Attachment--and loss.

The detection of psychiatric illness by questionnaire

Background. In recent years the 12-item General Health Questionnaire (GHQ-12) has been extensively used as a short screening instrument, producing results that are comparable to longer versions of the GHQ.Methods. The validity of the GHQ-12 was compared with the GHQ-28 in a World Health Organization study of psychological disorders in general health care. Results are presented for 5438 patients interviewed in 15 centres using the primary care version of the Composite International Diagnostic Instrument, or CIDI-PC.Results. Results were uniformly good, with the average area under the ROC curve 88, range from 83 to 95. Minor variations in the criteria used for defining a case made little difference to the validity of the GHQ, and complex scoring methods offered no advantages over simpler ones. The GHQ was translated into 10 other languages for the purposes of this study, and validity coefficients were almost as high as in the original language. There was no tendency for the GHQ to work less efficiently in developing countries. Finally gender, age and educational level are shown to have no significant effect on the validity of the GHQ.Conclusions. If investigators wish to use a screening instrument as a case detector, the shorter GHQ is remarkably robust and works as well as the longer instrument. The latter should only be preferred if there is an interest in the scaled scores provided in addition to the total score.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291796004242

The validity of two versions of the GHQ in the WHO study of mental illness in general health care

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60879-5.pdf

Clinical diagnosis of depression in primary care: a meta-analysis

Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated. These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines. These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions. Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.

/pdf/canadian-clinical-practice-guidelines-for-the-management-of-3kjxn44j0v.pdf

Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

BACKGROUND A review of the efficacy of antidepressant drug treatment in patients with obsessive-compulsive disorder (OCD), using a meta-analytic approach.

METHOD Randomised double-blind clinical trials of antidepressant drugs, carried out among patients with OCD and published in peer-reviewed journals between 1975 and May 1994, were selected together with three studies currently in press. Forty-seven trials were located by searching the Medline and Excerpta Medica-Psychiatry data bases, scanning psychiatric and psychopharmacological journals, consulting recent published reviews and bibliographies, contacting pharmaceutical companies and through cross-references. Hedges' g was computed in pooled data at the conclusion of treatment under double-blind conditions or at the latest reported point of time during this treatment period. For each trial, effect sizes were computed for all available outcome measures of the following dependent variables: obsessive-compulsive symptoms considered together; obsessions; compulsions; depression; anxiety; global clinical improvement; psychosocial adjustment; and physical symptoms.

RESULTS Clomipramine was superior to placebo in reducing both obsessive-compulsive symptoms considered together (g = 1.31; 95% CI = 1.15 to 1.47) as well as obsessions (g = 0.89, 95% CI = 0.36 to 1.42) and compulsions (g = 0.79; 95% CI = 0.34 to 1.24) taken separately. Also, selective serotonin re-uptake inhibitors (SSRIs) as a class were superior to placebo, weighted mean g being respectively 0.47 (95% CI = 0.33 to 0.61), 0.54 (95% CI = 0.34 to 0.74) and 0.52 (95% CI = 0.34 to 0.70) for obsessive-compulsive symptoms considered together, and obsessions and compulsions taken separately. Although on Y-BOCS the increase in improvement rate over placebo was 61.3%, 28.5%, 28.2% and 21.6% for clomipramine, fluoxetine, fluvoxamine, and sertraline respectively, the trials testing clomipramine against fluoxetine and fluvoxamine showed similar therapeutic efficacy between these drugs. Finally, both clomipramine and fluvoxamine proved superior to antidepressant drugs with no selective serotonergic properties.

CONCLUSION Antidepressant drugs are effective in the short-term treatment of patients suffering from OCD; although the increase in improvement rate over placebo was greater for clomipramine than for SSRIs, direct comparison between these drugs showed that they had similar therapeutic efficacy on obsessive-compulsive symptoms; clomipramine and fluvoxamine had greater therapeutic efficacy than antidepressant drugs with no selective serotonergic properties; concomitant high levels of depression at the outset did not seem necessary for clomipramine and for SSRIs to improve obsessive-compulsive symptoms.

Efficacy of drug treatment in obsessive-compulsive disorder. A meta-analytic review.

Ninety consecutive patients aged 14 and above attending a general practice in Verona completed the 30-item General Health Questionnaire (GHQ), were assessed by the general practitioner for the presence of psychiatric disturbances on a 5 point scale, and interviewed by a psychiatrist using the Clinical Interview Schedule (CIS). The Italian versions of both the GHQ and the CIS were confirmed as feasible instruments for general practice studies in Italy. Taking the Overall Severity Rating made by the psychiatrist (Psy-OSR) at the end of the CIS as the criterion, the best CIS threshold in discriminating between “cases” and “non cases” was 12/13, while the GHQ cut off point of 5/6 gave the best results in terms of balance between sensitivity (81%) and specificity (71%). According to this cutting score, 47.8% of patients were high scorers. The corresponding figures of sensitivity and specificity for a GHQ cut off 4/5 were 89% and 65%. A comparison of the performance of the GHQ-30, GHQ-12 and C-GHQ (Goodchild and Duncan-Jones method of scoring), obtained in the usual way, as well as using ROC analysis showed that the C-GHQ gave the best overall results, but the difference was not significant. Using the Psy-OSR ≥2 or the CIS Total Weighted Score ≥13 as indicators, the prevalence of “true” cases in this sample was 35.5% and 38.8% respectively, a rate lower than that reported by Fontanesi et al. (1985) in another general practice study in Italy.

Psychiatric screening in general practice in Italy. A validity study of the GHQ (General Health Questionnaire).

Background. The next generation of studies on antidepressant drug prescriptions in general practice needs to assess both the patterns of prescription and its appropriateness. This study aimed to assess the performance of the Personal Health Questionnaire (PHQ), a new questionnaire for detecting individuals with ICD-10 depressive disorders, to be used in association with companion instruments for assessing the ‘quality’ of antidepressant prescriptions in primary care settings. Methods. The PHQ was completed by 1413 primary care attenders (100 were re-tested after 7–14 days) and 139 were selected and interviewed using the SCAN-2 and the 17-item HDRS. All data were analysed using appropriately weighted procedures to control for two-phase sampling design and non-response bias. Individual weights were estimated by logistic regression analysis and trimming strategy. Results. PHQ internal consistency and test–retest on both Likert score and number of symptoms were high. The PHQ discriminated well between individuals with and without depressive disorders. A Likert score [ges ] 9 provided a good trade-off between sensitivity (0·78) and specificity (0·83). The screening accuracy of the PHQ in detecting subjects likely to benefit from antidepressant drug treatment (SCAN cases with a HDRS total score of 13 or higher) was satisfactory (ROC area 0·87; sensitivity 0·84; specificity 0·78). Conclusions. The PHQ can be strongly suggested as an accurate and economic screener to identify primary care attenders at high risk of being clinically depressed. However, in order to identify patients requiring antidepressant drug treatment, a second-phase assessment of PHQ high scorers (total score of [ges ] 10), using the HDRS, is needed.

The Personal Health Questionnaire: a new screening instrument for detection of ICD-10 depressive disorders in primary care.

A significant proportion of primary care patients are
affected by a depressive disorder and about half of these
patients are undetected and undertreated. Twenty-five primary care physicians (PCPs) were recruited
in five Italian centres. All consecutive patients who attended
the PCPs’ clinics in a 2-week period completed the Personal
Health Questionnaire (PHQ), and those scoring more than nine on
the PHQ were interviewed with the Hamilton Rating Scale for
Depression—17 items (HDRS-17). The appropriateness of
antidepressant drug treatment was assessed according to the
decision to treat, the coverage, the type of drug and the dosage
prescribed. The adjusted prevalence for ICD-10 depression in 2093
patients was 18.7%, while the conspicuous morbidity was 10.7%.
The ability of PCPs to detect a depression increased
proportionally with HDRS scores. The coverage, i. e. the
proportion of patients who would benefit from an antidepressant
(AD) and who actually received such drugs, was 20.9%. The drugs
most frequently prescribed were SSRI (36 %), followed by TCA
(21%) and by other AD. Most SSRI were prescribed at therapeutic
dosage, while two-thirds of TCA were at sub-therapeutic dosage.
About 37% of patients started a non-pharmacological treatment.
The severity of depression at the first consultation predicted
the persistence of a depressive state in the longer term. The ability of Italian PCPs to detect depression is
satisfactory when the patient’s depressive state is moderate or
severe. The appropriateness of antidepressant drug treatment
still needs to be improved.

Recognition of depression and appropriateness of antidepressant treatment in Italian primary care.

Objective: To investigate the usefulness of the milk-to-plasma (M/P) ratio for assessing the risks for the breastfed infant associated with the maternal use of SSRIs. Data sources: Medline, Toxnet, Embase, Current Contents, and PsycInfo indexed articles from 1980 to September 2006. Study selection and data extraction: All studies reporting the M/P ratio in mothers taking SSRIs while breastfeeding or studies which such an information could be calculated from data reported in the article. Data synthesis: Higher M/P ratios were rarely associated with a clinically significant impact on the babies during the early phases of breastfeeding. Conclusions: So far no evidence-based information seems to support the hypothesis that SSRIs characterized by a M/P ratio <1.0 should be preferred. Hence, physicians should consider different parameters when attempting to choose the safest SSRI for the breastfeeding woman. These parameters might be represented by the number of well-documented published adverse event reports and the tendency of each SSRI of inducing in the infants serum concentrations that are elevated above 10% of average maternal serum levels. In any case, if the mother wishes to breastfeed her infant while taking a SSRI, the baby should be closely monitored in order to promptly detect any iatrogenic event.

Cesario Bellantuono

Papers

Efficacy of drug treatment in obsessive-compulsive disorder. A meta-analytic review.

Psychiatric screening in general practice in Italy. A validity study of the GHQ (General Health Questionnaire).

The Personal Health Questionnaire: a new screening instrument for detection of ICD-10 depressive disorders in primary care.

Recognition of depression and appropriateness of antidepressant treatment in Italian primary care.

SSRIs during breastfeeding: spotlight on milk-to-plasma ratio