Objective: The goal of this study was to assess the effects of training primary care providers (PCPs) to use Motivational Interviewing (MI) when treating depressed patients on providers' MI performance and patients' expressions of interest in depression treatment ("change talk") and short-term treatment adherence.Methods: This was a cluster randomized trial in urban primary care clinics (3 intervention, 4 control). We recruited 21 PCPs (10 intervention, 11 control) and 171 English-speaking patients with newly diagnosed depression (85 intervention, 86 control). MI training included a baseline and up to 2 refresher classroom trainings, along with feedback on audiotaped patient encounters. We report summary measures of technical (rate of MI-consistent statements per 10 minutes during encounters) and relational (global rating of "MI Spirit") MI performance, the association between MI performance and number of MI trainings attended (0, 1, 2, or 3), and rates of patient change talk regarding depression treatments (physical activity, antidepressant medication). We report PCP use of physical activity recommendations and antidepressant prescriptions and patients' short-term physical activity level and prescription fill rates.Results: Use of MI-consistent statements was 26% higher for MI-trained versus control PCPs (P ‫؍‬ .005). PCPs attending all 3 MI trainings (n ‫؍‬ 6) had 38% higher use of MI-consistent statements (P < .001) and were over 5 times more likely to show beginning proficiency in MI Spirit (P ‫؍‬ .036) relative to control PCPs. Although PCPs' use of physical activity recommendations and antidepressant prescriptions was not significantly different by randomization arm, patients seen by MI-trained PCPs had more frequent change talk (P ‫؍‬ .001). Patients of MI-trained PCPs also expressed change talk about physical activity 3 times more frequently (P ‫؍‬ .01) and reported more physical activity (3.05 vs 1.84 days in the week after the visit; P ‫؍‬ .007) than their counterparts visiting untrained PCPs. Change talk about antidepressant medication and fill rates were similar by randomization arm (P > .05 for both). Funding: Funding for this study was provided by the National Institute of Mental Health grant nos. K23MH0829972 and 3K23082997-S1; National Institutes of Health/National Center for Advancing Translational Sciences Colorado CTSI grant no. KL2 TR000156 (to CE).Conflict of interest: none declared. In this study we investigated whether a multifaceted MI training improved (1) PCPs' MI performance during index visits with patients with newly diagnosed depression; (2) subsequent outcomes related to patients' expressed interest ("change talk") in improving this condition; and (3) short-term adherence to treatment 5 (Figure 1). Depression is projected to become the leading cause of disability worldwide by 2030 6 and is often treated, at least in part, in primary care. 7,8 In general, poor depression outcomes in primary care 9 -11 are in part because of pervasive nonadherence to depression treatment, which is ...

PURPOSE Primary care clinicians have diffi culty detecting suicidal patients. This report evaluates the effect of 2 primary care interventions on the detection and subsequent referral or treatment of patients with depression and recent suicidal ideation.METHODS Adult patients in 12 mixed-payer primary care practices and 9 not-forprofi t staff model health maintenance organization (HMO) practices were screened for depression. Matched practices were randomized within plan type to intervention or usual care. The intervention for mixed-payer practices entailed brief training of physicians and offi ce nurses to provide care management. The intervention for HMO practices consisted of guided development of quality improvement teams for depression care. A total of 880 enrolled patients met study criteria for depression, 232 of whom met criteria for recent suicidal ideation. Intervention effects on suicide detection and referral to mental health specialty care were evaluated with mixed-effects multilevel models in intent-to-treat analyses.RESULTS Depressed patients with recent suicidal ideation were detected on 40.7% of index visits in intervention practices, compared with 20.5% in usual care practices (odds ratio = 2.64, 95% confi dence interval, 1.45-5.07), with HMO plan type and male sex associated with detection. The interventions had no effect on referral of patients, starting an antidepressant, or suicidal ideation reported at a 6-month follow-up, although power was limited for all 3 analyses.CONCLUSIONS Primary care interventions to improve depression care can improve detection of recent suicidal ideation. Further work is needed to improve physician response to detection, including referral to specialty care and more aggressive treatment, and to observe the effect on outcomes. INTRODUCTION Suicide represents a major social 1 and economic 2,3 burden on the health of the American people and ranks among the top 10 causes of death for Americans aged 10 years and older. 4 Suicide attempts are even more common, 5-7 increase morbidity and health care costs, 3 and further elevate the risk of individuals for a subsequent completed suicide. 8 Suicide prevention has been identifi ed as a national priority 9,10 and is now the target of a comprehensive national strategy. 4 Primary care physicians have an important role in detecting patients at higher risk for suicide, and for prevention. Many [11][12][13][14] but not all 15 studies report that individuals make primary care visits before completing suicide. Improving primary care for suicidal patients poses several critical challenges. Completed suicide is relatively infrequent in primary care practice. Although suicidal ideation is more frequent than suicidal behavior or completed suicide, 16-21 the relationships among ideation, suicide attempts, and completed suicide are uncertain. 5,6,8,[22][23][24][25][26][27] Patients rarely volunteer suicidal ideation, although many will acknowledge ideation if asked directly 13 Rather than increasing primary care physician vigi...

A study was undertaken to compare the regeneration of rat peroneal nerves across a 0.5-cm gap repaired with either a permanent, porous or a resorbable, non-porous artificial nerve graft. The resorbable, impermeable artificial nerve graft was a synthetic passive conduit made from polyglycolic acid (PGA). The permanent, porous artificial nerve graft conduit was manufactured from a hydrophilic elastomeric biopolymer (HEB), and four variations were tested. Qualitative histology on short-term animals revealed similar inflammatory reactions to HEB and PGA. Axonal regeneration was evaluated in longer-term animals after three, four, and six months by qualitative and quantitative histology. Qualitative histology on longer-term animals demonstrated both artificial nerve grafts to be anti-immunogenic. All PGA-artificial nerve graft repairs among three-, four-, and six-month rats contained myelinated axons, as did all HEB-1 repairs. However, three other HEB-graft varieties accounted for a 25 percent failed regeneration rate. Quantitative histologic comparison of repair-site cross-sections in viable PGA and HEB matched pairs demonstrated statistically equivalent myelinated axon counts but larger average myelinated fiber diameters in HEB repairs, with p = .001.

OBJECTIVE:To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes. DESIGN AND SETTING:Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS:Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS:Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS:Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P = .06), receipt of any antidepressant (63.0% vs 20.1%; P = .001), and an adequate antidepressant trial (34.9% vs 5.9%; P = .004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P = .01) and an adequate antidepressant trial (46.0% vs 23.8%; P = .004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS:Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.KEY WORDS: depressive disorder; affective symptoms; moderator variables; somatoform disorders.

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Somatoform distress is a complex, common, and understudied phenomenon in primary care that can adversely affect the treatment of depression. Somatoform symptoms of conversion and hypochondriasis, but not somatization, were found to be risk factors for treatment nonadherence. Somatization and hypochondriacal symptoms may represent personality states that improve with pharmacotherapy, and conversion symptoms may be a personality trait resistant to medical treatment for depression.

Objective: High-quality patient-clinician communication is associated with better medication adherence, but the specific language components associated with adherence are poorly understood. We examined how patient and clinician language may influence adherence.Methods: We audio-recorded primary care encounters from 63 patients newly diagnosed with depression and prescribed an antidepressant medication. We rated clinicians' language (motivational interviewing-adherent statements [MIAs], reflections, and global ratings of empathy and "motivational interviewing spirit") along with patients' "change talk" (CT) demonstrating motivation to take medication. Filling a first prescription and an estimate of overall adherence, the proportion of >180 days covered (PDC) (primary outcome), were measured based on pharmacy records.Results: Fifty-six patients (88.8%) filled an initial prescription, and mean (standard deviation) PDC across all subjects was 45.2% (33.6%). MIAs, complex reflections, and empathy were associated with more CT (for all: r s >0.27; P < .05). Two or more and 0 or 1 CT statements were associated with 63.0% and 36.6% PDC, respectively. Empathy, motivational interviewing spirit, and CT were associated with filling the first prescription (for all: r s >0.25; P < .05). In an adjusted analysis, empathy (t ‫؍‬ 2.3; P ‫؍‬ .027) and >2 CT statements (t ‫؍‬ 2.3; P ‫؍‬ .024) were associated with higher PDC. Nonadherence to antidepressant medication is one of a few potentially modifiable predictors of a poor clinical outcome for people with depression, 1-3 and up to 50% of adults treated for depression in primary care experience clinically significant nonadherence due to side effects, delay in symptom relief, perceived harm of antidepressant medications, and other factors. 4,5 Up to 10% experience primary nonadherence due to not picking up the initial prescription. 6,7 Despite decades of research, there is currently a lack of knowledge about simple, effective interventions to improve medication adherence, and a Cochrane review concluded that most adherence interventions failed to achieve enduring medication adherence or improve patient outcomes.8 Meta-analytical evidence identifies the patient-clinician communication process as a critical and modifiable determinant of subsequent antidepressant adherence, and novel interventions targeting aspects of communication hold promise for positive effects. 9 -11 Yet which aspects of the clinician's or patient's communication are specifically associated with better or worse adherence are unclear.Researchers in the field of motivational interviewing (MI), a patient-centered style of communication intended to help patients resolve ambivalence and work toward improving a targeted maladaptive behavior, 12 have developed instru-

Training providers to frame discussions about depression using MI may improve upon standard management for depression. (PsycINFO Database Record