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

Anxiety and Depression Symptoms During the COVID-19 Pandemic: A Cluster Analysis of Individuals Living in Portugal

INTRODUCTION

The COVID-19 pandemic is an illustration of how a physical illness can damage people's minds. In this regard, the goal of this study was to see how different sociodemographic and behavioral factors were linked to anxiety and depression symptoms in a group of individuals living in Portugal.

METHODS

Between November 2020 and February 2021, a cross-sectional, snowball online study was conducted. The study's target population was adults over the age of 18, residents of the country. For the statistical analysis, the clustering technique - K-means algorithm was applied. The chi-squared test was used to determine the relationships between clusters and sociodemographic and behavioral characteristics. Statistical analyses were conducted in R language, with a significance level of 0.05. A total of 453 participants were included.

RESULTS

The majority were female (69.8%), under the age of 40 (60.8%), with a higher education degree (75.3%), and not married (54.4%). Furthermore, the majority were from the country's north region (66%). Cluster 1 (n = 194) was characterized by low or nonexistent levels of anxiety and depression symptoms, which means normal; cluster 2 by severe symptoms (n = 82), meaning case; and cluster 3 by mild symptoms (n = 177), which means borderline. Younger participants (p-value 0.024), female (p-value 0.041), with drinking habits (p-value 0.002), food insecurity (p-value < 0.001), food affordability exacerbation (p-value < 0.001), comorbidity (p-value < 0.001), use of anxiolytics (p-value < 0.001), insufficient household income (p-value 0.017) and income change (p-value < 0.001) were significantly associated with the anxiety-depression clusters. From the three clusters, cluster 2 was mainly represented by younger participants, with more persons stating that their household income was insufficient and that their income has changed as a result of COVID-19 and that they had the highest probability of food insecurity.

CONCLUSION

The impacts of a crisis on mental health extend longer than the event itself. We were able to observe that younger women with insufficient household income who suffered a change in income due to COVID-19 and were classified as food insecure presented higher levels of anxiety and depression symptoms. These results highlight the presence of a social gradient where we saw that people who were less advantaged in terms of socioeconomic position presented worse mental health outcomes, stressing, in this sense, the need to bring the best public health responses for these specific groups of the population.

The Relationship between Type 2 Diabetes, Differentiation of Self, and Emotional Distress: Jews and Arabs in Israel

Type 2 diabetes mellitus (T2DM) is considered a global epidemic, and is constantly on the rise. In Israel, the percentage of diabetics in the Arab population is twice that found in the Jewish population (12% and 6.2%, respectively). Findings suggest that low differentiation of self (DoS: emotional reactivity+ fusion with others, I-position, emotional cutoff) may raise vulnerability to certain physiological pathologies by increasing susceptibility to psychological distress. The major goal of this study was to test differences in DoS and emotional distress (anxiety and depressive symptoms) between diabetic and healthy participants. The second aim was to examine cultural differences within these metrics. Another purpose was to examine the relationship between DoS and emotional distress among healthy and diabetic participants. The sample included 261 participants, of whom 154 were healthy and 107 were diabetic. Diabetics reported more severe depressive symptoms, higher levels of anxiety and emotional cutoff and lower levels of I-position than healthy individuals. The groups did not differ in their levels of emotional reactivity + fusion with others. Arabs demonstrated higher levels of emotional cutoff, anxiety and depressive symptoms and lower levels of I-position than Jews. However, Arabs and Jews did not differ in their levels of emotional reactivity + fusion with others. Emotional reactivity + fusion with others contributed the most to diabetes among Arabs, while depressive symptoms contributed the most among Jews. Finally, among Jewish participants, age was positively correlated with emotional cutoff and depressive symptoms. Emotional cutoff was positively correlated with anxiety and depressive symptoms. Emotional reactivity + fusion with others was positively correlated with anxiety. Among Arab participants, age was positively correlated with emotional cutoff, anxiety and depressive symptoms. I-position was negatively correlated with all study variables. Emotional cutoff was positively correlated, anxiety and depressive symptoms. Emotional reactivity + fusion with others was positively correlated with anxiety and depressive symptoms.

Hardiness and sense of coherence and their relation to negative affect

This study attempted to determine the degree to which measures of health proneness and measures of negative affect represent two distinct, although related, constructs. In addition, it examined the relation between Antonovsky's salutogenic construct of sense of coherence (SOC) and Kobasa's health proneness construct of hardiness. Five health proneness and three negative affect measures were filled out by 164 male patients with coronary heart disease. The pattern of correlations between these measures and confirmatory factor analysis indicated that although the measures of health proneness are negatively related to measures of negative affect, these two sets of measures and the constructs to which they are related can be differentiated from each other. However, SOC was found to be less independent of negative affect than was hardiness.

La dépression dans les populations médicales

La prévalence élevée des états dépressifs dans la clientèle du généraliste (environ 10% des consultants) et chez les patients de médecine interne (15 à 25% des hospitalisés) est maintenant bien établie. Ce fait a été longtemps négligé par les praticiens et les psychiatres; même actuellement son importance reste sous-estimée.

La proportion d’états dépressifs non-identifiés par les praticiens varie de 1/3 à 2/3 selon les études. Les dépressions méconnues sont source de surconsommation médicale (consultations répétées, examens paracliniques, hospitalisations pour bilans) et ont une évolution moins favorable, plus chronique, que les dépressions identifiées et correctement traitées. Des cas sévères de dépression échappent souvent au dépistage, ce qui n’est pas sans conséquences graves: on sait en effet que la majorité des gens qui se suicident ont consulté un médecin dans le mois qui a précédé leur décès.

Parmi les facteurs qui rendent compte de la méconnaissance des états dépressifs par les médecins non-spécialistes, les uns tiennent aux patients qui, dans leur dialogue avec le généraliste, utilisent davantage le langage de la somatisation qu’ils ne verbalisent explicitement un vécu dépressif. D’autres tiennent aux praticiens, à leur intérêt prévalent et parlois exclusif pour les problèmes somatiques, à leur souci légitime de ne pas passer à côté du diagnostic d’une affection médicale, à l’idée qu’ils se font de la dépression et des déprimés, à leur propension à considérer toutes les manifestations dysphoriques comme conséquences légitimes de la maladie physique. Il faut aussi compter avec les conditions d’exercice du généraliste, le temps très court de sa consultation où il n’est pas facile de différencier une réelle pathologie dépressive, généralement liée à des troubles anxieux et moins nette que dans les consultations Psychiatriques, de troubles émotionnels mineurs, situationnels et transitoires.

Les instruments habituellement utilisés pour le dépistage et le diagnostic de la dépression (échelles d’autoévaluation, critères de diagnostic type RDC ou critères du DSM III) n’ont pas été validés pour les populations de patients somatiques. Récemment deux nouveaux instruments viennent d’être mis au point pour la détection de la symptomatologie dépressive chez les patients somatiques: I'échelle HAD (Hospital Anxiety and Depression Scale) de Zigmond et Snaith (1983) et le Questionnaire Abrégé d’Auto-Évaluation de la Symptomatologie Dépressive (QD2A) de Pichot et al. (1984). Ces échelles, de passation rapide et bien acceptées par les patients, peuvent servir d’aide au diagnostic pour le praticien dans la perspective d’un meilleur dépistage de la dépression et d’une prise en charge plus efficace des déprimés.

The Effect of Preexisting and Shoulder-Specific Depression and Anxiety on Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Few studies have considered the potential effect of depression or anxiety on outcomes after rotator cuff repair.

PURPOSE

To evaluate the effect of a preexisting diagnosis of depression or anxiety, as well as the feeling of depression and anxiety directly related to the shoulder, on the American Shoulder and Elbow Surgeons (ASES) score.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study is a retrospective review of prospectively collected data on patients who underwent arthroscopic rotator cuff repair and were evaluated by the ASES score preoperatively and at a minimum 12 months postoperatively as part of the senior author's shoulder registry. Preexisting diagnoses of depression and/or anxiety were recorded, and questions from the Western Ontario Rotator Cuff Index directed at feelings of depression or anxiety related to the shoulder were also evaluated. The Wilcoxon rank sum test was used to compare ASES scores between patients with and without anxiety and/or depression. Spearman correlation was used to correlate questions on depression and anxiety with ASES scores.

RESULTS

A total of 187 patients (63 females, 124 males; mean age, 58.6 years, SD, 8.7 years) undergoing arthroscopic rotator cuff repair were evaluated with a mean follow-up of 47.5 months (SD, 17.4 months; range, 12-77 months). Fifty-three patients (mean age, 60 years; SD, 8.6 years) had preexisting diagnoses of depression and/or anxiety and 134 patients (mean age, 58.1 years; SD, 8.7 years) did not. Patients with depression and/or anxiety had significantly lower preoperative and postoperative ASES scores (60.7 vs 67.8, P = .014; and 74.6 vs 87.1, P = .008, respectively). The change in ASES scores from preoperative to postoperative, however, was not significantly different (18.0 vs 14.9). A higher score of depression or anxiety related to the shoulder had a negative correlation with the preoperative (r = -0.76, P < .0001; and r = -0.732, P < .0001, respectively) and postoperative (r = -0.31, P = .0001; and r = -0.31, P = .0003, respectively) ASES scores, but a positive correlation (r = 0.50, P < .0001; and r = 0.43, P < .0001, respectively) with the change in ASES scores.

CONCLUSION

Patients with a history of depression and/or anxiety have lower outcome scores preoperatively and postoperatively; however, they should expect the same amount of relief from arthroscopic rotator cuff repair as those without a history of depression or anxiety. Stronger feelings of depression or anxiety directly related to the shoulder correlated with lower preoperative and postoperative outcome scores, but a greater amount of improvement from surgery. The results from this study suggest that a preexisting diagnosis of depression or anxiety, as well as feelings of depression or anxiety directly related to the shoulder, should be considered during the management of patients with rotator cuff tears.

Prospective Associations of Erythrocyte Composition and Dietary Intake of n-3 and n-6 PUFA with Measures of Cognitive Function

Polyunsaturated fatty acid (PUFA) consumption is recommended as part of a healthy diet, but evidence of the impact of individual species and biological concentrations on cognitive function is limited. We examined prospective associations of PUFA erythrocyte composition and dietary intake with measures of cognitive function among participants of the Boston Puerto Rican Health Study (aged 57 years). Erythrocyte and dietary PUFA composition were ascertained at baseline and associated with 2-year scores on the Mini-Mental State Exam (MMSE) (n = 1032) and cognitive domain patterns derived from a battery of tests (n = 865), as well as with incidence of cognitive impairment. Erythrocyte and dietary n-3 PUFA were not significantly associated with MMSE score. However, total erythrocyte and dietary n-3 very-long-chain fatty acids (VLCFA), and intake of individual species, were associated with better executive function (P-trend < 0.05, for all). There was evidence that greater erythrocyte n-6 eicosadienoic acid concentration was associated with lower MMSE and executive function scores (P-trend = 0.02). Only erythrocyte arachidonic acid (ARA) concentration predicted cognitive impairment (Odds Ratio = 1.26; P = 0.01). Among Puerto Rican adults, we found that n-3 VLCFA consumption may beneficially impact executive function. Further, these findings provide some evidence that n-6 metabolism favoring greater ARA tissue incorporation, but not necessarily dietary intake, could increase the risk of cognitive impairment.

Psychiatric Hospitalization Increases Short-Term Risk of Stroke

BACKGROUND AND PURPOSE

Recent evidence suggests that psychological distress, including the symptoms of psychiatric illness, may acutely increase the risk of stroke. However, existing studies are limited by small sample sizes, inherent recall bias, and poorly defined criteria for what constitutes psychological distress.

METHODS

We analyzed administrative data from the Healthcare Cost and Utilization Project for the state of California from 2007 to 2009 using a case-crossover design. Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for combined hemorrhagic and ischemic stroke risk occurring within 15, 30, 90, 180, and 365 days of a hospitalization for a psychiatric diagnosis (as defined by International Classification of Diseases, Ninth Revision, code) among adults.

RESULTS

Psychiatric hospitalizations within 1 year before stroke were found in 2585 (5.3%) of 48 558 stroke patients. Hospitalization for a psychiatric condition was associated with increased risk of stroke within all 5 time periods, with the highest odds of stroke occurring within 15 days (0-15 days: OR, 3.5; 95% confidence interval [CI], 2.6-4.8; 0-30 days: OR, 3.0; 95% CI, 2.4-3.8; 0-90 days: OR, 2.3; 95% CI, 2.0-2.7; 0-180 days: OR, 2.2; 95% CI, 2.0-2.5; and 0-365 days: OR, 2.6; 95% CI, 2.4-2.8).

CONCLUSIONS

Psychiatric hospitalization increases the short-term risk of stroke, particularly within the 15-day period after hospitalization.

Why are hospital doctors not referring to Consultation-Liaison Psychiatry? - a systemic review

BACKGROUND

Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP for inpatients with psychiatric comorbidities, referral rates from hospital doctors remain low. This review aims to understand barriers to CLP inpatient referral as described in the literature.

METHODS

We searched on Medline, PsychINFO, CINAHL and SCOPUS, using MESH and the following keywords: 1) Consultation-Liaison Psychiatry, Consultation Liaison Psychiatry, Consultation Psychiatry, Liaison Psychiatry, Hospital Psychiatry, Psychosomatic Medicine, the 2) Referral, Consultation, Consultancy and 3) Inpatient, Hospitalized patient, Hospitalized patient. We considered papers published between 1 Jan 1965 and 30 Sep 2015 and all articles written in English that contribute to understanding of barriers to CLP referral were included.

RESULTS

Thirty-five eligible articles were found and they were grouped thematically into three categories: (1) Systemic factors; (2) Referrer factors; (3) Patient factors. Systemic factors that improves referrals include a dedicated CLP service, active CLP consultant and collaborative screening of patients. Referrer factors that increases referrals include doctors of internal medicine specialty and comfortable with CLP. Patients more likely to be referred tend to be young, has psychiatric history, live in an urban setting or has functional psychosis.

CONCLUSION

This is the first systematic review that examines factors that influence CLP inpatient referrals. Although there is research in this area, it is of limited quality. Education could be provided to hospital doctors to better recognise mental illness. Collaborative screening of vulnerable groups could prevent inpatients from missing out on psychiatric care. CLP clinicians should use the knowledge gained in this review to provide quality engagement with referrers.

A Prospective Examination of the Mechanisms Linking Childhood Physical Abuse to Body Mass Index in Adulthood

Previous research has reported associations between childhood physical abuse and body mass index (BMI) in adulthood. This article examined the role of four potential mediators (anxiety, depression, posttraumatic stress, and coping) hypothesized to explain this relationship. Using data from a prospective cohort design, court-substantiated cases of childhood physical abuse (N = 78) and nonmaltreated comparisons (N = 349) were followed up and assessed in adulthood at three time points (1989-1995, 2000-2002, and 2003-2005) when participants were of age 29.2, 39.5, and 41.2, respectively. At age 41, average BMI of the current sample was 29.97, falling between overweight and obese categories. Meditation analyses were conducted, controlling for age, sex, race, smoking, and self-reported weight. Childhood physical abuse was positively associated with subsequent generalized anxiety, major depression, and post-traumatic stress disorder symptoms at age 29.2 and higher levels of depression and posttraumatic stress predicted higher BMI at age 41.2. In contrast, higher levels of anxiety predicted lower BMI. Coping did not mediate between physical abuse and BMI. Anxiety symptoms mediated the relationship between physical abuse and BMI for women, but not for men. These findings illustrate the complexity of studying the consequences of physical abuse, particularly the relationship between psychiatric symptoms and adult health outcomes.

The Relationship Between Posttraumatic Stress Symptoms and Physical Health in a Survey of U.S. Veterans of the Iraq and Afghanistan Era

BACKGROUND

Although a large body of literature has linked posttraumatic stress disorder (PTSD) with poor physical health among older veterans, less is known regarding the association between PTSD and health among relatively younger cohorts of veterans.

OBJECTIVE

The current study examined the association between PTSD and self-reported health among a sample of veterans who served in the recent conflicts in Iraq and Afghanistan.

METHOD

Veterans (N = 1030) who served in the wars in Iraq and Afghanistan completed measures of PTSD symptom severity and self-rated health between September 2009 and February 2010. Analyses examined the association between PTSD symptoms and health outcomes.

RESULTS

In analyses adjusted for age, sex, race, and combat exposure, PTSD symptom severity was positively related to the number of health conditions and health symptoms reported (ps<0.001). Additionally, in analyses adjusted for age, sex, race, combat exposure, number of health conditions, and number of health symptoms, PTSD symptom severity was associated with an increased likelihood of rating one's health as poor or fair and an increased likelihood of reporting that one's physical health limits participation in activities (ps<0.001).

CONCLUSION

These findings suggest that, consistent with previous research, PTSD symptom severity has a broad negative effect on physical health among veterans of the Iraq and Afghanistan era. Health promotion among veterans with PTSD may help attenuate risk of physical health consequences.

Child protection and adult depression: evaluating the long-term consequences of evacuating children to foster care during World War II

This paper combined data collected from war time government records with survey data including background characteristics, such as factors that affected eligibility, to examine the adult depression outcomes of individuals who were evacuated from Finland to temporary foster care in Sweden during World War II. Using war time government records and survey data for a random sample of 723 exposed individuals and 1321 matched unexposed individuals, the authors conducted least squares adjusted means comparison to examine the association between evacuation and adult depression (Beck Depression Inventory). The random sample was representative for the whole population of evacuees who returned to their biological families after World War II. The authors found no statistically significant difference in depressive symptoms during late adulthood between the two groups; for example, the exposed group had a 0.41 percentage points lower average Beck Depression Inventory score than the unexposed group (p = 0.907). This study provides no support for family disruption during early childhood because of the onset of sudden shocks elevating depressive symptoms during late adulthood.

Health-related conditions and depression in elderly mexican american and non-Hispanic white residents of a United States-Mexico border county: moderating effects of educational attainment

We investigated the prevalence of "high" levels of depressive symptomatology and 13 health-related medical conditions in elderly Mexican American (MA) and non-Hispanic white (NHW) residents of El Paso County, Texas. We analyzed the extent to which depressive symptoms in this population are associated with these conditions. Elderly MA residents possessed a higher prevalence of current depression, a relatively unique health-related condition profile, and were more likely to experience a set of conditions that impede participation in daily life-conditions that we found to be strongly associated with high depressive symptomatology in the elderly. After adjusting for educational attainment, using multiple regression analyses, depression was not associated with ethnicity and only six of the health related conditions showed significant differences between MA and NHW subjects. We believe these results provide an important insight into the mechanism of health-related conditions and depressive symptomatology in a large sample of elderly MAs; and how conditions typically attributed to MA ethnicity may in actuality be an artifact of socioeconomic status variables such as educational-attainment.

Neurocognitive correlates of alexithymia in asymptomatic individuals with HIV

Alexithymia, an impairment of affective and cognitive emotional processing, is often associated with human immunodeficiency virus (HIV) and may reflect effects of the virus on brain areas that are also important for multiple cognitive functions, such as the prefrontal and anterior cingulate cortices. We hypothesized that there would be a correlation between extent of alexithymia and cognitive performance associated with these brain areas, including attention, executive function, and visuospatial processing. Thirty-four asymptomatic HIV+ participants and 34 matched healthy HIV- volunteers were administered the Toronto Alexithymia Scale, a series of neuropsychological tests, and measures of apathy, depression, and quality of life (QoL). The HIV+ participants had significantly higher levels of alexithymia, depression and apathy than the HIV- group. The extent of alexithymia and two of its processing components (Difficulty Describing Feelings [DDF] and Externally Oriented Thinking), but not depression, correlated with performance on measures of executive and visuospatial abilities, consistent with dysfunction of the frontostriatal circuits and their cortical projections. Apathy was related to alexithymia and two processing components (Difficulty Identifying Feelings and DDF) but to only one cognitive measure. The higher rate of alexithymia, as well as cognitive dysfunction, in HIV may be a consequence of the infection on the frontostriatal system and its cortical connections. Our findings also demonstrated a dissociation of apathy and alexithymia in HIV, pointing to overlapping but distinct neural substrates within frontostriatal circuits. Alexithymia correlated strongly with QoL ratings, underscoring the importance of assessment and treatment of HIV-associated emotional and cognitive processing deficits.

Self-reported health and physician diagnosed illnesses in women with posttraumatic stress disorder and major depressive disorder

Posttraumatic stress disorder has been associated with poor physical health. Depression is also associated with poor health, and may be responsible for the apparent relationship between PTSD and health outcomes. The current study examined self-reported and physician diagnosed medical morbidity in women. Women with PTSD alone were compared to three other groups of women: women with PTSD and comorbid major depressive disorder (MDD), women with MDD only, or women with neither diagnosis (comparison group). Results suggest that PTSD, with or without MDD, is associated with poor health in women. Posttraumatic stress disorder severity was related to health complaints beyond the effects of both somatization and depressive symptoms among women with PTSD. Findings and implications are discussed in relation to previous research in the area.

Vitamin B6 is associated with depressive symptomatology in Massachusetts elders

OBJECTIVE

We examined the cross-sectional relationship between dietary vitamin B6 and plasma pyridoxyl-5'-phosphate concentrations (PLP) with depressive symptomatology among a representative sample of 618 elderly Caribbean Hispanics, and a neighborhood based comparison group of 251 non-Hispanic white (NHW) older adults in Massachusetts.

METHODS

Depressive symptomatology was assessed with the Center for Epidemiologic Studies Depression Scale (CES-D). 41% of Hispanics and 22.6% of NHWs had CES-D scores greater than 16, indicating depressive caseness. Dietary intake was calculated from a semi-quantitative food frequency questionnaire (FFQ) designed for this population.

RESULTS

PLP was significantly associated with CES-D score and depressive caseness in the total sample and in non-supplement users. Deficient levels of plasma PLP (plasma PLP < 20 nmol/L) approximately doubled the likelihood of depressive caseness. Total intake (diet + supplement) of vitamin B(6) was not associated with these outcomes. However, dietary vitamin B(6) was significantly associated with CES-D score and depressive caseness.

CONCLUSION

Longitudinal studies are needed to clarify the direction of causality between vitamin B6 and depressive symptoms.

The workload of GPs: patients with psychological and somatic problems compared

BACKGROUND

GPs state that patients with mental problems make heavy demands on their available time. To what extent these perceived problems correspond with reality needs more investigation.

OBJECTIVES

To investigate the effect of patients with psychological or social diagnoses on GP's workload, expressed in time investments.

METHODS

Data were derived of a cross-sectional National Survey in General Practice, conducted in The Netherlands in 2000-2002. For a year, all patient contacts with a representative sample of 104 general practices were registered. Patients diagnosed with one or more diagnoses in ICPC (International Classification of Primary Care) chapter 'Psychological' or 'Social' (n = 37,189) were compared to patients with only somatic diagnoses (n = 189,731). A subdivision was made in diagnoses depression, anxiety, sleeping disorders, stress problems, problems related to work or partner and 'other psychological or social problems'. Workload measures are the consultation frequency, number of diagnoses and episodes of illness of the patients involved.

RESULTS

Patients in all categories of psychological or social problems had almost twice as many contacts with their general practice as patients with only somatic problems. They received more diagnoses and more episodes of illness were shown. Patients with psychological or social diagnoses also contacted their general practice about their somatic problems more frequently, compared to patients with only somatic problems.

CONCLUSION

Patients with psychological or social problems make heavy demands on the GP's workload, for the greater part due to the increase in somatic problems presented.

Effectiveness Research: Transporting Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) From the Lab to School-Based Health Clinics

This paper describes the process of modifying and transporting an evidence-based treatment, Interpersonal Psychotherapy for Depressed Adolescents (IPT-A), from a university setting to school-based health clinics. It addresses conceptual issues involved in the shift from efficacy to effectiveness research as well as operational issues specific to the transport of IPT-A into school-based health clinics. Consideration is given to the rationale for an IPT-A effectiveness study, methodological concerns, and the timing of the move from the "lab" to the community. The authors identify challenges and barriers to initiating effectiveness and transportability research and provide suggestions for overcoming these barriers. Recommendations for conducting research in school-based practice settings are provided.

Domestic violence: prevalence in pregnant women and associations with physical and psychological health

OBJECTIVES

To examine the prevalence of domestic violence (DV) and its associations with obstetric complications and psychological health in women on antenatal and postnatal wards.

STUDY DESIGN

A cross-sectional survey conducted in an inner-London teaching hospital. Two hundred English-speaking women aged 16 and over, were interviewed between July 2001 and April 2002. The Abuse Assessment Screen was used to assess for experiences of DV. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). The analysis of predictors of obstetric complications grouped together those known to be associated with DV.

RESULTS

23.5% of women had lifetime experience of DV, 3% during the current pregnancy. Women with a history of DV were significantly more likely to be single, separated or in non-cohabiting relationship and to have smoked in the year prior to and/or during pregnancy. Higher EPDS scores were significantly associated with DV, single, separated or non-cohabiting status, and obstetric complications. Both a history of DV and increased EPDS scores were significantly associated with obstetric complications after controlling for other known risk factors.

CONCLUSIONS

Domestic violence is regarded as an important risk marker for the development of obstetric complications and depressive symptomatology. This finding of itself justifies training and education of maternity health professionals to raise awareness.

Self-reported heart attack in Mexican-American elders: examination of incidence, prevalence, and 7-year mortality

OBJECTIVES

To examine the prevalence, incidence, and mortality of self-reported heart attack in older Mexican Americans and to identify significant factors associated with heart attack.

DESIGN

Cross-sectional and longitudinal study.

SETTING

Baseline and three follow-up interviews in five southwestern states (Arizona, California, Colorado, New Mexico, and Texas) of the Hispanic Established Population for the Epidemiological Study of the Elderly.

PARTICIPANTS

Three thousand fifty Mexican Americans aged 65 to 107 (mean age = 73).

MEASUREMENTS

Sociodemographic factors (age, sex, marital status, language of interview, health insurance coverage, living arrangements, and financial strain) and health factors (smoking, alcohol consumption, obesity, diabetes mellitus, hypertension, stroke, cancer, hip fracture, arthritis, depression, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and mortality) were determined at baseline (1993-94). New heart attacks were assessed at follow-ups in 1995-96, 1998-99, and 2000-01. Vital status was determined over the 7-year follow-up.

RESULTS

Prevalence of self-reported heart attack was 9.1% at baseline. Incidence of self-reported heart attack was 6.1%, 9.1%, and 7.9%, respectively, for the three subsequent follow-ups. Older age, male sex, diabetes mellitus, hypertension, and stroke were significantly associated with heart attack at baseline. Age was a significant predictor for new heart attack at each follow-up. Having ADL (odds ratio (OR) = 2.91, 95% confidence interval (CI) = 2.19-3.86) and IADL (OR = 2.25, CI = 1.72-2.94) disabilities was significantly associated with self-reported heart attack. Subjects with heart attack were significantly more likely to die at 7 years (hazard ratio = 1.57, 95% CI = 1.29-1.91). Of those with self-reported heart attack, 42.4% had died of heart attack as the underlying cause of death by 7-year follow-up.

CONCLUSION

In Mexican Americans, self-reported heart attack was associated with being older and male and having diabetes mellitus, hypertension, stroke, and ADL and IADL disabilities. Nearly half of subjects with heart attack had died of heart attack as underlying cause of death by 7-year follow-up. Prevention and control for this disease would be especially important in this population to avoid early mortality.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Patient gender differences in the diagnosis of depression in primary care

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

Trauma-related sleep disturbance and self-reported physical health symptoms in treatment-seeking female rape victims

The purpose of the study was to assess the relationship between trauma-related sleep disturbance and physical health symptoms in treatment-seeking female rape victims. A total of 167 participants were assessed for PTSD symptoms, depression, sleep disturbance, and frequency of self-reported health symptoms. Results demonstrated that trauma-related sleep disturbance predicted unique variance in physical health symptoms after other PTSD and depression symptoms were controlled. The findings suggest that trauma-related sleep disturbance is one potential factor contributing to physical health symptoms in rape victims with PTSD.

The process and outcomes of care for major depression in rural family practice settings

Although primary care physicians provide the majority of care for rural residents with major depression, little is known about the quality of the care they provide. The aim of this study was to characterize the process and outcomes of care for rural patients with major depression, and to examine the relationship between the process and outcomes of care in this population. Six hundred and thirty-one patients in 21 primary care practices in small towns were screened; 47 patients (7.4% of patients screened) meeting DSM-III-R criteria for current major depression were recruited into the study, and 38 (81.0% of patients recruited) were followed an average of five months later using the Depression Outcomes Module (Rost, Smith, Burnam, & Burns, 1992). While 24 (63.1%) of the 38 depressed subjects received a prescription for one or more antidepressants between the index visit and follow-up, only 11 (28.9%) received pharmacologic treatment in concordance with the new Agency for Health Care Policy and Research (AHCPR) guidelines; 26 (68.4%) of 38 depressed patients continued to meet criteria for major depression at five months. Those who received pharmacologic treatment concordant with AHCPR guidelines showed more improvement at follow-up. The findings suggest that outcomes for major depression may be worse in rural family practice settings than in urban settings. The study also demonstrates that AHCPR guidelines define effective treatment for major depression in the study sample. The Depression Outcomes Module appears to be a reliable and valid instrument for monitoring the outcomes of care for major depression in family practice settings.

PTSD severity and health perceptions in female victims of sexual assault

In women with chronic posttraumatic stress disorder (PTSD), poor physical health may be related to their PTSD symptoms through an underlying negative affect or distress that accompanies the disorder, through the PTSD symptoms in general, or specifically through the chronic hyperarousal present in the disorder. The current study examined the relative contribution of these factors to reported physical symptoms in female victims of sexual assault. Seventy-six women with chronic PTSD were assessed, using measures of stressful life events, psychological difficulties, and perceived health. Negative life events, anger, depression, and PTSD severity were all related to self-reported physical symptoms; however, PTSD severity predicted self-reported physical symptoms beyond these other variables. Contrary to our hypothesis, the reexperiencing cluster of PTSD, and not the hyperarousal cluster, was related to self-reported physical symptoms.

Mind-body medicine in rheumatologic disease

Research over the last 20 years in Mind-Body Medicine has made significant contributions to the treatment of rheumatic disease. This approach is based on the concept that patients have the ability to influence their experience of illness through directed modification of their thoughts, emotions, and behaviors. This article finds that Mind-Body treatment results in significant, incremental symptom relief and improvement in disability status and well-being beyond that achieved through routine medical care. There is also evidence that these interventions reduce utilization of health care services, despite continuing progression of disease, a finding that has major economic implications for health policy.

Relationship of psychiatric status to Gulf War veterans' health problems

OBJECTIVE

A growing body of research has shown that there are important links between certain psychiatric disorders and health symptom reporting. Two disorders in particular (posttraumatic stress disorder (PTSD) and major depression) have been the most widely implicated to date, and this association has sometimes been used to explain the occurrence of ill-defined medical problems and increased somatic symptoms in certain groups, most recently Gulf War veterans.

METHODS

Structured psychiatric diagnostic interviews were used to examine the presence of major psychiatric (axis I) disorders and their relation to health symptom reporting in a well-characterized, stratified subset of Gulf War veterans and a non-Gulf-deployed veteran comparison group.

RESULTS

Rates of most psychiatric disorders were substantially lower than national comorbidity estimates, consistent with prior studies showing heightened physical and emotional well-being among active-duty military personnel. Rates of PTSD and major depression, however, were significantly elevated relative to the veteran comparison group. The diagnosis of PTSD showed a small but significant association with increased health symptom reports. However, nearly two-thirds of Gulf participants reporting moderate to high health symptoms had no axis I psychiatric diagnosis.

CONCLUSIONS

Results suggest that rates of psychiatric illness were generally low with the exception of PTSD and major depression. Although PTSD was associated with higher rates of reported health problems, this disorder did not entirely account for symptoms reported by participants. Factors other than psychiatric status may play a role in Gulf War health problems.

Depressive symptoms and mortality in older Mexican Americans

PURPOSE

We examined the prevalence of comorbid depressive symptomatology and leading chronic medical conditions, and their influence on death rates in older Mexican Americans.

METHODS

Data from the Hispanic Established Population for the Epidemiologic Study of the Elderly (EPESE) were used. Differences in death rates across sociodemographics, self-ratings of health, and health conditions were examined with analysis of variance statistics. Logistic regression models were used to examine main effects and interaction effects of each medical condition separately and in conjunction with depressive symptomatology.

RESULTS

Bivariate analyses indicated that death rates were substantially higher when a high level of depressive symptoms was comorbid with diabetes (OR = 3.84, 95% CI = 2.55-5.78), cardiovascular disease (OR = 4.04, 95% CI = 2.36-6.91), hypertension (OR = 2.27, 95% CI = 1.57-3.27), stroke (OR = 3.00, 95% CI = 1.44-6.15), and cancer (OR = 4.46, 95% CI = 2.48-8.01). Multivariate analyses indicated a synergistic effect for comorbid diabetes and depressive symptoms such that the odds of having died among diabetics with high levels of depressive symptoms (OR = 4.03, 95% CI = 2.67-6.11) were three times that of diabetics without high levels of depressive symptoms (OR = 1.36, 95% CI = 0.89-2.06).

CONCLUSIONS

High levels of depressive symptoms concomitant with major chronic medical conditions elevate the risk for death among older Mexican Americans. Given the fact that depression is often unrecognized and undertreated in the elderly, awareness of the potential for loss of life as well as the potential for treatment may help to improve this situation not only for older Mexican Americans, but for older adults in general.

What does treatment of depression really cost?

This DataWatch presents estimates of the health care charges for adults who are diagnosed and treated for depression in primary care. More than nine out of ten of these adults sought care for at least one nondepressive illness during the year following treatment initiation. One average, these conditions accounted for more than 70 percent of the total charges. Attempts to manage the costs of caring for depressed persons must consider the impact of nondepressive illness.

Combined medical and psychological symptoms: impact on disability and health care utilization of patients with arthritis

OBJECTIVES

Many reports indicate that patients with combined chronic illness and depressive symptomatology have more disability than those with illness alone, which may influence physician visits. Studies suggest that these combined conditions are unevenly accommodated by the delivery system and nonpsychiatric physicians often fail to recognize or treat these symptoms. To address this need, this study aimed to provide further information on combined conditions and report on relations found among arthritis disease symptoms, depression, and disability.

METHODS

The data was derived from a series of statewide surveys assessing the influence of psychosocial factors on disease course and treatment in a community sample of 277 patients under the care of a rheumatologist. A multivariate model was developed to assess these interrelationships, using measures of symptom severity, depression (CESD), disability (activities of daily living, days of restrictive activities, days in bed), service utilizations, and a few personal and health variables.

RESULTS

Even after removing somatic items from the CESD to reduce the risk of inflation due to physical disease, evidence was found for additive impact of depression on one measure of disability, days of restrictive activities. Patients with comorbid conditions also were a high-service utilization group. Very few patients reported receiving help in dealing with emotional problems, suggesting presence of substantial unmet need.

CONCLUSIONS

Nonpsychiatric physicians need to be aware of the mental health status of chronically ill patients. Although the association between medication use and depression suggests some awareness of the need to treat depression, especially in physically compromised patients, there may be some need to dispense psychological and psychosocial support to those in need.

Psychiatric morbidity and physician visits: lessons from Ontario

OBJECTIVES

The authors examine the association between psychiatric morbidity and visits to general practitioners and family practitioners in Ontario, Canada.

METHODS

A nested set of hypotheses were posed to account for different levels of use among persons with differing levels of psychiatric morbidity. The sample of 8,116 is drawn from a comprehensive household survey of physical and mental health that included the UM-CIDI standardized diagnostic interview.

RESULTS

The findings suggest that persons with psychiatric disorders make more visits than can be accounted for by sociodemographic factors, medical status, access, or by intentional use of the general medical system for mental health treatment.

CONCLUSIONS

Psychiatric morbidity is associated with higher rates of health service use. This effect is strongest among persons with multiple psychiatric disorders.

Medical comorbidity in elderly psychiatric inpatients

A multidisciplinary diagnostic evaluation was performed for 868 older psychiatric inpatients during a 46-month interval. A total of 402 (46%) met DSM-III-R criteria for organic mental disorders, 329 (38%) had mood disorders, 90 (10%) had psychotic disorders, and 47 (5%) had other mental disorders or conditions. Concurrent medical problems were systematically assessed and classified according to ICD-9-CM criteria. The patients suffered from a mean of 5.6 +/- 3.1 (SD) active medical problems (range 0-18). This level of medical comorbidity was significantly greater than that of older psychiatric outpatients and comparable to that of elderly inpatients in general medical hospitals. When the effects of age and education were controlled for, there were no significant differences in mean numbers of medical problems among the four groups of psychiatric inpatients. An association of major depression with diseases of the digestive system was observed and may be related to peripheral autonomic dysregulation.

Somatic disease and psychological disorder

The association between physical and psychological disorders has been demonstrated repeatedly. There are a number of explanations for this association, each of them pointing to specific diseases and operationalizations of mental distress. In this article, the relationship between various somatic diseases and a number of indices for psychological distress was investigated. Within one study population, patients with different somatic diseases were identified, and their experience with mental distress, their requests for help from their GP during consultations, and their GPs' diagnoses were registered and compared with the total study population: It appears that relationships could be demonstrated between experience of distress and presentation of psychological symptoms during consultations, on the one hand, and common physical disorders, on the other. Patients with neurological diseases (Parkinson's, epilepsy, multiple sclerosis) and gastric ulcers showed the same relationships, but were also more frequently diagnosed by the GP as having psychological disorders. Patients with a number of other serious somatic diseases, such as diabetes, cancer, and arthritis, did not distinguish themselves in a positive way on one of indices for psychological distress.

The prevalence of major depressive disorder and low self-esteem in medical inpatients

OBJECTIVE

To determine the prevalence of major depressive disorder in acutely ill medical inpatients, and the relationship of this to low self-esteem.

METHOD

A total of 186 patients were interviewed 6 or 7 days following admission to detect the presence of DSM-IV major depressive disorder (MDD). Patients were assessed using a new brief psychiatric interview, the Silverstone Concise Assessment for Depression (SCAD), which has previously been validated for use in the physically ill. The cognitive function of the patients was measured, using the Mini-Mental State Examination (MMSE), with patients scoring less than 22 on the MMSE being excluded from the study. The patients' self-esteem was also assessed, using the Rosenberg self-esteem rating scale. The severity and type of the patients' medical illness, and the recognition of psychiatric illness by both nurses and physicians were also noted.

RESULTS

The results showed that 18 patients (9.7%) were depressed. The depressed patients were significantly younger than the nondepressed patients (mean age 46.3 +/- 3.9 years versus 57.1 +/- 1.5 years, respectively) and were significantly more likely to be female (61% versus 44%, respectively). The depressed patients had a significantly lower self-esteem than the nondepressed patients, whose self-esteem was no different from the general population. However, the depressed patients were not more severely ill than the nondepressed patients. The results also demonstrated that both nurses and physicians were poor at recognizing the presence of major depression, with nurses recognizing 33% of cases compared to 22% for medical staff.

CONCLUSIONS

The results from this study demonstrate that while there is an increase in the incidence of depression in medically ill patients, this is not as great as has been previously reported, and is not related to severity of illness. The results from this study, therefore, are in keeping with other recent findings which show that the prevalence rates for MDD in medical patients is between 5% to 10% rather than the previously accepted range of 20% to 40%.

Management of depression in the outpatient office

Current practice suggests that primary care physicians are in the best position to identify initially and treat depression in the ambulatory setting. Educating primary care physicians about depression is essential for identifying and adequately caring for depressed patients. Depression is commonly seen and easily treated in primary care settings. A structured, consistent approach to the depressed patient is essential and should include patient education; eliciting information about symptoms; clinical observation about the examination; a history of previous psychiatric episodes; family history of affective disorders; history from relatives, other providers, or other clinics if necessary; aggressive use of medication alone or in combination with psychotherapeutic techniques; and appropriate referral. Depression is associated with significant suffering and disability and increased utilization of health care services. Depressed patients can present with a variety of somatic and cognitive symptoms. Primary care physicians should be alert for denial and minimization of symptoms as well as for the presence of stigmatization. The biologic, psychological, and social aspects of depression should be expanded on as needed according to the patient's illness beliefs. A medical model such as that used for explaining diabetes or coronary artery disease may be useful. Primary care physicians miss the diagnosis of depression in as any as two out of three cases, and when the diagnosis is made, patients are often undertreated and given antidepressants at subtherapeutic dosages and for only short periods of time. Treatment of depression can be extremely satisfying and gratifying for patients and physicians, who need to have a high index of suspicion for depression. All antidepressants have the same efficacy, and the selection is based primarily on their side-effect profile. The new generation of antidepressants are better tolerated, relieve symptoms of depression, improve the quality of life, and probably improve morbidity and mortality. In many cases, depression is chronic and recurrent, and treatment should be long-term to prevent relapses. As with other chronic diseases, if a patient requires treatment that the primary care provider cannot render alone, it needs to be coordinated. In particular, consultants may need to be called in for psychotherapy. Primary care physicians should feel confident that, given enough time and cooperation, they can almost always find a treatment regimen that succeeds in alleviating and perhaps preventing the great suffering and risk occasioned by depression in medically ill ambulatory patients.

Prevalence of psychiatric disorders in medical inpatients

The aim of the present study was to determine the prevalence of psychiatric disorders in acutely ill medical inpatients. A total of 313 consecutively admitted patients were interviewed using a semistructured psychiatric interview. Diagnoses were made according to DSM-IV diagnostic criteria during two time periods, the 7 days following admission and the month prior to admission. The results showed that 85 patients (27.2%) received a DSM-IV diagnosis, with several patients having comorbid diagnoses. Major depressive disorder was present in 16 patients (5.1%), most of whom also had major depressive disorder in the month prior to admission. This prevalence rate is above that of the general population (1.2% to 2.8%), but less than that reported in most previous studies (20% to 40%). Forty-three patients (13.7%) had an adjustment disorder, 18 patients (5.8%) had an anxiety disorder, and 17 patients (5.4%) had either alcohol dependence or abuse. Nurses were more proficient than medical staff at identifying patients who had received a DSM-IV diagnosis, recognizing 61% of cases compared with 41% for medical staff.

Major depression in primary care practice. Clinical characteristics and treatment implications

Major depression is thought to be underdiagnosed and undertreated in primary medical care facilities. The authors conducted a clinical trial that included a three-phase assessment so only ambulatory medical patients judged eligible for treatment of this disorder in medical settings were recruited. In addition to administering the Center for Epidemiologic Studies-Depression scale and the Diagnostic Interview Schedule's (DIS) Depression section, the psychiatrists evaluated the DIS-positive patients. This third assessment determined that clinical characteristics of DIS-positive patients were such that 70% of the patients could be treated for major depression in a primary care setting, 13% should probably be referred to a mental health facility, and 17% were experiencing conditions other than major depression.

The somatizing patient in general practice

OBJECTIVE

The exploratory study described in this article followed two groups of patients over a twelve-month period. Subjects were drawn from a pool of patients who had consulted their general practitioner during the three-month selection period. One group consisted of patients who had consulted their general practitioner at least once about a physical complaint that the GP regarded as predominantly psychosocial; these patients did not articulate complaints of an explicitly mental or social nature. The second group was characterized by the fact that its members voiced precisely such mental or social complaints.

METHOD

The study investigated the extent to which the two groups (which were comparable in the severity of their complaints) differ with respect to patient characteristics such as the severity of their possible respect to patient characteristics such as the severity of their possible psychological problems, the frequency with which they visited their GPs, and the types of complaints--e.g. mental, psychosomatic and purely physical--they presented.

RESULTS

It was found that patients in the first group, whose somatic complaints were seen to have a psychosocial basis, are not the dependent types generally mentioned in theories about somatization. In fact, they adopt a more independent attitude to the GP than do patients voicing mental complaints. There are indications that for "somatizing" patients, underlying mental problems are less important than for "psychologizing" patients.

CONCLUSIONS

Both the somatizing patients and the psychologizing patients continued very frequent visits to their GP during the 12-month research period, although chiefly to address physical complaints that the GP also assessed as such.

What does the BDI measure in chronic pain?

The Beck Depression Inventory (BDI) has been widely used to document the prevalence of depressive symptomatology in samples of chronic pain patients and as an outcome measure in studies of the psychological management of chronic pain. Several BDI items have a somatic content (sleep disturbance, fatigue, etc). Since chronic pain may have similar somatic effects, the significance of the total BDI score in this population is unclear. Two hundred and forty mixed chronic pain patients completed the BDI at screening interview for a psychologically based pain management programme; of these, 207 (mean age 50.1 years; 63% female) were later admitted to the programme when the BDI was readministered along with measures of pain, anxiety, pain-related cognitions, and physical performance. The mean BDI score of the sample was 18.1, with 71.7% meeting criteria (scoring 13 or more) for at least mild depression. A principal-components analysis of the BDI yielded 3 meaningful factors labelled: sadness about health, self-reproach, and somatic disturbance. Among the most frequently endorsed items were those loading on the somatic factor. The pattern of relationships between individual factor scores and measures of pain, mood, cognition, and physical functioning indicated that the use of the total BDI score may give a misleading impression of the nature and degree of affective disturbance in this group of patients. The implications of these findings for our understanding of BDI scores obtained by chronic pain patients are discussed.

General health, health care utilization, and medical comorbidity in dysthymia

OBJECTIVE

This article reviews the literature on the general health, health care utilization, prevalence, medical comorbidity, and treatment of dysthymia in medical settings.

METHOD

The literature was searched by using MEDLINE and by reviewing the bibliographies of recent publications. Studies were selected that included health data on patients with dysthymia or chronic depression according to DSM-III, DSM-III-R, ICD-9, or RDC criteria, or patients who were described as having persistent depressive symptoms.

RESULTS

This review shows that dysthymic patients are at increased risk for poor general health and frequently use medical services. Compared to the general population, dysthymia is more prevalent in primary care and among patients with various medical and neurological conditions, sleep disorders, chronic fatigue, hypothyroidism, and somatoform disorders. Pharmacotherapy is effective, but has not been well studied. Non-tricyclic antidepressants might be especially useful. Psychotherapy studies are virtually non-existent.

CONCLUSIONS

Although dysthymia is considered a minor depressive condition, these findings show that it is a significant public health problem, comparable to major depression. Recent efforts to improve the recognition and treatment of major depression in medical settings, therefore, should be extended to include the entire spectrum of depressive disorders. Future studies should investigate the type and pattern of medical comorbidity and health care utilization, different antidepressant and psychosocial therapies, and the clinical and biological correlates of treatment response in different chronic depressive subtypes in medical settings and compare them to major depressive and subsyndromal depressive conditions.

The psychosocial review of systems

Psychosocial problems have a significant impact on the course and cost of medical illness. However, many of these areas are generally neglected in medical interviews. This manuscript presents a condensed review of the major psychosocial domains, which together constitute what we term a psychosocial review of systems (PROS). Selected references are provided which document the importance of these areas to medical care, and serve as background reading for further inquiry. The psychosocial areas which are covered include: substance use, stress and life events, subjective views of symptoms, daily activity, social support, sexual concerns, finances, psychiatric history and symptoms, cultural issues, and functional status. The Psychosocial Review of Systems (PROS) can serve as a basic overview for the psychosocial aspects of medical education, and also as a content based instrument which has potential for development as an assessment tool to measure physician competence in eliciting relevant psychosocial data.

Underdiagnosis of depression in patients with coronary artery disease: the role of nonspecific symptoms

OBJECTIVE

To determine whether the underdiagnosis of major depression (MD) in patients with coronary artery disease (CAD) may be explained by low specificity and mild severity of depressive symptoms in affected patients.

METHOD

The Beck Depression Inventory (BDI) was used to assess depression symptoms in thirty-one patients with both CAD and MD, and eighty-three patients with CAD but without MD.

RESULTS

Only ten (48%) of the symptoms were significantly more common in the MD than in the non-MD group, and nine symptoms were present in at least 20 percent of both groups. Of these nine nonspecific symptoms, only one (insomnia) was more severe in the MD patients than in the non-MD group (p < .006). When all twenty-one symptoms were rank ordered by frequency, the most common symptoms in the MD group were also the most common in the non-MD group (r = .91, p < .001).

CONCLUSIONS

The symptoms of major depression were found to be relatively mild and nonspecific in patients with CAD. This may help to explain why depression is underdiagnosed in cardiac patients.

Pharmacotherapy of depression in the medically ill: directions for future research

A common problem facing the psychiatric consultant and the medical practitioner is evaluating depression in patients with concurrent medical illnesses. Depression is difficult to recognize in the medically ill, often presenting with "masked" symptoms and organized into unique syndromes. A primary concern of the clinician is identifying those patients who are likely to benefit from an antidepressant trial. Although antidepressants have been shown to sometimes be of benefit in medical populations, the symptoms predicting antidepressant response remain poorly defined. Important directions for future research include 1) evaluating the safety and efficacy of newer antidepressants in the medically ill and 2) identifying those depressive syndromes that may be responsive to pharmacotherapy.