***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Significant symptoms of depression are common in the older community-dwelling population . Although depressive symptoms and disability may commonly occur in the same person , whether depressive symptoms contribute to subsequent functional decline has not been eluci date d. OBJECTIVE To determine whether depressive symptoms in older persons increase the risk of subsequent decline in physical function as measured by objective performance-based tests . DESIGN A 4-year prospect i ve cohort study . SETTING The communities of Iowa and Washington counties , Iowa . PARTICIPANTS A total of 1286 persons aged 71 years and older who completed a short battery of physical performance tests in 1988 and again 4 years later . MAIN OUTCOME MEASURES Baseline depressive symptoms were assessed by the  Center for Epidemiological Studies Depression Scale .  Physical performance tests included an  assessment of st and ing balance , a timed 2.4-m ( 8-ft ) walk , and a timed test of 5 repetitions of rising from a chair and sitting down .  RESULTS After adjustment for baseline performance score , health status , and sociodemographic factors , increasing levels of depressive symptoms were predictive of greater decline in physical performance over 4 years ( odds ratio for decline in those with depressed mood vs those without , 1.55 ; 95 % confidence interval [ CI ] , 1.02 - 2.34 ) . Even among those at the high end of the functional spectrum , who reported no disability , the severity of depressive symptoms predicted subsequent decline in physical performance ( odds ratio for decline , 1.03 ; 95 % CI , 1.00 - 1.08 ) . CONCLUSIONS This study provides evidence that older persons who report depressive symptoms are at higher risk of subsequent physical decline . These results suggest that prevention or reduction of depressed mood could play a role in reducing functional decline in older persons BACKGROUND Exp and ing access to high- quality depression treatment will depend on the balance of incremental benefits and costs . We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care . METHODS Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years . A 2-step screening process identified patients with current depressive disorders , who were not in active treatment . Eligible patients were r and omly assigned to continued usual care ( n = 189 ) or to an organized depression management program ( n = 218 ) . The program included patient education , antidepressant pharmacotherapy initiated in primary care ( when appropriate ) , systematic telephone monitoring of adherence and outcomes , and psychiatric consultation as needed . Clinical outcomes ( assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months ) were converted to measures of " depression-free days . " Health services utilization and costs were estimated using health plan-st and ardized cl aims . RESULTS The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months ( 95 % confidence interval [ CI ] , 28.2 - 67.8 days ) . Estimated cost increases were $ 1008 per year ( 95 % CI , $ 534-$1383 ) for outpatient health services , $ 1974 per year for total health services costs ( 95 % CI , $ 848-$3171 ) , and $ 2475 for health services plus time-in-treatment costs ( 95 % CI , $ 880-$4138 ) . Including total health services and time-in-treatment costs , estimated incremental cost per depression-free day was $ 51.84 ( 95 % CI , $ 17.37-$108.47 ) . CONCLUSIONS Among high utilizers of medical care , systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs OBJECTIVE A r and omized controlled trial was conducted to examine the clinical effectiveness of providing general practitioners ( GPs ) with the results of a self-administered computerized assessment of common mental disorders . METHOD Attenders at a general practice in a deprived inner city area of South London were identified using case finding question naires . Six hundred and eighty-one subjects were r and omly allocated to three groups which differed in the information provided to the GP : 1 ) no additional information was given to the GP ; 2 ) the results of the 12 item General Health Question naire ( GHQ ) were given to the GP ( the GHQ is a paper and pencil question naire that assesses common mental disorders ) ; 3 ) the results of a self-administered computerized assessment ( PROQSY ) of common mental disorders were provided for the GP . RESULTS Clinical outcome was assessed using the 12-item GHQ . Consultations with the GP , prescriptions and referrals within and outside the practice were also recorded . The group in whom the GP received the results of the computerized assessment showed a modest clinical improvement , relative to the other two groups after 6 weeks . There was no difference in clinical outcome between the groups at 6 months . There appeared to be no increase in consultations or prescriptions in the computerized assessment group . CONCLUSIONS Self-administered computerized assessment s for psychiatric disorder have potential as a means of improving the clinical outcome of patients in primary care . It is likely that the effectiveness of the approach would be greatly increased by linking the results of computerized assessment s to clinical practice guidelines , tailored to the individual patient by means of computerized technology The usefulness of the  Zung Self-Rating Depression Scale  as a screening instrument to uncover masked depression , and the benefits of early identification and treatment with alprazolam , were evaluated in a general medical practice population . There was a 95 % scale acceptance by patients and a 12 % overall prevalence of depression based on SDS results . Patients who scored in the depressed range on the SDS were , on a r and omized basis , either identified immediately to their physicians and treated with alprazolam ( N = 21 ) or identified after 4 weeks ( natural history controls , N = 20 ) . Treatment result ed in improvement in 66 % of the identified group versus a 35 % spontaneous improvement in the control group ( p less than .05 ) OBJECTIVE To evaluate the recognition , management , and outcomes of depressed patients presenting in primary care . DESIGN Epidemiologic survey with 12-month follow-up . SETTING Primary care clinics of a staff-model health maintenance organization . PATIENTS AND MAIN OUTCOME MEASURES Consecutive primary care attenders aged 18 to 65 years ( n = 1952 ) were screened using the 12-item General Health Question naire ( GHQ-12 ) , and a stratified r and om sample ( n = 373 ) completed a psychiatric assessment , including the Composite International Diagnostic Interview ( CIDI ) , the 28-item GHQ  , and a brief self-rated disability question naire ( BDQ ) . Three-month follow-up assessment ( n = 347 ) repeated the  GHQ-28 and BDQ  , and 12-month follow-up ( n = 308 ) repeated the  CIDI , GHQ-28 , and BDQ .  Use of psychotropic drugs and mental health services was assessed using computerized pharmacy and visit registration records . RESULTS Structured interviews found 64 cases of current major depression ( weighted prevalence , 6.6 % ) and 58 cases of current subthreshold depression ( weighted prevalence , 8.8 % ) . Of those with major depression , 64 % ( n = 41 ) were recognized as psychologically distressed by the primary care physician , 56 % ( n = 36 ) filled at least one antidepressant prescription during the next 3 months , and 39 % ( n = 25 ) made at least one specialty mental health visit . Compared with recognized cases , those with unrecognized major depression were less symptomatic at baseline ( GHQ-28 score , 15.31 vs 11.07 ; P = .006 ) but showed a similar rate of improvement over 12 months ( F test for difference in slopes , P = .93 ) . CONCLUSIONS While many depressed primary care patients may go unrecognized and untreated , this group appears to have milder and more self-limited depression . A narrow focus on increased recognition may not improve overall outcomes . Treatment re sources might be best directed toward more intensive follow-up and relapse prevention among those now treated Depressive disorders are common , persistent , and recurring afflictions among primary care patients . They cause substantial suffering for patients and their families and are associated with a loss of personal productivity and a markedly increased risk for suicide . Further , the presence of depression puts persons with comorbid conditions , such as recent myocardial infa rct ion , at increased risk for illness and death . Persons with depression spend more time with their physicians during office visits and use more health care than persons without depression [ 1 ] . The annual health care cost associated with depression in the United States is estimated to be $ 43.7 billion [ 2 ] . Underscoring the importance of identifying patients with depression is that the effectiveness of therapy , including antidepressants , psychotherapy , and counseling , has clearly been established [ 3 ] . Despite these issues , primary care providers fail to diagnose and treat as many as 35 % to 50 % of patients with depressive disorders [ 4 , 5 ] . Obstacles to the appropriate recognition of depression include inadequate provider knowledge of diagnostic criteria ; competing comorbid conditions and priorities among primary care patients ; time limitations in busy office setting s ; concern about the implication s of labeling ; poor reimbursement mechanisms ; and uncertainty about the value , accuracy , and efficiency of screening mechanisms for identifying patients with depression . We address the last of these obstacles and assess the feasibility and operating characteristics of several case-finding instruments that have been used to detect depressive disorders in primary care setting s. Our ultimate goal is to familiarize providers with the advantages and disadvantages of these instruments so that they can make informed decisions about incorporating them into practice . Methods Data Acquisition We did a MEDLINE search of the English- language medical literature published from 1966 through February 1994 . Search terms included depressive disorder or depression , diagnosis , and the specific names of each of 11 case-finding instruments cited in previous relevant review s or bibliographies [ 6 - 9 ] . Other sources were references identified from pertinent articles and national experts in the field of depression . Experts included authors of papers that were selected for review and two members of the Agency for Health Care Policy and Research Guideline Panel on Depression . Of 906 articles identified through MEDLINE , 210 were deemed potentially relevant . These were review ed to identify studies that met the following selection criteria . Study sample s had to have been composed of primary care patients attending clinic . Patients were excluded if they had been selected because they had specific conditions ( such as chronic pain or cancer ) or because they had specific demographic characteristics ( for example , they were immigrants in a particular ethnic group ) . Both a case-finding instrument and a diagnostic criterion st and ard had to have been administered . The criterion st and ard had to have had formal st and ardized diagnostic criteria for depression . Accepted criterion st and ards were the Diagnostic Schedule Manual-3 criteria ( DSM-III or DSM-III-R ) and the Research Diagnostic Criteria , or a close approximation of these . St and ard interview procedures , such as the Diagnostic Interview Schedule or the Structured Clinical Interview for DSM-III , had to have been used to arrive at the diagnosis . Chart or physician diagnoses of depression that were made without specified formal interview procedures and diagnostic criteria were excluded . Nineteen studies involving nine case-finding instruments met the selection criteria : Fourteen were found during the MEDLINE search ; 1 came from a relevant bibliography ; and 4 were unpublished at the time of the search and came from experts [ 10 - 28 ] . Of the remaining articles screened , 92 % were excluded because they did not involve primary care patients , 6 % were excluded because they had used an inadequate criterion st and ard , and 2 % were excluded because they involved selected population s [ 29 , 30 ] or because they had tested modified and unvali date d versions of case-finding instruments [ 31 ] . Data Extraction Articles were abstract ed by two independent review ers . Determination of study quality was made on the basis of 1 ) whether the case-finding instrument was administered and interpreted independently of the criterion st and ard and 2 ) whether the proportion of persons receiving the criterion st and ard assessment was less than or more than 50 % of those approached for criterion st and ard assessment . Quality assessment addressed method ologic issues relevant to the evaluation of diagnostic tests ( such as independent assessment and selection bias ) and did not necessarily reflect the ability of studies to address their original aims . There were no disagreements about quality assessment s. Data Synthesis Established cut-points for case-finding instruments ( Table 1 ) were used . Two-by-two tables were constructed that categorized numbers of screened-positive and screened-negative persons who did and did not meet criterion st and ard diagnosis for major depression and major depression or dysthymia . Kraemer 's method [ 32 ] was used to adjust for verification bias for studies that used two-stage assessment techniques ; whereby the criterion st and ard was administered only to a r and om sample of persons who screened negative on case-finding instruments [ 33 ] . The authors of all but one study provided us with additional data and analyses when two-by-two tables could not be derived from abstract ion of the published article . This one study [ 28 ] was dropped from further review because its authors could not be contacted and tables could not be derived from published information . Table 1 . Characteristics of  Case-Finding Instruments That Have Been Used to Detect Depression in Primary Care Setting s * A scattergram ( 
    Output:
    
and Over the past 2 weeks , have you felt little interest or pleasure in doing things ? ) ,
appear to perform as well as longer instruments .