satisfied these validating criteria among 1213 primary care back pain patients assessed at baseline and at 1, 2 and 5 year follow-ups. From multiple measures of back pain intensity and dysfunction, Latent Transition Regression Analysis empirically identified four pain severity latent classes: no pain; mild pain; moderate pain and limitation; and severe, limiting pain. From one observation point to the next, patients were most likely to remain in the same pain severity class, but chronic pain was better characterized as a dynamic state than a static trait. Among persons with severe, limiting pain, prognostic variables (depression, diffuse pain, pain persistence) improved prediction of future severe, limiting pain. A risk score developed from pain severity and prognostic measures identified risk levels corresponding to 50 and 80% probability thresholds for predicting future clinically significant back pain. At baseline and 1 year, 6.1 and 4.4% of study patients met or exceeded the 80% risk threshold for probable chronic back pain. An additional 20.3% at baseline and 12.5% at 1 year met or exceeded the 50% risk threshold for possible chronic back pain. Defining chronic pain prospectively, by risk thresholds for future clinically significant pain, provides an empirically grounded approach to chronic pain assessment.

Adolescent↗
PubMed2005

Applying depression-specific change concepts in a collaborative breakthrough series.

BACKGROUND: Twenty ethnically and geographically diverse health care organizations, including 15 Bureau of Primary Health Care centers, participated in an Institute for Healthcare Improvement (IHI) collaborative Breakthrough Series (BTS) project on depression. Teams attended three learning sessions that emphasized the chronic illness care model, key depression change concepts, and how to initiate plan-do-study-act cycles. RESULTS: Seventeen of the 20 organizations completing the BTS achieved a faculty assessment of at least a 4 (5 indicates significant improvement). More than 2000 patients initiated depression treatment and were registered in the plan's depression registries. Patients in the centers who used the recommended measures had the following outcomes: 56% had significant change in their depressive symptoms at 12 weeks, 87% completed follow-up assessments, 54% continued antidepressant medication for at least 10 weeks, and 90% completed a structured diagnostic assessment before treatment. DISCUSSION: On the basis of the feedback from ten successful teams, the essential change concepts for depression were establishing and maintaining a patient registry, care coordination, diagnostic assessment, and proactive follow-up. Many of the BTS centers have continued to expand their depression treatment programs. The IHI BTS appears to be a viable method of disseminating evidence-based depression care.

Case Management↗
PubMed2005

Clinical and functional outcomes of depression treatment in patients with and without chronic medical illness.

BACKGROUND: In patients with chronic medical conditions, depression can be viewed as an expected reaction to illness or an independent condition requiring active treatment. We examine how clinical and functional outcomes of depression treatment compare in primary-care patients with and without chronic medical illness. METHOD: Health plan administrative data were used to identify primary-care patients initiating antidepressant treatment, including a general sample (n=204) and cohorts with ischemic heart disease (n=68), diabetes (n=93), or obstructive lung disease (n=74). Telephone interviews at baseline, 2 months, and 6 months assessed depression (Structured Clinical Interview for DSM-IV, Hopkins Symptom Checklist depression scale), functional status (SF-36) and days of disability because of to illness. RESULTS: At baseline, depression severity in patients with diabetes and obstructive lung disease was similar to those without medical co-morbidity, but significantly lower in those with ischemic heart disease. Social and emotional functioning were similar across all groups, but those with chronic medical illness reported greater physical impairment. All groups showed significant improvement in depression over six months, but the rate of improvement was significantly slower in those with heart disease. All groups showed significant and similar improvement in social and emotional functioning, but physical functioning showed little change. Days of disability and restricted activity improved significantly in all groups. Improvement in depression during treatment was strongly related to change in disability. CONCLUSIONS: Patients with chronic medical illness and co-morbid depression show significant improvements in mood, social and emotional functioning, and disability following initiation of depression treatment. Depression may be a stronger determinant of disability than is stable chronic medical illness.

Adult↗