Diagnostic co-morbidity in 2300 psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview

Validity of the DSM-5 Mixed Features Specifier Interview

OBJECTIVES

To examine the reliability and validity of a semi-structured interview assessing the features of the DSM-5 mixed features specifier. Our goal was to develop an instrument that could be used for both diagnostic and severity measurement purposes.

METHODS

Four hundred fifty-nine psychiatric patients in a depressive episode were interviewed by a trained diagnostic rater who administered semi-structured interviews including the DSM-5 Mixed Features Specifier Interview (DMSI). We examined the inter-rater reliability and psychometric properties of the DMSI. The patients were rated on clinician rating scales of depression, anxiety, and irritability, and measures of psychosocial functioning, suicidality, and family history of bipolar disorder.

RESULTS

The DMSI had excellent joint-interview interrater reliability. More than twice as many patients met the DSM-5 mixed features specifier criteria during the week before the assessment than for the majority of the episode (9.4% vs. 3.9%). DMSI total scores were more highly correlated with a clinician-rated measure of manic symptoms than with measures of depression and anxiety. More patients with bipolar depression met the mixed features specifier than patients with MDD. Amongst patients with MDD, those with mixed features more frequently had a family history of bipolar disorder, were more frequently diagnosed with anxiety disorders, attention deficit disorder, and borderline personality disorder, more frequently had attempted suicide, and were more severely depressed, anxious, and irritable.

CONCLUSION

The DMSI is a reliable and valid measure of the presence of the DSM-5 mixed features specifier in depressed patients as well as the severity of the features of the specifier.

Diagnostic psychiatric and somatic comorbidity in patients with depression in the Western Balkan countries

INTRODUCTION

This paper aims to examine the frequency and significance of diagnostic comorbidity of psychiatric disorders and somatic diseases in a sample of patients with depression as well as present current psychopharmacological treatment of the patients in the sample.

METHODS

The subjects in this study sample were 489 patients from the four Western Balkan countries with current primary diagnosis of major depression according to ICD 10. Comorbid psychiatric disorders and non-psychiatric illnesses were noted according to ICD 10 criteria during the diagnostic interview and analysed later. Additionally, the pharmacological treatment (existing and newly introduced) for each patient was noted and analysed later.

RESULTS

At least one comorbid psychiatric disorder was present in 72.5% of patients. The most frequent were anxiety disorders (53.6%), specifically generalized anxiety disorder (20.2%); non-organic sleep disorders (50.7%), specifically insomnia (48.4%); and sexual dysfunctions (21.4%), specifically lack of sexual desire (20.2%). Comorbidity with any non-psychiatric illness was present in 80.3% of patients. The most frequent were circulatory system diseases (55.9%), specifically hypertension (45.9%); endocrine, nutritional and metabolic disorders (51.3%), specifically hyperlipidaemia (24.0%); and other non-psychiatric disorders (60.7%), specifically low back pain (22.7%). All patients received pharmacological treatment with different medications. Most patients received monotherapy or combination therapy of antidepressants, anxiolytics, antipsychotics and antiepileptics. The most frequently used antidepressants were escitalopram, sertraline, and duloxetine. The most frequently used anxiolytics were alprazolam and diazepam, the most used antiepileptic was pregabalin, and the most used antipsychotics were olanzapine, quetiapine, and aripiprazole.

CONCLUSION

The results of the study confirm the results of previous research studies about the high prevalence of psychiatric and non-psychiatric comorbidities in patients with depression that were conducted in the past. It would be important if future studies could prove the importance of those comorbidities on clinical severity, choice of treatment, and its outcome in patients with depression.

Telehealth treatment of patients with major depressive disorder during the COVID-19 pandemic: Comparative safety, patient satisfaction, and effectiveness to prepandemic in-person treatment

BACKGROUND

The COVID-19 pandemic impelled a transition from in-person to telehealth psychiatric treatment. There are no studies of partial hospital telehealth treatment for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the effectiveness of partial hospital care of patients with MDD treated virtually versus in-person.

METHODS

Outcome was compared in 294 patients who were treated virtually from May 2020 to December 2021 to 542 patients who were treated in the in-person partial program in the 2 years prior to the pandemic. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being.

RESULTS

In both the in-person and telehealth groups, patients with MDD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups also reported a significant improvement in positive mental health, general well-being, coping ability, and functioning. A large effect size of treatment was found in both treatment groups. Contrary to our hypothesis, the small differences in outcome favored the telehealth-treated patients. The length of stay and the likelihood of staying in treatment until completion were significantly greater in the virtually treated patients.

LIMITATIONS

The treatment groups were ascertained sequentially, and telehealth treatment was initiated after the COVID-19 pandemic began. Outcome assessment was limited to a self-administered questionnaire.

CONCLUSIONS

In an intensive acute care setting, delivering treatment to patients with MDD using a virtual, telehealth platform was as effective as treating patients in-person.

Correlates of treatment seeking in individuals with social anxiety disorder: Findings from a nationally representative sample

Despite the availability of well-established and efficacious treatments for social anxiety disorder, most socially anxious individuals do not seek treatment and those who do often suffer for years before seeking treatment. A more comprehensive understanding of the factors related to treatment seeking for social anxiety disorder is needed. This study utilized the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a large representative U.S. adult sample, to examine the relationships between treatment seeking for social anxiety disorder and demographic characteristics, psychiatric comorbidities, social anxiety disorder symptomatology, and specific feared situations. Socially anxious individuals (n = 1,255) were identified using DSM-V criteria and treatment seeking was measured by either seeking help from a professional or being prescribed medication for social anxiety disorder symptoms. Results indicate key relationships between treatment seeking and age as well as comorbid anxiety disorders. Importantly, this study found that specific feared situations such as fear of small groups (AOR = 1.78) and speaking in social gatherings (AOR = 1.66), and specific social anxiety disorder symptoms such as panic attacks (AOR = 2.92) were significantly and uniquely associated with increased treatment seeking for social anxiety disorder.

Telehealth Treatment of Patients With Borderline Personality Disorder in a Partial Hospital Setting During the COVID-19 Pandemic: Comparative Safety, Patient Satisfaction, and Effectiveness of In-Person Treatment

There are no studies of the safety and effectiveness of telehealth psychiatric treatment of partial hospital level of care, in general, and for borderline personality disorder (BPD) in particular. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors compared the effectiveness of their partial hospital treatment program in treating patients with BPD. For both the in-person and telehealth partial hospital level of care, patients with BPD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups reported a significant improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment was found in both treatment groups. No patients attempted suicide. Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, and improved functioning and well-being for patients with BPD.

Individual treatment goals and factors influencing goal attainment in patients with somatic symptom disorder from the perspective of clinicians: A concept mapping study

OBJECTIVE

Overviews of treatment goals and influencing factors may support shared decision making and optimize customized treatment to the patient with somatic symptom disorder (SSD). The aim of this study was to identify and structure comprehensive sets of treatment goals and factors influencing goal attainment in patients with SSD from the perspective of clinicians.

METHODS

Using a concept mapping procedure, clinicians participated in interviews (N = 17) and card sorting tasks comprising 55 treatment goals and 55 factors influencing goal attainment (N = 38).

RESULTS

We identified four overarching categories (A to D) of nine clusters (1 to 9) of treatment goals: A. empowerment (A1. personal values, A2. committed action, A3. self-esteem), B. skill improvement (B4. interpersonal skills, B5. emotion and stress regulation), C. symptom reduction (C6. dysfunctional beliefs, C7. somatic symptoms, C8. psychological symptoms), and D9. active and structured lifestyle. Also, we identified four overarching categories (A to D) of nine clusters (1 to 9) of factors influencing goal attainment: A1. therapeutic alliance, B. social and everyday context (B2. [family] system, B3. meaningful daily schedule, B4. social and economic circumstances), C. ability to change (C5. externalizing tendency, C6. reflective and psychological skills, C7. perspective and motivation), and D. psychological vulnerability (D8. vulnerable personality, D9. [psychiatric] comorbidity).

CONCLUSION

The overviews of treatment goals and factors influencing goal attainment reflect different paradigmatic backgrounds of clinicians. The results can be used, in combination with the perspective of the patient, to define treatment goals, and to monitor and evaluate change in outcomes.

Previous disorders and depression outcomes in individuals with 12-month major depressive disorder in the World Mental Health surveys

AIMS

Major depressive disorder (MDD) is characterised by a recurrent course and high comorbidity rates. A lifespan perspective may therefore provide important information regarding health outcomes. The aim of the present study is to examine mental disorders that preceded 12-month MDD diagnosis and the impact of these disorders on depression outcomes.

METHODS

Data came from 29 cross-sectional community epidemiological surveys of adults in 27 countries (n = 80 190). The Composite International Diagnostic Interview (CIDI) was used to assess 12-month MDD and lifetime DSM-IV disorders with onset prior to the respondent's age at interview. Disorders were grouped into depressive distress disorders, non-depressive distress disorders, fear disorders and externalising disorders. Depression outcomes included 12-month suicidality, days out of role and impairment in role functioning.

RESULTS

Among respondents with 12-month MDD, 94.9% (s.e. = 0.4) had at least one prior disorder (including previous MDD), and 64.6% (s.e. = 0.9) had at least one prior, non-MDD disorder. Previous non-depressive distress, fear and externalising disorders, but not depressive distress disorders, predicted higher impairment (OR = 1.4-1.6) and suicidality (OR = 1.5-2.5), after adjustment for sociodemographic variables. Further adjustment for MDD characteristics weakened, but did not eliminate, these associations. Associations were largely driven by current comorbidities, but both remitted and current externalising disorders predicted suicidality among respondents with 12-month MDD.

CONCLUSIONS

These results illustrate the importance of careful psychiatric history taking regarding current anxiety disorders and lifetime externalising disorders in individuals with MDD.

Exposure Therapy With Personalized Real-Time Arousal Detection and Feedback to Alleviate Social Anxiety Symptoms in an Analogue Adult Sample: Pilot Proof-of-Concept Randomized Controlled Trial

BACKGROUND

Exposure therapy is highly effective for social anxiety disorder. However, there is room for improvement.

OBJECTIVE

This is a first attempt to examine the feasibility of an arousal feedback-based exposure therapy to alleviate social anxiety symptoms in an analogue adult sample.

METHODS

A randomized, pilot, proof-of-concept trial was conducted to evaluate the acceptability, safety, and preliminary efficacy of our treatment program. Sessions were administered once a week for 4 weeks (1 hour each) to an analogue sample of 50 young adults who reported at least minimal social anxiety symptoms. Participants in both intervention and waitlist control groups completed assessments for social anxiety symptoms at the baseline, week 5, and week 10.

RESULTS

Most participants found the intervention acceptable (82.0%, 95% CI 69.0%-91.0%). Seven (14.9%, 95% CI 7.0%-28.0%) participants reported at least one mild adverse event over the course of study. No moderate or serious adverse events were reported. Participants in the intervention group demonstrated greater improvements on all outcome measures of public speaking anxiety from baseline to week 5 as compared to the waitlist control group (Cohen d=0.61-1.39). Effect size of the difference in mean change on the overall Liebowitz Social Anxiety Scale was small (Cohen d=0.13).

CONCLUSIONS

Our results indicated that it is worthwhile to proceed to a larger trial for our treatment program. This new medium of administration for exposure therapy may be feasible for treating a subset of social anxiety symptoms. Additional studies are warranted to explore its therapeutic mechanisms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02493010; https://clinicaltrials.gov/ct2/show/NCT02493010.

Improving Access to Psychological Therapies (IAPT) - The Need for Radical Reform

Improving Access to Psychological Therapies is a UK government-funded initiative to widen access to the psychological treatment of depression and anxiety disorders. The author has had the opportunity to independently assess 90 Improving Access to Psychological Therapies clients, using a standardised semi-structured interview, the Structured Clinical Diagnostic Interview for DSM Disorders (SCID) and to listen to their account of interaction with the service. The results suggest that only the tip of the iceberg fully recovers from their disorder (9.2%) whether or not they were treated before or after a personal injury claim. There is a pressing need to re-examine the modus operandi of the service.

Improving Access to Psychological Therapies (IAPT) - The Need for Radical Reform

Improving Access to Psychological Therapies is a UK government-funded initiative to widen access to the psychological treatment of depression and anxiety disorders. The author has had the opportunity to independently assess 90 Improving Access to Psychological Therapies clients, using a standardised semi-structured interview, the Structured Clinical Diagnostic Interview for DSM Disorders (SCID) and to listen to their account of interaction with the service. The results suggest that only the tip of the iceberg fully recovers from their disorder (9.2%) whether or not they were treated before or after a personal injury claim. There is a pressing need to re-examine the modus operandi of the service.

Comorbid PTSD and Social Anxiety Disorder: Associations With Quality of Life and Suicide Attempts

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) frequently co-occur. Preliminary data from treatment-seeking and veteran samples suggest that the impact of PTSD-SAD comorbidity may be additive, conferring distress and impairment beyond that of either disorder alone. The current study sought to clarify and extend existent research using wave 2 of the National Epidemiologic Survey of Alcohol and Related Conditions, an epidemiological sample of American adults. Individuals who met criteria for comorbid PTSD-SAD were compared to those with either disorder alone on measures of lifetime suicide attempts or quality of life as measured by the Medical Outcomes Study Questionnaire. Relative to those with either PTSD or SAD, individuals with comorbid PTSD-SAD demonstrated an elevated risk of lifetime suicide attempts and substantially lower levels of physical and mental quality of life. The psychosocial consequences of PTSD-SAD comorbidity are substantial. Patients may benefit from early interventions to remediate social distress and improve support networks before more intensive psychotherapeutic interventions.

Childhood trauma and negative memory bias as shared risk factors for psychopathology and comorbidity in a naturalistic psychiatric patient sample

BACKGROUND

Both childhood trauma and negative memory bias are associated with the onset and severity level of several psychiatric disorders, such as depression and anxiety disorders. Studies on these risk factors, however, generally use homogeneous noncomorbid samples. Hence, studies in naturalistic psychiatric samples are lacking. Moreover, we know little about the quantitative relationship between the frequency of traumatic childhood events, strength of memory bias and number of comorbid psychiatric disorders; the latter being an index of severity. The current study examined the association of childhood trauma and negative memory bias with psychopathology in a large naturalistic psychiatric patient sample.

METHODS

Frequency of traumatic childhood events (emotional neglect, psychological-, physical- and sexual abuse) was assessed using a questionnaire in a sample of 252 adult psychiatric patients with no psychotic or bipolar-I disorder and no cognitive disorder as main diagnosis. Patients were diagnosed for DSM-IV Axis-I and Axis-II disorders using a structured clinical interview. This allowed for the assessment of comorbidity between disorders. Negative memory bias for verbal stimuli was measured using a computer task.

RESULTS

Linear regression models revealed that the frequency of childhood trauma as well as negative memory bias was positively associated with psychiatric comorbidity, separately and above and beyond each other (all p < .01).

CONCLUSIONS

The results indicate that childhood trauma and negative memory bias may be of importance for a broader spectrum of psychiatric diagnoses, besides the frequently studied affective disorders. Importantly, frequently experiencing traumatic events during childhood increases the risk of comorbid psychiatric disorders.

Help seeking for social anxiety: A pilot randomised controlled trial

OBJECTIVE

Although social anxiety disorder is a persistent and debilitating condition, only a minority of people with social anxiety disorder seek help and little is known about methods for promoting help seeking for social anxiety disorder. This pilot trial explored the potential effectiveness of an online program designed to increase help-seeking intentions for social anxiety disorder.

METHODS

Australian adults with symptoms of untreated social anxiety disorder were recruited online and randomised to either the Shyness Information Online intervention (n = 41) or an online attention control condition (n = 41). Each program together with a baseline and postintervention survey was delivered in one session. The primary outcome was intentions to seek help from a professional. Secondary measures included anxiety literacy, help-seeking attitudes, internalised stigma, and perceived need for treatment. The acceptability of the program content and feasibility of the recruitment method were also examined.

RESULTS

Although they did not demonstrate a significantly greater increase in help-seeking intentions relative to the control group (p = 0.097), those receiving the intervention showed more favourable attitudes towards seeking psychological help (Hedges'g = 0.38; p = 0.025) and a higher level of perceived need for treatment (p ≤ 0.001). Participants also showed a greater knowledge about social anxiety disorder at post-intervention than the control participants (adjusted Hedges' g = 0.46, p < 0.001). Most respondents were satisfied with the intervention content; the recruitment strategy appeared feasible.

CONCLUSIONS

Further investigation of the intervention is warranted to test its effectiveness, explore the relationships between factors that influence social anxiety disorder help-seeking behaviour and to further test the validity of the social anxiety disorder help-seeking model on which the intervention was based.

Development of the C4 inventory: a measure of common characteristics that complicate care in outpatient psychiatry

Background

Psychiatric syndromes are complicated by comorbidity and other factors that burden patients, making guideline-informed psychiatric care challenging, and negatively affecting outcome. A comprehensive intake tool could improve the quality of care. Existing tools to quantify these characteristics do not identify specific complications and may not be sensitive to phenomena that are common in psychiatric outpatients.

Objective

To develop a practical inventory to capture observations related to complex care in psychiatric outpatients and quantify the overall burden of complicating factors.

Design

We developed a checklist inventory through literature review and clinical experience. The inventory was tested and compared with related measures in a cross-sectional study of 410 consenting outpatients at the time of initial assessment.

Results

The summed score of inventory checklist items was significantly correlated with patient-assessed measures of distress (K10, r=0.36) and function (WHODAS 2.0, r=0.31), and physician-assessed measures of function (GAF, r=−0.42), number of psychiatric diagnoses [F(df3)=33.6], and most complex diagnosis [F(df3)=37.4]. In 53 patients whose assessment was observed by two clinicians, inter-rater reliability was acceptable for both total inventory score (intraclass correlation, single measures = 0.74) and agreement on specific items (mean agreement score = 90%).

Conclusions

The Psychiatric C4 Inventory is a reliable instrument for psychiatrists that captures information that may be useful for quality improvement and resource planning. It demonstrates convergent validity with measures of patient distress, function, and complexity. Further tests of validity and replication in other settings are warranted.

Screening young adult cancer survivors for distress with the Distress Thermometer: Comparisons with a structured clinical diagnostic interview

BACKGROUND

The validity of the Distress Thermometer (DT) as a screen for psychological distress in young adult cancer survivors was assessed by comparing it with the results of a psychiatric diagnostic interview, the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (SCID), to evaluate the accuracy of the DT and identify optimal cutoff scores for this population.

METHODS

A total of 247 survivors aged 18 to 40 years completed the DT and SCID. Based on the SCID, participants were classified as having: 1) ≥ 1 SCID diagnoses; 2) significant symptoms, but no SCID diagnosis; or 3) no significant SCID symptoms. Receiver operating characteristic analyses determined the sensitivity and specificity of all possible DT cutoff scores for detecting survivors with a SCID diagnosis, and subsequently for survivors with significant SCID symptoms or a SCID diagnosis.

RESULTS

The recommended DT cutoff score of ≥5 failed to identify 31.81% of survivors with a SCID diagnosis (sensitivity of 68.18% and specificity of 78.33%), and 32.81% of survivors with either significant SCID symptoms or a SCID diagnosis. No alternative DT cutoff score met the criteria for acceptable sensitivity (≥85%) and specificity (≥75%).

CONCLUSIONS

The DT does not reliably identify young adult cancer survivors with psychiatric problems identified by a "gold standard" structured psychiatric interview. Therefore, the DT should not be used as a stand-alone psychological screen in this population. Cancer 2016;122:296-303. © 2015 American Cancer Society.

Defining Subthreshold PTSD in the DSM-IV Literature: A Look Toward DSM-5

Subthreshold posttraumatic stress disorder (PTSD), whether due to absence of symptom development or partial remission, is the subject of research and clinical work despite being absent from the DSM. A problem with the literature is that subthreshold definitions are inconsistent across studies and therefore aggregating results is difficult. This study compared the diagnostic hit rates and validity of commonly used definitions of Subthreshold PTSD in a single sample. Three definitions of Subthreshold PTSD were extracted from the literature and two were formed, including a model of DSM-5 PTSD-criterion sets, and a definition that requires six or more PTSD symptoms, but no particular criterion set. Participants (N = 654) with a criterion A stressor, but without full PTSD diagnosis, were included. Most individuals did not meet any definition of Subthreshold PTSD. Findings are discussed in light of previous research and need for increased understanding of the diagnostic implications of Subthreshold PTSD.

Formal psychological assessment in evaluating depression: a new methodology to build exhaustive and irredundant adaptive questionnaires

Psychological Assessment can be defined as a complex procedure of information collection, analysis and processing. Formal Psychological Assessment (FPA) tries to improve this procedure by providing a formal framework to build assessment tools. In this paper, FPA is applied to depression. Seven questionnaires widely used for the self-evaluation of depression were selected. Diagnostic criteria for major depressive disorder were derived from the DSM-5, literature and Seligman's and Beck's theories. A Boolean matrix was built, including 266 items from the questionnaires in the rows and 20 selected attributes, obtained through diagnostic criteria decomposition, in the columns. In the matrix, a 1 in a cell meant that the corresponding item investigated the specific attribute. It was thus possible to analyze the relationships between items and attributes and among items. While none of the considered questionnaires could alone cover all the criteria for the evaluation of depressive symptoms, we observed that a set of 30 items contained the same information that was obtained redundantly with 266 items. Another result highlighted by the matrix regards the relations among items. FPA allows in-depth analysis of currently used questionnaires based on the presence/absence of clinical elements. FPA allows for going beyond the mere score by differentiating the patients according to symptomatology. Furthermore, it allows for computerized-adaptive assessment.

Assessing the utility of intermediate phenotypes for genetic mapping of psychiatric disease

Intermediate phenotypes are traits positioned somewhere between genetic variation and disease. They represent a target for attempts to find disease-associated genetic variants and elucidation of mechanisms. Psychiatry has been particularly enamoured with intermediate phenotypes, due to uncertainty about disease aetiology, inconclusive results in early psychiatric genetic studies, and their appeal relative to traditional diagnostic categories. In this review, we argue that new genetic findings are relevant to the question of the utility of these constructs. In particular, results from genome-wide association studies of psychiatric disorders now allow an assessment of the potential role of particular intermediate phenotypes. Based on such an analysis, as well as other recent results, we conclude that intermediate phenotypes are likely to be most valuable in understanding mechanism.

Clinical predictors of diagnostic status in individuals with social anxiety disorder

OBJECTIVE

In psychiatric patients, comorbidity tends to be the rule, rather than the exception. This is especially true for patients with social anxiety disorder (SAD), but research on the implications of diagnostic status has been limited. This study aimed to examine the frequency of SAD as: (1) the only diagnosis, (2) a principal diagnosis with comorbid conditions, or (3) a comorbid condition when another diagnosis is principal in a treatment-seeking population. The study also sought to identify clinical features that distinguish people in these diagnostic groups.

METHOD

Our sample included 684 adult participants presenting for treatment in a specialty clinic for anxiety disorders. We established diagnoses with semistructured clinical interviews, and participants completed self-report measures of social anxiety, associated transdiagnostic symptoms, general distress, and impairment due to psychological difficulties. We analyzed group differences and investigated predictors of principal SAD diagnosis.

RESULTS

Over half of participants reported symptoms that met criteria for a SAD diagnosis (51.8%). Of these, 8.8% had SAD only (no comorbid psychiatric diagnoses), 48.6% had multiple conditions with SAD as the principal diagnosis, and 42.7% had multiple conditions with SAD as an additional diagnosis. SAD-only was associated with less severe impairment and transdiagnostic symptoms. Among participants with comorbid conditions, greater fear of negative evaluation, behavioral avoidance, and coping with substances predicted a principal SAD diagnosis, whereas SAD as an additional diagnosis was more likely when participants presented with greater anxiety sensitivity, intolerance of uncertainty, and thought avoidance.

CONCLUSIONS

Our findings suggest that principal diagnosis of SAD is common in a treatment-seeking population and is associated with more severe disorder-specific symptoms and less severe transdiagnostic features related to anxiety. Implications for assessment and treatment planning in clinical practice are discussed.

Influence of depressive symptoms on speech perception in adverse listening conditions

It is widely acknowledged that individuals with elevated depressive symptoms exhibit deficits in inter-personal communication. Research has primarily focused on speech production in individuals with elevated depressive symptoms. Little is known about speech perception in individuals with elevated depressive symptoms, especially in challenging listening conditions. Here, we examined speech perception in young adults with low- or high-depressive (HD) symptoms in the presence of a range of maskers. Maskers were selected to reflect various levels of informational masking (IM), which refers to cognitive interference due to signal and masker similarity, and energetic masking (EM), which refers to peripheral interference due to signal degradation by the masker. Speech intelligibility data revealed that individuals with HD symptoms did not differ from those with low-depressive symptoms during EM, but they exhibited a selective deficit during IM. Since IM is a common occurrence in real-world social settings, this listening deficit may exacerbate communicative difficulties.

Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18-65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.

The genetics of major depression

Major depression is the commonest psychiatric disorder and in the U.S. has the greatest impact of all biomedical diseases on disability. Here we review evidence of the genetic contribution to disease susceptibility and the current state of molecular approaches. Genome-wide association and linkage results provide constraints on the allele frequencies and effect sizes of susceptibility loci, which we use to interpret the voluminous candidate gene literature. We consider evidence for the genetic heterogeneity of the disorder and the likelihood that subtypes exist that represent more genetically homogenous conditions than have hitherto been analyzed.

The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: a meta-analysis

Although co-occurring posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) is associated with greater distress, impairment, and health care utilization than PTSD alone, the magnitude of this problem is uncertain. This meta-analysis aimed to estimate the mean prevalence of current MDD co-occurrence among individuals with PTSD and examine potential moderating variables (U.S. nationality, gender, trauma type, military service, referral type) that may influence the rate of PTSD and MDD co-occurrence. Meta-analytic findings (k = 57 studies; N = 6,670 participants) revealed that 52%, 95% confidence interval [48, 56], of individuals with current PTSD had co-occurring MDD. When outliers were removed, military samples and interpersonal traumas demonstrated higher rates of MDD among individuals with PTSD than civilian samples and natural disasters, respectively. U.S. nationality, gender, and referral type did not significantly account for differences in co-occurrence rates. This high co-occurrence rate accentuates the importance of routinely assessing MDD among individuals with PTSD and continuing research into the association between these disorders.

Overcoming the problem of diagnostic heterogeneity in applying measurement-based care in clinical practice: the concept of psychiatric vital signs

Measurement-based care refers to the use of standardized scales to measure the outcome of psychiatric treatment. Diagnostic heterogeneity poses a challenge toward the adoption of a measurement-based care approach toward outcome evaluation in clinical practice. In the present article, we propose adopting the concept of psychiatric vital signs to facilitate measurement-based care. Medical vital signs are measures of basic physiologic functions that are routinely determined in medical settings. Vital signs are often a primary outcome measure, and they are also often adjunctive measurements. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the frequency of depression and anxiety in a diagnostically heterogeneous group of psychiatric outpatients to determine the appropriateness of considering their measurement as psychiatric vital signs. Three thousand psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV supplemented with items from the Schedule for Affective Disorders and Schizophrenia. We determined the frequency of depression and anxiety evaluated according to the Schedule for Affective Disorders and Schizophrenia items. In the entire sample of 3000 patients, 79.3% (n = 2378) reported clinically significant depression of at least mild severity, 64.4% (n = 1932) reported anxiety of at least mild severity, and 87.4% (n = 2621) reported either anxiety or depression. In all 10 diagnostic categories examined, most patients had clinically significant anxiety or depression of at least mild severity. These findings support the routine assessment of anxiety and depression in clinical practice because almost all patients will have these problems as part of their initial presentation. Even for those patients without depression or anxiety, the case could be made that the measurement of depression and anxiety is relevant and analogous to measuring certain physiologic parameters in medical practice such as blood pressure and body temperature regardless of the reason for the visit.

Guided self-help as the first step for bulimic symptoms: implementation of a stepped-care model within specialized psychiatry

OBJECTIVE

This study describes the implementation and effectiveness of the first step, guided self-help (GSH), in a clinical setting, of a stepped-care model of cognitive behavior therapy for patients with bulimic symptoms.

METHOD

Eighty-nine patients participated.

RESULTS

In the intent to-treat analyses, the effect sizes were small to moderate (0.25-0.66). However, the effect sizes were substantially larger (0.44-1.66) for the patients who completed all the GSH sessions (45%). The majority of noncompleters stayed within psychiatric services. Supplementary treatments were mostly directed towards comorbid conditions, especially depression. Those discontinuing treatment in advance where characterized by more lifetime diagnoses and higher ratings on the restraint subscale of the EDE-Q.

DISCUSSION

GSH within specialized psychiatry might be effective for about 30% of the patients. There is no indication of patients losing their confidence in psychiatric services by being offered GSH as the first treatment.

Physical health problems after single trauma exposure: when stress takes root in the body

Research has established that chronic stress, including traumatic events, leads to adverse health outcomes. The literature has primarily used two approaches: examining the effect of acute stress in a laboratory setting and examining the link between chronic stress and negative health outcomes. However, the potential health impact of a single or acute traumatic event is less clear. The goal of this literature review is to extend the literature linking both chronic trauma exposure and posttraumatic stress disorder to adverse health outcomes by examining current literature suggesting that a single trauma may also have negative consequences for physical health. The authors review studies on health, including cardiovascular, immune, gastrointestinal, neurohormonal, and musculoskeletal outcomes; describe potential pathways through which single, acute trauma exposure could adversely affect health; and consider research and clinical implications.

Medication for borderline personality disorder: a survey at a secure hospital

OBJECTIVES

To study the use of medication in the treatment of inpatients with borderline personality disorder (BPD). To survey clinicians' views on the UK National Institute for Health and Clinical Excellence (NICE) Guideline on BPD.

METHODS

Cross-sectional survey of the use of psychotropics purely for BPD at a large secure UK psychiatric hospital, together with interviews with the treating psychiatrists.

RESULTS

A total of 79 patients had a DSM diagnosis of BPD, of whom 80% were receiving one or more psychotropics and 48% were receiving two or more. Most prescriptions were off-label. Antipsychotics followed by antidepressants were the most frequent class of drug prescribed for BPD. Clozapine was the most commonly prescribed drug and according to the treating psychiatrists the one most likely to lead to a major improvement in target symptoms. Other psychotropics were generally rated as resulting in minor improvement or no change. Clinicians were aware they were prescribing contrary to NICE but justified this on the basis of having to treat severe and complex cases.

CONCLUSIONS

Use of psychotropics (especially clozapine), off-label prescribing and polypharmacy were very common in these inpatients with BPD. Randomised controlled trials of the use of clozapine in severe BPD are needed.

Severe insomnia is associated with more severe presentation and greater functional deficits in depression

Depression is among the most common reasons for seeking psychiatric treatment, and insomnia symptoms are common in the clinical picture of depression. The present study examines the clinical presentation and psychosocial functioning among depressed outpatients with severe symptoms of insomnia in comparison to depressed outpatients without severe insomnia symptoms. The present sample included 2900 treatment-seeking individuals, with 1057 patients having a principal diagnosis of major depressive disorder (MDD). All patients were evaluated using the Structured Clinical Interview for DSM-IV Disorders (SCID), Schedule for Affective Disorders (SADS), and self-report measures of mood and psychosocial functioning. SADS Insomnia ratings were used to determine the presence of severe insomnia symptoms. Clinical, demographic, and psychosocial variables were obtained from the SCID and self-report measures. Among the patients with MDD, 24.7% endorsed severe insomnia symptoms. These individuals were older at time of presentation, were less likely to be married, had a lower education level, had a longer duration of the current depressive episode, were rated as more severe on the CGI, had poorer current functioning via GAF, and had higher HAM-D 21 scores. After controlling for severity, MDD patients with severe insomnia symptoms had poorer social functioning over the past 5 years, though this did not reach the significance level of p < .01, and significantly lower scores on 3 of the 8 SF-36 subscales (p < 0.01). These findings indicate that severe insomnia symptoms are associated with poorer psychosocial functioning and a more severe clinical presentation in patients with MDD. This argues for addressing severe insomnia symptoms among depressed patients, either via behavioral treatment or pharmacologic treatment options.

Treatment-seeking for social anxiety disorder in a general outpatient psychiatry setting

Many individuals with social anxiety disorder (SAD) seek treatment principally for another psychiatric disorder, but when directly asked, a majority of these individuals also desire treatment for SAD. Several reasons may exist for why individuals with SAD do not seek treatment for it, such as the severity or functional impairment related to SAD. The aim of the current study was to examine factors related to SAD severity, impairment, and comorbidity, to gain a better understanding of what factors may be related to treatment-seeking for SAD. In 819 psychiatric outpatients with SAD, initial results showed that age, duration of SAD illness, number of social fears endorsed, Clinical Global Impression score, Sheehan Disability Scale ratings for social life and distress, presence of major depressive disorder, and presence of depressive disorder not otherwise specified (DDNOS) were associated with treatment-seeking for SAD status. However, a regression analysis found that DDNOS was the most robust predictor of treatment-seeking for SAD status, followed by the number of feared social situations. Other factors should be examined in the future, such as knowledge of SAD and available treatment options.

Clinical correlates of desire for treatment for current alcohol dependence among patients with a primary psychiatric disorder

BACKGROUND AND OBJECTIVES

Rates of treatment-seeking for alcohol use disorders are notably low. To elucidate the clinical correlates of treatment-seeking for alcoholism, this study compared patients with current alcohol dependence and a primary psychiatric diagnosis who endorsed a desire for alcoholism treatment to patients who refused treatment or who were unsure.

METHOD

A total of 131 (54 females) psychiatric outpatients with current alcohol dependence completed an intake assessment at a large hospital-based psychiatric clinic and at the end of the intake were asked whether they would like to receive treatment for alcohol problems.

RESULTS

Compared with alcohol-dependent patients who refused treatment for alcoholism or who were unsure (n=46), patients who expressed a desire for treatment (n=85) were older, were more likely to be female, reported higher levels of social impairments, and were more likely to endorse the following alcohol dependence symptoms: (i) multiple unsuccessful efforts or persistent desire to stop or cut down on their drinking; and (ii) drinking more than intended.

CONCLUSIONS

Approximately, 35% of patients who met current DSM-IV criteria for alcohol dependence reported no interest (or were unsure) in alcoholism treatment despite being engaged in treatment-seeking for another psychiatric disorder.

SCIENTIFIC SIGNIFICANCE

These findings extend previous epidemiological studies documenting treatment-seeking patterns for alcoholism by identifying clinical features associated with interest in treatment for this disorder among psychiatric outpatients.

Paradigm shifts and the development of the diagnostic and statistical manual of mental disorders: past experiences and future aspirations

OBJECTIVE

Work is currently under way on the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, due to be published by the American Psychiatric Association in 2013. Dissatisfaction with the current categorical descriptive approach has led to aspirations for a paradigm shift for DSM-5.

METHOD

A historical review of past revisions of the DSM was performed. Efforts undertaken before the start of the DSM-5 development process to conduct a state-of-the science review and set a research agenda were examined to determine if results supported a paradigm shift for DSM-5. Proposals to supplement DSM-5 categorical diagnosis with dimensional assessments are reviewed and critiqued.

RESULTS

DSM revisions have alternated between paradigm shifts (the first edition of the DSM in 1952 and DSM-III in 1980) and incremental improvements (DSM-II in 1968, DSM-III-R in 1987, and DSM-IV in 1994). The results of the review of the DSM-5 research planning initiatives suggest that despite the scientific advances that have occurred since the descriptive approach was first introduced in 1980, the field lacks a sufficiently deep understanding of mental disorders to justify abandoning the descriptive approach in favour of a more etiologically based alternative. Proposals to add severity and cross-cutting dimensions throughout DSM-5 are neither paradigm shifting, given that simpler versions of such dimensions are already a component of DSM-IV, nor likely to be used by busy clinicians without evidence that they improve clinical outcomes.

CONCLUSIONS

Despite initial aspirations that DSM would undergo a paradigm shift with this revision, DSM-5 will continue to adopt a descriptive categorical approach, albeit with a greatly expanded dimensional component.

Posttraumatic stress disorder with and without alcohol use disorders: diagnostic and clinical correlates in a psychiatric sample

This study compared outpatients (n=196) with PTSD versus PTSD+alcohol use disorders (AUD) on clinical measures. PTSD+AUD patients were more likely to meet criteria for Borderline and Antisocial Personality Disorders. Emotion dysregulation may help account for the relationship between PTSD and AUD.

Post-traumatic stress disorder: emerging concepts of pharmacotherapy

Post-traumatic stress disorder (PTSD) can result from a traumatic experience that elicits emotions of fear, helpless or horror. Most individuals remain asymptomatic or symptoms quickly resolve, but in a minority intrusive imagery and nightmares, emotional numbing and avoidance, and hyperarousal persist for decades. PTSD is associated with psychiatric and medical co-morbidities, increased risk for suicide, and with poor social and occupational functioning. Psychotherapy and pharmacotherapy are common treatments. Whereas, research supports the efficacy of the cognitive behavioral psychotherapies, there is insufficient evidence to unequivocally support the efficacy of any specific pharmacotherapy. Proven effective pharmacologic agents are sorely needed to treat core and targeted PTSD symptoms, and for prevention. This review describes current and emerging pharmacotherapies that advance these goals.

Diagnosing alcohol abuse in alcohol dependent individuals: diagnostic and clinical implications

In DMS-IV, the diagnosis of alcohol abuse is precluded by the diagnosis of alcohol dependence. The goal of this study was to examine the diagnostic and clinical implications of diagnosing alcohol abuse among alcohol dependent individuals. Treatment-seeking psychiatric outpatients with a lifetime history of alcohol dependence (n=544), some of whom (n=45) did not meet lifetime criteria for alcohol abuse completed in-depth, face-to-face, semi-structured clinical assessments of DSM-IV axis I and axis II psychopathology. Alcohol dependent patients who did not meet criteria for alcohol abuse were significantly more likely to be female, have a later age of onset for alcohol dependence, have fewer dependence symptoms, and have a lower rate of positive family history for alcoholism, and were less likely to report a lifetime history of DSM-IV drug use disorders and PTSD. These findings suggest that diagnosing alcohol abuse among alcohol dependent patients may be clinically useful as an index of severity and higher likelihood of comorbid drug abuse and dependence. Future studies are needed to establish whether these differences are clinically significant in terms of the course of the disorder and response to treatment.

Posttraumatic stress disorder and other psychopathology in substance abusing patients

Studies demonstrating greater problem severity in substance abuse patients with posttraumatic stress disorder (PTSD) versus those without have rarely considered other co-occurring psychiatric disorders. This study of 466 male veterans recently admitted to outpatient substance abuse treatment attempts to identify problems associated with PTSD versus those associated with other nonsubstance use Axis I disorders. Problem severity, particularly psychiatric, was examined across four groups of patients with substance use disorders (SUDs). Those with: 1, SUDs only (SU-Only); 2, PTSD, but no other Axis I disorders (SU+PTSD); 3, PTSD and other Axis I disorders (SU+PTSD+Axis I); and 4, no PTSD, but other Axis I disorders (SU+other Axis I). Results suggested a hierarchy of psychiatric, and to a lesser extent, other life problem severities associated with these diagnostic groupings. The most severe group was SU+PTSD+Axis I, followed in decreasing severity by the SU+other Axis I, SU+PTSD, and SU-Only groups. Additional analyses comparing the SU+PTSD+Axis I patients with a subgroup of Axis I patients with more than one Axis I disorder (SU+multiple Axis I) revealed few group differences except for more lifetime suicide attempts and psychiatric hospitalizations in the SU+PTSD+Axis I group. The findings suggest that it is not PTSD per se, but the frequent co-occurrence of PTSD and other psychopathology that largely accounts for previously reported greater problem severity of SUD patients with PTSD.

The factor structure and severity of DSM-IV alcohol abuse and dependence symptoms in psychiatric outpatients

OBJECTIVE

The goal of the present study was to examine the factor structure and estimated severity of alcohol-use disorder (AUD) symptoms in a sample of treatment-seeking psychiatric outpatients.

METHOD

Participants (n = 1,027; 51.2% women) met the screening criteria for the lifetime assessment of AUDs according to the Structured Clinical Interview for the DSM-IV (SCID-I/P; First et al., 1995) and as a result completed an assessment of alcohol abuse and dependence symptoms. The average (SD) age of the sample was 36.6 (11.4) years, and 71% of participants met lifetime DSM-IV criteria for an AUD.

RESULTS

Exploratory factor analysis of the tetrachoric correlation matrix of alcohol abuse and dependence criteria revealed that a single factor best accounted for the data in this sample. Results of Rasch model analyses indicated that the severity ordering of the DSM-IV abuse and dependence symptoms was not consistent with the hierarchical structure suggested by the DSM-IV. Instead, abuse items were found to be spread across a full range of the AUD continuum and were not consistently in the lower ranges of severity.

CONCLUSIONS

This study extends the literature by examining a treatment-seeking psychiatric outpatient sample and using a semistructured diagnostic interview administered by mental health professionals. Methodological considerations and implications for the conceptualization of AUD are discussed.

Does comorbid Social Anxiety Disorder impact the clinical presentation of principal Major Depressive Disorder?

BACKGROUND

Although previous research has examined comorbidity in principal Social Anxiety Disorder (SAD), few studies have examined the disorders for which those with comorbid SAD seek treatment. Further, studies have shown that depressive disorders often are associated with SAD, but few have examined the clinical characteristics of patients with this particular comorbidity.

METHOD

The current study examined the prevalence of various principal Axis I disorders in 577 individuals diagnosed with comorbid SAD.

RESULTS

Consistent with previous research, Major Depressive Disorder (MDD) was the most frequent principal diagnosis in patients with comorbid SAD. Those with principal MDD and comorbid SAD (MDD-SAD) were compared to those with MDD without SAD (MDD) on demographic and clinical characteristics. Patients with MDD-SAD versus those with MDD were more severe in terms of social functioning, duration of depressive episode, suicidal ideation, time out of work, presence of current alcohol abuse/dependence, and age of onset of MDD. Social functioning, duration of episode, suicidal ideation, and age of onset of MDD remained significant even after controlling for additional comorbid disorders.

CONCLUSIONS

Findings suggest the need for future research to determine how treatments could be adapted for this commonly occurring comorbidity.