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Biomedical subjects

Moonseong Heo

Publications and source records attributed to Moonseong Heo.

At least 19 recordsLinked to original sources
PubMed2007

Suicidal ideation among elderly homecare patients.

OBJECTIVES: To identify the prevalence, correlates, and one-year naturalistic course of suicidal ideation in a representative sample of elderly adults newly admitted to visiting nurse homecare. METHOD: Five hundred and thirty-nine participants (aged > or =65), newly initiating homecare for skilled nursing services, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV) and measures of depression severity, medical comorbidity, functional status, and social support. Participants were classified as having no suicidal ideation in the past month, passive ideation, active ideation, or active ideation with poor impulse control or suicide plan. RESULTS: Fifty-seven participants (10.6%) reported passive and six (1.2%) reported active suicidal ideation. Higher depression severity, greater medical comorbidity, and lower subjective social support were independently associated with the presence of any level of suicidal ideation. At one year, suicidal ideation persisted for 36.7% of those with ideation at baseline, and the incidence of suicide ideation was 5.4% CONCLUSIONS: The high prevalence, persistence, and incidence of suicidal ideation in medically ill home healthcare patients underscore the relevance of this population for suicide prevention efforts. The clinical and psychosocial factors associated with suicidal ideation in this underserved, high-risk population are potentially modifiable, and thus useful targets for suicide prevention interventions.

Aged↗
PubMed2006

Salivary cortisol and psychopathology in children bereaved by the september 11, 2001 terror attacks.

BACKGROUND: Studies suggest that stressful events increase risk for childhood anxiety and depression and hypothalamic-pituitary-adrenal (HPA) axis dysregulation. This prospective longitudinal study evaluated relationships among severe psychosocial stress, psychiatric morbidity, and HPA axis function in children. METHODS: Forty-five children (mean age: 8.9 +/- 2.9 years) suffering parent death from September 11, 2001 terror attacks and 34 nonbereaved children (mean age: 9.3 +/- 2.5 years) were evaluated prospectively at 6-month intervals in this 2-year study. Assessments involved diagnostic interviews (Child Schedule for Affective Disorders and Schizophrenia [K-SADS]) for psychopathology and 3 days of baseline salivary cortisol and a salivary dexamethasone suppression test for HPA axis function. RESULTS: Bereaved children, but not nonbereaved children, had significantly increased rates of psychiatric disorders involving anxiety disorders, especially posttraumatic stress disorder (PTSD), after September 11, 2001 compared with retrospective assessments before September 11, 2001. Morning (AM) and 4:00 pm baseline cortisol were significantly and persistently higher for bereaved than nonbereaved children. Compared with bereaved children without psychopathology, bereaved children with PTSD had significantly lower 4:00 pm baseline cortisol and significantly greater 4:00 pm cortisol suppression. Children with generalized anxiety disorder had significantly less AM cortisol suppression than children without psychopathology. CONCLUSIONS: Children bereaved by sudden, unexpected parent death had persistent psychological dysfunction and HPA axis dysregulation in this study.

Adolescent↗
PubMed2006

A delusion assessment scale for psychotic major depression: Reliability, validity, and utility.

BACKGROUND: Although delusions are the hallmark of major depression with psychotic features, a scale to measure the intensity of beliefs across multiple delusional domains in this condition has been unavailable. The development and assessment of the Delusional Assessment Scale (DAS) are described. METHODS: Scale items were selected initially based on previous studies of delusional ideation in schizophrenia. A three-point item to assess mood congruence was added. A 15-item scale was assessed in 92 subjects participating in the four-site collaborative study of the pharmacotherapy of major depression with psychotic features. Maximum likelihood method was used to determine scale factors. The internal consistency of these factors was determined. Comparisons between scale scores and ratings from the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham 1962) were used to assess convergent and discriminant validity. RESULTS: The data were fit by a five-factors model (impact, conviction, disorganization, bizarreness, and extension). Inter-rater reliability of the five factors ranged from .77 for conviction and .74 for impact to .37 for disorganization. Internal consistency for each of the five factors was > or =.72. Scores on specific domains were significantly correlated with the BPRS unusual thought content item and positive symptom subscale scores. CONCLUSIONS: The DAS is a reliable measure of 5 delusional domains.

Adult↗
PubMed2006

Outcomes of minor and subsyndromal depression among elderly patients in primary care settings.

BACKGROUND: Although depressive conditions in later life are a major public health problem, the outcomes of minor and subsyndromal depression are largely unknown. OBJECTIVE: To compare outcomes among patients with minor and subsyndromal depression, major depression, and no depression, and to examine putative outcome predictors. DESIGN: Cohort study. SETTING: Patients from primary care practices in greater New York City, and Philadelphia and Pittsburgh, Pennsylvania. PATIENTS: 622 patients who were at least 60 years of age and presented for treatment in primary care practices that provided usual care in a randomized, controlled trial of suicide prevention. Of the 441 (70.9%) patients who completed 1 year of follow-up, 122 had major depression, 205 had minor or subsyndromal depression, and 114 did not have depression at baseline. MEASUREMENTS: One year after a baseline evaluation, data were collected by using the following tools: Hamilton Depression Rating Scale, the depressive disorders section of the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), Charlson Comorbidity Index, Multilevel Assessment Instrument for measuring instrumental activities of daily living, Physical Component Summary of the Medical Outcomes Study Short Form-36, and Duke Social Support Index. RESULTS: Patients with minor or subsyndromal depression had intermediate depressive and functional outcomes. Mean adjusted 1-year Hamilton depression score was 10.9 (95% CI, 9.6 to 12.2) for those with initial major depression, 7.0 (CI, 5.9 to 8.1) for those with minor or subsyndromal depression, and 2.9 (CI, 1.6 to 4.2) for those without depression (P < 0.001 for each paired comparison). Compared with patients who were not depressed, those who had minor or subsyndromal depression had a 5.5-fold risk (CI, 3.1-fold to 10.0-fold) for major depression at 1 year after controlling for demographic characteristics (P < 0.001). Cerebrovascular risk factors were not associated with a diagnosis of depression at 1 year after controlling for overall medical burden. Initial medical burden, self-rated health, and subjective social support were significant independent predictors of depression outcome. LIMITATIONS: Participants received care at practices that had personnel who had been given enhanced education about depression treatment; 29.1% of participants withdrew from the study before completing 1 year of follow-up. CONCLUSIONS: The intermediate outcomes of minor and subsyndromal depression demonstrate the clinical significance of these conditions and suggest that they are part of a spectrum of depressive illness. Greater medical burden, poor subjective health status, and poorer subjective social support confer a higher risk for poor outcome.

Activities of Daily Living↗
PubMed2006

Frontal signal hyperintensities in mania in old age.

OBJECTIVE: Signal hyperintensities (SH) on magnetic resonance (MR) imaging have been associated with increased age and with mood disorders. Frontal and subcortical neuropathology has been implicated in the pathophysiology of mania and bipolar disorders. The authors assessed frontal and subcortical SH in elderly bipolar manic patients and the comparison group, and hypothesized that SH scores would be greater in the patient group. METHOD: MR imaging was performed in patients aged > or = 60 years with bipolar disorder, mania, and in a same-aged community comparison group. SH were rated blindly using the Boyko system. Frontal deep white matter and basal ganglia SH were assessed in the left and right hemispheres. RESULTS: SH scores were significantly greater in patients (N = 40) than the comparison group (N = 15) in frontal deep white matter (left: p = 0.003; right: p = 0.023) based on Mann-Whitney two-sample exact tests. The SH scores in the subcortical gray regions overlapped in these groups. In patients, higher right frontal SH scores were associated with later age at onset of mania. CONCLUSIONS: Frontal deep white matter SH may be increased in elders with bipolar disorder. Further study of the relationship of SH to age at onset in elders is warranted.

Aged↗
PubMed2006

A randomized, placebo-controlled trial of sertraline in the treatment of night eating syndrome.

OBJECTIVE: The authors assessed the efficacy of sertraline in the treatment of night eating syndrome. METHOD: Thirty-four outpatients diagnosed with night eating syndrome were randomly assigned to receive either sertraline (N=17) or placebo (N=17) in an 8-week, double-blind, flexible-dose (50-200 mg/day) study. A mixed effects linear regression model was used to analyze change in the primary outcome measure, Clinical Global Impression (CGI) improvement rating. Secondary outcomes included changes in night eating symptoms, the number of nocturnal awakenings and ingestions, total daily caloric intake after the evening meal, CGI severity ratings, quality of life ratings, and weight. RESULTS: Sertraline was associated with significantly greater improvement than placebo. Twelve subjects in the sertraline group (71%) were classified as having responded (CGI improvement rating < or = 2, indicating much or very much improved) versus only three (18%) in the placebo group. There were also significant improvements in night eating symptoms, CGI severity ratings, quality of life ratings, frequency of nocturnal ingestions and awakenings, and caloric intake after the evening meal. Overweight and obese subjects in the sertraline group (N=14) lost a significant amount of weight by week 8 (mean=-2.9 kg, SD=3.8) compared with overweight and obese subjects receiving placebo (N=14) (mean=-0.3 kg, SD=2.7). CONCLUSIONS: In this 8-week trial, sertraline was effective in the treatment of night eating syndrome and was well tolerated.

Adult↗
PubMed2006

A paradigm for facilitating pharmacotherapy at a distance: sertraline treatment of the night eating syndrome.

OBJECTIVE: To test a novel method of facilitating pharmacotherapy at a distance and assess the effectiveness of sertraline for the treatment of night eating syndrome (NES). METHOD: The effectiveness of the selective serotonin reuptake inhibitor sertraline in the treatment of NES was assessed at a distance. NES is characterized by a delay in the circadian rhythm of food intake, with evening hyperphagia and/or nighttime awakenings and ingestions. Persons who contacted us through our Web site, e-mail, or telephone for help with their NES completed a Night Eating Questionnaire and received a semistructured interview (Night Eating Syndrome History and Inventory) to determine the presence of NES. Fifty such persons received treatment with sertraline from their own physicians, to whom we offered consultation. Participants completed questionnaires every 2 weeks for 8 weeks and received a final telephone interview to assess their progress. Outcomes were compared with those from an earlier face-to-face open-label trial of sertraline. The study was conducted from September 2003 to May 2005. RESULTS: Both the questionnaires and interviews showed improvements in 5 key aspects of NES: the general Night Eating Symptom Scale, evening hyperphagia, nighttime awakenings, nocturnal ingestions, and the Beck Depression Inventory (all p < .001), and the mean body weight of the 41 overweight and obese subjects, reported by survey, fell 3.0 kg (p = .01). These results are similar to those obtained in an earlier face-to-face trial of sertraline with NES. CONCLUSION: The study confirmed the effectiveness of sertraline in the treatment of NES and introduced a paradigm for facilitating pharmaco-therapy at a distance.

Body Weight↗
PubMed2005

Neuroendocrine profiles associated with energy intake, sleep, and stress in the night eating syndrome.

CONTEXT: Night eating syndrome (NES) is characterized by evening hyperphagia and frequent awakenings with ingestion of food. It is associated with obesity and depressed mood. Greater understanding of hormonal influences on NES is desirable. OBJECTIVE: Our objective was to evaluate 25-h profiles of hormones involved in energy balance, sleep, and stress in NES. DESIGN: Blood assays for glucose, insulin, ghrelin, leptin, melatonin, cortisol, TSH, and prolactin were sampled repeatedly among NES and control subjects. Food intake and depressive symptoms were assessed. SETTING AND PARTICIPANTS: Fifteen NES and 14 matched control participants stayed three nights in a General Clinical Research Center. MAIN OUTCOME MEASURES: We assessed differences between NES and control participants in the 25-h profiles of eight hormones. RESULTS: Nocturnal food intake was higher among NES participants, although their daily calorie intake was similar to that of controls. Reflecting their increased nocturnal intake, insulin (P < 0.001) and glucose levels (P = 0.07) among NES participants were higher than those of controls. Ghrelin levels were significantly lower in NES participants than in controls from 0100-0900 h (P = 0.003). Levels of plasma cortisol, melatonin, leptin, and prolactin did not differ between groups, but there was a trend for TSH levels (P = 0.07) to be higher during the 25 h in NES. NES participants had greater depressive symptoms than controls (P < 0.001). The differences in the levels of glucose, insulin, and ghrelin between NES and controls are closely associated with nocturnal food intake.

Adult↗
PubMed2005

Executive dysfunction and the course of geriatric depression.

BACKGROUND: Executive dysfunction is common in geriatric depression and persists after improvement of depressive symptoms. This study examined the relationship of executive impairment to the course of depressive symptoms among elderly patients with major depression. METHODS: A total of 112 nondemented elderly patients with major depression participated in an 8-week citalopram trial at a target daily dose of 40 mg. Executive functions were assessed with the initiation/perseveration subscale of the Dementia Rating Scale and the Stroop Color-Word test. Medical burden was rated with the Cumulative Illness Rating Scale. RESULTS: Both abnormal initiation/perseveration and abnormal Stroop Color-Word scores were associated with an unfavorable response of geriatric depression to citalopram. In particular, initiation/perseveration scores below the median (< or =35) and Stroop scores at the lowest quartile (< or =22) predicted limited change in depressive symptoms. Impairment in other Dementia Rating Scale cognitive domains did not significantly influence the outcome of depression. CONCLUSIONS: Executive dysfunction increases the risk for poor response of geriatric depression to citalopram. Because executive functions require frontostriatal-limbic integrity, this observation provides the rationale for investigation of the role of specific frontostriatal-limbic pathways in perpetuating geriatric depression. Depressed elderly patients with executive dysfunction require vigilant clinical attention because they might be at risk to fail treatment with a selective serotonin reuptake inhibiting antidepressant.

Aged↗
PubMed2005

Are health care professionals advising adults with arthritis to become more physically active?

OBJECTIVE: To describe the proportion and characteristics of adults with self-reported, doctor-diagnosed arthritis who report ever having been advised by a health professional to become more physically active and to assess whether the advice was associated with recent physical activity. METHODS: Using population-based data from the 2003 Behavioral Risk Factor Surveillance Survey, respondents were classified according to their arthritis status, whether or not they were ever advised by a health professional to increase their physical activity to help them better manage their arthritis, and whether they engaged in exercise or physical activity within the past month. RESULTS: Overall, 42% of respondents with arthritis reported ever being advised to increase their physical activity to help their arthritis. Respondents who were more likely to have ever received the advice were female, middle-aged or older, African American, Hispanic, overweight or obese, sedentary or insufficiently physically active, and had higher levels of education. Persons who reported ever receiving the advice were less likely to report that they had exercised within the past month. A higher level of education was the only variable associated with recent exercise or physical activity among those advised to be more active. CONCLUSION: Less than 50% of adults with arthritis report ever being advised by a health professional to become more physically active. Advice alone appears insufficient to promote increased physical activity in adults with arthritis.

Adolescent↗
PubMed2005

Comparison of statistical methods for analysis of clustered binary observations.

When correlated observations are obtained in a randomized controlled trial, the assumption of independence among observations within cluster likely will not hold because the observations share the same cluster (e.g. clinic, physician, or subject). Further, the outcome measurements of interest are often binary. The objective of this paper is to compare the performance of four statistical methods for analysis of clustered binary observations: namely (1) full likelihood method; (2) penalized quasi-likelihood method; (3) generalized estimating equation method; (4) fixed-effects logistic regression method. The first three methods take correlations into account in inferential processes whereas the last method does not. Type I error rate, power, bias, and standard error are compared across the four statistical methods through computer simulations under varying effect sizes, intraclass correlation coefficients, number of clusters, and number of observations per cluster, including large numbers 20 and 100 of observations per cluster. The results show that the performance of the full likelihood and the penalized quasi-likelihood methods is superior for analysis of clustered binary observations, and is not necessarily inferior to that of the fixed-effects logistic regression fit even when within-cluster correlations are zero.

Cluster Analysis↗
PubMed2005

Performance of a mixed effects logistic regression model for binary outcomes with unequal cluster size.

When a clustered randomized controlled trial is considered at a design stage of a clinical trial, it is useful to consider the consequences of unequal cluster size (i.e., sample size per cluster). Furthermore, the assumption of independence of observations within cluster does not hold, of course, because the subjects share the same cluster. Moreover, when the clustered outcomes are binary, a mixed effect logistic regression model is applicable. This article compares the performance of a maximum likelihood estimation of the mixed effects logistic regression model with equal and unequal cluster sizes. This was evaluated in terms of type I error rate, power, bias, and standard error through computer simulations that varied treatment effect, number of clusters, and intracluster correlation coefficients. The results show that the performance of the mixed effects logistic regression model is very similar, regardless of inequality in cluster size. This is illustrated using data from the Prevention Of Suicide in Primary care Elderly: Collaborative Trial (PROSPECT) study.

Algorithms↗
PubMed2005

A comparison of multiplicity adjustment strategies for correlated binary endpoints.

Several Bonferroni-type adjustments have been proposed to control for family wise type I error among multiple tests. However, many of the approaches disregard the correlation among endpoints. This can result in a conservative hypothesis testing strategy. The James procedure is an alternative approach that accounts for multiplicity among correlated continuous endpoints. Here a simulation study compares four Bonferroni-type alpha-adjustments (Bonferroni, Dunn-Sidák, Holm, and Hochberg) and the James p-value adjustment when used for multiple correlated binary variables. These procedures provided adequate protection against familywise type I error for correlated binary endpoints, albeit, at times, in an overly cautious manner. That is, when correlations among endpoints exceed 0.60, the result is somewhat conservative for the approaches that do not account for those correlations. Among the adjustments examined, the James approach appears to be the uniformly preferred method. Analyses of data from a randomized controlled clinical trial of treatments for mania in bipolar disorder are used to illustrate the application of the multiplicity adjustments.

Antipsychotic Agents↗
PubMed2005

Changes in the prevalence of US adults with arthritis who meet physical activity recommendations, 2001-2003.

CONTEXT: Increased physical activity is recommended for adults with arthritis. OBJECTIVE: The objective of this study was to update and compare recent physical activity prevalence estimates of US adults with self-reported doctor-diagnosed arthritis. DESIGN: The authors studied the 2001 and 2003 Behavioral Risk Factor Surveillance Survey (BRFSS), an annual random-digit telephone survey conducted by state health departments. SETTING: The authors conducted a population-based sample from 50 states and the District of Columbia. PARTICIPANTS: The study included a total of 52,311 adults, 18 years or older, reporting doctor-diagnosed arthritis in 2001, and 82,839 reporting doctor-diagnosed arthritis in 2003. MAIN OUTCOME MEASURES: Reported level of physical activity was classified into 3 categories: physically inactive, insufficiently active, and meeting public health recommendations. RESULTS: Between 2001 and 2003, the prevalence of physical inactivity decreased by 1.1% (23.8% versus 22.7%), the prevalence of insufficient levels of physical activity increased by 0.2% (38% versus 38.2%), and the prevalence of meeting physical activity recommendations increased by 0.9% (38.3% versus 39.2%). Compared with 2001 estimates, the prevalence of meeting physical activity recommendations increased by 6.2% (54.8% versus 61%) among those aged 18 to 24 years, 3.5% (36.4% versus 39.9%) among never smokers, 3% (49.4% versus 52.4%) among those aged 25 to 34 years, 2.4% (29.9% versus 32.3%) among obese adults, and among those aged 55 to 64 years (36.9% versus 39.3). Prevalence of inactivity increased by 3.2% among Hispanics (30.4% versus 33.6%) and 2.9% among those with 8 or fewer years of education (47.6% versus 50.5%). CONCLUSIONS: Prevalence estimates of the 3 levels of physical activity among adults with arthritis changed very little. Given the established benefits of physical activity for arthritis, public health efforts to promote increased activity should continue to be developed and refined.

Adolescent↗
PubMed2005

Remission in depressed geriatric primary care patients: a report from the PROSPECT study.

OBJECTIVE: This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. METHOD: Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (> or =60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. RESULTS: First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. CONCLUSIONS: Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled.

Aged↗
PubMed2004

Overweight, obesity, and colorectal cancer screening: disparity between men and women.

BACKGROUND: To estimate the association between body-mass index (BMI: kg/m2) and colorectal cancer (CRC) screening among US adults aged >or= 50 years. METHODS: Population-based data from the 2001 Behavioral Risk Factor Surveillance Survey. Adults (N = 84,284) aged >or= 50 years were classified by BMI as normal weight (18.5-<25), overweight (25-<30), obesity class I (30-<35), obesity class II (35-<40), and obesity class III (>or= 40). Interval since most recent screening fecal occult blood test (FOBT): (0 = >1 year since last screening vs. 1 = screened within the past year), and screening sigmoidoscopy (SIG): (0 = > 5 years since last screening vs. 1 = within the past 5 years) were the outcomes. RESULTS: Results differed between men and women. After adjusting for age, health insurance, race, and smoking, we found that, compared to normal weight men, men in the overweight (odds ratio [OR] 1.25, 95% CI = 1.05-1.51) and obesity class I (OR = 1.21, 95% CI = 1.03-1.75) categories were more likely to have obtained a screening SIG within the previous 5 years, while women in the obesity class I (OR = 0.86, 95%CI = 0.78-0.94) and II (OR = 0.88, 95%CI = 0.79-0.99) categories were less likely to have obtained a screening SIG compared to normal weight women. BMI was not associated with FOBT. CONCLUSION: Weight may be a correlate of CRC screening behavior but in a different way between men and women.

Aged↗
PubMed2004

Empirical Bayes estimation of gene-specific effects in micro-array research.

Micro-array technology allows investigators the opportunity to measure expression levels of thousands of genes simultaneously. However, investigators are also faced with the challenge of simultaneous estimation of gene expression differences for thousands of genes with very small sample sizes. Traditional estimators of differences between treatment means (ordinary least squares estimators or OLS) are not the best estimators if interest is in estimation of gene expression differences for an ensemble of genes. In the case that gene expression differences are regarded as exchangeable samples from a common population, estimators are available that result in much smaller average mean-square error across the population of gene expression difference estimates. We have simulated the application of such an estimator, namely an empirical Bayes (EB) estimator of random effects in a hierarchical linear model (normal-normal). Simulation results revealed mean-square error as low as 0.05 times the mean-square error of OLS estimators (i.e., the difference between treatment means). We applied the analysis to an example dataset as a demonstration of the shrinkage of EB estimators and of the reduction in mean-square error, i.e., increase in precision, associated with EB estimators in this analysis. The method described here is available in software that is available at http://www.soph.uab.edu/ssg.asp?id=1087.

Bayes Theorem↗
PubMed2004

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial.

OBJECTIVE: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. DESIGN: Cluster randomised controlled trial. SETTING: Five healthcare organisations in the United States and 60 affiliated practices. PATIENTS: 405 patients, aged > or = 18 years, starting or changing treatment for depression. INTERVENTION: Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. MAIN OUTCOME MEASURES: Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (> or = 50% decrease in scores) and remission (score of < 0.5). RESULTS: At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). CONCLUSION: Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Adult↗