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
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