Best Presentation by a Student (two awards given)
“Predictors and Prevalence of Depression in a Rural Cohort:
Addressing a Primary Care Challenge”
Sarah Roberts; Jeanette Scheid, MD, PhD; and Barbara Levin, MD, MPH. Sarah Roberts – Michigan State University, East Lansing, presenter
 Given the shortage of rural mental health professionals, the primary-care physician plays an increasingly central role in the identification and treatment of mental illnesses. We evaluated the prevalence of depression in two rural community family practice facilities and a birthing center in Eastern Tennessee, and assessed the relationship between depression and specific risk factors in this population, such as gender, age, ethnicity, income, health status and education level. Finally, we compared the actual prevalence of depression to the prevalence predicted by the primary care physicians of that region and to statewide, regional and national prevalence statistics. The Beck Depression Inventory (BDI-II) was used to assess the presence of depressive symptoms in patients who presented for general medical treatment during the two-week study period. Interviews with physicians and community mental health providers were used to identify population-specific challenges and barriers to obtaining mental health care in this region. We found a prevalence of depression symptoms of 42% in these communities, higher than that predicted by the primary care providers of the region, and furthermore confirmed expected relationships of depression to certain risk factors. Using this information, we are able to educate both physicians and medical staff in the rural practices about the prevalence of depression in their community and to recommend that review of mental health problems be incorporated into the standard medical interview.
“The Effects of Reason for Visit Measures of Psychosocial Stress, Mental Health, and Discrimination” Jennifer Wilkerson and Mack T. Ruffin IV, MD, MPH. Jennifer Wilkerson – University of Michigan, Ann Arbor, presenter
Background: Multiple mechanisms, which combine biological and psycosocial factors, have been proposed to explain the influences of stress on health, development of disease, and persistence of disease, particularly cervical cancer, our disease of interest. A number of instruments have been created and validated in order to measure the impact of psychosocial factors in health. In many clinical settings these instruments are completed at the time of an appointment. No investigators have reported on the impact of the setting of instrument completion on the measurement. This is of critical importance for investigators using these tools with study participants recruited in physician offices. Therefore, we proposed to determine if there was any relationship of reason for encounter to the outcome of Perceived Stress Scale (PSS), perceived discrimination, Revised Life Stressor Checklist, Family APGAR (social support), the Life Orientation Test (LOT) and the Primary Care Beck Depression Inventory (BDI-PC). Methods: The study participants consisted of women attending one of two Family Medicine clinics between the ages of 18 and 45, female, and have a history of a normal Pap smear within the past two years. A single questionnaire consisting of the validated tools was used. Results: A total of 141 women participated in the current study, with 60 participants from Clinic A and 81 participants from Clinic B. The women recruited from Clinic A were significantly ( p = .001) more likely to be African American and reported lower formal education and household income. Family APGAR and Revised Life Stressor Checklist scores were significantly different between clinics ( p = 0.007 and p = .001). Significant differences were also found between clinic sites for perceived discrimination ( p = .052) and major life events ( p = .023). The reason for clinic visit was not related to any of the stress measures.
Conclusion: Perceived Stress Scale (PSS), perceived discrimination, Revised Life Stressor Checklist, Family APGAR (social support), the Life Orientation Test (LOT) and the Primary Care Beck Depression Inventory (BDI-PC) commonly used measures are not related to reason for encounter at the time of an appointment. Please see the poster on the relationship of these measures to cervical lesions and infection with HPV.
Best Presentation by a Resident
“Seasonal Variation in Postpartum Depression”
Veena Panthangi, MD; Manjeet Geeta, MD; Eileen Reickert, MD; Patricia West, PhD. Veena Panthangi, MD – St. John Hospital and Medical Center, Detroit, presenter.
Background : Postpartum Depression (PPD) is a serious, debilitating and treatable condition with a prevalence of 10-20%. This study attempts to define the significance of seasonal variation of PPD. Purpose: The purpose of this study was to assess the prevalence of seasonal variation in postpartum depression and other social factors affecting the disorder. Methods: This was a cross-sectional study conducted at two Family Medicine clinics and an OB/GYN clinic, over a period of 21 months. Mothers were given a questionnaire to fill out during their 5-8 wk postpartum visit including demographic data and the Edinburg Postpartum Depression Scale (EPDS). PPD was defined as a score of =/> 13 on the EPDS. Data was analyzed by chi-square test and ANOVA. RESULTS : Of the 505 patients, 497 completed the questionnaire. The study showed 18.4% of the total sample was depressed. 18.7% patients were depressed during winter, 22% during spring, 13.4% during summer, 21.5% during fall. This gave a p=0.248 by chi-square test and ANOVA by month showed a depression rate of 2.6% in July, approximately 30% in Sept, Dec and Feb, p=0.065, neither showing a statistical significance. We found that patients with excellent support at home had less PPD (13%) than mothers with adequate support (43.7%), or very little or no support (30.8%), p<0.0005. We also found that mothers with more children were at greater risk for PPD, p < 0.0005. Patients with prior history of depression were also at significant risk for PPD. Conclusion: Although we found a lower rate of PPD in the summer compared to all other seasons, stronger associations with increased PPD rate were observed for social stressors, small babies, multi-gravity, history of depression and currently taking anti-depressants. Recommendations: It is highly recommended that physicians be on high alert for this disorder in women delivering at all times of the year. Further research should be directed towards elucidating the role of multigravidity and social stressors on PPD.
Best Presentation by a Practitioner
“A Systematic Approach to Diabetes Mellitus Care in Underserved Populations: Improving Care of Minority and Homeless Persons”
Philip J. Baty, MD, and Susan Vivano, RN. Philip Baty, MD– St. Mary's Health Care, Grand Rapids, presenter.
Background: Many underserved populations are at a disproportionate risk for Diabetes Mellitus and associated complications. We identified four community health centers that deliver primary care to Hispanic, African Americans, homeless persons, migrant workers, and the working poor. Through the use of clinical practice guidelines and a chronic disease registry we attempted to reduce disparities in care provided to at-risk patients. Methods: This study compares common Diabetes measures in Diabetes Mellitus patient populations before feedback to the clinics with outcomes after regular clinic specific feedback. Providers were given specific feedback regarding their care of persons with Diabetes and monthly Diabetic registries were made available outlining outcomes right down to the actual lab values. We compare four clinic outcomes with thirteen suburban Family Practice and Internal Medicine office outcomes.
Results: Nearly five thousand patients were evaluated in 2004 (4692) and 2005 (5504) in both groups. Both groups showed improvement in A1c measured, A1c under 7, LDL control, retina exams, urine micro albumin testing. While only the offices (9%) showed improvement in A1c >9.0 control while the clinic showed worsening control (-6%). Despite improvement in scores at the suburban practices variation between the clinics and offices were reduce for all measures except A1c and retina exams. The clinics had 4% greater improvement in A1c done, 22% greater improvement in LDL done, 15% in LDL <130 and 8% in LDL less than 100 and 15% greater improvement in urine micro albumin screening when compared to the offices. Conclusion: Comprehensive and standardized approaches to care of minority and at risk populations result in significant improvement in clinical outcomes and help reduce disparities between vulnerable and Caucasian populations. The reduction in disparity is remarkable because the suburban offices are performing at a very high level on most measures when compared to national standards.
Best Presentation by a Teacher/Faculty
“Does Disease Management Affect Patient Attitudes, Beliefs, or Practices in Chronically Depressed Patients? A Report From the Depression in Primary Care Project”
Michael Klinkman, MD, MS; Sabrina Avripas, MSW; Tanya Adman, MSW; James Aikens, PhD; Kevin Kerber, MD; and Julie Kuebler, CNP. Sabrina Avripas, MSW – University of Michigan, Ann Arbor, presenter.
Background: Recent studies examining depression disease management report improvements in short- and intermediate term clinical outcomes, but little is known about the sustainability of these improvements, particularly for chronically depressed patients. The role of potential mediating mechanisms such as patient attitudes, treatment beliefs, and self-management practices in sustaining change remains largely unexplored. The Depression in Primary Care program is a tailored depression disease management program following principles of the Chronic Care Model; clinicians were free to refer none, some, or all of their depressed patients at their discretion. This study assessed the impact of DPC enrollment on patient attitudes, beliefs, and practices regarding depression treatment over an 18-month period. Methods: Comprehensive mailed surveys administered at baseline, 6, 12, and 18 months to 105 chronically depressed primary care patients identified at study initiation. Respondents were drawn from 5 UMHS intervention sites, where some received the DPC intervention and some did not, and 5 matched UMHS control sites, where no subjects received the DPC intervention. Outcome Measures: Self-reported PHQ-8, SF-12, treatment alliance, and a battery of validated scales assessing attitudes, beliefs, and treatment preferences and practices. Results: Three groups were compared: 26 intervention-site patients referred to DPC [DPC], 46 unreferred intervention-site patients [INT] and 31 control-site patients [CONT]. No significant differences between groups were noted at baseline in demographic, clinical, or outcome variables. Almost all patients were currently in active treatment and receiving antidepressant medications. Mean PHQ scores showed a slightly greater decline in the DPC group than INT or CONT (-2.9 vs.-1.9 and -1.8, p=ns), and DPC patients had a higher remission rate (45% vs. 28% and 30%, p=ns) over 12 months. By 18 months, scores had returned to near baseline in all 3 groups. No significant differences were seen at 6, 12, or 18 months in measures of treatment alliance, attitudes, beliefs, or treatment preferences. Conclusions: Primary care-based depression disease management did not have a significant impact on patient beliefs, attitudes, or the treatment alliance in this sample of chronically depressed patients. In the absence of change in these proposed mediators, the sustainability of clinical improvement in disease management programs is uncertain.
Honorable Mention for Presentation by a Resident
“Does Neuro-Stimulants Use Improve Functionality in Patients With Decreased Level of Consciousness?”
Erin DIviney MD; Claudia Pop MD; Mark Sumers MD; Sunil S. Menawat MD; and Michael Worzniak MD. Erin Diviney, M.D. – Oakwood Annapolis Hospital, Dearborn, presenter.
Previous studies have shown an effect of improved level of consciousness in patients with coma with use of Methylphenidate (1). We were interested in evaluating the effects of Methylphenidate on patients with less drastic deficits in their level of consciousness but still with cognitive or functional deficits that give them a high Disability Rating Score (DRS).
We designed a study following a protocol previously used in clinical practice by one of the PI in treating similar patients. Prior to inclusion, patients were deemed medically stable for CHF, infection, electrolytes and neurological function. Those patients with an initial DRS score greater than four were included. A test dose of 5 mg methylphenidate (at 6 am & 12 noon) was given. After two days, the dose was increased to 10 mg, twice daily. If the DRS remained greater than 4 the dose was increased for a maximum of 20 mg twice daily. Patients were evaluated biweekly.
Population studied included ten patients (2 males and 8 females) the average age was 85.4 years. The average initial DRS was 17.3 and the average final DRS was 6 (p=0.03 X 10 -5 ). The most notable difference was in the categories of Arousability, Awareness & Responsivity and in Cognitive Ability for Self Care Activities. This portion of the DRS improved from an initial average of 10.1 to a final value of 1.6 (p=0.01 X 10 -4 ). No complications occurred in the study period.
Methylphenidate appears to stimulate the neurons in the reticular activating system of the midbrain, which seem to function to establish general consciousness. Our data suggests that improved consciousness improves functionality. There is a cumulative effect, suggesting learning or revival of previously learned behavior. Improved awareness can allow for active engagement by the patients and positively impact their rehabilitation to participate in activities of daily living.
Honorable Mention for Presentation by a Resident “Impact of the Hospitalist Movement on Family Medicine Education”
Antonino Colombo, MD; Nirmal Patel, MD; and Robina Sidhu, MD. Robina Sidhu, MD– Midland Family Medicine Residency Program, Midland, presenter. Introduction/Background: The Hospitalist movement started in mid 1990s and has been rapidly expanding to about 12,000 providers in 2005 and estimated 30,000 by 2010. It has promised cost containment and improved length of stays. Hospitalist care is rapidly changing the family medicine landscape. Our goal was to assess the impact of the hospitalist movement on family medicine residency education to date and to look at the penetrance of hospitalists at training sites. Additionally we assessed the attitude of Family Medicine Directors towards the hospitalist movement. Methods: A two-wave email survey of Family Medicine Residency Directors was sent nationally. The email addresses were obtained from the AAFP residency directory. The survey was designed to assess penetrance of hospitalists at training sites, attitude of Family Medicine Residency Program Directors toward and residency utilization of hospitalists. Results: The survey was sent to a total of 407 programs and our response rate was 16% (66). From the 66 responses we received, 74% (49) had hospitalists. Out of these 49, 88% (43) had internists as their hospitalists and 47% (23) had Family Physicians as the hospitalists. Some of the programs had both Internists and Family physicians, as their hospitalists hence there were an overlap. From the 66 responses, 74% (49) felt the hospitalist movement causes a lack of Family Medicine Philosophy in patient care. Conclusion: The impact of the hospitalist movement on family medicine education has multiple dimensions. Hospitalist medicine is a growing specialty within this nation. Do we embrace the movement or utilize the hospitalist to assist in education? Some residencies have started teaching Hospitalist medicine to Family Medicine Residents. Hospitalists are here to stay and Family Medicine educators will need to adapt to the use of them in hospitals and teaching facilities while maintaining a Family Medicine philosophy of care.
This continuing medical education program was sponsored by
- Department of Family Practice, Michigan State University
- Department of Family Medicine, University of Michigan
- Department of Family Medicine, Wayne State University
- Michigan Academy of Family Physicians Foundation
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