EPRESSION IS COMMON, WITHthe 1-year prevalence rate of major depressive disorder estimated at between 6.6% and 10.3% in the general population 1,2 and roughly 25% of all primary care visits involving patients with clinically significant levels of depression. 3 Psychotherapy is effective at treating depression, 4 and most primary care patients prefer psychotherapy to antidepressant medication. 5 When referred for psychotherapy, however, only a small percentage of patients follow through. 6 Attrition from psychotherapy in randomized controlled trials is often 30% or greater 7 and can exceed 50% in clinical practice. 8 The discrepancy between patients' preference for psychotherapy and the low rates of initiation and adherence is likely due to access barriers. Approximately 75% of depressed primary care patients report barriers that make it extremely difficult or impossible to attend regular psychotherapy sessions. 9,10 These barriers are largely structural and include time constraints, lack of available and accessible services, transportation problems, and cost.

In spite of repeated calls for research and interventions to overcome individual and systemic barriers to psychological treatments, little is known about the nature of these barriers. To develop a measure of perceived barriers to psychological treatment (PBPT), items derived from 260 participants were administered to 658 primary care patients. Exploratory factor analysis on half the sample resulted in 8 factors, which were supported by confirmatory factor analysis conducted on the other half. Associations generally supported the criterion validity of PBPT scales, with self-reported concurrent use of psychotherapy and psychotherapy attendance in the year after PBPT administration. Depression was associated with greater endorsement of barriers. These findings suggest that the PBPT may be useful in assessing perceived barriers.

Acceptance of screening mammography recommendations decreases with age. Among the women who agreed to the recommendation for screening mammography, insurance type and health care provider level of training best predicted adherence.

Several important changes in clinical research studies published in JAMA, Lancet, and NEJM have taken place between 1971 and 1991. Clinical trials have increased in frequency, largely replacing studies containing ten or fewer subjects. Health services research has increased in prevalence, reflecting growing interest in studies addressing the delivery of health care. Our data support the hypothesis that exclusion of women from clinical research studies is an important contributor to the paucity of data concerning women's health.

The Medical Humanities and Bioethics Program at Northwestern University's Feinberg School of Medicine is responsible for humanities education in all four years of medical school: five units of the required four-year Patient, Physician, and Society course, 37 to 40 medical humanities seminars in years one and two, more than 125 ethics case conferences in third-year clerkships, and electives for fourth-year students. The program faculty also participate in ethics and humanities education in residencies, and the program offers an annual one-year fellowship. The program introduced the small-group teaching that now characterizes much of the school's curriculum, and its course units and seminars have been a resource for faculty development and curricular innovation. Drawing on literature, religion, ethics, philosophy of medicine, film, history, social and cultural anthropology, and jurisprudence, humanities education is designed to foster habits of discourse on social and moral issues in medicine. Small-group teaching and interactive learning are its central pedagogical methods. Essential to their successful use in a school that enrolls approximately 170 students each year is a large cadre of volunteer clinicians who serve as tutors and the college system, a four-part division of each class instituted by the 1993 curriculum reform. Students are evaluated on preparation, class participation, and regular writing assignments. All course units and seminars are pass/fail (as are all first- and second-year courses); tutors supply narrative comments. The courses themselves are thoroughly evaluated by students and reviewed both by the relevant faculty-student committee and at an annual curriculum retreat.

OBJECTIVE:To define the prevalence and detection rates of mental disorders among high utilizers as compared with typical utilizers, and to examine the effect of case-mix adjustment on these parameters. DESIGN:Cross-sectional study. SETTING:General internal medicine outpatient clinic associated with an urban, academic medical center. PATIENTS:From patients attending a general medicine clinic, 304 were selected randomly in three utilization groups, defined by number of clinic visits: (1) high utilizers; (2) case-mix adjusted high utilizers; and (3) typical utilizers (control patients). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:The presence of any mental disorder was ascertained by the PRIME-MD screening instrument. Chart review on all patients was performed to ascertain mental disorders detected by primary care physicians. The prevalence of mood disorders was markedly higher in high utilizers (29%) than in adjusted high utilizers (15%) or controls (10%) ( p Ͻ .001). Anxiety disorders were slightly, but not statistically, more prevalent in the group adjusted for case mix (16%) than in other high utilizers (12%) or controls (9%). Alcoholism was significantly more prevalent in controls (12%) than in adjusted (6%) or other high utilizers (3%) ( p Ͻ .03). The discrepancy in detection rates between PRIME-MD and chart review for any mental disorder was less for high utilizers (37% vs 31%) as compared with adjusted high utilizers (31% vs 11%) or controls (24% vs 8%). CONCLUSIONS:Mood disorders are associated with a high overall burden of illness, while anxiety disorders are more predominant among outliers after case-mix adjustment. Detection rates differ substantially by utilization pattern. Screening efforts can be more appropriately targeted with knowledge of these patterns.

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We varied the softness and nodularity of silicone breast models to assess the effects of age-related breast tissue characteristics on lump detection. In two sets of six silicone breast models manufactured to simulate premenopausal and postmenopausal breast tissue, respectively, 82 internal medicine attending and housestaff physicians more readily detected lumps among models simulating older breast tissue. The proportion of models with one or more false-positive findings was higher among models simulating postmenopausal breast tissue. We conclude that age-related changes in breast tissue most likely contribute to the higher sensitivity of clinical breast examination in older women.