Late-life Abuse Associated with Poor Mental Health
Older women exposed to verbal and physical abuse have poorer mental health. Analyzing data on 93,676 women aged 50-79 years participating in the national Women's Health Initiative, researchers found that compared with nonabused women, women reporting exposure to physical abuse, verbal abuse, or both had lower scores on the mental component of the 36-item RAND Medical Outcomes Study (4.6, 5.4, and 8.1, respectively), greater number of depressive symptoms (1.6, 1.6 and 3, respectively), greater social strain, and lower optimism. At follow-up three years after study enrollment, women who did not report abuse at baseline but subsequently experienced abuse showed greater depressive symptoms and poorer RAND 36 MCS scores, even after controlling for baseline mental health. Notably, exposure to verbal abuse had a stronger adverse effect on psychological health than physical abuse only. The authors conclude that detecting and alleviating abusive situations may have significant beneficial effects on the mental health and overall quality of life of older women, and they recommend that clinicians consider the possibility of abuse exposure in their older female patients who have depressive symptoms.
Psychosocial Effects of Physical and Verbal Abuse in Postmenopausal Women
By Charles P. Mouton, M.D., M.S., et al
Howard University College of Medicine, Washington, D.C.
Family Physicians Continue to Provide Well-Child Care to Young Children Despite Drop in Prenatal Care
Despite a significant decline in the provision of prenatal services by family physicians between 1995 and 2004 from 11.6 percent to 6.1 percent of all prenatal visits, family physicians continued to provide a stable share of well-child care in the first two years of life. Analyzing data from the National Ambulatory Medical Care Survey on 4,999 well-child visits, representing 213 million visits, researchers found the percentage of well-child visits for children younger than two years of age made to family physicians remained stable at 15 percent between 1995 and 2007. Additionally, they find that visits to family physicians were associated with higher rates of Medicaid insurance and were more likely to occur in non-metropolitan areas, and in the Midwest and West geographic regions. The researchers conclude that these findings suggest a decline in prenatal services is not a likely contributing factor to the recent decline in outpatient care for children of all ages by family physicians in the United States. Additionally, they conclude these findings challenge the long-standing argument used within family medicine that stopping maternity care may leave physicians with an older practice population, resulting in fewer children and young families for whom to care.
Trends in Well-Child Visits to Family Physicians by Children Younger Than 2 Years of Age
By Donna Cohen, M.D., M.Sc., and Andrew Coco, M.D., M.S.
The Research Institute at Lancaster General Hospital, Pennsylvania
Social Contact as Effective as Physical Activity in Boosting Mood in Depressed Elderly
In a study of older people with depression, a home-based physical activity program was no more successful than social visiting at improving mood and quality of life. The randomized controlled trial involved 193 people aged 75 and older with depressive symptoms recruited from primary care practices in Auckland, New Zealand. Both those who received an individualized physical activity program and those who received social visits showed improvements in quality-of-life measures related to mood and mental health during the study period, indicating that depressive symptoms can improve with time, and that the social visit component of the control group and intervention group was an important part of the success. The physical activity component, on the other hand, did not result in additional benefit. The authors conclude that social contact may be as effective as physical activity in improving mood and quality of life for those with depressive symptoms.
Home-Based Activity Program for Older People With Depressive Symptoms: DeLLITE – A Randomized Controlled Trial
By Ngaire Kerse, Ph.D, M.B.Ch.B., et al
University of Auckland, New Zealand
Cardiovascular Disease Most Common Cause of Dizziness Among Elderly in Primary Care
A large study from the Netherlands finds that contrary to most previous studies, cardiovascular disease, not vestibular disease, is the most common major cause of dizziness in elderly patients in primary care. Based on evaluations of 417 patients aged 65 to 97 years, researchers found that cardiovascular disease was the most common major contributory cause of dizziness (57 percent), followed by peripheral vestibular disease (14 percent) and psychiatric illness (10 percent). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23 percent) – much higher than reported in previous studies. Sixty-two percent of the patients were assigned more than one contributory cause of dizziness, suggesting that primary care clinicians should consider multiple causes when treating dizzy patients.
Causes of Persistent Dizziness in Elderly Patients in Primary Care
By Otto R. Maarsingh, M.D., et al
VU University Medical Center, The Netherlands
Patients Receiving Chronic Opioid Therapy Less Likely to Receive Preventive Services
Patients receiving chronic narcotic therapy for noncancer pain are less likely to receive some preventive services. Examining the records of 704 patients in seven rural primary care clinics, researchers found patients receiving chronic opioid therapy for noncancer pain were less likely to receive screening for cervical or colorectal cancer. The effect was also observed for lipid screening but didn't reach statistical significance. While the study does not elucidate the specific reasons or mechanisms that may underlie the disparities, the authors cite multiple concerns that may complicate clinical decision making regarding the prescription of opioids: lack of data on the risks and benefits of opioid therapy, possible; physical dependence, tolerance and addiction; possible diversion of opioid medication for other purposes; and concern about possible sanctions by state and federal regulatory agencies. These concerns, they posit, may result in extra time demands, failures in the patient-physician relationship, and less time spent on other aspects of clinical care, including preventive services.
Chronic Opioid Therapy and Preventive Services in Rural Primary Care: An Oregon Rural Practice-based Research Network Study
By David I. Buckley, M.D., M.P.H., et al
Oregon Health & Science University, Portland
Depression Instruments Used to Enhance Patients' Acceptance of Diagnosis, Not to Diagnose
Although depression instruments were originally conceptualized for screening, diagnosing, or, more recently, facilitating the management of depression, researchers find that primary care clinicians in their everyday practice actually use those instruments when they need to persuade a patient to accept his or her diagnosis of depression, when they lack time, or when they are not familiar with the patient. Analysis of 70 individual interviews and three focus groups with 24 primary care clinicians revealed that clinicians rarely use depression instruments for routine screening purposes or for monitoring the treatment of depression; routine screening and case finding do not fit in the real world of competing demands and limited practice resources. Accordingly, these instruments have been reinvented to deal with a real-world problem: convincing patients, believed to be depressed, that they are depressed and negotiating a shared agenda for initial treatment. The authors assert that the burden of this initial dance is overlooked by current guidelines for depression, yet it is deemed one of the greatest imposed on clinicians practicing in primary care. They conclude that future research and policy work in depression care warrant further investigation into ways to better foster familiarity, enhance the process of arriving at a shared agenda, and catalyze a more efficient process of care that bridges the gap between idealized and real-world practice.
Reinvention of Depression Instruments by Primary Care Clinicians
By Seong-Yi Baik, Ph.D., et al
University of Louisville, Kentucky
Parents Open to Pediatric Counseling to Promote Healthy Lifestyle in Primary Care
Parents welcome physicians' efforts to address family lifestyle change to prevent obesity in preventive pediatric visits. Findings from three focus groups to evaluate a pilot intervention aimed at addressing risk behaviors for obesity among urban preschool children indicate that the primary care office is a legitimate entry point for intervening in the problem of childhood overweight. Focus group participants welcomed physician-directed, family-centered goal setting for obesity-related risk behaviors, and they were accepting of subsequent referral to a health educator for behavior change counseling. Parents were more accepting of nutrition discussions than increasing activity (citing a lack of safe outdoor space) or decreasing sedentary behaviors (citing many benefits of television viewing). The focus group discussions revealed that sometimes overwhelming barriers to change are rooted in the low-income urban context, such as complex family dynamics around control of resources and generational conflict and cultural beliefs about food. Parents expressed frustration with physicians for offering advice about changing behavior but not how to achieve it, for dismissing concerns about picky eating or undereating, and in some cases for labels of overweight, which they believe were inappropriately applied. The researchers conclude these findings indicate physicians need help to deliver some health behavior change messages effectively. Behavior change messages, they assert, should be focused toward raising healthy children rather than preventing obesity.
Counseling to Prevent Obesity Among Preschool Children: Acceptability of a Pilot Urban Primary Care Intervention
By M. Diane McKee, M.D., M.S., et al
Albert Einstein College of Medicine, New York
Essay: Physicians Should Employ Principles of Behavioral Psychology to Persuade Patients to Make Healthy Decisions
In this essay, researchers argue that when patients' biases distort their health decisions in harmful and potentially correctable ways, physicians are ethically justified to use principles of behavioral psychology to rebias and persuade them to make good decisions about health behavior or treatment. The authors describe methods for framing health decisions to patients in ways that are more likely to motivate them to make better choices that are less biased and more consistent with their long-term goals. They argue that marketers have been using these methods for decades to get patients to engage in unhealthy behaviors; it is time for clinicians to also make use of behavioral psychology in their personal interactions with patients to promote health and long-term goals. They contend that doing so will often enhance, rather than limit, patients' autonomy.
Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients' Decisions
By J.S. Swindell, Ph.D., et al
Baylor College of Medicine, Houston, Texas
Treatment for Acute Ischemic Stroke, A Physician's Experience
A practicing radiologist in Singapore relates his experience as a patient undergoing treatment for acute ischemic stroke and reflects on how that experience changed him and his attitude toward his practice and his patients. He concludes that while effective treatment requires great aptitude and appropriate use of high-tech diagnostic treatment tools, it also requires talking with patients and families, sharing and showing emotions, and offering words of encouragement.
Journey During Acute Ischemic Stroke: A Physician's Experience
By Low Chen Hoong, F.R.C.R. and Vijay K. Sharma, M.D.
Medi-Rad Associates Radiology Clinic, Singapore and National University Hospital, Singapore
Applying the Principles of Participatory Research to Improve Translational Research Efforts
Researchers propose that incorporating the principles of community-based participatory research into translational research can enhance its ability to improve health care. Applying participatory research methods, such as engaging in collaborative partnerships, building on existing community strengths, investing in long-term relationships, and engaging in research as a cyclical, iterative process, increases the likelihood that research questions will be relevant, interventions will be sustainable and research findings will be translated into systematic action.
System-Based Participatory Research in Health Care: An Approach for Sustainable Translational Research and Quality Improvement
By Julie A. Schmittdiel, Ph.D., et al
Kaiser Permanente, Oakland, California
The Dance: Caring for Patients with Depression in Ethnic Communities
Reporting on how family physicians experience working with patients from different ethnic minority communities in recognizing and caring for depression, researchers find that family physicians perceive working across cultural differences, with both biomedical and social models of depression and at both the community and individual levels not as a barrier to high-quality care, but rather as a central element of that care. In in-depth interviews, eight family physicians who had extensive experience in depression care in three refugee patient groups in Victoria and Tasmania, Australia, described their work as the act of negotiation across differences in ethnicity, culture and language by means of a sensitive, implicit process. The authors call for future research to more clearly characterize and measure this process of negotiation and explore its effect on depression outcomes.
Managing Depression Among Ethnic Communities: A Qualitative Study
By John Furler, M.B.B.S., F.R.A.C.G.P., Grad. Dip., Ph.D., et al
The University of Melbourne, Victoria
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.
Journal
The Annals of Family Medicine