Mental Health: Research Findings

Substance abuse is a medical problem that requires timely treatment, not only because of its detrimental effects on health, but also because of its link to other adverse effects, such as family violence. Nearly one-third of U.S. adults suffer from some type of mental disorder or substance abuse. The number of people aged 12 and over with alcohol and/or illicit drug dependence or abuse approaches 23 million (9 percent). Yet, of people who needed treatment for illicit drug use in 2006, only 20 percent of adults 18 to 44 and 11 percent of children 12-17 received it.

• Different groups of women smoke for different reasons and may respond to different interventions and messages.

  This study identified three subgroups of women who smoked daily. The first group (48 percent of the sample) worked full time, were heavy smokers (more than half a pack a day), and were generally happy. The second group (19 percent) started smoking casually during their college years and exercised regularly. The third group (33 percent), mostly mothers, smoked because they were addicted and received a psychological benefit from smoking. Identifying these groups may help target smoking cessation interventions and messages. For example, women in the first group may respond to messages appropriate to their self-confidence as a means of empowering them to quit. The college-aged women may be receptive to education campaigns on the unacceptability of smoking, its negative health effects, and the danger of addiction. The women in the third group may best be deterred by smoking bans in public places and high taxes on tobacco, and best served by medically supervised cessation programs that address addiction and depression. The findings were based on a study of 443 Midwestern women who participated in a longitudinal tobacco-use study that began in 1980 with follow-ups in 1987, 1993, and 1999. Rose, Chassin, Presson, et al., "A latent class typology of young women smokers," Addiction 102(8):1310-1319, 2007(AHRQ Grant HS144178).

• Substance use is prevalent and problematic use is frequent among depressed adolescents.

  This study of individuals aged 12 to 21 years old, who had high levels of depression symptoms, found highly prevalent substance use and frequent problematic use. The proportions of both problematic and nonproblematic users rose with increasing ages: at ages 13 to 15, 14 percent were problematic users and 9 percent nonproblematic users; by ages 19 to 21, the proportions had risen to 26 and 25 percent, respectively. In addition to older age, problematic use was associated with male gender, externalizing symptoms, white ethnicity/ race, and having more friends. The most widely used substances were tobacco, alcohol, and marijuana; other substances included amphetamines, barbiturates, cocaine, LSD, tranquilizers, and heroin and other opioids. Primary care clinicians should probe carefully for substance use risk in this group of patients, suggest the researchers. Goldstein, Asarnow, Jaycox, et al.,"Correlates of 'non-problematic' and 'problematic' substance use among depressed adolescents in primary care," Journal of Addictive Diseases (26(3):39-52, 2007 (AHRQ Grant HS09908).

• Screening for alcohol misuse in the emergency department may provide patients with early evaluation, prevention, and treatment of depression.

  Mostly Hispanic and black young adults seeking care at an urban emergency department (ED) were about twice as likely to suffer depressive symptoms if they had problems misusing alcohol. Researchers examined the association between four levels of alcohol misuse (at-risk drinking, problem drinking, alcohol abuse, and binge drinking) and recent depressive symptoms among a random sample of 412 adults seen at the ED. Half of these patients (51 percent) reported depressive symptoms during the past week on a 20-item depression scale, such as loss of appetite, lack of energy, and crying spells. This rate is twice that of depressive symptoms in the general adult population (24 percent). Patients with at-risk drinking, problem drinking, drinking abuse, and binge drinking were 2.5, 2.1, 2.6, and 1.9 times more likely to have suffered depressive symptoms in the past week. Hajazi, Bazargan, Gaines, and Jermanez, "Alcohol misuse and report of recent depressive symptoms among ED patients," American Journal of Emergency Medicine 26: 537-544, 2008 (AHRQ grant HS14022).

• Substance abuse and psychiatric illness account for 80 percent of hospital admissions among homeless veterans.

  Homeless veterans admitted to the hospital for psychiatric or substance abuse diagnoses were a median of 10-18 years younger than housed veterans. These findings suggest that homeless veterans have either a more rapid disease course, leading to earlier medical problems, or lower admission thresholds sufficient to prompt hospital admission. Homeless veterans were also more likely to have been admitted for psychiatric and substance abuse diagnoses than housed veterans (80 vs. 29 percent). The confluence of mental illness, substance abuse, and chaotic social situations render homeless people, including veterans, susceptible to early disease, high hospitalization rates, and premature death. Researchers compared the age at hospital admission and primary discharge diagnoses in a national sample of 43,868 veterans who were hospitalized at 141 Veterans Administration medical centers between 1996 and 1998. Adams, Rosenheck, Gee, et al., "Hospitalized younger: A comparison of a national sample of homeless and housed inpatient veterans," Journal of Health Care for the Poor and Underserved 18:173-184, 2007 (AHRQ grant HS11415).

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Cognitive Impairment/Psychosis

Alzheimer's disease (AD) affects 4.5 million Americans and is the most common cause of dementia among the elderly. AD also can include hallucinations, agitation, and other signs of psychosis. Another 2.4 million Americans (1.1 percent of the population) suffer from schizophrenia. These and other types of cognitive impairment can significantly limit the functioning and quality of life of individuals, whose families often carry a high caregiving burden. Research is underway to improve care delivery for patients suffering from these debilitating conditions and to find new medications to alleviate symptoms and slow cognitive decline.

• Better ways must be developed to get at-risk adults, especially those from ethnic minorities, to participate in memory screening for Alzheimer's disease.

  The Alzheimer's Association convened a think tank meeting on the "Diagnosis and Assessment of Alzheimer's Disease in Diverse Populations" in 2007 in Chicago. Thirty clinicians and researchers met to discuss how Alzheimer's disease (AD) affects various communities differently and how its diagnosis and treatment present challenges specific to certain population groups. A number of major points emerged from the meeting. Researchers need to deconstruct racial and ethnic variables into more meaningful variables, given that studies show that blacks and Hispanics suffer a greater incidence of AD than whites. Clinics need to provide comfortable culturally sensitive environments for the families they serve in order to keep patients in the screening program. Finally, investigators must learn more about how chronic disease such as hypertension and diabetes interact with AD pathology, especially among ethnic minorities, who suffer disproportionately from these conditions. Dilsworth-Anderson, Hendrie, Manly, et al., "Diagnosis and assessment of Alzheimer's disease in diverse populations," Alzheimer's and Dementia 4:305-309, 2008 (AHRQ grant HS10884).

• One in five elderly patients hospitalized for psychiatric conditions ends up back in the hospital within 6 months.

  The hospital readmission rate for elderly patients suffering from schizophrenia and bipolar disorder was about 50 percent higher than for patients who were depressed or had substance abuse disorders. Patients who had two or more psychiatric conditions were at greater risk for readmission than patients who suffered from just one condition. Hospital stays of 5 days or longer decreased the chances that patients with affective disorders (for example, depression of bipolar disorder) would be rehospitalized. Twenty-nine percent of patients with affective disorders who had stays of 4 or fewer days were readmitted, while just 16 percent with nonaffective disorders (for example, anxiety or substance abuse) were rehospitalized. To prevent readmissions, patients, especially those with affective disorders, should not be prematurely discharged, and could benefit from tailored discharge plans and aftercare. The findings were based on analysis of 2002 Medicare data from 41,839 patients. Prince, Akincigil, Kalay, et al., "Psychiatric rehospitalization among elderly persons in the United States," Psychiatric Services 59(9):1038-1045, 2008 (AHRQ Grant HS16097).

• Only 50-60 percent of patients treated for schizophrenia follow their medication regimen for an extended period, increasing their risk of hospitalization.

  Only 12 percent of Medicaid-insured patients with schizophrenia stayed on their medications for a full year. Compared with patients who continued to refill their medications, those who missed refilling their medication for as little as 10 days had a 54 percent increased risk of hospitalization for mental health problems and a 77 percent higher risk of hospitalization for schizophrenia. Those patients whose medication gaps were longer than 30 days were 60 percent and 49 percent respectively more likely to be hospitalized for mental health problems and schizophrenia. The researchers analyzed the Medicaid and Medicare claims data of 1,191 patients with schizophrenia from two State Medicaid programs to determine the extent to which gaps in taking atypical antipsychotic medications, medication switching, and augmentation with additional antipsychotics were related to hospitalization risk. Of the individuals whose records were studied, 552 were hospitalized over 3 years. Law, Soumerai, Degnan, and Adams, "A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia," Journal of Clinical Psychiatry 69(1): 47-53, 2008 (AHRQ grant HS10391).

• Twenty four percent of those caring for persons with Alzheimer's disease will end up visiting the emergency department or being admitted to the hospital.

  In addition, the use of these acute care services is associated with being depressed. Family and friends caring for individuals with Alzheimer's disease (AD) were interviewed to provide information on the patient's behaviors, actions, and activities of daily living, and on their own moods and the use of acute care services. Nearly a quarter (24 percent) of caregivers had either visited an emergency department (ED) or had been hospitalized in the 6 months prior to participating in the study. ED visits and hospitalizations most often occurred among caregivers caring for patients with cognitive, functional, behavioral, and psychological symptoms. These caregivers were also likely to suffer from more symptoms of depression. The researchers note that cognitive decline in a loved one, which is usually expected, is not as stressful to caregivers as the patient's agitation, aggression, and other symptoms. In this study, 153 patients with AD were recruited from two large primary care practices. Schubert, Boustani, Callahan, et al.,"Acute care utilization by dementia caregivers within urban primary care practices," Journal of General Internal Medicine 23(11):1736-1740, 2008 (AHRQ grant HS10884).

• Rural Alabama caregivers of patients with dementia are typically women from their early 20s to early 80s, who provide an average of nearly 50 hours of care per week.

  Many of these caregivers also work outside of home, and one-fifth of them also care for a second person in the family (for example, a young child or another elderly person) an average of 31 hours a week. Yet the average caregiver rated their caregiver burden as moderate, and most of them rated their quality of life as average or high. Nearly all of them used religion as a coping mechanism. However, white and black caregivers had significantly different characteristics and coping styles. Compared with black caregivers, white caregivers were more likely to be married, older, have higher incomes, have fewer problems paying bills, and to care for parents. White caregivers were more likely to engage in private religious activities such as praying, while black caregivers were more likely to participate in organized religious activities. White caregivers used more medications and used acceptance and humor to cope more often than black caregivers. White caregivers felt generally more burdened by caregiving than their black counterparts. Both had low use of formal care support services. Kosberg, Kaufamn, Burgio, et al.,"Family care giving to those with dementia in rural Alabama," Journal of Aging and Health 19: 3-21, 2007 (AHRQ grant HS13189).

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Depression

Nearly 7 percent of U.S. adults suffer from major depression in a given year. Up to 3 percent of children and 8 percent of adolescents also suffer from depression. A growing number of adults and children are being diagnosed and treated for depression by primary care doctors instead of specialists. Also, the link between depression and chronic disease is becoming more evident. The impact of depression on work, school, quality of life, and overall health is enormous. Yet it remains underrecognized and undertreated. AHRQ's substantial portfolio of depression research includes a focus on adolescents, those with chronic disease, the elderly, women, primary care of depression, as well as other topics.

Adolescents

• The U.S. Preventive Services Task Force now recommends screening adolescents 12 to 18 years of age for clinical depression only when appropriate systems are in place to ensure accurate diagnosis, treatment, and follow-up care.

  In a separate recommendation, the Task Force found insufficient evidence to assess the balance of benefits and harms of screening children 7 to 11 years of age for clinical depression. Depression can cause difficulties in school and disruptions of family and social relationships as well as diminished quality of life. Children and adolescents with depression are at increased risk of suicide and are more likely to suffer from depression in early adulthood. The Task Force reviewed new evidence on the benefits and harms of screening children and adolescents for clinical depression, the accuracy of screening tests administered in the primary care setting, and the benefits and risks of treating clinical depression using psychotherapy and/or medications in patients 7 to 18 years of age. Petitti, Calonge, DeWitt, et al., "Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendations Statement," Pediatrics 123(4):1223-1228, 2009.

• One in four young adults will suffer a depressive episode between the ages of 18 and 25.

  A depressive episode during this stage of "emerging adulthood" can get in the way of reaching developmental milestones such as getting a job or paying one's own rent. It can also cause substantial social problems. Depressed mood, identity concerns, problems with relationships, and problematic transactions with the health care system prevented adolescents in this study from reaching developmental milestones. Many felt they had wasted time during their depression, while their peers advanced in life. Inability to accomplish these transitional tasks further worsened concerns about their identity as well as their depressed mood. Some still felt optimism about their future when they got over their depression. Researchers used interviews with 15-year-old individuals with depression to gain insight into the troubling issues they face. Kuwabara Voorheers, Gollan, and Alexander, "A qualitative exploration of depression in emerging adulthood: Disorder, development, and social context," General Hospital Psychiatry 29:317-324, 2007 (AHRQ grant HS15699).

Chronic Disease

• Individuals with more depressive symptoms are more likely to benefit from training in chronic illness self-management.

  Individuals suffering from chronic illnesses such as diabetes and asthma must manage their condition through behaviors such as control of diet and exercise and measurement of breathing capacity or blood-sugar level.

  Researchers examined the impact of a training program to enhance patient self-efficacy for self-managing chronic illness among 415 adults with a variety of chronic diseases, impaired activities of daily living, and/or depression. The program focused on medical, role, and emotional self-management tasks and six chronic disease self-management skills (problem solving, decisionmaking, resource utilization, formation of patient-provider partnership, action planning, and self-tailoring). Six weeks later, the training program led to significant increases in feelings of self-efficacy in the one-fourth of individuals with the highest depressive symptom burden (score of 15-28 on the CES-D), and only when delivered via in-home visits (not by telephone). Jerant, Kravitz, Moor-Hill, and Franks, "Depressive symptoms moderated the effect of chronic illness self-management training on self-efficacy," Medical Care 46(5):523-531, 2008 (AHRQ grant HS13603).

• Patients with diabetes and depression tend to skip self-care behaviors that would help keep their diabetes in check.

  This study found that nearly one-fifth of patients with type 2 diabetes probably suffered from major depression and an additional two-thirds had at least some depressive symptoms. Both the very depressed patients and those with a few depressive symptoms (subclinical depression) were less likely than the 14 percent of patients who were not depressed to perform self-management tasks needed to control their blood-sugar levels. For example, individuals with major depression (including those on antidepressants) spent fewer days than others following the recommended diet (such as eating lots of fruits and vegetables and spacing carbohydrates throughout the day), exercise, and glucose self-monitoring regimens. They were also 2.3 times more likely to miss medication doses in the prior week than patients who were not depressed. The findings were based on a survey of 879 patients with type 2 diabetes from 2 primary care clinics. Gonzalez, Safren, Cagliero, et al., "Depression, self-care, and medication adherence in type 2 diabetes," Diabetes Care 30(9):2222-2227, 2007 (AHRQ grant HS14010).

• Persons with HIV disease commonly suffer from mental health problems and substance abuse, whose care depends, in part, on the structure of their medical clinic.

  Patients who were cared for at HIV specialty clinics or clinics with a combination of care management and affiliated mental health care were twice as likely to be cared for by a mental health specialist as patients at other clinics. Those cared for at clinics with on-site case management and on-site or off-site affiliated substance abuse care were four and three times, respectively, more likely to receive outpatient substance abuse care than patients at other clinics. Case managers may facilitate linkages to mental health care and substance abuse care by making referrals, scheduling appointments, and arranging transportation. The researchers surveyed patients and clinic directors at 200 clinics participating in the HIV Cost and Services Utilization Study, a nationally representative sample of persons in care for HIV. Ohi, Landon, Cleary, and LeMaster, "Medical clinic characteristics and access to behavioral health services for persons with HIV," Psychiatric Services 59:400-407, 2008 (AHRQ grant HS10408 and HS10222).

Elderly

• Disparities remain in the diagnosis and treatment of depression among nursing home residents.

  Educated females in nursing homes who had ever been married were more likely than other residents to be diagnosed with depression. Black residents were half as likely as white residents to be diagnosed with depression. Residents older than 75 were a third less likely than those aged 65 to 75 to be diagnosed with depression. Residents with severe cognitive impairment were a third less likely to be diagnosed than residents with normal cognitive functioning. Disparities were also found in the treatment realm. Residents who were aged 75 and older, black, had severe mental illness, were entirely dependent on assistance with activities of daily living, and had severe cognitive impairment were all less likely to receive treatment for their depression than patients with higher education levels, who were or had been married, and had one or more physical ailments. These findings were based on analysis of 2000 data on 76,735 residents of 921 Ohio nursing homes. Levin, Wei, and Akincigil, "Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio," Journal of the American Medical Directors Association 8(9):585-594, 2007 (AHRQ Grant HS011825).

• Depressive symptoms are linked to greater cognitive decline among the elderly.

  Elderly persons with depressive symptoms at the beginning of the study had a greater decline in cognitive skills during the 7-year period than did those without such symptoms. The link between depressive symptoms and cognitive decline was independent of age, gender, education, baseline cognitive score, limitations in the activities of daily living, diabetes, stroke, heart attack, and vision impairment. It is not clear whether treating depression will reduce the onset of cognitive decline, note the study authors. They examined a group of 2,812 Mexican Americans over age 65 for 7 years to determine links between depressive symptoms and cognitive decline. Raji, Reyes-Ortiz, Kuo, et al., "Depressive symptoms and cognitive change in older Mexican Americans," Journal of Geriatric Psychiatry and Neurology 20(3):145-152 , 2007 (AHRQ Grant HS11618).

• Elderly use of antidepressants does not seem to increase hospitalization for pneumonia.

  Hospitalization for pneumonia and aspiration pneumonia was 1.6 and 1.45 times respectively more common among elderly antidepressant users. However, antidepressants did not seem to increase hospitalization for pneumonia, after adjustment for other factors such as chronic neurological and pulmonary conditions. Patients prescribed antidepressants suffered from pneumonia during the expected wintertime peak in late January typical of elderly persons not taking antidepressants (controls). Researchers analyzed 12,044 cases of hospitalization for pneumonia and 48,175 controls from a database of medical records from about 2,000 general practitioners in the United Kingdom from 1987 to 2002. They also identified 159 cases of hospitalization for aspiration pneumonia and 636 controls. Bilker, Leonard, et al., "Observed association between antidepressant use and pneumonia risk was confounded by comorbidity measures," Journal of Clinical Epidemiology 60:911-91, 2007 (AHRQ Contract No. 290-005-004; AHRQ Publication No. 08-R011).

General

• New report finds little evidence to determine the usefulness of genetic tests in the treatment of depression.

  There is insufficient evidence to determine if current gene-based tests intended to personalize the dose of medications in a class of drugs called selective serotonin reuptake inhibitors (SSRIs) improve depression outcomes or aid in treatment decisions in the clinical setting, according to a new evidence report supported by AHRQ and the Centers for Disease Control and Prevention's National Office of Public Health Genomics. The report found that tests evaluating differences in genes belonging to the Cytochrome P450 (CYP450) family, which affect the rate at which a person metabolizes SSRIs, are largely accurate. They noted that other genetic factors and non-genetic factors such as diet and other medical conditions may have an impact on a patient's response to treatment. Most studies included a small number of people, did not test for all variations of the enzymes, and were poorly designed, according to the researchers. The report was prepared by a team of researchers at the Duke University Evidence-based Practice Center in Durham, North Carolina. Testing for CYP450 Polymorphisms in Adults With Non-Psychotic Depression Treated With SSRIs (AHRQ Publication No. 07-E002).*

• Sleep deprivation, lack of leisure time, and other stresses of resident training lead to depression and burnout among many medical residents.

  One in five residents participating in this study met the criteria for depression and 74 percent met the criteria for burnout. Residents with depression made 6.2 times as many medication errors per resident month as residents who were not depressed (1.55 vs. 0.25). Burnt-out residents and non-burnt-out residents made similar rates of errors per resident month (0.45 vs. 0.53). In addition, residents who were depressed or burnt out reported poorer health than peers who did not have these problems. The findings indicate that the mental health of medical residents may be a more important contributor to patient safety than previously suspected. The findings were based on responses to questionnaires administered to 123 residents in 3 pediatric residency programs at 3 children's hospitals. Fahrenkopf, Sectish, Barger, et al., "Rates of medication errors among depressed and burnt-out residents: Prospective cohort study," British Medical Journal 336(7642):488-491, 2008 (AHRQ grant HS1333).

• Depression Prognosis Index can predict depression among primary care patients.

  Coexisting physical and mental problems, a history of depression treatment, minority race, and other factors predict poor depression outcome. Low social functioning and support, being older and male, and being unemployed are also predictors of poor depression outcome, found the Depression Prognosis Index (DPI) used in this study. The researchers enrolled 1,471 patients with major depression being treated in 108 primary care practices. They ranked patients in quartiles based on their self-reported characteristics. At the 6-month followup, 64 percent of those with the poorest prognosis had a likely diagnosis of major depression while only 14 percent of those in the healthiest group had a similar diagnosis. Thus, the ability of the DPI to predict 6-month depression outcomes compared favorably with that of prognostic indicators of general medical problems. Rubenstein, Rayburn, Keeler, et al., "Predicting outcomes of primary care patients with major depression: Development of a Depression Prognosis Index," Psychiatric Services 58(8), 2007 (AHRQ grant HS08349).

Primary Care

• Up to one in four primary care patients suffer from depression; yet, primary care doctors identify less than one-third (31 percent) of these patients.

  Primary care clinicians are slightly more likely to diagnose depression among patients with suicidal thoughts or who sleep all the time (hypersomnia) or can't sleep (insomnia). Of the 304 patients in this study (mostly Latinos and blacks), 75 percent were significantly depressed, and 58 percent had both significant depression symptoms and functional impairment (such as insomnia). Suicidal thoughts increased 5.4 fold the likelihood of physician diagnosis of depression, and hypersomnia or insomnia doubled the likelihood of diagnosis. Other depression symptoms (for example, fatigue, poor appetite, excessive guilt, and agitation) and chronic medical conditions had no effect on physician diagnosis of depression. Ani, Bazargan, Hindman, et al.,"Depression symptomatology and diagnosis: Discordance between patients and physicians in primary care settings," BMC Family Practice 9(1), 2008 (AHRQ grant HS14022).

• Black patients are less likely to express their depression than white patients (10.8 vs. 38.4 statements) during primary care visits.

  This study also found that physicians uttered fewer rapport-building statements during visits with black patients than white patients (30.7 vs. 29.7 statements) and made fewer depression-related statements during visits with black patients (4.3 vs. 13.4 statements). Yet, even in visits where communication about depression occurred, physicians considered fewer black than white patients as suffering significant emotional distress (67 vs. 93 percent). There were no differences in depression communication by concordance of physician-patient race or gender. The researchers studied primary care visits of 46 white and 62 black, nonelderly adults with depressive symptoms, who were receiving care from 1 of 54 physicians in urban community-based practices. Ghodes, Roter, Ford, et al., "Patient-physician communication in the primary care visits of African Americans and whites with depression," Journal of General Internal Medicine 23(5):600-606, 2008 (AHRQ grant HS13645).

• Primary care patients suffering from major depression, who are involved in decisions about their care and receive mental health treatment, are more satisfied with their care.

  Fewer than half (43 percent) of the patients in this study received appropriate care for depression (25.9 percent received antidepressants, 27.6 percent counseling, and 10.2 percent both). On average, patients rated their provider a 3.3 out of 5 on the shared decisionmaking scale. Primary care patients who received mental health treatment (antidepressants and/or therapy) were 1.6 times more likely to be satisfied with their care than those who did no receive such care. Those who shared decisionmaking with their doctors were nearly three times more likely to be satisfied with their care than those who were not involved in decisions. The findings were based on analysis of responses to surveys administered to patients in the collaboration and usual care groups at baseline and 6 months later. Swanson, Bastani, Rubenstein, et al., "Effect of mental health care and shared decisionmaking on patient satisfaction in a community sample of patients with depression," Medical Care Research and Review 64(4): 416-430, 2007 (AHRQ grant HS11407).

• Antidepressants and therapy may be cost-effective for patients with medically unexplained symptoms.

  Individuals complaining of physical problems for which there is little or no disease explanation (somatization) make up 5 to 10 percent of primary care patients. These individuals, many of whom are depressed, often embark on a quest to find a disease that they fear but do not have. This typically results in numerous laboratory tests, consultations, and treatments of nonexistent conditions. Not only is this a costly enterprise, but physicians often ignore these patients' emotional distress, note the researchers. They randomized 206 HMO patients with medically unexplained symptoms to usual care or multimodal treatment (antidepressants and therapy). This reduced patient depression and improved satisfaction with providers, decreased physical disability, boosted use of antidepressants, and reduced use of addicting agents such as painkillers. This approach also resulted in insignificantly higher care costs ($1,071) over the 1-year period for the treatment versus the usual care group. Luo, Goddeeris, Gardiner, and Smith, "Costs of an intervention for primary care patients with medically unexplained symptoms: A randomized controlled trial," Psychiatric Services 58(8):1079-1086, 2007 (AHRQ grant HS14206).

Women

• The symptoms of major depression are essentially the same in women who are pregnant and women who are not.

  Depressed pregnant women and depressed nonpregnant women have similar severity of depressive symptoms. Depressed pregnant women have fewer intense feelings of suicide and guilt, and significantly less difficulty falling asleep, but are more likely to show slowed movement and/or speech, found this study. The findings are consistent with previous findings that childbearing alone has a modest, clinically insignificant effect on psychiatric symptoms. The researchers recommend that symptoms of psychological distress should not be written off as a normal part of pregnancy and that more attention should be focused on screening and identifying depressed pregnant women. They recruited the two samples of pregnant women (61 depressed and 41 nondepressed) from a larger study at Stanford University and recruited 53 depressed nonpregnant women from a larger study of acupuncture treatment of depression. Manber, Blasey, and Allen, "Depression symptoms during pregnancy," Archives of Women's Health 11:43-48, 2008 (AHRQ grant HS09988).

• Identifying a patient with depression is often missed amid the bustling activity of an emergency department. Yet that environment may be a good venue for detecting it.

  Researchers reviewed audio recordings of conversations between providers and 871 women aged 18 to 65 who visited either a city or suburban hospital's emergency department (ED) between June 2001 and December 2002. Of the 486 women randomized to complete a health risk survey on a computer, nearly half of them (48 percent) reported they felt sad or depressed for more than 2 weeks during the past month, and 28 percent said they felt sad or depressed for most of the prior 2 weeks. Providers were more likely to address depression and other psychosocial issues when the patient self-disclosed these risk factors on the computer. However, even when prompted to do so by the computer, providers addressed depression with only 70 patients (8 percent) and had significant discussions with only 20 patients (2 percent). It was not uncommon for ED providers to dismiss patients concerns, be judgmental, interrupt their response, or ask multiple questions at one time. On a positive note, in most significant discussions, providers expressed empathy (85 percent) and asked well-worded sensitive questions (90 percent). Rhodes, Kushner, Bisgaier, and Prenoveau, "Characterizing emergency department discussions about depression," Academic Emergency Medicine 14(10):908-11, 2007 (AHRQ grant HS11096).