A critical review of internet information about depression

OBJECTIVE

The source and quality of information about depression available on the Internet were examined.

METHODS

Online searches using the phrase "depression and treatment" were conducted on ten major Internet search engines. The first 20 sites generated by each engine were examined. The Web sites and the individual Web pages they contained were categorized by source, target audience, and affiliation with either a for-profit or a not-for-profit organization. Each site was rated by whether it mentioned the nine symptoms and five major criteria of a major depressive episode and whether it made any of three basic treatment recommendations. Ratings were compared to determine whether treatment differences between the sites could be attributed to the site's source.

RESULTS

The search generated a total of 178 active sites. Overall, the quality of information was poor. Only half of the sites mentioned any DSM-IV diagnostic symptom or criteria in their descriptions of depression, and only a quarter listed 11 to 14 symptoms or criteria. Almost half of the sites made no mention of medications, psychotherapy, or professional consultation as suggested treatments for depression. Almost two-thirds of the pages were found on for-profit sites. Documents from these sites scored lower on diagnostic accuracy and treatment recommendations than those from not-for-profit sites.

CONCLUSIONS

The quality of information on the Internet produced by the search was quite low. For-profit Web sites appeared much more frequently than not-for-profit sites among the first 20 sites generated by each search engine, and they contained poorer information.

Clinician Attributions for Symptoms and Treatment of Gulf War–Related Health Concerns

BACKGROUND

Several clinical syndromes are defined solely on the basis of symptoms, absent an identifiable medical etiology. When evaluating and treating individuals with these syndromes, clinicians' beliefs might shape decisions regarding referral, diagnostic testing, and treatment. To assess clinician beliefs about the etiology and treatment of "Gulf War illness," we surveyed a sample of general internal medicine clinicians (GIMCs) and mental health clinicians (MHCs).

METHODS

Clinicians (77 GIMCs and 214 MHCs) at the Veterans Affairs Puget Sound Health Care System, Seattle, Wash, and the Veterans Affairs Medical Center in Portland, Ore, responded to a mailed survey of their beliefs about Gulf War illness.

RESULTS

Compared with GIMCs, MHCs were more likely to believe that Gulf War illness was the result of a "physical disorder" and that symptoms resulted from viruses or bacteria, immunizations, exposure to toxins, chemical weapons, or a combination of toxins and stress (P <.05). Conversely, GIMCs were more likely than MHCs to believe that Gulf War illness was a "mental disorder" and that symptoms were due to stress or posttraumatic stress disorder (P <.05). In addition, MHCs were more likely to endorse biological interventions to treat Gulf War illness (P <.01), whereas GIMCs were more likely to endorse psychological interventions.

CONCLUSIONS

Clinicians' beliefs about the etiology and effective treatment of Gulf War illness vary and thus might contribute to the multiple referrals often reported by Gulf War veterans. Health care models for Gulf War veterans and others with symptom-based disorders necessitate collaborative interdisciplinary approaches.

The case against physician assisted suicide

Physician assisted suicide (PAS) engenders debate about the meaning of professional identity, what is proper in the doctor/patient relationship, and the physician's appropriate role in society. Polarization on PAS largely arises from different views on what defines compassion in relieving pain and suffering, and the proper balance between individual autonomy and social imperatives. This paper discusses the ethical, social and economic arguments against PAS, including a historical perspective on other socially-sanctioned inappropriate uses of medical technology and expertise. This paper maintains that a truly dignified death does not come at the hand of a physician-healer, despite compelling arguments that it is a compassionate act.

A comparative study of family functioning among Vietnamese and Cambodian refugees

This study was designed to determine the extent of family problems among a clinic population of Cambodian and Vietnamese refugees, and to identify similarities and differences between the two groups. All 107 patients with adolescent children from a total clinic population of 298 were interviewed using a semistructured questionnaire, results were tabulated, and statistical methods were applied. The types of problems with children described by parents were classified into the dimensions of communication, personal behaviors, school performance, social behaviors, and antisocial behaviors. There were significantly more problems described by Vietnamese parents as compared with Cambodian parents. Vietnamese parents reported significantly more dissatisfaction with life in the United States. For both ethnic groups, parents' relationships with their adolescent children were a major source of concern and had a major impact on parents' perceptions of their own health. Yet, there were important ethnic differences between these refugee groups in how patients perceived their problems.

A prospective study of the natural course of alcoholism in a Native American village

This study examines the natural course of alcoholism in a Native American village. We found that the remission rates of alcoholism were quite similar despite the different methods used: life histories (SADS-L interview) showed a 63% remission rate; a 19-year follow-up prospective showed 60% in remission; and following a cohort of all those who developed alcoholism in the village over the previous 19 years revealed a 60.9% remission rate. The data also showed vast differences in drinking problems between men and women. In the span of 19 years, the differences of point prevalence rates of alcoholism between men and women have jumped from that of two times (52% vs 26%) to five times (36.4% vs 7%). Furthermore, the results showed women had a higher rate of alcohol abuse (8.4% vs 3.6%) and a far higher remission rate (82% vs 52%) when compared to men. Three-fourths of the men in the studied sample had a lifetime history of alcohol dependence. They usually began drinking in their teens and developed dependency by their early twenties. About half stopped after an average of 15 years of drinking. The majority (83%) of the subjects who stopped drinking did so spontaneously or for specific personal-related reasons rather than because they received alcohol treatment.

Group therapy with WWII ex-POW's: long-term posttraumatic adjustment in a geriatric population

In this assessment of group therapy with WWII ex-POWs, the small cohort limits generalizations; however, we offer a longitudinal perspective on group process. Posttraumatic suppression and denial of emotions appears to be adaptive for time-limited periods but is not a long-term solution. More lasting changes in self-esteem and social interaction may be partially achieved through a supportive group environment that fosters cognitive synthesis and reorganization.

Psychotherapy of the victims of massive violence: countertransference and ethical issues

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.

The natural history of medical and psychiatric disorders in an American Indian community

In 1969, a Pacific Northwest American Indian community cohort (n = 100) was interviewed for the presence of physical and psychiatric illnesses. The same community was studied again in 1988. This study describes the outcome among the original 100 subjects. The schedule for Affective Disorders and Schizophrenia Lifetime Version (SADS-L) served as the basic interview instrument, supplemented by data from medical records, death certificates, and medical and community informants. Twenty-five subjects had died, 13 from cardiovascular disorders and seven from alcohol-related illnesses. Among the 46 subjects re-interviewed, hypertension, heart disease, and diabetes had become significant sources of medical morbidity. Alcoholism was the most significant cause of psychiatric morbidity, particularly among males. This study indicates that greater attention should be focused upon prevention and treatment of alcoholism, cardiovascular disorders, and diabetes in this community and in other American Indian populations.

Posttraumatic stress disorder, depression, and somatic symptoms in U.S. Mien patients

This report describes treatment over a period of 6 years of Mien refugees from highland Laos in the Indochinese Psychiatric Program of the Oregon Health Sciences University (Portland, OR). The medical and psychiatric problems of 84 patients were presented through somatic symptoms such as headache, dizziness, or musculoskeletal pain. Primary care medical problems were identified and treated, with the major focus on the two most common psychiatric diagnoses: major depression and posttraumatic stress disorder. Cultural beliefs about illness and medication interfered with adherence to prescribed treatment. A marked sensitivity to side effects of certain antidepressants also resulted in subtherapeutic doses. Patients rarely volunteered their traumatic histories, psychiatric problems, or dissatisfaction with medications. However, the effective use of medication for somatic complaints, along with the continuing recognition of Mien health beliefs in psychosocial treatments, allowed for the development of a trusting doctor-patient relationship and continued psychiatric care.

Treating psychiatric disorders among Mien refugees from highland Laos

The Mien, a Southeast Asian hill people, have immigrated to various countries throughout the world since the mid-1970s. They have brought their ancient culture with them, including beliefs and practices related to health, illness, and healing. During the last several decades they have suffered much war-related trauma, including extensive human, material and symbolic losses. This report describes our clinical experience with Mien refugees in the Indochinese Psychiatric Program of the Oregon Health Sciences University. We discuss symptom presentation among this group of patients, diagnostic and treatment issues, and the impact of cultural health beliefs upon illness and treatment. Major depression and post-traumatic stress disorder have been the most commonly encountered psychiatric diagnoses, usually revealed through somatic symptoms. Not only must clinicians take careful medical and psychiatric histories, but they must also be alert to the high probability of an extensive history of trauma. Clinical improvement in response to psychotropic medications has been limited. As a result, psychosocial and psychotherapeutic approaches to treatment have been developed and expanded and now are commonly employed, effectively combining support and education in the creation of a holding environment that includes both individual and group formats. Two case histories are presented which describe symptom presentation, health belief systems and therapeutic issues involved in treating Mien patients. They also illustrate that traditional and Western healing approaches can co-exist in the optimal care of these patients.

Sam Shepard and the dysfunctional American family: therapeutic perspectives

In depicting dysfunctional families Sam Shepard brought a greater intensity level to family portrayals than had previously been seen in modern American theater. In part, his plays appear to reflect the tumultuous tone of the late 1960s and early 1970s when American society was in flux and when the national uncertainty reached down to the basic unit of society, the family. Yet, despite addressing recently emerging social issues, Shepard's plays also depict universal family conflicts. There have been and always will be compelling forces that threaten domestic cohesiveness. While Shepard's families reflect extremely high levels of disorganization, they also demonstrate scenarios recognizable to all family therapists. They reassert the family's power and its influence on individual development. They also indirectly ask us to reflect on our current clinical practice and research. Family therapists need to continue to pay attention the content issues of family organization as well as therapeutic techniques. Shepard's plays remind therapists to look beyond internal dynamics in order to consider connections and affiliations that integrate families with outside communities. He underscores the importance of knowing the meaning and context of traditional rites of passage within families. Family therapists or other care providers may unwittingly undermine the significance of these family rituals by prescription of "expert" advice.

The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees

All 322 patients at a psychiatric clinic for Indochinese refugees were surveyed to determine the presence of posttraumatic stress disorder (PTSD). If PTSD was not diagnosed at the time of initial evaluation, a structured reinterview was performed. Seventy percent of the patients (N = 226) met the criteria for a current diagnosis of PTSD, and an additional 5% (N = 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93%) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1988, 46% (N = 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make.

Culture and society in posttraumatic stress disorder: implications for psychotherapy

Cultural belief systems, along with traditional family and social role expectations, greatly affect psychosocial adjustment in individuals recovering from severe trauma. In the cross-cultural psychotherapy of posttraumatic stress disorder (PTSD) anthropological and sociological perspectives can contribute to a more comprehensive diagnostic formulation and suggest possible approaches to treatment.

Antidepressant blood levels in Southeast Asians. Clinical and cultural implications

After long-term treatment with tricyclic antidepressants (TCA), the TCA blood levels of 41 depressed Southeast Asian patients were determined by high-pressure liquid chromatography. No detectable medicine level was found in 25 (61%) of the patients and a therapeutic level by American standards was found in only six (15%), indicating a high incidence of noncompliance. A Cambodian subgroup, however, was significantly more compliant than either the Vietnamese or Mein patients. After patient education and a discussion of problems and benefits of medicine, compliance improved with Vietnamese and Cambodians but not with the Mien. Cultural and educational factors influence compliance with medicine and responsiveness to education. Because the Cambodians also suffered from posttraumatic stress disorder, it is probable that the presence of this illness increased compliance. Preliminary data among these patients indicate that Asians probably need the same dose of imipramine as Americans to achieve a "therapeutic" level. Reports that Asians need lower doses of TCA medicine are limited by the high noncompliance rates with Asians. These high rates probably reflect cultural beliefs about illness and medication usage. It is valuable to perform TCA blood levels on Asian patients for whom antidepressants have been prescribed to monitor compliance and to lead into a discussion of benefits and side effects of the medicine. Evidence of noncompliance can lead to a productive doctor-patient discussion about beliefs and effects of the medication.

A review of mental health services for refugees between 1975 and 1985 and a proposal for future services

A lack of federal planning and foresight and an uneven and poorly coordinated network of state services have resulted in fragmented mental health care for the large number of Southeast Asian and other refugees who have entered the United States since 1975. The author reviews the history of mental health services for refugees between 1975 and 1985 and proposes the development of separate mental health and health services for refugees that are responsive to their political, social, economic, and cultural needs. Ideally the services would be provided within existing medical institutions and staffed by medical, psychiatric, and social services personnel assisted by culturally sensitive translators. The author outlines the role of government and organized psychiatry in shaping new programs for refugees and promoting their mental health.

Clinical relevance of grief and mourning among Cambodian refugees

From 1975 to 1979, one to two million Cambodians were executed or died of disease and starvation during the rule of the Pol Pot government. In the aftermath of that catastrophe, many survivors have developed symptoms of post-traumatic stress disorder. There is some evidence that the intrusive symptoms of this disorder, such as nightmares, sleep disorders, and startle reactions, can be treated with medication. But other psychosocial problems that are similar to those found in chronic grief, such as avoidance behavior, shame, and decreased involvement with other individuals, are more resistive to treatment. On a cross-cultural level, the interpretations of, or meanings given to, specific symptoms by the patient may be influenced by culturally-specific religious beliefs, rituals, and social traditions. For the clinician, these cultural factors have relevance not only for engaging the patient in treatment, but also in the planning of specific therapeutic interventions.

The medical management of the paranoid patient

Patients who are medically ill and distrustful of their care-providers are unfortunately a fact of life for most physicians. Medical management of such patients can be a frustrating experience because their suspiciousness is usually heightened by the stress of medical illness. Most often the patient's mistrust covers profound feelings of personal inadequacy and is a defense against feared passivity. Understanding of basic paranoid thought processes combined with knowledge of practical management techniques will lead to increased confidence and effectiveness when interacting with these difficult patients.

One-year follow-up study of posttraumatic stress disorder among survivors of Cambodian concentration camps

One year after receiving a diagnosis of posttraumatic stress disorder, five of 12 Cambodian concentration camp survivors who entered a treatment program no longer met the diagnostic criteria for the disorder, and symptoms in three others had improved. The intrusive symptoms of nightmares, sleep disorders, and startle reactions showed the most consistent improvement. Avoidance behavior, shame, and caring for others improved the least. The authors advocate use of tricyclic antidepressant medication and a consistent, supportive long-term psychotherapeutic commitment in treating this severely traumatized group.