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

Neuroimaging, Cognitive, and Neurobehavioral Outcomes Following Carbon Monoxide Poisoning

Carbon monoxide is a colorless, odorless gas produced as a byproduct of combustion. Carbon monoxide is the leading cause of poisoning injury and death worldwide. Morbidity following CO poisoning includes neurologic sequelae, neuropathologic abnormalities on brain imaging, neurobehavioral changes, and cognitive impairments. It is estimated that as high as 50% of individuals with carbon monoxide poisoning will develop neurologic, neurobehavioral, or cognitive sequelae. Carbon monoxide related cognitive impairments included impaired memory, attention, executive function, motor, visual spatial, and slow mental processing speed. Given the high rate of brain related morbidity and the fact that the majority of carbon monoxide is avoidable, awareness and prevention of carbon monoxide poisoning is warranted.

Reliability and validity of the Hospital Anxiety and Depression Scale in an emergency department in Saudi Arabia: a cross-sectional observational study

BACKGROUND

Depression and anxiety are prevalent psychiatric comorbidities that are known to have a negative impact on a patient's general prognosis. But screening for these potential comorbidities in a hospital's accident and emergency department has seldom been undertaken, particularly in Saudi Arabia and elsewhere in the Middle East. The Hospital Anxiety and Depression Scale (HADS) has been extensively used to evaluate these psychiatric comorbidities in various clinical settings at all levels of health care services except for the accident and emergency department. This study therefore aimed to assess the reliability and validity of the HADS for anxiety and depression among patients at a hospital accident and emergency department in Saudi Arabia.

METHODS

This cross-sectional observational study was conducted from January to December 2012. The participants were 257 adult patients (aged 16 years and above) who presented at the accident and emergency department of King Khalid University Hospital, Riyadh, Saudi Arabia, who met our inclusion criteria. We used an Arabic translation of the HADS. We employed factor analysis to determine the underlying factor structure of that instrument in assessing reliability and validity.

RESULTS

We found the Arabic version of the HADS to be acceptable for 95% of the subjects. We used Cronbach's alpha coefficient to evaluate reliability, and it indicated a significant correlation with both the anxiety (0.73) and depression (0.77) subscales of the HADS, thereby supporting the validity of the instrument. By means of factor analysis, we obtained a two-factor solution according to the two HADS subscales (anxiety and depression), and we observed a statistically significant correlation (r = 0.57; p < 0.0001) between the two subscales.

CONCLUSION

The HADS can be used effectively in an accident and emergency department as an initial screening instrument for anxiety and depression. It thus has great potential as part of integrated multidisciplinary care.

Cognitive functioning, mental health, and quality of life in ICU survivors: an overview

Critical illness can and often does lead to significant cognitive impairment and to the development of psychological disorders. These conditions are persistent and, although they improve with time, often fail to completely abate. Although the functional correlates of cognitive and psychological morbidity (depression, anxiety, and posttraumatic stress disorder) have been studied, they may include poor quality of life, inability to return to work or to work at previously established levels, and inability to function effectively in emotional and interpersonal domains. The potential etiologies of cognitive impairment and psychological morbidity in ICU survivors are particularly poorly understood and may vary widely across patients. Potential contributors may include the potentially toxic effects of sedatives and narcotics, delirium, hypoxia, glucose dysregulation, metabolic derangements, and inflammation. Patients with preexisting vulnerabilities, including predisposing genetic factors, and frail elderly populations may be at particular risk for emergence of acceleration of conditions such as mild cognitive impairment.

Depression after myocardial infarction: TNF-α-induced alterations of the blood-brain barrier and its putative therapeutic implications

Patients experiencing an acute myocardial infarction (AMI) have a three times higher chance to develop depression. Vice versa, depressive symptoms increase the risk of cardiovascular events. The co-existence of both conditions is associated with substantially worse prognosis. Although the underlying mechanism of the interaction is largely unknown, inflammation is thought to be of pivotal importance. AMI-induced peripheral cytokines release may cause cerebral endothelial leakage and hence induces a neuroinflammatory reaction. The neuroinflammation may persist even long after the initial peripheral inflammation has subsided. Among those selected brain regions that are prone to blood-brain barrier dysfunction, the paraventricular nucleus of the hypothalamus (PVN), a major center for cardiovascular autonomic regulation, is indicated to play a mediating role. Optimal cardiovascular therapy improves cardiovascular prognosis without major effects on depression. By the same token, antidepressant therapy in cardiovascular disease is associated with modest improvement in depressive symptoms, however without improvement in cardiac outcome. The failure of current antidepressants and the growing number of patients suffering from both conditions legitimize the search for better antidepressive therapies, from patients as well as society perspectives. Though we appreciate the mutual character of the interaction between depression and AMI, the present review focuses on the side of AMI induced depression and discusses the role of inflammation, represented by the proinflammatory cytokine TNF-α, as potential underlying mechanism. It is conceivable that inhibition of the inflammatory response post-AMI, through targeted anti-inflammatory pharmacotherapeutical agents may prevent the development of depressive symptoms and ultimately may improve cardiovascular outcomes.

Cognitive functioning, mental health, and quality of life in ICU survivors: an overview

The significant and sometimes permanent effects of critical illness on wide-ranging aspects of functioning are increasingly recognized. Among the areas affected are acute and long-term cognitive functioning, depression, anxiety, PTSD, and quality of life. These and other areas are increasingly being studied and indeed are increasingly the focus of clinical attention and investigations. These conditions have been a focus of attention for more than a dozen years, with much improvement occurring in the ability to characterize these phenomena. For instance, in intervening years, it has been learned that cognitive impairment is highly prevalent and functionally disruptive and that it occurs in wide-ranging domains. Key questions remain unanswered with regard to vital questions such as determining causes, risk factors, and mechanisms as well as the degree to which brain injuries associated with critical illness are amenable to rehabilitation. Little remains known about the effects of critical illness on elderly ICU cohorts and on the neurologic functioning of individuals with preexisting impairment versus those who are normal. Few data exist regarding the development of strategies designed to prevent the emergence of neuropsychological deficits after critical illness. Although great progress has been made and is ongoing, a pressing need exists for additional investigation of cognitive impairment and other conditions,such as PTSD and quality of life after critical illness, that will seek to untangle the many pertinent questions related to this condition and that will ultimately offer help and hope to the thousands of survivors affected by this condition.

Experiences of Self-Esteem in Outpatients Diagnosed With Psychosis

The aim of the article is explore the meaning of self-esteem for individuals with psychotic disorders. To understand how individuals with psychosis experience self-esteem, eight participants (four females and four males) were interviewed using a semistructured open-ended format with scripted questions. Individuals with psychotic disorders maintained a sense of self by pursuing social and interpersonal activities that sustained and enhanced their self-esteem. Neither the positive symptoms nor the negative symptoms commonly associated with psychotic disorders appeared to diminish self-esteem. Also, participants did not describe their sense of self-esteem as being contingent on, or as a direct function of, having a psychotic disorder. For the individuals in this pilot study, self-esteem did not appear to be affected by having a psychotic disorder or by the stigma associated with having been given such a diagnosis. Individuals were able to engage in and maintain social and interpersonal relationships that contributed to their having a positive sense of self-worth. Further study is required to confirm and elaborate on this surprising set of findings.

Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome

OBJECTIVE

Depression and anxiety are common morbidities of critical illness. We assessed risk factors of depression and anxiety in Acute Respiratory Distress Syndrome (ARDS) survivors at 1 and 2 years post-hospital discharge.

METHOD

Risk factors for depression and anxiety at 1 and 2 years were assessed using stepwise multiple regression analyses, with and without 1-year outcomes.

RESULTS

ARDS survivors had depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. Predictors of depression at 1 year were alcohol dependence, female gender and younger age (P=.006). Predictors of anxiety were ratio of arterial oxygen tension to inspired oxygen fraction and duration of mechanical ventilation (P<.005). Predictors of depression at 2 years were depression at 1 year and the presence of cognitive sequelae (P<.0001). Predictors of anxiety at 2 years was anxiety at 1 year (P<.0001).

CONCLUSIONS

Medical variables that predicted depression or anxiety at 1 year no longer predicted depression and anxiety at 2 years. Medical variables appear to have a short-term effect on psychiatric outcomes. At 2 years lifestyle behaviors including history of smoking along with cognitive sequelae, depression and anxiety at 1 year predict depression and anxiety.

[Outcome of simultaneous psychosomatic/internal-medicine inpatient care--a naturalistic follow-up study]

OBJECTIVES

The effectiveness of simultaneous psychosomatic and internal-medicine inpatient care has not yet been satisfyingly investigated. What outcome is found in patients treated in a psychosomatic/internal medicine setting? Can we predict a reduction in depression and symptom severity?

METHODS

The study design is prospective and naturalistic. Patients from a psychosomatic/internal-medicine setting and a solely internal-medicine ward filled in self-report questionnaires on the day of admission, five days thereafter, and three months after discharge.

RESULTS

A total of 221 patients from a psychosomatic/internal-medicine setting and 418 patients from a solely internal-medicine ward were included. Patient characteristics differed significantly between the two wards. Treatment was associated with a reduction of depression and somatic symptom severity over time. Depression severity improved more in the psychosomatic/internal-medicine setting than in the internal-medicine ward (ES = 0.37 vs. ES = 0.65). The strongest predictor of improvement of depression and somatic symptom severity was the patients' belief that their physical well-being was influenced by psychological factors (B = 1.44 and 1 = 0.65).

CONCLUSIONS

The results document a differential approach to admission in an integrated psychosomatic/internal medicine setting and underline the favourable course for psychological and somatic symptoms.

Cognitive functioning, mental health, and quality of life in ICU survivors: an overview

Critical illness can and often does lead to significant cognitive impairment and to the development of psychological disorders. These conditions are persistent and, although they improve with time, often fail to completely abate. Although the functional correlates of cognitive and psychological morbidity (depression, anxiety, and posttraumatic stress disorder) have been studied, they may include poor quality of life, inability to return to work or to work at previously established levels, and inability to function effectively in emotional and interpersonal domains. The potential etiologies of cognitive impairment and psychological morbidity in ICU survivors are particularly poorly understood and may vary widely across patients. Potential contributors may include the potentially toxic effects of sedatives and narcotics, delirium, hypoxia, glucose dysregulation, metabolic derangements, and inflammation. Patients with preexisting vulnerabilities, including predisposing genetic factors, and frail elderly populations may be at particular risk for emergence of acceleration of conditions such as mild cognitive impairment.

Risk factors of symptom underestimation by physicians

OBJECTIVE

The aims of this study were to characterize patient-physician agreement on various psychological and somatic symptoms in internal medicine inpatients and to identify predictors of symptom severity underestimation by physicians.

METHODS

Consecutive adult inpatients of two internal medicine wards of a university hospital completed visual analogue scales (VASs) for severity of disability, anxiety, depression, somatic symptoms, and pain at the time of admission (n=639, participation rate=70%) and 5 days thereafter (n=401, participation rate=82%). In addition, the Patient Health Questionnaire 9 (PHQ-9) depression scale and the Clinical Global Impression Scale--Revised were used. At the same time, the six treating physicians independently rated the complaints of their patients using the same VAS. Rates of overestimation, concordance, and underestimation of symptom severity were analyzed. Logistic regression analyses were used to identify predictors of symptom underestimation by physicians.

RESULTS

Concordance between patients and physicians regarding disability, anxiety, depression, somatic symptom severity, and pain reached 50-60%. Symptom severity of patients suffering from major depressive episode was significantly more often underestimated than that of nondepressed patients (all P<.01). Of all the variables, greater depression on the PHQ depression score was the most important risk factor for symptom underestimation by physicians (OR ranging from 1.29 to 1.57; all P<.05, except underestimation of disability). Symptom underestimation of pain severity was also associated with panic disorder symptoms (odds ratio, 2.44; P=.01).

CONCLUSION

Depressed patients seem to be at greater risk of symptom underestimation by their physicians--a finding bearing implications for avoidance of underdiagnosis and insufficient treatment. Mutual understanding could be improved by better doctor-patient communication skills. Brief self-report depression screeners might help to reliably identify patients at risk for symptom underestimation by physicians.

The increased need for liaison psychiatry in surgical patients due to the high prevalence of undiagnosed anxiety and depression

BACKGROUND

Depression is the most common mental disease in patients hospitalized with physical illness. Disorders of anxiety and depression in general hospitals are frequently underdiagnosed and inappropriately treated.

AIM

To assess the prevalence of undiagnosed anxiety and depression in surgical inpatients and assess the referral rate and utilization of liaison psychiatry services.

METHODS

A prospective study of surgical admissions (n = 96) to two surgical services at two separate institutions between 01/01/05 and 31/12/05. The Hospital Anxiety and Depression (HADS) scale was used to evaluate all patients.

RESULTS

About 12.5% of patients had significant depression, 18.75% had significant anxiety, and 8.3% had significant mixed anxiety and depression. About 22.9% of patients warranted referral to liaison psychiatry services for further assessment and management.

CONCLUSIONS

Anxiety and depression are highly prevalent in surgical inpatients. An increased awareness of the possibility of undiagnosed psychiatric disorders is required, along with prompt and appropriate use of liaison psychiatry services.

Diagnosis and pharmacological treatment of depressive disorders in a general hospital

OBJECTIVE: To determine the point prevalence of depressive disorders in medical inpatients, to identify related sociodemographic and medical factors and to evaluate the psychotropic treatment given. METHOD: A cross-sectional study identifying the prevalence of depressive disorders and related factors combined with a prospective longitudinal study evaluating the psychopharmacological treatment were conducted. Medical inpatients, aged 18 years or older, presenting suitability to be interviewed and giving written informed consent were selected. The sample was composed of 125 subjects. The following instruments were used: a sociodemographic questionnaire; the Mini International Neuropsychiatric Interview; and the Beck Depression Inventory. Data related to medical, personal and family histories of psychiatric disorders and psychotropic use were collected by interview and from patient charts. The study took place at the Hospital Santa Isabel, in Blumenau, located in the state of Santa Catarina, Brazil, from January to July of 2002. RESULTS: The prevalence of depressive disorders was 26%. The factors that correlated with depressive disorders were being female, having an income lower than 3 times the minimum wage, having a personal history of depressive disorders, using psychotropic drugs, scoring higher than 13 on the Beck Depression Inventory and having been referred for a psychiatric consultation (p < 0.05). Only 43.8% of the individuals with depressive disorders received antidepressants. Most of the depressed patients were being treated with benzodiazepines (62.5%). The most frequently prescribed drugs were diazepam and fluoxetine. CONCLUSIONS: Approximately one-quarter of the medical inpatients had depressive disorders. However, antidepressants were prescribed for less than half of them. Women with a history of depression, using benzodiazepines and having a low income presented significantly higher rates of depressive disorders. Physicians should suspect depression in patients presenting such characteristics.

Rapid screening for major depression in post-myocardial infarction patients: an investigation using Beck Depression Inventory II items

OBJECTIVE

To determine the ability of three questions from the Beck Depression Inventory II (BDI-II) to detect major depressive disorder (MDD) in a cohort of patients hospitalised for acute myocardial infarction (MI).

DESIGN

Prospective observational study.

SETTING

Coronary care unit and cardiac step-down unit of an urban academic medical centre.

PATIENTS

131 post-MI patients within 72 h of symptom onset.

INTERVENTIONS

Patients were administered the BDI-II and participated in a structured diagnostic interview for MDD. Three individual BDI-II items (regarding sadness, loss of interest and loss of pleasure) were examined individually and in two-question combinations to determine their ability to screen for MDD.

MAIN OUTCOME MEASURES

Sensitivity, specificity, negative and positive predictive values and proportion of patients with MDD correctly identified.

RESULTS

The individual items and two-question combinations had good sensitivity (76-94%), specificity (70-88%) and negative predictive values (97-99%). Item 1 (sadness) performed the best of the individual items (48% with a positive response to the item had MDD; 3% with a negative response had MDD; over 80% of patients with MDD were correctly identified). A combination of questions about sadness and loss of interest performed best among the two-question combinations (37% with positive response had MDD v 1% with a negative response; 94% of patients with MDD were identified).

CONCLUSIONS

One to two questions regarding sadness and loss of interest serve as simple and effective screening tools for post-MI depression.

Affective outcome following carbon monoxide poisoning: a prospective longitudinal study

OBJECTIVE

To longitudinally assess the prevalence of depression and anxiety following carbon monoxide (CO) poisoning and to assess the contributions of mode of poisoning (accidental versus suicide attempt), cognitive sequelae, and oxygen dose (hyperbaric oxygen versus normobaric oxygen) to depression and anxiety.

BACKGROUND

CO is the most common cause of poisoning in the United States and may result in neuropathologic changes and cognitive and neurologic sequelae, yet little is known regarding affective outcomes.

METHOD

We prospectively assessed affect in 127 CO-poisoned patients. Self-report inventories of depression and anxiety were administered at 6 weeks and at 6 and 12 months post CO poisoning. The primary outcome was prevalence of depression and anxiety at 6 weeks. To determine the effect of mode of poisoning, cognitive sequelae, and oxygen dose, odds ratio estimates were calculated at all three times using logistic regression.

RESULTS

Depression and anxiety were present in 45% of patients at 6 weeks, 44% at 6 months, and 43% at 12 months. Patients with suicide attempt and cognitive sequelae had higher prevalence of depression and anxiety at 6 weeks. At 12 months, there were no differences in depression or anxiety regardless of mode of poisoning, presence of cognitive sequelae, or oxygen dose.

CONCLUSIONS

CO poisoning results in significant depression and anxiety that persist to at least 12 months. Patients with cognitive sequelae and suicide attempt had a higher rate of depression and anxiety at 6 weeks but not at 12 months. Clinicians need to be aware of affective morbidity following CO poisoning and remain vigilant about CO prevention.

Quality of life, emotional, and cognitive function following acute respiratory distress syndrome

Acute Respiratory Distress Syndrome (ARDS) is characterized by lung injury and hypoxemia, has a high mortality rate, and is associated with significant morbidity including cognitive and emotional sequelae and decreased quality of life. There is limited information regarding which of these factors are associated with decreased quality of life. This study assessed the relationships between quality of life, cognitive and emotional function in ARDS survivors at 1-year post-hospital discharge. Sixty-six ARDS survivors were administered a battery of neuropsychological tests, measures of emotional function and quality of life 1 year post-hospital discharge. At 1 year 45% of the ARDS patients had cognitive sequelae and 29% had mild to moderate symptoms of depression and anxiety. Depression, anxiety, and intensive care unit length of stay were significantly correlated with decreased quality of life. Cognitive impairments did not correlate with decreased quality of life. Illness severity and emotional function, but not cognitive sequelae, are associated with decreased quality of life 1 year following ARDS. ARDS is common and may result in significant cognitive and emotional morbidity and decreased quality of life.

Identification of depression by medical and surgical general hospital physicians

Little information is available about identification of mental distress by general hospital physicians (GHPs). We compared, among patients admitted in a General Hospital, depressed patients with patients identified as depressed by the GHPs. A random sample of 1,039 patients were screened with the 12-item General Health Questionnaire. Afterwards, all high scorers and a probability sample of low scorers were interviewed with a variety of measures, including the Composite International Diagnostic Interview-Primary Care version (CIDI-PHC). GHPs recorded the presence of depression on a Physician Encounter Form. Patients were more likely to have depression detected on medical than surgical wards. Of the 195 patients who had a depression, the GHPs assessed 32.5% as depressed. A number of factors associated with CIDI diagnoses were not significantly associated with being identified by the GHPs - female gender, two or more life events in the previous year, and a previous history of depression. The identification by the GHPs was associated with a higher probability of contacts with medical professionals and of antidepressant drug prescriptions during the year which followed the first interview.