Depression and physical illness: The prevalence, causation, and diagnosis of comorbidity

Depression assessment and management: evaluating a community-based mental health training program for nurses

This mental health training program was designed to increase primary care nurses' knowledge and skills about depression. The program emphasized criteria for assessing depression, presented psychopharmacologic and psychotherapeutic content, discussed care coordination among several agencies and providers, and addressed referral resources. Cultural and developmental issues were highlighted. The 237 participants had significant knowledge gains after the program on comparison of pretest and posttest measures. Client record audit found significant increases in the assessment of and intervention with depression. The training program successfully increased primary care nurses' abilities to use knowledge about depression in clinical practice.

The role of somatic complaints in the diagnosis of depression in children and adolescents

The question of whether somatic complaints are a significant feature of depression independent of anxiety was explored. Structured interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children) and Child Behavior Checklist data from depressed and nondepressed psychiatric controls were analyzed to explore the interaction of somatic complaints, anxiety, and depression. Seventy percent of the children who met criteria for depression also had significant somatic complaints in contrast to 34% of the controls. Findings revealed that frequency of somatic complaints increased with severity of depression regardless of coexisting anxiety.

Comorbid psychiatric disorders in elderly medical patients: a 1-year prospective study

Cross-sectional studies have revealed a high prevalence of comorbid psychological problems among geriatric medical patients, a low rate of detection by primary care professionals, and greater psychosocial dysfunction and poorer physical health associated with comorbidity. Less is known about the course and impact of psychiatric comorbidity. Psychiatric status, physical health status, psychosocial functioning, and health care utilization for a sample of geriatric patients (n = 102) were assessed on admission to a medical hospital and again one year later. Results revealed a very stable and high prevalence of comorbid psychological problems, especially depression, a low rate of treatment by mental health professionals, greater physical impairment consistently associated with psychiatric comorbidity, but few health care utilization differences. A closer look at depression revealed that it typically began in late life and did not readily resolve.

Assessment and management of depression: an imperative for community-based practice

The purpose of this mental health training program was to increase primary care nurses' knowledge and skills about depression. The program emphasized criteria for assessing depression, presented psychopharmacological and psychotherapeutic content, discussed care coordination among multiple agencies and providers, and addressed referral resources. Highlighted were cultural and developmental issues for Native Americans, Mexican-Americans, the elderly, and adolescents. The training program successfully increased primary care nurses' knowledge about depression and their abilities to use this knowledge in clinical practice.

Illness worry and disability in fibromyalgia syndrome

Fibromyalgia (FM) is a common syndrome of functional somatic symptoms. This article examines whether an amplifying somatic style (increased body awareness and illness worry) might explain the distress and disability expressed by FM patients. Twenty FM patients were compared to twenty-three rheumatoid arthritis (RA) patients on measures of depressive and somatic symptomatology, pain, disability, and amplifying somatic style. FM patients reported greater somatic symptomatology, equivalent levels of pain, and less physical disability than did RA patients. No differences were observed between groups on body awareness or illness worry. Illness worry correlated highly with symptomatology for both groups but with physical disability only among FM patients. Results suggest that disability in functional somatic syndromes may be determined by patients' worry about having a serious disease. Feelings of vulnerability and apprehension about having an illness of unknown origin may contribute to FM sufferers' activity limitations, inability to sustain a work effort, and varied somatic distress.

What does a doctor do with psychosocial problems in primary care?

Though a lot has been published on the prevalence of psychosocial disorders in primary care, less is known about the actual treatment, given by primary care providers. This article describes treatment given to complaints which are considered by the physician as being psychosocial by nature. Treatment has been assessed by means of observation. A database of approximately 1500 videotaped consultations, sampled from thirty general practitioners has been used for this purpose. The possibilities and limitations of (generalist) psychosocial treatment in primary care are discussed.

Depressive symptomatology and medical co-morbidity in a primary care clinic

Most primary care patients exhibiting significant depressive symptomatology fail to meet DSM-III criteria for a major depressive disorder (MDD). Yet, such patients have substantial morbidity and dysfunction attributable to their affective syndrome. Since surprisingly little is known about this group's clinical characteristics, we studied 618 general medicine patients aged eighteen to sixty-four years. In this population, fifty-seven (9.2%) scored quite high when screened on the Center for Epidemiological Studies Depression Scale (greater than or equal to 27) while not meeting MDD criteria on the Diagnostic Interview Schedule. Membership in the "depression symptoms only" (DSO) group was predicted by a logistic regression model including female gender, more severe medical illness, higher likelihood of operative procedures, and less frequent cardiovascular diagnoses. Our findings suggest that the DSO state is associated with substantial "medical" morbidity. Prospective studies of subclinical depression in the primary care setting are urged to clarify etiologic and treatment concerns.

Depression and abnormal illness behavior in cancer patients

Evaluation of the incidence of depression among cancer patients has been the object of a number of studies. Recent reports of medically ill patients have indicated that depression is related to several dimensions of abnormal illness behavior (e.g., hypochondriasis, irritability, denial, disease conviction). To investigate the relationship between depression and abnormal illness behavior in cancer patients, a study was conducted of 196 patients with a recent diagnosis of cancer and with a good performance status (Karnofsky score greater than 80). The Hamilton Depression Rating Scale (HDRS) and the Illness Behavior Questionnaire (IBQ) were administered in their validated Italian forms. A cutoff point of 17 on the HDRS revealed 38.26% of the patients as having symptoms of depression, whereas a more conservative cutoff point of 21 indicated a depressive state in 23.97% of the patients. Depressed patients had higher scores on all the IBQ dimensions except that of psychologic versus somatic perception of illness. The results were confirmed by the correlation between the parameters. Higher levels of denial were reported by females and by patients receiving adjuvant or palliative chemotherapy, who had, however, lower levels of dysphoria than patients not receiving treatment. Higher levels of irritability were shown in hospitalized patients. No relationship was found between medical status variables (Karnofsky score, tumor status, and disease extent) and psychologic measures, except for denial. The findings seem to confirm the importance of assessment of depression and illness behavior in cancer patients and suggest the need for more thorough investigation of the psychosocial variables associated with them.

Depression among patients with a chief complaint of chronic fatigue

The prevalence of mood disorders among patients with chronic fatigue was examined in a group of 100 adults who had experienced fatigue symptoms for an average of 13 years. Patients received a comprehensive history, physical and laboratory evaluation and completed the National Institute of Mental Health Diagnostic Interview Schedule and the Beck Depression Inventory (BDI). Among 44 patients with depressive illness, the onset of their first depressive episode was strongly associated with and preceded the onset of chronic fatigue. The BDI, fatigue history, demographic factors, and findings from the physical examination and laboratory had only modest success in discriminating those patients with depressive illness from other patients. We conclude that depressive illness is an important precursor of chronic fatigue.

Treating depression in primary care practice. An application of decision analysis

Decision analysis approaches complex treatment issues by considering alternative strategies in an explicit and logical manner, and examining their outcomes in the face of varied assumptions. Significant data gaps impede full application of this framework to the treatment of depressed primary care patients. Nevertheless, decision analysis already can be useful in emphasizing needed clinical information in treating these patients and highlighting future directions for research.

The development of a self-administered psychophysical scaling method: internal consistency and temporal stability in chronic pain patients

Twenty chronic pain patients carried out a self-administered cross-modal matching task to scale pain intensity and unpleasantness descriptors on 2 occasions separated by 2-3 weeks. Measures of psychological distress (HAD and GHQ) and verbal intelligence (Mill Hill Synonym Test) were also taken. On the 2 occasions 65% and 70% of patients were able to scale intensity words with an internal consistency of r greater than or equal to 0.90. Eleven (55%) patients met this criterion on both occasions. The percentage of patients meeting the internal consistency criterion for unpleasantness descriptors was much lower, 25% and 40% on the 2 occasions. For patients who met the internal consistency criterion for intensity words there was very high test-retest stability for the group scale values of the intensity words. There was no evidence that the level of psychological distress was associated with ability to scale unpleasantness words. Intelligence was positively related to the ability to scale intensity descriptors.

Anxiety and depression in the medical setting: an overview

Many physicians fail to correctly diagnose, treat, or refer their patients with anxiety and depression. These are common and costly disorders, but many barriers often prevent effective care for them in medical settings. Greater knowledge about these disorders and closer working relationships with mental health specialists should lead to decreased morbidity and mortality.

Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions

An extensive series of investigations over the past 2 decades clearly demonstrate that mental disorders are present in approximately 25% of primary care patients and that physicians underdiagnose these illnesses. The factors producing this bias are poorly understood and should be focused upon in future research. Also requiring much more study is the efficacy of pharmacologic and psychosocial treatments initially validated with psychiatric populations. Clinical trials should determine whether standardized interventions can be utilized with medical patients whose symptom profiles and organic comorbidity may differ from those of psychiatric populations.

Six-month outcomes for medical patients with major depressive disorders

The courses of depressive disorders and factors affecting recovery rates among patients treated in primary medical care facilities have rarely been studied. The authors investigated the clinical status of 274 patients initially and six months after they sought care at one of three primary care sites. Through use of the highly structured Diagnostic Interview Schedule, they found that physicians assigned a depressive diagnosis to only a fourth of the patients so assessed by the structured interview. Nevertheless, the rates of persisting major depressive disorders at follow-up were found to be very similar for patients whom both the structured interview and the physician initially considered depressed and those so diagnosed by structured interview but not by the physician (25% and 31%, respectively). An analysis of factors associated with course of illness suggests that psychiatric status at the initial assessment and the number of assigned medical diagnoses rather than the physician's recognition and treatment of depression strongly predict continued affective disorder.