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Biomedical subjects

Wayne J Katon

Publications and source records attributed to Wayne J Katon.

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

Clinical factors associated with relapse in primary care patients with chronic or recurrent depression.

BACKGROUND: Because in most patients depression is a relapsing/remitting disorder, finding clinical factors associated with risk of relapse is important. The majority of patients with depression are treated in primary care settings, but few previous studies have examined predictors of relapse in primary care patients with recurrent or chronic depression. METHODS: Data from a cohort of 386 primary care patients in a clinical trial were analyzed for clinical and demographic predictors of relapse over a one-year post-study observational period. Patients were selected for a high risk of relapse, based on a history of either 3 previous depressive episodes or dysthymia, and enrolled in a randomized trial of relapse prevention. RESULTS: Factors found to be associated with significantly higher risk of relapse included poorer medication adherence in the 30 days prior to the trial, lower self-efficacy to manage depression, and higher scores on the Child Trauma Questionnaire. LIMITATIONS: Use of a sample of limited diversity taken from a clinical trial, and use of retrospective information from patients with potential for recall bias. CONCLUSIONS: The findings of this report suggest specific risk factors to be targeted in depression relapse prevention interventions. It is encouraging that two of the factors associated with increased risk of relapse, self-efficacy and medication adherence have been seen to improve with the intervention utilized in the primary care trial from which the studied cohort was drawn.

Adult↗
PubMed2006

The interpersonal experience of health care through the eyes of patients with diabetes.

Patients with chronic illness often face challenges navigating the US health care system because of the system's lack of coordination and continuity. Patients with more difficulty relying on others and with reluctance in engaging frequently or in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and a perceived "wall" between providers and patients were frustrating for most study patients. Patients with fearful and dismissing attachment style reported that these aspects of the health care system often interfered with their ability to partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to improve patient-centered care and customer service are discussed.

Adult↗
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

Using relationship styles based on attachment theory to improve understanding of specialty choice in medicine.

BACKGROUND: Patient-provider relationships in primary care are characterized by greater continuity and depth than in non-primary care specialties. We hypothesized that relationship styles of medical students based on attachment theory are associated with specialty choice factors and that such factors will mediate the association between relationship style and ultimately matching in a primary care specialty. METHODS: We determined the relationship styles, demographic characteristics and resident specialty match of 106 fourth-year medical students. We assessed the associations between 1) relationship style and specialty choice factors; 2) specialty choice factors and specialty match, and 3) relationship style and specialty match. We also conducted mediation analyses to determine if factors examined in a specialty choice questionnaire mediate the association between relationship style and ultimately matching in a primary care specialty. RESULTS: Prevalence of attachment styles was similar to that found in the general population and other medical school settings with 59% of students rating themselves as having a secure relationship style. Patient centeredness was directly associated, and career rewards inversely associated with matching in a primary care specialty. Students with a self-reliant relationship style were significantly more likely to match in a non-primary care specialty as compared to students with secure relationship style (OR = 5.3, 95% CI 1.8, 15.6). There was full mediation of the association between relationship style and specialty match by the specialty choice factor characterized by patient centeredness. CONCLUSION: Assessing relationship styles based on attachment theory may be a potentially useful way to improve understanding and counsel medical students about specialty choice.

Adult↗
PubMed2006

Dissemination of evidence-based mental health interventions: importance to the trauma field.

Randomized controlled trials have established the efficacy of psychotherapy and medication treatments for posttraumatic stress disorder (PTSD). Despite these advancements, many individuals do not receive guideline-concordant PTSD care. In an effort to advance dissemination of evidence-based PTSD treatments, the authors review several examples of dissemination efforts of mental health interventions. The first examples describe the dissemination of multifaceted collaborative care interventions for patients with depressive disorders and evidence-based interventions for patients with severe mental illness. The final example explores evolving efforts to adapt and disseminate interventions to acutely injured trauma survivors. For each example, the authors describe the problem with prior clinical approaches, the program to be disseminated, the barriers and levers to implementation and the progress in overcoming these barriers.

Case Management↗
PubMed2006

Cognitive impairment and depression outcomes in the IMPACT study.

INTRODUCTION: It is unclear whether cognitive impairment affects acute and long-term treatment response in geriatric depression. In addition, little is known about the long-term outcome of depression among older individuals who experience cognitive decline during a course of treatment for depression. The authors examined both of these issues using data from the IMPACT trial. METHODS: The sample consisted of 1,684 participants in the IMPACT study who had baseline and two-year follow-up data. Subjects were randomized to one year of active intervention with a depression care manager or usual care. After one year, all subjects had usual care for another year. Data were collected for two years. The authors used the Six-Item Cognitive Screener to examine acute and long-term effects on depression outcome of baseline cognitive impairment and of cognitive decline. Depression measures included the HSCL-20 and an estimation of depression-free days. Outcomes were determined using both linear regression and repeated-measures analyses. RESULTS: Depressed subjects in the active intervention group had better depression outcomes at one year regardless of baseline cognitive impairment. Cognitively impaired subjects within each treatment group had similar outcomes to subjects without cognitive impairment. Subjects who experienced decline in cognitive score over two years had worse 24-month depression outcomes compared with subjects whose cognitive score did not change. CONCLUSIONS: Cognitively impaired depressed patients can experience significant improvement in depression with appropriate acute and continuation-phase management. Older depressed adults experiencing ongoing cognitive decline may be at higher risk for poor depression outcomes and may require more careful clinical monitoring and management of both cognitive and affective symptoms.

Aged↗
PubMed2006

Depressive symptom deterioration in a large primary care-based elderly cohort.

OBJECTIVE: The purpose of this study is to examine the incidence and clinical predictors of symptom deterioration in depressed elderly patients who have responded to treatment in primary care. METHOD: A cohort study of 901 older adults from 18 primary care clinics in five states who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression and/or dysthymia at baseline interview, had participated in a trial of collaborative care for depression compared to usual care, and had improved to the point of no longer meeting criteria for major depression at 12 months were observed for one year (18 and 24 months) after enrolling in the original study. RESULTS: A total of 40% of patients met criteria for significant depressive symptom deterioration over the 12- to 24-month observational period. Among usual-care patients, higher initial severity of depression and a higher number of residual DSM-IV depressive symptoms at 12 months were significant predictors of symptom deterioration. No variables predicted symptom deterioration in intervention patients. CONCLUSIONS: There is a high rate of symptom deterioration among elderly patients in primary care who are treated for depression. Efforts to improve long-term outcomes of older patients with major depression and/or dysthymia should focus on providing more intensive treatment and follow up for patients with residual depressive symptoms.

Antidepressive Agents↗
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↗
PubMed2006

Quality of mental health care for youth with asthma and comorbid anxiety and depression.

OBJECTIVES: Youth with asthma have a high rate of anxiety and depressive disorders, and these comorbid disorders are associated with increased asthma symptom burden and functional impairment. This study examined the rates and predictors of recognition of anxiety and depressive disorders among youth (ages 11 to 17) with asthma who are seen in primary care settings as well as the quality of mental health care provided to those with comorbid anxiety and depression over a 12-month period. METHODS: This study used automated utilization and pharmacy data from a health maintenance organization to describe the rate of recognition of Diagnostic and Statistical Manual of Mental Disorders, edition IV, anxiety and depressive disorders and the quality of mental health care provided for the 17% of youth with asthma and comorbid anxiety and/or depression during the 12-month period prior to diagnosis. Psychiatric diagnoses were based on a telephone version of the Computerized Diagnostic Interview Schedule for Children (Version 4.0). RESULTS: Approximately 35% of youth with 1 or more anxiety and depressive disorders and 43% of those with major depression were recognized by the medical system during a 12-month period. Greater functional impairment (odds ratio [OR] 3.32, 95% confidence interval [CI] 1.25-8.79), higher severity on parent-rated anxiety and depressive symptoms (OR 2.49, 95% CI 1.04-6.00), and a greater number of primary care visits (OR 1.26, 95% CI 1.10-1.44) were associated with significantly higher recognition rates while having Medicaid or Washington state medical insurance was associated with lower rates of recognition (OR 0.27, 95% CI 0.08-0.92). Only approximately 1 in 5 youths with comorbid major depression received an adequate dosage and duration of antidepressant medication, and only 1 in 6 received a minimally adequate number of psychotherapy sessions (> or =4 visits). CONCLUSION: Rates of recognition of comorbid anxiety and depressive disorders are low in youth with asthma and few youth with asthma and comorbid anxiety and depression receive guideline-level mental health treatment.

Adolescent↗
PubMed2006

Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas.

CONTEXT: Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying provider types, practice locations, and practice productivity. PURPOSE: To identify mental health shortage areas using existing licensing and survey data. METHODS: The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state-61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions. FINDINGS: Notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000. CONCLUSIONS: States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

Geography↗
PubMed2006

Transforming mental health care at the interface with general medicine: report for the presidents commission.

This paper is based on a report commissioned by the Subcommittee on Mental Health Interface With General Medicine of the Presidents New Freedom Commission on Mental Health. Although mental and medical conditions are highly interconnected, medical and mental health care systems are separated in many ways that inhibit effective care. Treatable mental or medical illnesses are often not detected or diagnosed properly, and effective services are often not provided. Improved mental health care at the interface of general medicine and mental health requires educated consumers and providers; effective detection, diagnosis, and monitoring of common mental disorders; valid performance criteria for care at the interface of general medicine and mental health; care management protocols that match treatment intensity to clinical outcomes; effective specialty mental health support for general medical providers; and financing mechanisms for evidence-based models of care. Successful models exist for improving the collaboration between medical and mental health providers. Recommendations are presented for achieving high-quality care for common mental disorders at the interface of general medicine and mental health and for overcoming barriers and facilitating use of evidence-based quality improvement models.

Advisory Committees↗
PubMed2006

Isn't this just bedtime snacking? The potential adverse effects of night-eating symptoms on treatment adherence and outcomes in patients with diabetes.

OBJECTIVE: Night-eating syndrome is characterized by excessive eating in the evening and nocturnal awakening with ingestion of food. Psychosocial variables and emotional triggers may be associated with these behaviors. In patients with diabetes, such behaviors may lead to glucose dysregulation and contribute to obesity and complications. RESEARCH DESIGN AND METHODS: In 714 tertiary care patients with type 1 and 2 diabetes, we determined the proportion of patients reporting eating >25% of their daily food intake after regular suppertime. We also screened patients for major depression, childhood maltreatment histories, nonsecure attachment styles, and emotional eating triggers. We examined whether patients reporting night-eating behaviors had greater psychosocial distress, higher HbA(1c) (A1C) levels, more obesity, and more diabetes complications compared with patients without night-eating behaviors. RESULTS: Night-eating behaviors were reported in 9.7% of patients. Compared with patients without night-eating behaviors, those with these behaviors were less adherent with diet, exercise, and glucose monitoring and more likely to be depressed, to report childhood maltreatment histories, to have nonsecure attachment styles, and to report eating in response to anger, sadness, loneliness, worry, and being upset. Controlling for age, sex, race, and major depression, patients with night-eating behaviors, compared with patients without night-eating behaviors, were more likely to be obese (odds ratio 2.6 [95% CI 1.5-4.5]), to have A1C values >7% (2.2 [1.1-4.1]) and to have two or more diabetes complications (2.6 [1.5-4.5]). CONCLUSIONS: Night-eating behaviors are associated with adverse outcomes in patients with diabetes. Use of clinical screening tools may help identify patients with night-eating behaviors.

Adolescent↗
PubMed2005

Mood disorders in the medically ill: scientific review and recommendations.

OBJECTIVE: The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES: Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION: Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS: A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Clinical presentation of delirium in patients undergoing hematopoietic stem cell transplantation.

BACKGROUND: Delirium is common in patients undergoing hematopoietic stem cell transplantation (HSCT) and is associated with considerable morbidity and excess mortality in diverse patient samples. Although delirium can be treated successfully, it is largely undiagnosed. Understanding the clinical presentation of delirium may help improve the recognition of delirium in these patients. In the current study, the authors investigated the clinical presentation of delirium in HSCT patients, including the time course of these symptoms and comorbid affective distress, fatigue, and pain. METHODS: Ninety patients ages 22-62 years were recruited prior to undergoing their first allogeneic or autologous HSCT. Delirium, distress, and pain symptom assessments were conducted prospectively 3 times per week from pretransplantation through Day 30 posttransplantation. RESULTS: Delirium episodes occurred in 50% of patients and lasted approximately 10 days, with peak severity at the end of the second week posttransplantation. Factor analysis revealed three groups of delirium symptoms representing psychosis-behavior, cognition, and mood-consciousness. Delirium episodes were characterized by rapid onset of psychomotor and sleep-wake cycle disturbance that persisted and cognitive symptoms that continued to worsen throughout much of the episode. Rises in psychosis-behavior and cognitive symptoms predated the start of delirium episodes by approximately 4 days. Affective distress and fatigue were common and appeared to be associated most with psychosis-behavioral delirium symptoms. CONCLUSIONS: The results describe in detail the clinical presentation of delirium in patients undergoing HSCT. Affective distress and fatigue commonly were associated with delirium. These findings may aid clinicians in improving the recognition and treatment of delirium in this population and avoiding further morbidity and potential mortality.

Adult↗
PubMed2005

Cost-effectiveness of improving primary care treatment of late-life depression.

CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years. RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Age Factors↗