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Biomedical subjects

Steven K Dobscha

Publications and source records attributed to Steven K Dobscha.

13 recordsLinked to original sources
PubMed2006

Depression decision support in primary care: a cluster randomized trial.

BACKGROUND: Intensive collaborative interventions improve depression outcomes, but the benefit of less intensive interventions is not clear. OBJECTIVE: To determine whether decision support improves outcomes for patients with depression. DESIGN: Clinician-level, cluster randomized, controlled trial. SETTING: 5 primary care clinics of 1 Veterans Affairs medical center. PARTICIPANTS: 41 primary care clinicians, and 375 patients with depression (Patient Health Questionnaire [PHQ-9] depression scores of 10 to 25 or Hopkins Symptom Checklist-20 [SCL-20] scores > or = 1.0). MEASUREMENTS: The primary outcome was change in depression score (SCL-20) at 6 and 12 months. Secondary outcomes were health-related quality-of-life (36-item Short Form for Veterans [SF-36V] score), patient satisfaction, antidepressant use, and health care utilization. INTERVENTION: Clinicians received depression education and were randomly assigned to depression decision support or usual care. The depression decision support team, which consisted of a psychiatrist and nurse, provided 1 early patient educational contact and depression monitoring with feedback to clinicians over 12 months. RESULTS: Although SCL-20 depression scores improved in both groups, the intervention had no effect compared with usual care. The difference in slopes comparing intervention and control over 12 months was 0.20 (95% CI, -0.37 to 0.78; P = 0.49), which was neither clinically nor statistically significant. Changes in SF-36V scores also did not differ between groups. At 12 months, intervention patients reported greater satisfaction (P = 0.002) and were more likely to have had at least 1 mental health specialty appointment (41.1% vs. 27.2%; P = 0.025), to have received any antidepressant (79.3% vs. 69.3%; P = 0.041), and to have received antidepressants for 90 days or more (76.2% vs. 61.6%; P = 0.008). LIMITATIONS: Usual care clinicians received depression education and had on-site mental health support, which may have mitigated intervention effectiveness. CONCLUSIONS: Decision support improved processes of care but not depression outcomes. More intensive care management or specialty treatment may be needed to improve depression outcomes.

Adult↗
PubMed2006

Reducing drug costs at a Veterans Affairs hospital by increasing market-share of generic fluoxetine.

We previously showed that a multifaceted intervention designed to contain costs of prescribing selective serotonin reuptake inhibitors (SSRIs) at a Veterans Affairs hospital resulted in substantial projected savings. Intervention components included clinician education and pharmacy and computer information process changes. We now report on effects of altering the intervention to promote prescribing of generic fluoxetine. Over 30 months, fluoxetine's market-share increased from 12 to 32% of all SSRIs prescribed. A total of $2,500,000 in cost avoidance resulted from substituting generic for brand fluoxetine, and $600,000 resulted from increases in market-share of fluoxetine. The results highlight the robustness and flexibility of the intervention approach.

Cost Control↗
PubMed2006

Integration and coordination of pain management in primary care.

Pain is one of the most common symptoms reported to primary care providers and has significant implications for health care costs. The primary aim of this article is to describe and illustrate how to integrate the treatment of chronic pain in the primary care setting. First, we address the integration and coordination of care between mental health and primary care. We then present a typical case and discuss the patient's treatment, outcome, and prognosis. The article concludes with a discussion of issues that frequently arise when integrating psychological treatment for pain in primary care settings.

Alcohol Drinking↗
PubMed2005

Use of videoconferencing for depression research: enrollment, retention, and patient satisfaction.

The goal of this study was to describe the effects of using videoconferencing on participant enrollment, research measure administration and responses, study retention, and satisfaction. We recruited 400 patients from the Portland Veterans Affairs Primary Care Clinics for a randomized clinical trial of a care management intervention for depression. Patients recruited from distant clinic sites had the option of traveling to Portland, Oregon, for initial interviews or being interviewed using videoconferencing. Interviews included obtaining informed consent and administration of research measures. Remote participants were subsequently asked to complete a 12-item mail survey regarding the interview. There were no significant problems with the process of interviewing and obtaining informed consent by videoconferencing, as reported by patients and clinic staff. Twenty of the 31 participants interviewed by videoconferencing returned the satisfaction questionnaire. Participants indicated a high degree of satisfaction with these interviews, and expressed willingness to recommend videoconferencing to others. No differences were observed between the Patient Health Questionnaire depression scores of videoconferencing and in-person participants, and there was no significant difference in the 6-month rate of loss to follow-up in the randomized trial. Videoconferencing allows patients in rural and remote locations to participate in psychiatric research and expands sources of recruitment for research projects.

Depression↗
PubMed2004

Oregon physicians' responses to requests for assisted suicide: a qualitative study.

In 1997, the Oregon Death with Dignity Act was enacted, allowing physicians to prescribe lethal dosages of medication to competent, terminally ill patients who request them. To improve our understanding of physicians' reactions to requests for assisted suicide, we performed semistructured interviews of 35 Oregon physicians who had received requests from patients. Interviews were completed in 2000, and audiotaped, transcribed, and analyzed using qualitative techniques. Requests for assisted suicide had a powerful impact on physicians and their practices. Physicians often felt unprepared, and experienced apprehension and discomfort before and after receiving requests. Prominent sources of discomfort included concerns about adequately managing symptoms and suffering, not wanting to abandon patients, and incomplete understanding of patients' preferences, especially when physicians did not know patients well. Participation in assisted suicide required a large investment of time and was emotionally intense. Regardless of whether they prescribed or not, physicians did not express major regrets about their decisions. Requests often facilitated discussion of important issues, and many physicians felt that the process increased their confidence and assertiveness in discussing end-of-life issues with other patients. Physicians rarely sought support from colleagues; instead, they tended to discuss emotional aspects of their experiences with their spouses.

Attitude of Health Personnel↗
PubMed2004

Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item.

OBJECTIVE: To evaluate the psychometric properties of a single-item depression screen against validated scoring algorithms for the Patient Health Questionnaire (PHQ) and the utility of these algorithms in screening for depression and suicidality in a Department of Veterans Affairs (VA) primary care setting. STUDY DESIGN: Recruitment phase of a randomized trial. METHODS: A total of 1211 Portland VA patients with upcoming primary care clinic appointments were administered by telephone a single item assessing depressed mood over the past year and the PHQ. The PHQ-9 (9 items) encompasses DSM-IV criteria for major depression, the PHQ-8 (8 items) excludes the thoughts of death or suicide item, and the PHQ-2 (2 items) assesses depressed mood and anhedonia. Patients whose responses suggested potential suicidality were administered 2 additional items assessing suicidal ideation. Patients receiving mental health specialty care were excluded. RESULTS: Using the PHQ-9 algorithm for major depression as the reference standard, the VA single-item screen was specific (88%) but less sensitive (78%). A PHQ-2 score of > or =3 demonstrated similar specificity (91%) with high sensitivity (97%). For case finding, the PHQ-8 was similar to the PHQ-9. Approximately 20% of patients screened positive for moderate depression, 7% reported thoughts of death or suicide, 2% reported thoughts of harming themselves, and 1% had specific plans. CONCLUSIONS: The PHQ-2 offers brevity and better psychometric properties for depression screening than the single-item screen. The PHQ-9 item assessing thoughts of death or suicide does not improve depression case finding; however, one third of patients endorsing this item reported recent active suicidal ideation.

Aged↗
PubMed2003

Oregon physicians' perceptions of patients who request assisted suicide and their families.

In 1997, the Oregon Death with Dignity Act was enacted, allowing a physician to prescribe a lethal dose of medication for a competent, terminally ill patient who requests one. In 2000, we conducted single, semistructured, in-depth, face-to-face interviews with 35 Oregon physicians who received a request for a lethal prescription. The interviews focused on physicians' perceptions of patients who requested assisted suicide, the reasons for the request, and the reactions of their families. The interviews were audiotaped, transcribed, and analyzed using qualitative techniques. Physicians described requesting patients as having strong and vivid personalities characterized by determination and inflexibility. These individuals wanted to control the timing and manner of death and to avoid dependence on others. These preferences reflected long-standing coping and personality traits. Physicians perceived that these patients viewed living as purposeless and too effortful, and that they were ready for death. The requests, which were forceful and persistent, could occur at any point after diagnosis of the terminal illness, and were paralleled by refusal of medical interventions including palliative treatments. Many family members were reluctant to support these requests until they recognized the strength of the preference.

Attitude of Health Personnel↗
PubMed2003

Strategies to decrease costs of prescribing selective serotonin reuptake inhibitors at a VA Medical Center.

OBJECTIVE: The authors examined the efficacy of a multifaceted intervention designed to contain the cost of prescribing selective serotonin reuptake inhibitors (SSRIs) to inpatients and outpatients served by a Veterans Affairs (VA) medical center. METHODS: Elements of the intervention included identification of a preferred agent, tablet splitting, education and feedback for prescribers, and an electronic record and ordering system to facilitate changes in prescriber behaviors. VA databases were searched for information on use and costs of antidepressants. RESULTS: Over 35 months the number of patients treated with SSRIs and the amount spent on SSRIs increased. However, the mean monthly cost per patient decreased from $57.12 to $42.19. The projected cost savings over the 35 months was approximately $700,000; one-fourth of the savings was due to tablet splitting and three-fourths to changes in the proportions of the various SSRIs prescribed. A survey of the top 75 antidepressant prescribers showed that after the educational interventions, 91 percent were aware that citalopram was the medical center's preferred antidepressant, and 59 percent identified it as their own preferred first-line treatment. DISCUSSION AND CONCLUSIONS: The results suggest that multifaceted interventions can influence antidepressant costs through provider education and changes in pharmacy and computerized information processes, resulting in substantial cost savings for institutions.

Citalopram↗
PubMedDate not supplied

Measuring adherence to depression treatment guidelines in a VA primary care clinic.

The primary objectives of this pilot study were to develop a measure of adherence for depression practice guidelines and to assess the degree to which providers and patients adhere to guidelines in a VA primary care setting. The Depression Guideline Measure (DGM) is based on three national guidelines. The DGM was used to review medical records of 111 patients with Patient Health Questionnaire (PHQ) scores >or=10. Interrater reliability for 15 of 19 DGM checklist items was excellent (kappa > 0.75). There was a broad range of adherence to guideline criteria: only 13.5% of patients were contacted for follow-up within 2 weeks, while 100% of providers documented follow-up plans. Forty percent of patients saw mental health providers, and 63% were prescribed antidepressants. A secondary objective of the study was to explore the relationship between guideline adherence and changes in PHQ scores. Among 51 patients who completed follow-up PHQs, no associations were detected. The results suggest that the DGM shows promise as a reliable measure of guideline adherence and that guideline criteria are frequently not met in busy primary care clinics. More research is needed to determine the validity of the DGM and the impact of guideline adherence on depression outcomes.

Depressive Disorder↗
PubMedDate not supplied

Depression and suicidal ideation in patients who discontinue the life-support treatment of dialysis.

OBJECTIVE: The objective of this study was to determine the prevalence of major depression and suicidal ideation in patients who stop the life-support treatment of dialysis. METHODS: The authors prospectively studied 79 subjects who discontinued maintenance dialysis at eight facilities in North America. Structured interviews were conducted with 23 patients and 76 families. RESULTS: The prevalence of major depression in the sample was between 5% and 25%, and only 1 of 22 patients considered himself to have the illness of depression. Approximately 12% of the respondents were unsure or believed that discontinuing dialysis was the equivalent of suicide. This belief did not correlate with measures of depression. In comparison with the general population there seemed to be an increased prevalence of past suicide attempts. CONCLUSIONS: Most patients who decide to stop dialysis do not seem to be influenced by major depression or ordinary suicidal ideation. Although the sample size was small, these results highlight the need to further examine the theoretical framework and terminology of depression and suicide in the context of terminal illness.

Aged↗
PubMedDate not supplied

Psychiatry resident graduate comfort with general medical issues: impact of an integrated psychiatry-primary medical care training track.

OBJECTIVE: To determine if a psychiatry-primary medical care (PPMC) training track impacts comfort and behaviors related to addressing general medical issues after residency. METHOD: Thirty five psychiatry resident graduates completed mailed surveys; nine of them had completed the PPMC track. RESULTS: Compared to non-PPMC participants, PPMC participants felt better prepared to address medical issues and tended to perform more consultations and feel more comfortable referring patients to general medical providers. They were not more likely to perform routine health screenings. CONCLUSION: Integrated training tracks may impact resident preparedness and career choice but may be insufficient to influence practice behaviors related to delivering general medical care.

Attitude↗