Source: NIMH, February 25, 2008
Doctors spend little time discussing mental health issues with their older patients and rarely refer them to a mental health specialist even if they show symptoms of severe depression, according to an NIMHfunded study published December 2007 in the Journal of the American Geriatrics Society.
People age 65 and older represent 12 percent of the U.S. population, but they accounted for a disproportionate 16 percent of suicide deaths in 2004. Improved mental health screening in primary care may improve detection and treatment of mental disorders before drastic consequences, such as suicide, can occur.
To determine how doctors deliver mental health care to their elderly patients, researcher Ming Tai-Seale, Ph.D., of Texas A&M Health Science Center and colleagues analyzed 385 videotaped visits of 35 doctors with 366 of their elderly patients. The researchers identified topics discussed and how much time was devoted to each topic. Mental health-related topics occurred in 22 percent of visits, typically lasting about two minutes. An average visit lasted about 16 minutes overall. The majority of that time was spent discussing biomedical and other topics.
Efforts to treat or provide care for a mental health issue varied widely among the doctors participating in the study. Most fell into one of three patterns of care: 1) listening to the patient for an extended period of time and referring him or her to a mental health care specialist; 2) gathering information but providing inadequate treatment; or 3) being dismissive toward the patient and his or her emotional distress, and failing to follow up.
More female patients (27 percent) discussed a mental health topic during a typical visit than male patients (12 percent). In addition, the researchers found that the gender pairing of doctor and patient affected the likelihood of discussing mental health issues. Female-tofemale doctor-patient pairs were most likely to discuss mental health, while male-to-male doctor-patient pairs were least likely.
The results indicate that primary care doctors need more support in how to identify, treat and refer patients to mental health specialists, concluded the researchers.
Source: NIMH, February 25, 2008
People with major depression accompanied by high levels of anxiety are significantly less likely to benefit from antidepressant medication than those without anxiety, according to a study based on data from the NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. The study was published online ahead of print in January 2008, in the American Journal of Psychiatry. The STAR*D trial examined four levels of treatment for difficult-totreat depression, all of which tested different medications and medication combinations. Results from the four levels of treatment are available on the NIMH website.
This new study is the largest to date to determine if people with major depression and co-occurring high levels of anxiety respond differently to treatment than those without co-occurring anxiety. Maurizio Fava, M.D., of Massachusetts General Hospital, and colleagues examined response and remission rates among the 53 percent of STAR*D participants (1530 of the 2876 participants treated in the first two treatment steps) who were identified as having "anxious depression" - major depression coupled with significant symptoms of anxiety.
During Level 1 treatment, 42 percent of those with anxious depression responded to treatment and got somewhat better, compared to 53 percent of those without anxiety. Among those who remitted, or became symptom-free, rates were much lower - only 22 percent of those with anxious depression became symptom-free, compared to 33.4 percent of those without anxiety.
In Level 2 treatment, when participants who did not respond in Level 1 could either switch to another antidepressant or add another to the existing one, participants with anxious depression fared significantly worse than those without anxiety, regardless of whether they switched or added medication. They also experienced more frequent and more severe side effects from the medications. The researchers also found that those with anxious depression were more likely to be unemployed, have less education, have more severe depression, have suicidal thoughts, and have more coexisting illnesses, both medical and psychiatric. They were more likely to be hospitalized during the trial, as well.
The results are consistent with previous research showing that people with depression and high levels of anxiety are less likely to respond to antidepressant medication, regardless of what medication is used. They also may lead to more recognition and possible diagnosis of anxious depression. "Clinicians should be aware of a patient's sociodemographic situation and take note if he or she shows significant anxiety along with depression," said Dr. Fava. "The combination likely warrants a more personalized treatment approach."
In addition to antidepressants, high levels of anxiety may be treated with anti-anxiety medications such as benzodiazepines or betablockers, and with psychotherapy. More information about treatment options for anxiety is available on the NIMH website.
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