Relationship between depression and non-adherence to anticoagulant therapy after valve replacement

Management of anticoagulant therapy after mechanical valve replacement is difficult in developing countries because of patient non-adherence. The effect of depression on adherence to drug therapy and to a clinic visit schedule was evaluated for 62 patients who received prostheses. All were prescribed a once-per-day regimen of warfarin and were scheduled for three appointments at the anticoagulant clinic for dose adjustment at 3-week intervals. According to the Center for Epidemiological Studies Depression Scale, 22 were depressed. Non-depressed patients were more compliant than depressed patients; adherence was inversely correlated with depression scores. While depression had no relationship with age, sex and cardiac symptoms, there was a relationship with anxiety and poor social support.

Place of chronic insomnia in the course of depressive and anxiety disorders

BACKGROUND

Insomnia is frequent in the general population and is often related to a psychiatric illness. However, little is known about how the chronicity of insomnia affects this relation and how often subjects with chronic insomnia have antecedents of psychiatric disorders.

METHODS

A total of 14,915 subjects aged from 15 to 100 years representative of the general population of the United Kingdom, Germany, Italy, and Portugal were interviewed by telephone using the Sleep-EVAL system. The questionnaire assessed current psychiatric disorders according to the DSM-IV classification and a series of questions assessed the psychiatric history. Insomnia was considered as chronic when it lasted for 6 months or more.

RESULTS

The prevalence for insomnia accompanied with impaired daytime functioning was 19.1% and significantly increased with age. More than 90% of these subjects had a chronic insomnia. About 28% of subjects with insomnia had a current diagnosis of mental disorders and 25.6% had a psychiatric history. A DSM-IV insomnia disorder was found in 6.6% of the sample. Presence of severe insomnia, diagnosis of primary insomnia or insomnia related to a medical condition, and insomnia that lasted more than one year were predictors of a psychiatric history. In most cases of mood disorders, insomnia appeared before (> 40%) or in the same time (> 22%) than mood disorder symptoms. When anxiety disorders were involved, insomnia appeared mostly in the same time (>38%) or after (> 34%) the anxiety disorder.

CONCLUSIONS

The study shows that psychiatric history is closely related to the severity and chronicity of current insomnia. Moreover, chronic insomnia can be a residual symptom of a previous mental disorder and put these subjects to a higher risk of relapse.

The links between the Adolescent Dissociative Experiences Scale (A-DES), fantasy proneness, and anxiety symptoms

The purpose of this study was to further examine the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES). A sample of normal adolescents (N = 331) aged 12 to 18 years completed the A-DES and questionnaires measuring posttraumatic stress disorder (PTSD) symptoms, other anxiety disorder symptoms, and fantasy proneness. Factor analysis indicated that the A-DES, at least in nonreferred youths, is assessing a single dimension of dissociation. Furthermore, A-DES scores are not only significantly related to PTSD symptoms but also to other anxiety disorder symptoms (i.e., generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder) and fantasy proneness. Theoretical and practical implications of these findings are briefly discussed.

Evaluating the efficacy of habit reversal: comparison with a placebo control

BACKGROUND

The purpose of this study was to compare the effectiveness of habit reversal with a placebo control as a treatment for chronic nail biting in adults.

METHOD

Thirty adults with a chronic nail-biting problem (occurring > or = 5 times/day nearly every day for > or = 4 weeks and causing physical damage or social impairment) were randomly assigned to a placebo control or habit reversal group. Five participants withdrew from the study prior to the completion of treatment. The remaining individuals in both groups received a total of 2 hours of treatment over 3 sessions. Individuals in the habit reversal group (N = 13) received the components of awareness training, competing response training, and social support. Individuals in the placebo control group (N = 12) simply discussed their nail biting. At pretreatment, posttreatment, and a 5-month follow-up, nail length was measured, photographs were taken of the damaged nails and later rated by independent observers, and data on participant depression, anxiety, and self-esteem were obtained. Treatment compliance and acceptability data were collected at posttreatment only.

RESULTS

Results showed that habit reversal produced a greater increase in nail length at posttreatment and follow-up when compared with the placebo. Data from the independent raters confirmed these findings. Habit reversal was also viewed as a more acceptable intervention by the participants. At posttreatment, the habit reversal group had increased their nail length by 22% from pretreatment compared with a 3% increase for the placebo group. At follow-up, the habit reversal group maintained a 19% increase in nail length from pretreatment compared with a 0% increase for the placebo group.

CONCLUSION

Findings from this study suggest habit reversal is more effective than a placebo control and should be considered a well-established intervention for body-focused repetitive behaviors.

Recall of childhood psychopathology more than 10 years later

OBJECTIVE

This study investigated recall in a sample of depressed, anxious, and normal children followed up as adults. Strengths of this study were that the length of the retest interval was substantial, follow-up information was collected by blind interviewers, and childhood diagnoses were clearly documented.

METHOD

The sample consisted of 144 subjects with a childhood diagnosis of depression, 48 with a childhood diagnosis of anxiety, and 128 normal controls. Best-estimate diagnoses assigned at follow-up were compared with childhood primary diagnoses.

RESULTS

Reliability and sensitivity were fair for major depressive disorder (mean = 0.46 and 50%, respectively) and any depression (mean = 0.57 and 65%, respectively). Reliability and sensitivity were relatively lower for anxiety (mean = 0.32 and 43%, respectively). Sensitivity for any diagnosis was good (mean = 71%). Specificity was good among all diagnostic categories (range = 73%-100%). Results suggest better diagnostic recall for females than for males. Recall was slightly better for subjects who were older than age 12 during their original episode. Age-of-onset reliability was poor (major depressive disorder = 0.22, any depression = 0.22, and any anxiety = -0.13).

CONCLUSIONS

Recall of any childhood disorder is moderately reliable and accurate. Recall of a specific disorder is less accurate. Depression was more likely to be recalled than anxiety. High specificity suggests that participants were not biased to report disorders not present in childhood.

[The significance of structural dynamics for a theory of neurosis and personality disorders]

Following the psychopathological approach of Janzarik (structural dynamics), this paper develops a two-dimensional theory for the understanding of neuroses and personality disorders. The dynamic dimension serves to describe the symptomatology between the two poles of anxiety and depression. The structural dimension differs according to the maturity of the personal identity between mature neurotic personality organization on the one hand and severe personality disorder on the other.

DSM-IV criteria for generalized anxiety disorder in older adults: Distinguishing the worried from the well

This study compared 36 older adults with generalized anxiety disorder (GAD), 22 older adults with subsyndromal anxiety symptoms, and 32 normal controls on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) for GAD. GAD patients reported more frequent and uncontrollable worry, somewhat different worry content, higher prevalence of most associated symptoms, and more distress or impairment than the subsyndromal group or normal controls. Individuals with subsyndromal anxiety reported more excessive, frequent, and uncontrollable worry than asymptomatic individuals, along with more sleep disturbance, fatigue, and distress or impairment. Results indicate that the key features of late-life GAD are distress and impairment, frequency and uncontrollability of worry, muscle tension, and sleep disturbance and that clinicians treating older adults with GAD should monitor and treat residual symptoms.

Reliability and Validity of the Revised Children's Manifest Anxiety Scale in a French-Canadian Sample

The aim of this study was to examine the reliability and validity of a French version of the Revised Children's Manifest Anxiety Scale (RCMAS). A sample of 2,666 school-age French-Canadian children completed the questionnaire. With regard to factor structure, the 5-factor model found in U.S. normative samples was confirmed. The internal consistency of the 5 scales and of the 2 global scales was good to excellent. Test-retest reliabilities after a 6-month period were also similar to those of the original version. Finally, the concurrent validity, assessed by a correlation with the State-Trait Anxiety Inventory for Children, was also found to be good. Results of the present study show that the French version of the RCMAS is a good instrument to assess anxiety in children.

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE

To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting.

DATA SOURCES

Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR.

CONCLUSIONS

Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services.

IMPLICATIONS FOR PRACTICE

This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.

[Spectrum of therapeutic efficacy and safety of Lorafen (lorazepam) use for anxiety disorders]

Presented here, are the results of 4-weeks lorafen monotherapy in 31 in-patients of psychiatric and cardio-surgical clinics divided, respectively, into 2 groups: 16 patients with chronic anxiety disorders and 15--with acute developed before an coronary artery bypass surgery in ischemic heart disease. A dynamics of the patients' state was evaluated with Hamilton Rating Scale for Anxiety and the Hospital Anxiety and Depression Scale. Lorafen proved to be highly effective, with percentage of responders being about 77% (24 patients out of 31). Therapeutically effective dosage was 3.7 +/- 1.1 mg daily for chronic anxiety disorders and 2.1 +/- 0.6 mg--for situation-induced anxiety. Lorafen was shown to be tolerable and safety.

Functional status and somatization as predictors of medical offset in anxious and depressed patients

OBJECTIVE

Certain anxious/depressed primary care patients decrease medical utilization after mental health treatment. Previous research has established demo-graphic and medical comorbidities as distinguishing these patients. We asked whether characteristics such as symptom severity, somatization, or health-related quality of life (HRQoL) could also distinguish patients who reduce or increase primary care utilization after mental health care.

METHODS

Primary care patients in a mixed-model HMO were screened for untreated anxiety with and without depression, using the Symptom Checklist (SCL-90-R) and medical records abstractions, and also for HRQoL (SF-36). We identified 165 symptomatic patients who subsequently received mental health treatment and then defined two subgroups: 1) offset patients (reduced medical utilization the year after initiation of mental health treatment) (N=97); and 2) no-offset patients (increased utilization) (N =68).

RESULTS

Three HRQoL domains (general health perceptions, physical functioning, and role functioning- physical) predicted increased offset savings in the year after initiation of mental health treatment. Each point of improved functioning in these domains was associated with 4 dollars to 10 dollars of additional offset savings. Somatization-related comorbidities were predictive of greater additional costs (230 dollars).

CONCLUSION

Using models to predict individual patient costs, we found that HRQoL and somatic comorbidities did not predict by anxiety/depression symptom severity or medical comorbidities, but by increasing or decreasing utilization after mental health care. Patients with higher functioning levels and no somatic comorbidities were most likely to reduce utilization. These findings support growing evidence for the need of inclusion of reliable indicators of somatization and patients' functioning in offset research and inpatient care.

[Thinking on the coming psychiatry--what the DSM-diagnosis brought about in our psychiatry]

Since the DSM-III diagnosis has been introduced in our psychiatric practices in 1980, the mental disorders which have been thought to be of psychological quality now came to have the biological basis. This means the rebirth of W. Griesinger's concept in which the psychosis is the brain disease. We should say, the mental disorders are the brain disease. This movement is a new conservatism. The second characteristics are widening of concept "mental disorder". The personality disorder is new category which is different from the classical concept of psychopathy. Now all psychiatric professors in Japan have recognize the concept "borderline personality disorder". This means that the psychiatrist has taken over the responsibility about the psychosocial problems from which they had kept themselves away in their clinical practices. The third is that the generalized anxiety disorder and the social anxiety disorder have been included in the DSM diagnosis. These are the borderland concept between the healthy and pathological condition which has been thought to belong to the mental health area. These have given us, the psychiatrist, the opportunity to think again on what the mental soundness really is.

Multiple informant agreement and the anxiety disorders interview schedule for parents and children

OBJECTIVE

To examine concordance of child, parent, and consensus agreement on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P), for an outpatient sample of children and adolescents and to explore moderators of those relations. Child characteristics (age, gender, social desirability), a family environment variable (conflict), and type of diagnoses (internalizing, externalizing) were systematically examined.

METHOD

These relations were examined in 165 children and adolescents referred to a psychological clinic by family practitioners, pediatricians, schools, and mental health professionals. Participants were individually administered the ADIS-C or ADIS-P by separate clinicians, and consensus diagnoses were determined in a clinical conference. Agreements between child-parent, child-consensus, and parent-consensus were determined.

RESULTS

Poor levels of agreement were found among our informants, especially between child and parent and to some extent between child and consensus. Agreement was higher between parent and consensus, suggesting that our clinicians tended to favor parent input over child input. Although the effects were complex, characteristics of the child, family, and type of diagnosis moderated or qualified these findings.

CONCLUSIONS

Although discrepancies exist among our informants, our overall findings suggest important information is obtained from each informant and, when combined with certain modifying characteristics, may lead to diagnostic and treatment decisions.

An open-label, flexible-dose study of olanzapine in the treatment of trichotillomania

BACKGROUND

Thus far, only selective serotonin reuptake inhibitors have been systematically studied in the treatment of trichotillomania, and the results are conflicting. This open-label study is the first to systematically evaluate an atypical neuroleptic, olanzapine, as a monotherapy in the treatment of trichotillomania.

METHOD

Twenty-one patients were screened and 18 patients were enrolled in a 3-month open-label study of olanzapine for trichotillomania (diagnosis based on modified DSM-IV criteria). Patients with comorbid psychiatric disorders or on treatment with psychoactive medication were excluded. Olanzapine was titrated gradually in 2.5-mg/week increments up to a maximum dose of 10 mg/day.

RESULTS

Seventeen patients who completed at least 1 week of olanzapine treatment were evaluated. Hair pulling, as measured by the Massachusetts General Hospital Hairpulling Scale, decreased by 66% from baseline (p < or =.001), and mean scores on the Hamilton Rating Scale for Anxiety decreased by 63% (p < or =.05). Clinical Global Impressions scale scores also revealed significant improvement as a whole (p < or =.001), with 4 patients having complete symptom remission at the end of the study period.

CONCLUSION

Findings suggest that olanzapine may be an effective monotherapy for trichotillomania.

Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings

OBJECTIVE

The authors present data from a pilot research program initiated to develop, refine, and test the outcomes of CBT-GAD/PC, a version of cognitive-behavior therapy (CBT) that targets the needs of older adults with generalized anxiety disorder (GAD) in primary care (PC).

METHODS

The study involved a small, randomized clinical trial comparing the impact of CBT-GAD/PC to usual care (UC) in a sample of 12 older medical patients with GAD.

RESULTS

Outcome data suggested significant improvements in worry and depression after CBT-GAD/PC, relative to UC.

CONCLUSION

Authors discuss results in terms of the "real-world" applicability of this treatment for late-life GAD, and present implications for future research.

[Meaning of "becoming" in the Japanese psychopathologic view as compared with the German-speaking view]

Until now, Japanese cultural concepts such as "ki" and "aida" were used to introduce new perspectives to psychopathology. Universal concepts can also serve this purpose when the culturally different connotations are worked out. In this study,we discuss the concept "becoming," which is not only universal but also undoubtedly one of the key words in psychiatry. As is well known,Zutt made a contribution to psychopathology with a clear differentiation between "becoming" and "doing." It is interesting that some Japanese linguists also mentioned the same difference, namely that between the Japanese logic of "becoming" and the Western logic of "doing." Accordingly, tai-jin-kyôfu as anxiety about "becoming" is contrasted with sociophobia as anxiety about "doing." However, "becoming" in the sense of Zutt is different from the Japanese in three aspects,namely the physical, social and temporal ones. These differences refer to the various meanings of "nature." Finally,we mention the possibility of applying the Japanese term "becoming" to psychopathology.

Clinical correlates of inpatient suicide

BACKGROUND

Previous suicide assessment research has led to standard predictors of risk. Despite this, there are approximately 30,000 suicides per year in the United States, 5% to 6% of which occur in hospitals. The primary purpose of this study is to improve our ability to assess risk and intervene successfully.

METHOD

Charts from 76 patients who committed suicide while in the hospital, or immediately after discharge, were reviewed. The week before suicide was rated for both standard risk predictors and, using items from the Schedule for Affective Disorders and Schizophrenia (SADS), for presence and severity of symptoms found to be correlated with acute risk in recent studies.

RESULTS

Regarding standard predictors, only 49% (N = 37) had any prior suicide attempt and 25% (N = 19) were admitted for this reason. Thirty-nine percent (30/76) were admitted for suicidal ideation, but 78% denied suicidal ideation at their last communication about this; 46% (N = 35) showed no evidence of psychosis; of those on precautions (N = 45), 51% (N = 23) were on q 15 minute suicide checks or 1:1 observation; and 28% (N = 21) had a no-suicide contract in effect. On SADS ratings, 79% (N = 60) met criteria for severe or extreme anxiety and/or agitation.

CONCLUSION

Standard risk assessments and standard precautions used were of limited value in protecting this group from suicide. Adding severity of anxiety and agitation to our current assessments may help identify patients at acute risk and suggest effective treatment interventions. The importance of a matched comparison group to ascertain if this sample can be blindly discriminated from inpatients who do not commit suicide is clear.

Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co-morbidity include recent stress, lower self-rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms.

Neuroendocrine response to meta-chlorophenylpiperazine and ipsapirone in relation to anxiety and aggression

The aim of this study was to establish the association of trait anxiety and anger with hormonal responses to acute challenges with two different 5-HT agonists in a mixed group of patients with depressed mood. Fifteen patients and 16 normal controls received single oral doses of 0.5 mg/kg meta-chlorophenylpiperazine (MCPP), a 5-HT(2C) agonist, and 10 mg of ipsapirone, a 5-HT(1A) agonist, according to a double-blind, placebo-controlled, cross-over design. Dutch-adapted versions of the Spielberger Trait-Anxiety Inventory and the Spielberger Trait-Anger Scale administered assessed at study entry. Hormonal responses, expressed as drug-placebo differences, to MCPP and ipsapirone (changes in cortisol, ACTH and prolactin) were measured. Blood levels of MCPP and ipsapirone were also measured. MCPP and ipsapirone elevated cortisol, ACTH and prolactin. In the patient group, there was a significant correlation between trait anxiety and the cortisol response to MCPP. No significant correlations between the ACTH and prolactin responses to MCPP and levels of anxiety/anger were observed in the patients. No significant correlations could be established between levels of anxiety/anger and hormonal responses to ipsapirone. This study provided evidence for an association between measures of anxiety/aggression and the hormonal response to MCPP. Thus, in subjects with depressed mood, high levels of anxiety suggest a higher probability of 5-HT(2C) disturbances.

Is "shy bladder syndrome" a subtype of social anxiety disorder? A survey of people with paruresis

Paruresis is characterized by the fear of not being able to urinate in public bathrooms and has been classified by some to be a sub-type of social anxiety disorder (social phobia). Despite the existence of a consumer advocacy organization, the "Intentional Paruresis Association (www.paruresis.org)," there is sparse literature on this condition. A survey of people affiliated with the "International Paruresis Association" was undertaken using a self-report questionnaire with items that addressed demographic variables, the phenomenology of paruresis, comorbid disorders, and the impact of symptoms on quality of life. Sixty-three patients (59 M, 4 F) completed the questionnaire. The mean age of the subjects was 38.1+/-12 years, with the mean duration of symptoms being 24.5+/-13 years. Paruresis impacts significantly on sufferers' lives, with approximately one third limiting or avoiding parties, sports events, or dating and just over half of the sample limiting the job they choose to do. Social anxiety disorder (SAD) and depression are the most common comorbid disorders and the most common disorders in family members. Analysis of Liebowitz Social Anxiety Scale (LSAS) scores showed higher performance than social interaction subscale scores across the whole sample (whether suffering from SAD or not.) However, compared to subjects without co-morbid SAD, those with comorbidity had higher total, performance, and social interaction scores. Thus, paruresis can be a chronic and disabling symptom, and there seems to be an association between paruresis and other performance anxieties. Further research to characterize paruresis and to determine effective treatments is needed.

Anxiety sensitivity and PTSD among female victims of intimate partner violence

The purpose of this study was to evaluate the relationship between anxiety sensitivity (AS) and posttraumatic stress disorder (PTSD) in women. The study involved three groups: women with no history of exposure to serious trauma (n = 30), women who had been exposed to intimate partner violence (IPV) but never developed PTSD (n = 23), and women with IPV exposure and current PTSD (n = 19). As a part of a larger study, they completed measures of AS, PTSD symptomatology, and depression. Women with PTSD reported the highest levels of AS, although traumatized women with PTSD reported more AS than did women with no trauma history. AS-related psychological concerns were a statistical predictor of PTSD symptoms when the entire sample of women was considered but not among the subset with a trauma history. Nonetheless, AS may be an important factor to consider in treatment of individuals with PTSD.

[The generalized anxiety disorder--disease pattern, diagnostics and therapy]

OBJECTIVES AND METHODS

The Generalized Anxiety Disorder (GAD) is probably the most frequent anxiety disorder, demonstrating a chronic course and severe psychosocial impairments. GAD is seldom diagnosed in practice and research on GAD has in the past been sparse. This may be linked to the less dramatic symptomatology and the diagnostic criteria which were first clearly defined by DSM-IIIR and ICD-10. This article reviews diagnostics, epidemiology and current research on psychotherapy in GAD.

RESULTS AND CONCLUSIONS

Whereas cognitive-behavioral therapy (CBT) is regarded as empirically supported treatment, controlled and manualized studies of psychodynamic therapy in GAD do not exist. However, the results obtained thus far are promising. There is a definite need for further research in this area. Finally, we present an ongoing randomized controlled trial which compares manualized psychodynamic therapy and CBT in GAD. In this trial, efficacy and mechanisms of change (fearful cognitions vs. Core Conflictual Relationship Theme) in both therapies are being evaluated.

[Screening for mental disorders in cardiac and orthopaedic rehabilitation]

The detection of patients with comorbid mental disorders is of high clinical importance in cardiac and orthopaedic rehabilitation. To simplify detection of cases, screening instruments are recommended. This study investigated the discriminant validity of the General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS-D) to identify patients with comorbid mental disorders and specifically affective or anxiety disorders. 213 patients with cardiovascular diseases and 206 patients with musculoskeletal diseases participated in a two-stage survey. Patients were assessed with the GHQ-12 and the HADS-D; and they were examined for DSM-IV mental disorders by clinical standardized interview (CIDI). Validity of the two screenings regarding the detection of mental disorders was compared using ROC-analysis. In both patient groups the HADS-D performed better in nearly all analyses compared to the GHQ-12, especially in the detection of affective disorders (AUC in cardiac patients 0.78, in orthopaedic patients 0.79). Both screening instruments can be used for the detection of comorbid affective and anxiety disorders in patients with cardiovascular and musculoskeletal diseases. Limitations in performance of screening instruments are due to the different methodological approaches of tests as well as to difficulties in diagnosing mental disorders in patients with physical illness.