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

Drug-drug Interactions in Psychiatric Practice, Part 1: Reasons, Importance, and Strategies to Avoid and Recognize Them

This column begins a series exploring drug-drug interactions (DDIs) with a special emphasis on psychiatric medications. As explained in this column, this topic is important for multiple reasons. First, a large percentage of the population is receiving psychiatric medications. Second, these patients are likely to be on multiple medications which means that they are at risk for an adverse DDI. Third, DDIs may occur but not be recognized even though they have significant health care consequences for the patient. Fourth, these consequences can range from a catastrophic outcome to more everyday clinical problems involving a myriad of presentations as enumerated in this column. Also discussed in this column is the fact that all drugs, including psychiatric medications, interact on the basis of their pharmacodynamics and pharmacokinetics rather than their therapeutic use. Therefore, psychiatric medications may interact with medications prescribed for nonpsychiatric reasons as well as with other psychiatric medications. Tables are included that explain reasons for multiple medication use and principles to follow to minimize the risk of adverse DDIs.

Are there meaningful differences between major depressive disorder, dysthymic disorder, and their subthreshold variants?

A number of researchers have proposed adding an increasing number of subthreshold variants of major depressive disorder (MDD) as new mood disorder. However, this research has suffered from a number of theoretical and methodological flaws that the current investigation has attempted to address. Individuals with MDD (n = 470) were compared with individuals with subthreshold MDD (n = 57). Individuals with MDD reported consistently more severe symptoms, albeit of small magnitude, as well as differences in comorbidity with only two disorders. Results also indicated that diagnosis did not significantly predict rate of symptom change when MDD was compared with its subthreshold variant. Taken together, the aforementioned evidence suggests that small differences exist between MDD and its subthreshold variant. In addition, the extent to which the latter serves as useful analogs for the former may depend upon the variables under study.

A different approach toward screening for bipolar disorder: the prototype matching method

Most screening scales for psychiatric disorders consist of a series of questions about the signs and symptoms of the disorder of interest, and to determine whether a patient screens positive, the scores of the individual items are summed and the total score is compared with an empirically derived threshold. A problem with the score summation approach toward case identification on screening scales is that different studies may find that different thresholds are optimal for distinguishing cases from noncases. An alternative approach toward screening is the prototype matching approach, in which respondents are asked to indicate how well their clinical history matches the described prototype. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the symptom summation and prototype matching approaches toward screening for bipolar disorder in a large sample of psychiatric outpatients. Nine hundred sixty-one psychiatric outpatients were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and completed the Bipolar Spectrum Disorders Scale (BSDS). The BSDS is a unique screening scale consisting of a prototypic description of bipolar disorder. The respondent checks off which items in the prototypic paragraph describes them and also answers a single multiple-choice question at the end of the paragraph asking how well the paragraph describes them. The results of a receiver operating curve analysis found that the score summation and prototype matching approaches toward screening on the BSDS performed equally well. These findings provide preliminary evidence that an alternative approach toward psychiatric screening, the prototype matching approach, is as effective as the traditional score summation method. This raises the intriguing possibility of developing a combined screening scale/educational instrument that can be formatted as a brochure and thus placed in clinicians' waiting rooms, thereby facilitating use of the measure.

Performance of the mood disorders questionnaire in a psychiatric outpatient setting

OBJECTIVES

The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.

METHODS

A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.

RESULTS

Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.

CONCLUSIONS

In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers' recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ's utility in routine clinical practice.

A clinically useful depression outcome scale

If the optimal delivery of mental health treatment ultimately depends on examining outcome, then precise, reliable, valid, informative, and user-friendly measurement is the key to evaluating the quality and efficiency of care in clinical practice. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the reliability and validity of the Clinically Useful Depression Outcome Scale (CUDOS). The CUDOS was designed to be brief (completed in less than 3 minutes), quickly scored (in less than 15 seconds), clinically useful (fully covering the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of major depressive disorder and dysthymic disorder), reliable, valid, and sensitive to change. We studied the CUDOS in more than 1400 psychiatric outpatients and found that the scale had high internal consistency and test-retest reliability. The CUDOS was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The CUDOS was also highly correlated with interviewer ratings of the severity of depression, and CUDOS scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The CUDOS was a valid measure of symptom change. Finally, the CUDOS was significantly associated with a diagnosis of major depressive disorder. Thus, the results of this large validation study of the CUDOS shows that it is a reliable and valid measure of depression that is feasible to incorporate into routine clinical practice.

Screening for personality disorders

A brief but valid self-report measure to screen for personality disorders (PDs) would be a valuable tool in making decisions about further assessment and in planning optimal treatments. In psychiatric and nonpsychiatric samples, we compared the validity of three screening measures: the PD scales from the Inventory of Interpersonal Problems, a self-report version of the Iowa Personality Disorder Screen, and the selfdirectedness scale of the Temperament and Character Inventory. Despite their different theoretical origins, the screeners were highly correlated in a range from .71 to .77. As a result, the use of multiple screeners was not a significant improvement over any individual screener, and no single screener stood out as clearly superior to the others. Each performed modestly in predicting the presence of any PD diagnosis in both the psychiatric and nonpsychiatric groups. Performance was best when predicting a more severe PD diagnosis in the psychiatric sample. The results also highlight the potential value of multiple assessments when relying on self-reports.

Complexity of medication use in the Veterans Affairs healthcare system: Part I: Outpatient use in relation to age and number of prescribers

CONTEXT

Multiple medication use is associated with an increased incidence of adverse drug-drug interactions (DDIs), medication errors, noncompliance, hospitalization, and healthcare costs. Drugs acting systemically or gastrointestinally ("SG" drugs) are of particular concern because of their potential to interact. A better understanding is needed of the relationship between multiple medication use, particularly of SG drugs, and age, number of prescribers, and common drug regimens.

OBJECTIVE

to determine the levels of multiple SG medication use in relation to age, number of prescribers, and common drug regimens in an outpatient population served by U.S. Veterans Integrated Service Network 15 (VISN 15).

DESIGN, SETTING, AND PARTICIPANTS

cross-sectional analysis of the subset of 5,003 currently active patients from a stratified random sample of 7,000 potentially active outpatients (1,000 each from 7 sites comprising VISN 15) selected from the prescription database on a single day.

MAIN OUTCOME MEASURES

number of SG drugs/patient; number and frequency of SG drug entities and regimens.

RESULTS

Most patients (97%) were dispensed at least one SG drug: 80% received > or =2 SG drugs, of which 42% received 2-4 SG drugs, 24%, 5-7 SG drugs, and 14%, > or =8 SG drugs. 394 different SG drugs were dispensed, only 88 of which occurred in 1% or more of patients. A significant increase (p < 0.0001) in level of multiple medication use occurred with increasing age and number of prescribers. Proportions of patients receiving 8 or more SG drugs approximately doubled with each additional prescriber, up to 4 or more prescribers. No drug regimen containing 2 or more drugs occurred in 1% or more of patients; 71% of patients were receiving a unique drug regimen (based on specific SG drugs without regard to dose or administration schedule).

CONCLUSIONS

The uniqueness of SG drug regimens suggests no single prescriber could have extensive clinical experience with even a small fraction of the drug regimens patients receive. These findings suggest that potential DDIs cannot be predicted based on occurrence of common drug regimens in a general patient population. A follow-up study (reported separately) investigated whether common drug regimens can be identified by selecting for a specific drug treatment (e.g., an antidepressant). The improved ability to predict DDIs is particularly relevant for psychiatric patients, who are at increased risk for DDIs because of greater frequency of multiple medication use. In addition, DDIs may present in this population in ways that mimic worsening of primary symptoms, which may lead to increased doses of the medication that is actually responsible for the problem, causing still more toxicity.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients

CONTEXT

A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens.

OBJECTIVE

to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact.

DESIGN, SETTING, AND PARTICIPANTS

Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged > or = 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged > or = 60 years; 2 missing age information.

MAIN OUTCOME MEASURES

number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants.

RESULTS

Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received > or = 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received > or = 8 drugs. In both the AD and NoAD groups, 62%-96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients.

CONCLUSIONS

AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Compliance: the impact of adverse events and tolerability on the physician's treatment decisions

A hidden factor that can influence patient compliance is the physician's concern about the tolerability and safety of prescribed medication. Patients may complain about medication side effects that are unpleasant but not dangerous, and this in itself may decrease patient compliance. However, physicians' awareness about adverse events may influence the choice of a drug, and patients' adherence to treatment. In the acute phase of treatment there is a concern about the suicide potential of the depressed patient. The tricyclic antidepressants (TCAs) are toxic in overdose, in contrast to the relative safety of the SSRIs, SNRIs and mirtazapine. Safety issues are also a concern during long-term treatment with antidepressants, i.e., during the continuation and maintenance phases of treatment. Long-term effects such as weight gain and sexual dysfunction distinguish different classes of antidepressants. A particular clinical challenge is the situation when antidepressant medication is administered to a patient with a comorbid medical illness treated with other drugs. This occurs frequently in elderly patients, and may result in an increase in adverse events and/or drug-drug interactions. Therefore, one strategy to determine the usefulness of a medication is to study its efficacy, tolerability and adverse events in a vulnerable population. Data from a recently completed open study of mirtazapine orally disintegrating tablets in depressed nursing home patients indicate that it was effective and well tolerated. This study used an orally disintegrating tablet formulation (Remeron SolTab), which was well received by both the patients and staff. Data on patient preferences in another open outpatient study looking at patients at least 50 years of age showed that patients also preferred mirtazapine orally disintegrating tablets to conventional tablets, and indicated that they would be more likely to comply with a prescription for an orally disintegrating tablets than conventional tablets.

The Diagnostic Inventory for Depression: A self-report scale to diagnose DSM-IV major depressive disorder

In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Diagnostic Inventory for Depression (DID), a new self-report scale designed to assess the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) symptom inclusion criteria for a major depressive episode, assess psychosocial impairment due to depression, and evaluate subjective quality of life. A large sample of 626 psychiatric outpatients completed the DID and were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The measure's test-retest reliability, discriminant and convergent validity, and sensitivity to clinical change were investigated. The DID subscales achieved high levels of internal consistency and test-retest reliability. The DID was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The DID also was highly correlated with interviewer ratings of the severity of depression and psychosocial functioning, and DID symptom severity scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The DID was a valid measure of symptom change. Finally, the DID was significantly associated with a diagnosis of major depressive disorder.

Emotional disorders in primary care

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues.

Prevalence of subthreshold forms of psychiatric disorders in persons making suicide attempts in Hungary

BACKGROUND

Suicide and suicide attempts have been associated to psychiatric illnesses; however, little is known about the role in suicide risk of those symptoms that do not meet the full criteria for a DSM-IV disorder. The aim of this study was to examine the prevalence of subthreshold psychiatric disorders among suicide attempters in Hungary.

METHODS

Using a modified structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses and their subthreshold forms defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 140 consecutive suicide attempters, aged 18-65 years.

RESULTS

Eighty-three-point-six percent of the attempters had one or more current threshold diagnoses on Axis I and in addition more than three-quarters (78.6%) of the subjects had at least one subthreshold diagnosis. Six-point-four percent of the subjects (N = 9) had neither subthreshold nor threshold diagnoses at the time of their suicide attempts. Ten percent of the subjects (N = 14), not meeting the full criteria for any DSM-IV diagnoses, had at least one subthreshold diagnosis. In 68.6% of the subjects (N = 96), both subthreshold and threshold disorders were diagnosed at the time of their suicide attempts. The number of subthreshold and threshold diagnoses were positively and significantly related (chi2 = 5.12, df = 1, P < 0.05). Sixty-three-point-six percent of the individuals received two or more current threshold diagnoses on Axis I and 44.3% of the individuals (N = 62) had two or more subthreshold diagnoses at the time of their suicide attempts.

LIMITATIONS

The subthreshold definitions in this study included only those forms of the disorders which required the same duration as the criteria DSM-IV disorder with fewer symptoms. Conclusions - Suicide attempts showed a very high prevalence of subthreshold disorders besides psychiatric disorders meeting the full criteria required according to the DSM-IV. Subthreshold forms of mental disorders need to be taken into account in suicide prevention.

Effects of depressive symptoms on health-related quality of life in asthma patients

OBJECTIVE

To assess the effects of depressive symptoms on asthma patients' reports of functional status and health-related quality of life.

DESIGN

Cross-sectional study.

SETTING

Primary care internal medicine practice at a tertiary care center in New York City.

PATIENTS

We studied 230 outpatients between the ages of 18 and 62 years with moderate asthma.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed in person in English or Spanish with two health-related quality-of-life measures, the disease-specific Asthma Quality of Life Questionnaire (AQLQ) (possible score range, 1 to 7; higher scores reflect better function) and the generic Medical Outcomes Study SF-36 (general population mean is 50 for both the Physical Component Summary [PCS] score and Mental Component Summary [MCS] score). Patients also completed a screen for depressive symptoms, the Geriatric Depression Scale (GDS), and a global question regarding current disease activity. Stepwise multivariate analyses were conducted with the AQLQ and SF-36 scores as the dependent variables and depressive symptoms, comorbidity, asthma, and demographic characteristics as independent variables. The mean age of patients was 41 +/- SD 11 years and 83% were women. The mean GDS score was 11 +/- SD 8 (possible range, 0 to 30; higher scores reflect more depressive symptoms), and a large percentage of patients, 45%, scored above the threshold considered positive for depression screening. Compared with patients with a negative screen for depressive symptoms, patients with a positive screen had worse composite AQLQ scores (3.9 +/- SD 1.3 vs 2.8 +/- SD 0.8, P <.0001) and worse PCS scores (40 +/- SD 11 vs 34 +/- SD 8, P <.0001) and worse MCS scores (48 +/- SD 11 vs 32 +/- SD 10, P <.0001) scores. In stepwise analyses, current asthma activity and GDS scores had the greatest effects on patient-reported health-related quality of life, accounting for 36% and 11% of the variance, respectively, for the composite AQLQ, and 11% and 38% of the variance, respectively, for the MCS in multivariate analyses.

CONCLUSIONS

Nearly half of asthma patients in this study had a positive screen for depressive symptoms. Asthma patients with more depressive symptoms reported worse health-related quality of life than asthma patients with similar disease activity but fewer depressive symptoms. Given the new emphasis on functional status and health-related quality of life measured by disease-specific and general health scales, we conclude that psychological status indicators should also be considered when patient-derived measures are used to assess outcomes in asthma.

Subthreshold depression in the elderly: qualitative or quantitative distinction?

Recent studies revealed that subthreshold depression (or "subclinical" or "subsyndromal" depression) can have clinical validity because it is related to dysfunction and disability and is a risk factor for major depression. However, none of these studies focused on old age. Therefore, one aim of the psychiatric part of the multidisciplinary Berlin Aging Study (BASE) was also to detect milder forms of psychopathological syndromes, especially subthreshold depression, compared with specified forms such as major depression and dysthymia according to the DSM-III-R. The present evaluation shows that subthreshold depression can be characterized in 2 ways: firstly, as a quantitatively minor variant of depression or a depression-like state with fewer symptoms or with less continuity; and secondly, as qualitatively different from major depression with fewer suicidal thoughts or feelings of guilt or worthlessness, while worries about health and weariness of living occur with a similar frequency.

'Subthreshold' mental disorders. A review and synthesis of studies on minor depression and other 'brand names'

BACKGROUND

Subthreshold conditions (i.e. not meeting full diagnostic criteria for mental disorders in DSM-IV or ICD-10) are prevalent and associated with significant costs and disability. Observed more in primary care and community populations than in speciality settings, varying conceptualisations have been applied to define these conditions.

AIMS

To examine definitional issues for subthreshold forms of depression (e.g. minor depression) and to suggest future directions for research and nosology in psychiatry and primary care.

METHOD

A Medline search was conducted. The relevant articles were reviewed with regard to specific categories of information.

RESULTS

Studies applied a myriad of names and definitions for subthreshold depression with varying duration, symptom thresholds and exclusions. Prevalence rates also vary depending upon the definitions, settings and populations researched.

CONCLUSIONS

Future research needs to apply methodological and intellectual rigour and systematically consider a broader clinical and nosological context. In addition, collaboration between psychiatry and primary care on research and clinical issues is needed.

Consultation-liaison psychiatrists management of depression

Prospective data on 1,360 consecutive inpatients referred to the consultation-liaison psychiatry service of 2 metropolitan general teaching hospitals and diagnoses as having a Depressive Illness Spectrum Disorder were collected by using the MICRO-CARES clinical database system. The distribution of DSM-III-R diagnoses was major depression (MD) 49%; dysthymia (DYS) 15%; organic or substance-induced mood disorder or depressive disorder not otherwise specified (ORG/NOS) 14%; and adjustment disorder with depressed mood (AD) 29%s. Antidepressants were prescribed in 59% of the MD cases, 40% of the DYS cases, 36% of the ORG/NOS cases, and 17% of the AD cases. In confirmed MD, antidepressants were prescribed in 69%, and significantly more often in those who were older, female, had a prior history of physical illness, had a neoplasm or a disorder of the nervous or musculoskeletal systems, had higher Axis IV scores, or were referred because of pain or terminal illness. The patients with confirmed MD prescribed antidepressants had a longer length of stay and were referred later than those not prescribed antidepressants. The results illustrate the importance of all the forms of depression in consultation-liaison psychiatry and the vigor with which all forms are treated.

Depression in primary care--more like asthma than appendicitis: the Michigan Depression Project

OBJECTIVE

To explore the relationships between detection, treatment, and outcome of depression in the primary care setting, based upon results from the Michigan Depression Project (MDP).

METHODS

A weighted sample of 425 adult family practice patients completed a comprehensive battery of questionnaires exploring stress, social support, overall health, health care utilization, treatment attitudes, self-rated levels of stress and depression, along with the Center for Epidemiologic Studies Depression Scale (CES-D), the Hamilton Rating Scale for Depression (HAM-D), and the Structured Clinical Interview for DSM-III (SCID), which served as the criterion standard for diagnosis. A comparison sample of 123 depressed psychiatric outpatients received the same assessment battery. Family practice patients received repeated assessment of depressive symptoms, stress, social support, and health care utilization over a period of up to 60 months of longitudinal follow-up.

RESULTS

The central MDP findings confirm that significant differences in past history, severity, and impairment exist between depressed psychiatric and family practice patients, that detection rates are significantly higher for severely depressed primary care patients, and that clinicians use clinical cues such as past history, distress, and severity of symptoms to "detect" depression in patients at intermediate and mild levels of severity. As well, there is a lack of association between detection and improved outcome in primary care patients.

CONCLUSION

These results call into question the assumption that "depression is depression" irrespective of the setting and physician, and they are consistent with a model of depressive disorder as a subacute or chronic condition characterized by clinical parameters of severity, staging, and comorbidity, similar to asthma. This new model can guide further investigation into the epidemiology and management of mood disorders in the primary care setting.

Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care

A considerable body of knowledge noe exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of "competing demands" derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated "domains," representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of "face validity" for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.

Direct and buffer effects of social support and personal coping resources in individuals with arthritis

The direct and buffer effects of various aspects of social support and personal coping resources on depressive symptoms were examined. The study concerned a community-based sample of 1690 older persons aged 55-85 yrs, of whom 719 had no chronic disease, 612 had mild arthritis and 359 had severe arthritis. Persons with arthritis reported more depressive symptoms than persons with no chronic diseases. Irrespective of arthritis, the presence of a partner, having many close social relationships, feelings of mastery and a high self-esteem were found to have direct, favourable effects on psychological functioning. Mastery, having many diffuse social relationships, and receiving emotional support seem to mitigate the influence of arthritis on depressive symptoms, which is in conformity with the buffer hypothesis. Favourable effects of these variables on depressive symptomatology were only, or more strongly, found in persons suffering from severe arthritis.

Psychological status among elderly people with chronic diseases: does type of disease play a part?

Psychological status, including depressive symptoms, anxiety, and mastery, was measured in a community-based sample of 3,076 persons aged 55 to 85 with various chronic diseases. Strong, linear associations were found between the number of chronic diseases and depressive symptoms and anxiety, indicating that psychological distress among elderly people is more apparent in the presence of (more) diseases. Furthermore, in contrast to general assumptions that mastery is a relatively stable state, our results indicate that mastery is affected by having chronic diseases. The 8 groups of chronically ill patients (with cardiac disease, peripheral atherosclerosis, stroke, diabetes, lung disease, osteoarthritis, rheumatoid arthritis, or cancer) did differ in their associations with psychological distress. Psychological distress is most frequently experienced by patients with osteoarthritis, rheumatoid arthritis, and stroke, whereas diabetic and cardiac patients appear to be the least psychologically distressed. Differences in disease characteristics, such as functional incapacitation and illness controllability, may partly explain these observed psychological differences across diseases.

Antidepressant-treated patients in ambulatory care long-term use of non-psychotropic and psychotropic drugs

BACKGROUND

Despite the problems involved in treating depression and concomitant medical disease, there are virtually no longitudinal studies on drug utilisation among depressed patients.

METHOD

Use of prescription drugs among all first-time users of antidepressants in a defined population five years before and six years after the index (first) treatment was compared to a referent group without antidepressant treatment. The generalised estimating equations (GEE) method was used for analysis.

RESULTS

The antidepressant-treated group used considerably more non-psychotropic drugs during the whole study period than the referent group. They also used more psychotropic drugs, a use which increased in connection with the initiation of antidepressant treatment, and stayed high for a further five years.

CONCLUSIONS

The high use of prescription drugs indicated widespread somatic and psychiatric health problems during the whole study period. Antidepressant-treated patients are at risk for drug interactions and adverse effects, and would benefit from a closer collaboration between psychiatry and medicine.

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.

Depressive symptoms and mental health service utilization in a community sample

This study examines the utilization of health visits for mental health purposes by community respondents with depressive symptoms. Data are drawn from first wave interviews of the Epidemiologic Catchment Area (ECA) project at the Baltimore, Durham, and Los Angeles sites. The results indicate that persons with depressive symptoms, even in the absence of a recent DIS/DSM-III disorder, are at increased risk for making mental health related visits. The risk of visiting a general medical provider or mental health specialist for mental health treatment tends to increase as the number of depressive symptoms increase. Sociodemographic factors including age, racial background, and employment status also influence the risk of making a mental health related visit.