Three relatively simple metabolic markers can help identify overweight individuals who are sufficiently insulin resistant to be at increased risk for various adverse outcomes. In the absence of a standardized insulin assay, we suggest that the most practical approach to identify overweight individuals who are insulin resistant is to use the cut-points for either triglyceride concentration or the triglyceride-high-density lipoprotein cholesterol concentration ratio.

) has recognized the importance of a "constellation of lipid and nonlipid risk factors of metabolic origin" as cardiovascular disease (CVD) risk factors. The ATP III report designated this cluster of related CVD risk factors as "the metabolic syndrome" and stated that "this syndrome is closely linked to insulin resistance." There is now considerable evidence that insulin resistance and/or compensatory hyperinsulinemia are CVD risk factors (2-8), and ATP III recognition of the importance of insulin resistance, and of its manifestations, as increasing CVD risk has focused attention on the metabolic syndrome.In addition to emphasizing the CVD risk of insulin resistance and its manifestations, the ATP III recommended criteria for identifying individuals with the metabolic syndrome. Application of these criteria to the database of the Third National Health and Nutrition Examination Survey (NHANES III) demonstrated that ϳ22% of the population at large met the ATP III criteria for the diagnosis of the metabolic syndrome (9). Although insulin resistance is presumed to be the basic defect leading to the metabolic syndrome (1), neither assessment of insulin resistance nor hyperinsulinemia were among the proposed ATP III criteria. This omission was not surprising because specific measurements of insulin resistance are not clinically practical. Plasma insulin concentrations are often used as surrogate measures of insulin resistance, but their ability to predict insulin resistance is relatively modest (10). Furthermore, because techniques for measuring plasma insulin concentration are not standardized, values will vary substantially from one clinical laboratory to another. Finally, no specific plasma insulin concentration has been validated as a predictor of CVD. Thus, the decision of the ATP III to use putative manifestations of insulin resistance and compensatory hyperinsulinemia to identify subjects with the metabolic syndrome is understandable.Reports have subsequently been published showing that application of the criteria proposed by the ATP III for the diagnosis of the metabolic syndrome identifies individuals at increased CVD risk (11,12). However, because the abnormalities selected by the ATP III to diagnose the metabolic syndrome (obesity, hyperglycemia, hypertriglyceridemia, a low HDL cholesterol concentration, and hypertension) are known CVD risk factors (13-17), it might have been anticipated that CVD risk would be increased in those individuals who had at least three of these abnormalities. On the other hand, the relationship between insulin resistance and the five abnormalities selected by the ATP III to diagnose the metabolic syndrome has not been defined. Furthermore, CVD is not the only clinical syndrome with increased prevalence in insulin-resistant individuals; in addition to type 2 diabetes (18) From the

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BACKGROUND Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions. METHODThe Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site.RESULTS Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care.CONCLUSIONS Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care. INTRODUCTIONT o address patient, physician, and health system barriers to adequate care of depression and other mental health conditions of late life, innovative models are being tested to enhance the recognition and management of mental health problems in primary care.1-3 The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a multisite effectiveness trial designed to assess the use of a mental health and substance abuse (MH/SA) specialist co-located in the primary care practice to enhance treatment (the integrated care model) and the use of direct referral to specialty care (the enhanced referral model) for older adults with depression, anxiety, or alcohol use problems. We asked the clinicians to offer their perspectives on the specifi c interventions tested in PRISM-E. Given the heterogeneity of how primary care clinicians manage depression, 4 it is important to be aware of systems of care that clinicians Our study differs from previous studies of attitudes of primary care clinicians regarding MH/SA treatment given to patients in primary care. First, most studies have focused on depression, 5-7 whereas we were able to examine several conditions that affect older adults in relation to primary health care. Second, we have focused on the mental health care of older adults, in contrast with other studies that have not considered the specifi c needs of older persons. [5][6][7] Most importantly, unlike stu...

Religious participation is positively associated with older adults' mental health status and treatment effects, but results regarding mental health service utilization were inconclusive.