Bulimic Eating Disorders in Primary Care: Hidden Morbidity Still?

The current study examined the features of women with bulimic-type eating disorders (n = 24) attending primary care in two smaller urban regions of the USA. The assessment included measures of eating disorder psychopathology, medical comorbidity, impairment in role functioning, potential barriers to treatment and actual use of health services. Eating disorders, primarily variants of bulimia nervosa and binge eating disorder not meeting formal diagnostic criteria, were associated with marked impairment in psychosocial functioning. Although two-thirds of participants recognized a problem with their eating, less than 40% had ever sought treatment from a health professional for an eating or weight problem and only one in ten had sought such treatment from a mental health specialist. Only one-third had ever been asked about problems with eating by a primary care practitioner or other health professional. However, more than 80% had sought treatment from a health professional for symptoms of anxiety or depression. Most reported some degree of discomfort in discussing eating problems with others, and half reported that they would not be truthful about such problems if asked. Having an eating disorder was associated with several chronic medical conditions, including joint pain, gastrointestinal problems and fatigue. Although the small sample size limits any firm conclusions, the findings suggest that the health burden of bulimic-type eating disorders is substantial but remains largely hidden. Efforts may be needed to improve the eating disorders “mental health literacy” of both patients and primary care practitioners in order to facilitate early, appropriate intervention.     

Help-Seeking from Clergy and Spiritual Counselors Among Veterans with Depression and PTSD in Primary Care

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months). Participants were asked about (1) openness to seeking help for emotional problems from spiritual counselors/clergy and (2) actual contact with spiritual counselors/clergy in the past 6 months. At baseline, almost half of the participants, 359 (47.2 %), endorsed being “very” or “somewhat likely” to seek help for emotional problems from spiritual counselors; 498 (65.4 %) were open to a primary care provider, 486 (63.9 %) to a psychiatrist, and 409 (66.5 %) to another type of mental health provider. Ninety-one participants (12 %) reported actual spiritual counselor/clergy consultation. Ninety-five (10.3 %) participants reported that their VA providers had recently asked them about spiritual support; the majority of these found this discussion helpful. Participants with current PTSD symptoms, and those with a mental health visit in the past 6 months, were more likely to report openness to and actual help-seeking from clergy. Veterans with depression and PTSD are amenable to receiving help from spiritual counselors/clergy and other providers. Integration of spiritual counselors/clergy into care teams may be helpful to Veterans with PTSD. Training of such providers to address PTSD specifically may also be desirable.     

Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients

Primary care is often the place where patients with depression and comorbid insomnia seek treatment. The experience of comorbid insomnia with depression can have a significant impact on the efficacy of other depression treatments and exacerbate depressive symptoms. Using the empirically based Cognitive-Behavioral Treatment for Insomnia (CBT-I) to target the comorbid experience of insomnia in patients with depression can help improve sleep and potentially modify some depressive symptoms. Additional rationale for such an approach includes that a positive therapeutic experience may enhance engagement with or adherence to other psychotherapeutic interventions. Although other brief CBT-I interventions have been developed for primary care, none of them were actually delivered to depressed patients or implemented in primary care. Therefore, this paper describes a brief CBT-I intervention that was designed to be delivered in 4 sessions lasting from 15 to 45 minutes each within a primary care setting to depressed veterans. A case study is provided along with sample materials used in this intervention. In addition, we share implementation tips based on our experiences and feedback from eight veterans who have completed the intervention to date. Overall, the intervention was generally well received and suggests that the intervention may be feasibly delivered in a primary care setting.     

Clinically Significant Depressive Symptoms in African American Adolescent Females in an Urban Reproductive Health Clinic

Adolescent depression is a major public health concern. Depression and depressive symptoms are more prevalent in adolescent females and are associated with high-risk sexual behavior. Only one third of adolescents receive professional help for their depression, although about 90% visit their primary care providers on average 2–3 times per year. It is imperative that health professionals seek additional methods in the identification and treatment of depressive symptoms. This paper presents findings of the presence of clinically significant depressive symptoms in African American female adolescents receiving routine health care services within an adolescent primary care reproductive health clinic. Results revealed higher rates of depressive symptoms in this subsample of African American adolescent females when compared to the national sample, suggesting that primary care reproductive health clinics are a viable setting for the identification of depressive symptoms among low income, African American female adolescents. Psychosocial interventions and recommendations for the integration of primary care reproductive health, and behavioral health consultation services are presented.     

Primary care physicians attitude toward diagnosis and treatment of late-life depression

Underdiagnosis and undertreatment of late-life depression is common, especially in primary care settings. To help assess whether physicians attitude and confidence in diagnosing and managing depression serve as barriers to care, a total of 176 physicians employed in 18 primary care groups were administered surveys to assess attitudes towards diagnosis, treatment, and management of depression in elderly patients, (individuals over 65 years of age). Logistic regression was performed to assess the association of physician characteristics on attitudes. Nearly all of the physicians surveyed felt that depression in the elderly was a primary care problem, and 41% reported late-life depression as the most common problem seen in older patients. Physicians were confident in their ability to diagnose and manage depression, yet 45% had no medical education on depression in the previous three years. Physicians confidence in their ability to diagnose, treat, and manage depression, and their reported adequacy of training, do not appear to correspond to the amount of continuing medical education in depression, suggesting that physician overconfidence may potentially be serving as a barrier to care.     

A Pilot Study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression

The purpose of this study was to evaluate a culturally adapted cognitive-behavioral treatment (CBT) for major depression among Hispanics in primary care. Cultural adaptations were applied based on a range of cultural considerations described in the literature. Fifteen Hispanic primary care patients with major depression were enrolled. All participants received the 12-session intervention and completed baseline, posttreatment, and 6-month follow-up assessments. Four participants (27%) dropped out of the treatment. Analyses focused on changes from baseline functioning using a Wilcoxon Signed Rank Test. Results showed significant reductions in depressive, anxious, and somatic symptoms at posttreatment and 6-month follow-up. Mean reduction of depressive symptoms at posttreatment was 57%. Findings of acceptable treatment retention rates and clinically meaningful reductions in depressive symptoms showed promise for this intervention to treat Hispanics with major depression. Future studies should conduct a more rigorously controlled evaluation of this intervention.     

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.     

Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults

Telephone psychotherapy is an emerging form of delivery of care that has recently demonstrated utility and efficacy for adult depression when provided as an adjunct to antidepressant treatment in primary care trials. This study constitutes one of the initial evaluations of cognitive behavioral therapy-telephone treatment (CBT-TT) as a stand-alone treatment for adult depression in specialty care. Thirty adults initiating psychotherapy for depression at a mental health clinic participated in the trial. The majority of participants (69%) were very satisfied with the 8-session CBT-TT, reduction in depression severity was significant over 3 and 6 months, and 42% of participants were considered recovered at termination. These outcomes closely parallel the findings from an earlier primary care trial, despite specialty care participants beginning treatment with more severe depression and without adjunctive antidepressant medication. These findings suggest that CBT-TT for adult depression is feasible and has potential as a stand-alone treatment. Implementation of this telephone-based delivery approach in primary and specialty care settings is discussed.     

Holocaust survivors in a primary care setting: fifty years later

Past studies have not assessed the prevalence of emotional disturbances in Holocaust survivors seeking medical treatment in a family practice environment. The present study examined the prevalence of lifetime (the presence of symptomatology at any time) and current posttraumatic stress disorder (PTSD) symptoms, general anxiety, and depression in Holocaust survivors seeking medical treatment in a primary care setting. 20 of the 27 Holocaust survivors in our sample received a current diagnosis of PTSD and reported significant symptoms of depression and general anxiety. Although 74% of the survivors were currently diagnosed with PTSD, participants in this study had reported an overall decline in reexperiencing, hyperarousal, and overall PTSD symptoms but exhibited increased avoidance and numbing symptoms throughout the lifespan. These preliminary results suggest that removing avoidance as a defense mechanism during the course of psychotherapy may leave these survivors without an adequate way for coping with their trauma, subsequently increasing their vulnerability to psychopathology. Implications for psychological interventions are provided.     

Who benefits from psychotherapies for adult depression? A meta-analytic update of the evidence

It is not clear whether specific target groups for psychotherapies in adult depression benefit as much from these treatments as other patients. We examined target groups that have been examined in randomized trials, including women, older adults, students, minorities, patients with general medical disorders, and specific types of depression, and we examined where patients were recruited. We conducted subgroup and multivariate metaregression analyses in a sample of 256 trials (with 332 comparisons) comparing psychotherapy with an inactive control condition. Only 22% of the studies had low risk of bias (RoB), heterogeneity was high and there was a considerable risk of publication bias. A meta-regression analysis among low RoB studies showed that effect sizes found for studies among women, older adults, patients with general medical disorders, patients recruited from primary care, and patients scoring above a cut-off on a self-rating depression scale, did not differ significantly from effect sizes from other studies. For other target groups, the number of low RoB studies was too small to draw any conclusion. We found few indications that psychotherapies for adult depression are more or less effective in women, older adults, patients with comorbid general medical disorders, and primary care patients.     

Pilot Randomized Trial of a Self-Help Behavioral Activation Mobile App for Utilization in Primary Care

Mobile technologies can be leveraged to meet the need for evidence-based psychological depression treatment via primary care. The purpose of the present study was to preliminarily examine the feasibility and efficacy of a self-help brief behavioral activation mobile application (app; “Moodivate”) for depressive symptoms among adults treated via primary care. Participants (N = 52) were recruited from primary care practices between January and December 2017 and were randomized 2:2:1 to receive (a) Moodivate, (b) an active control cognitive-behavioral therapy-based mobile app (“MoodKit”), or (c) treatment as usual (TAU; no app). Participants completed assessments of depressive symptoms weekly for 8 weeks. App analytics data were captured to examine Moodivate feasibility (analytics unavailable for control app). Moodivate participants on average had 46.76 (SD = 30.10) app sessions throughout the trial duration, spent 3.50 (2.76) minutes using the app per session, and spent 120.76 (101.02) minutes using the app in total throughout the trial. Nearly 70% of Moodivate participants continued to use the app 1 month after trial enrollment and 50% at the end of the 8-week follow-up period. A generalized estimating equation model examining change in depressive symptoms over time by treatment condition indicated a significant interaction between time and treatment condition (χ² = 42.21, df = 14, p < .001). As compared to TAU, participants in both app conditions evidenced significant decreases in depressive symptoms over time, and these treatment gains were sustained across the trial period. These results preliminarily indicate feasibility of Moodivate as well as efficacy of both Moodivate and MoodKit for the treatment of depression among adults recruited via primary care. Future studies should focus on larger-scale examinations of treatment efficacy and effectiveness across primary care settings.     

Self-help for binge eating disorder in primary care: A randomized controlled trial with ethnically and racially diverse obese patients

Objective

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

Method

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

Results

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

Conclusions

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.     

Prevalence,Detection and Correlates of PTSD in the Primary Care Setting: A Systematic Review

Research suggests that posttraumatic stress disorder (PTSD) is common, debilitating and frequently associated with comorbid health conditions, including poor functioning, and increased health care utilization. This article systematically reviewed the empirical literature on PTSD in primary care settings, focusing on prevalence, detection and correlates. Twenty-seven studies were identified for inclusion. Current PTSD prevalence in primary care patients ranged widely between 2 % to 39 %, with significant heterogeneity in estimates explained by samples with different levels of trauma exposure. Six studies found detection of PTSD by primary care physicians (PCPs) ranged from 0 % to 52 %. Studies examining associations between PTSD and sociodemographic variables yielded equivocal results. High comorbidity was reported between PTSD and other psychiatric disorders including depression and anxiety, and PTSD was associated with functional impairment or disability. Exposure to multiple types of trauma also raised the risk of PTSD. While some studies indicated that primary care patients with PTSD report higher levels of substance and alcohol abuse, somatic symptoms, pain, health complaints, and healthcare utilization, other studies did not find these associations. This review proposes that primary care settings are important for the early detection of PTSD, which can be improved through indicated screening and PCP education.     

Anxiety and Depression in Medically Ill Older Adults

Anxiety and depression are extremely common in the elderly with medical problems. They can manifest not only as symptoms of a primary psychiatric illness, but also as physiologic sequelae of medical illnesses and medical treatments. Recognition and treatment of depression and anxiety in the medically ill is especially difficult. If these states go untreated, they result in higher morbidity and mortality, higher health care costs and utilization, and poorer functional status and outcomes. Three of the most common medical illnesses that afflict geriatric patients, cardiovascular disease, pulmonary disease, and rheumatoid arthritis, will be presented to illustrate the difficulty in recognizing depression and anxiety and the impact of treating these symptoms in the medically ill elderly. Multidisciplinary approaches combining optimal medication regimens and psychosocial interventions can be effective for treatment of anxiety and depression in the medically ill elderly.     

Prevention of depression with primary care patients: A randomized controlled trial

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasbile, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.     

Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care

Although past work has shown that alcohol use co-occurs with anxiety/depression among Latinos, little work has examined the variables that qualify such associations. The present investigation sought to address whether pain severity (i.e. pain intensity and/or pain-related disability, respectively) moderated relations between hazardous drinking and depressive/anxious arousal symptoms among an economically disadvantaged Latino sample recruited from a primary care medical setting. Participants included 253 adult Latinos (M_age = 38.5 years, SD = 10.8; 86.6% female) who attended a community-based primary care clinic. There was a significant interaction of hazardous drinking with pain intensity in relation to depressive symptoms and significant interactions of hazardous drinking and pain-related disability in relation to depressive and anxious arousal symptoms. Hazardous drinking was associated with more severe depressive/anxious arousal symptoms only when pain intensity/disability was high. This is the first study to demonstrate the moderating role of pain intensity and disability in associations between hazardous drinking and anxiety/depression among Latinos in a primary care medical setting.     

The Effects of Spirituality and Religion on Outcomes in Patients with Chronic Heart Failure

Heart failure (HF) is a chronic progressive disease with marked morbidity and mortality. Patients enduring this condition suffer from fluctuations in symptom burden such as fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body image and depression. As physicians, we often ask patients to trust in our ability to ameliorate their symptoms, but oftentimes we do not hold all of the answers, and our best efforts are only modestly effective. The suffering endured by these individuals and their families may even call into question one??s faith in a higher power and portends to significant spiritual struggle. In the face of incurable and chronic physical conditions, it seems logical that patients would seek alternative or ancillary methods, notably spiritual ones, to improve their ability to deal with their condition. Although difficult to study, spirituality has been evaluated and deemed to have a beneficial effect on multiple measures including global quality of life, depression and medical compliance in the treatment of patients with HF. The model of HF treatment incorporates a multidisciplinary approach. This should involve coordination between primary care, cardiology, palliative care, nursing, patients and, importantly, individuals providing psychosocial as well as spiritual support. This review intends to outline the current understanding and necessity of spirituality??s influence on those suffering from HF.