Showing papers in "International Journal of Psychiatry in Medicine in 1997"

Assessing Psychiatric Impairment in Primary Care with the Sheehan Disability Scale

Abstract: Objective:Several recent studies have documented that substantial functional impairment is associated with many of the mental disorders seen in primary care. However, brief measures of mental health-related functional impairment are not commonly applied in primary care settings. The Sheehan Disability Scale (SDS), a three-item instrument for assessing such impairment, is evaluated in this study. Method: A psychometric analysis of the SDS was conducted with a sample of 1001 primary care patients at Kaiser Permanente in Oakland, California. The SDS and the Symptom Driven Diagnostic System for Primary Care assessments were completed.Results:The internal consistency reliability of the SDS is high, with coefficient alpha of 0.89. The construct validity was substantiated in two ways. A one-factor model fit the data quite well. Furthermore, patients with each of six psychiatric disorders had significantly higher impairment scores than those who did not. Finally, over 80 percent of the patients with mental disord...

Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults

Abstract: Objective:First, to examine and explain the relationship between religious service attendance and plasma Interleukin-6 (IL-6) levels, and second, to examine the relationship between religious attendance and other immune-system regulators and inflammatory substances.Methods:During the third in-person interview (1992) of the Establishment of Populations for Epidemiologic Studies of the Elderly (EPESE) project, Duke site, 1718 subjects age sixty-five or over had blood drawn for analysis of immune regulators and inflammatory factors, including IL-6 measurements. IL-6 was examined both as a continuous variable and at a cutoff of 5 pg/ml. Information on attendance at religious services was available from the 1992 interview and two prior interviews (1986 and 1989).Results:Religious attendance was inversely related to high IL-6 levels (> 5 pg/ml), but not to IL-6 measured as a continuous variable. Bivariate analyses revealed that high religious attendance in 1989 predicted a lower proportion of subjects with high...

Anxiety and Depression in Patients Receiving Implanted Cardioverter-Defibrillators: A Longitudinal Investigation:

Abstract: Objective:The implantable cardioverter-defibrillator (ICD) has dramatically improved survival rates following sudden cardiac death episodes. However, researchers have devoted little attention to the psychosocial consequences of living with the device. The current study used a longitudinal design to evaluate the impact of adaptation to the ICD on incidence and severity of anxiety and depression.Method:ICD recipients were administered standardized anxiety and depression questionnaires as well as questions evaluating quality of life related to the ICD in two consecutive yearly assessments. A preliminary evaluation of potentially important theoretical variables, such as the perceived predictability and controllability of shock onset was also conducted.Results:One-third of the study population (N = 38) had clinically significant levels of anxiety, depressed mood, and fear of symptoms of autonomic arousal. These negative affective states persisted over time, with 40 to 63 percent of subjects continuing to have ...

Fluoxetine in depressed patients on dialysis.

Abstract: Objective:To test the safety and efficacy of fluoxetine in patients with renal failure on dialysis.Method:Fourteen patients with major depression and end stage renal disease on hemodialysis were randomized into two groups for an eight-week study. Subjects as well as investigators were blinded as to which subject received fluoxetine and which placebo. Patients were carefully monitored concerning adverse events, serum fluoxetine and norfluoxetine levels, and psychological measurements of degree of depression.Results:No patients discontinued treatment because of adverse events, all of which were minor. All psychological tests showed improvement in depression at the four-week and eight-weeks point, although statistical significance could only be demonstrated at the fourth week of this study. All patients in the active group had serum plasma concentrations of fluoxetine and norfluoxetine less than 250 ng/ml at eight weeks, similar to levels in patients with normal renal function in a previous open label study....

Religious coping in the nursing home: a biopsychosocial model.

Abstract: Objective: To examine psychosocial and physical health correlates of religious coping in medically ill chronically institutionalized older adults. Religious coping is defined as the extent to which persons use religious beliefs and practices to help them to cope. Method: This is a cross-sectional cohort study conducted in a 120 bed VA-affiliated and a 125 bed university-affiliated community-based nursing home in Durham, North Carolina. Participants were 115 chronic care nursing home residents; mean age of the sample was seventy-nine years, 44 percent were women, and 17 percent were African Americans. Subjects were enrolled for a one-month period during which comprehensive psychosocial and health assessments were performed, including evaluation of cognitive function (Mini-Mental State Exam), physical function (Barthel index), severity of medical comorbidity (Cumulative Illness Rating Scale), self-reported physical pain (vertical verbal descriptor scale), depressive symptoms (Geriatric Depression Scale), social support (social network), and religious coping (Religious Coping Index). Results: Over 43 percent of the sample scored in the depressed range of the Geriatric Depression Scale. Almost 60 percent reported they used religion at least to a large extent when coping with their problems; 34 percent said that it was the most important factor that enabled them to cope. Patients who used religion to cope had greater social support (p = .01), more severe medical illness (p = .04), and better cognitive functioning (p = .02). Conclusions: Religious beliefs and practices are frequently used by chronically institutionalized older adults to help them to cope. Religious coping is associated with more severe medical illness, higher social support, and better cognitive functioning.

Vegetative and Psychological Symptoms Associated with Depressed Mood over the First Two Years after Stroke

Abstract: Introduction:In patients with acute physical illness, symptoms used in the diagnosis of major depression such as sleep or appetite disturbance may be nonspecific for depression. This study was undertaken to examine the association of depressed mood with other depressive symptoms to determine which symptoms were most useful in the accurate diagnosis of major depression after stroke.Methods:Using a structured mental status examination, 142 patients with acute stroke were followed at three, six, twelve, and twenty-four months.Results:The median number of vegetative and psychological symptoms among patients with depressed mood was more than three times the respective rates among nondepressed patients at all time points over two years. Autonomic anxiety, morning depression, subjective anergia, worrying, brooding, loss of interest, hopelessness, and lack of self-confidence were significantly more frequent among depressed patients than nondepressed patients throughout the entire two-year period. Some symptoms su...

Treatment of Depression in Older Primary Care Patients in Health Maintenance Organizations

Abstract: Objective:To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy.Design:Char...

PRIME-MD: Its Utility in Detecting Mental Disorders in American Indians

Abstract: Objective:To examine the utility of using PRIME-MD (Primary Care Evaluation of Mental Disorders) for diagnosing mental disorders in American IndiansMethod:One hundred randomly selected, adult, American-Indian patients who receive health care services at an urban Indian Health Service primary care clinic were evaluated for mental disorder by three primary care physicians using the PRIME-MD diagnostic assessment procedure The main outcome measures were PRIME-MD diagnoses, diagnoses by an independent mental health professional, and treatment/referral decisionsResults:Eighteen percent of the patients had a threshold (met full DSM-IV criteria) PRIME-MD diagnosis, and an additional 17 percent had a subthreshold PRIME-MD diagnosis The most frequently occurring PRIME-MD diagnoses were: probable alcohol abuse/dependence, major depressive disorder, and generalized anxiety disorder Over 60 percent of the patients with a PRIME-MD diagnosis who were known “somewhat” or “fairly well” to their physician had not bee

Risperidone in the Treatment of Delusions of Infestation

Abstract: Objective: The aim of this study is to describe the efficacy and safety of risperidone, in the treatment of delusions of infestation. Method: The authors present a three-case series in which risperidone was used to treat delusions of infestation. Results: All three patients responded to risperidone and experienced no extrapyramidal side effects. Two of our patients had failed treatment with haloperidol and another had failed treatment with pimozide. Conclusions : Risperidone was an effective and safe treatment in three cases of delusions of infestation. It is possible that 5-HT 2 antagonism is essential for therapeutic benefit in this condition.

The ‘Research Magnificent’ in Late Life: Psychiatric Epidemiology and the Primary Health Care of Older Adults

Abstract: Objective:Primary care occupies a strategic position in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment.Method:The literature was selectively reviewed for each theme to ask the central question, “What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?”Results:The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the “middle ground of psychiatric epidemiology”—primary health care—have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how thes...

Sociodemographic predictors of response to antidepressant treatment

Abstract: OBJECTIVE Our goal was to assess whether sociodemographic variables such as gender, marital status, level of education, and employment status are related to the changes in social functioning that have been reported after drug treatment in outpatients with major depressive disorder. METHOD Eligible subjects were 166 depressed outpatients participating in a study involving open treatment with fluoxetine 20 mg/day for eight weeks. Diagnosis of major depressive disorder was made with the use of the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P), and patients were required to have a seventeen-item Hamilton Rating Scale for Depression (HAM-D-17) score > or = at study entry. All subjects were administered the HAM-d-17 and the Social Adjustment Scale-Self-Report (SAS-SR) before and after treatment with fluoxetine. RESULTS We found that SAS-SR scores decreased significantly following treatment with fluoxetine from a mean score at baseline of 2.6 +/- 0.7 to a mean score at endpoint of 2.3 +/- 0.6. After adjusting for the degree of change in HAM-D-17 scores, we found a significant relationship between degree of change in SAS-SR and level of education. No statistically significant relationships were observed between SAS-SR change and age, gender, marital status, and employment status. CONCLUSION The degree of improvement in psychosocial functioning observed in depressed outpatients following antidepressant treatment appears to be related to the level of education at study entry, but not to other sociodemographic variables. Further studies need to investigate the nature of this relationship.

Deciphering the physician-older patient interaction.

Abstract: Objective The purpose of this article is to provide a commentary on non-verbal communication in the physician-older patient interaction. Method A literature review of physician-older patient communication yielded several published studies on this topic. Nonverbal behaviors were rarely examined in this body of literature even though the need to adopt a more "biopsychosocial" model of care was mentioned in several of the articles. The nonverbal communication literature was also reviewed to determine whether aging had been a variable of interest with regard to encoding (sending) and decoding communication (receiving) skills. Results To date there have been very few studies that have investigated the role of nonverbal communication in the physician-older patient interaction. Selected encoding and decoding characteristics for both physicians and patients are discussed with the context of the aging process. In lieu of direct evidence linking nonverbal behavior and physician-older patient communication, possible implications are offered for the following characteristics: expression of emotion, pain expression, gestures, gaze, touch, hearing, and vocal affect. Three relevant outcomes (satisfaction with care, quality of life, and health status) are also discussed within the nonverbal behavior-aging framework. Conclusion The connection between nonverbal behavior and how physicians and older patients interact with one another has not been rigorously examined. Identifying and improving nonverbal communication will likely enhance the verbal exchange in the medical encounter and may improve the older patient's quality of care.

Serotonin reuptake inhibitors and the adequacy of antidepressant treatment.

Abstract: Objective:To determine whether the use of serotonin reuptake inhibitors (SSRIs) improves antidepressant medication prescribing patterns for both psychiatric and non-psychiatric physicians.Data Sources/Setting:Drug utilization review of 4,103 prescriptions for antidepressant medications with patients diagnosed with depressive disorders over an eighteen-month period from the formulary records of a large insurance company.Design:Using standards developed for clinical guidelines, variation in trial and treatment adequacy between drug types and physician specialty was studied.Principal Findings:Thirty-five percent of initial antidepressant trials were not prescribed for an adequate duration or at an adequate dosage level. SSRIs were more likely to be prescribed adequately than any other antidepressant reviewed. Psychiatrists were more likely to prescribe antidepressants at an adequate dosage level, whereas non-psychiatric physicians were more likely to attain adequate duration of treatment.Conclusions:A greate...

Health Services Research on Mental Health in Primary Care

Abstract: Objective:The article seeks to provide an international perspective on the facilitating role of health services research in the treatment of psychiatric disorders in primary care. It builds on Goldberg and Huxley's model describing pathways to mental care for the psychiatrically ill in the community.Method:Seventy studies were selected for review by Medline search, sixteen studies by contacting prominent researchers in the field. All studies are discussed more or less extensively.Results:Case identification strategies including screening tools and diagnostic modules have been developed. Other strategies include educational training programs and psychiatric consultation services designed to facilitate psychopharmacological and other types of treatment of psychiatric disorders in primary care. Several models for the linkage of primary care and specialty mental health providers are discussed, and a primary care psychiatry programme is examined.Conclusion:Better psychiatric training of general practitioners (...

Perceived Mental Health and Disablement of Primary Care and End-Stage Renal Disease Patients

Abstract: Objective: To compare perceived current mental health and disablement between primary care and end-stage renal disease (ESRD) patients, and to study social support and stress and severity of illness as possible determinants of mental health and disablement. Method: Observational cross-sectional analysis of 414 primary care patients in a rural community health center and 125 ESRD patients inquiring hemodialysis in two community dialysis units. The Duke Health Profile (DUKE) anxiety-depression scale was used to assess mental health; the DUKE disability scale, to indicate disablement; the Duke Social Support and Stress Scale, to measure support and stress; and the Duke Severity of Illness Scale, to rate severity of illness. Results: Perceived current mental health in terms of anxiety and depression symptoms was worse for primary care than for ESRD patients, and perceived current disablement was no different for the two groups. Patients' perception of their health status and of stress from family members were more closely associated with their level of anxiety and depression symptoms than were their diagnostic profiles or overall severity of illness. In turn, their level of anxiety and depression symptoms was the principal correlate of their disablement. Conclusions: The demonstration of strong relationships among anxiety and depression symptoms, disablement, and family stress in these two very different patient populations should stimulate further research and motivate clinicians to evaluate all three parameters as part of routine patient care.

Antidepressant Efficacy and Cardiovascular Safety of Venlafaxine in Young Vs Old Patients with Comorbid Medical Disorders

Abstract: Objective: To determine whether venlafaxine exerts a differential effect on blood pressure in young versus old depressed patients. Method: We compared thirty-four consecutive patients treated with 50-250 mg/day venlafaxine for major depressive disorder or another major mood disorder at our medical college's ambulatory neuropsychiatry program. We obtained baseline and follow-up blood pressure measurements. Each patient also received a baseline and final Clinical Global Impressions (CGI) score; global improvement was determined by consensus of two clinicians. Results: Sixteen nongeriatric patients (age, 13 to 56 years) were compared with eighteen elderly patients (age, 65 to 86 years). Most patients (88%) had serious medical comorbidities or histories. Despite a higher mean daily venlafaxine dosage for patients in the young group, no significant changes in systolic blood pressure were noted in either group. For the older group, we found a non-statistically significant 4.7 mm Hg mean increase in diastolic blood pressure. No patient became hypertensive. We also found a negative correlation between baseline diastolic blood pressure and change in diastolic blood pressure during treatment with venlafaxine. This inverse relationship was statistically significant in the older patients. Conclusions: Venlafaxine was not associated with significant, sustained changes in blood pressure in any patient receiving dosages of 50-250 mg/day. Minimal changes in diastolic blood pressure were no more likely to occur in older venlafaxine-treated patients than in younger ones. Higher baseline diastolic blood pressure in older patients, but not in younger ones, seemed to protect against diastolic adrenergic blood pressure effects of venlafaxine.

Reassurance therapy: what to say to symptomatic patients with benign or non-existent medical disease.

Abstract: Reassurance is one of the most important therapies that primary care physicians give; however, little has been written about it in the literature. This article suggests six steps needed for effective reassurance in patients with benign disease or symptoms not explained by disease. These include: 1) question and examine the patient, 2) assure the patient that serious illness is not present, 3) suggest the symptom will resolve, 4) tell the patient to return to normal activity, 5) consider non-specific treatment, and 6) follow the patient. Only if these systematic steps are followed will reassurance consistently work. Since examination of the patient is a critical component of reassurance therapy, it can most effectively be administered by individuals who include a physical assessment as a part of the clinical evaluation.

Evidence based health care in old age psychiatry.

Abstract: Objective:The purpose of this article is to present the current status and future needs of old age psychiatry in relation to evidence-based health care.Method:The opportunities and difficulties of ...

Diagnosis and Management of Late Life Depression: A Guide for the Primary Care Physician

Abstract: Objective:The purpose of this article is to provide a brief and practical approach for the primary care physician regarding the recognition, diagnosis, and management of depression in elderly patients.Method:Empirical evidence and current recommendations regarding the recognition, diagnosis, and treatment of depression are reviewed as the basis for this approach. Appropriate modifications for geriatric depression are added where indicated.Results:The recommendations are listed by category and briefly explained.Conclusions:It is important to be vigilant for the variety of depressive presentations that occur in older primary care patients. Neurological causes of depression (such as stroke), suicide, and a longer time to recovery are all more frequent concerns in older depressed patients.

Reference to psychiatric consultation in the discharge letter of general hospital inpatients.

Abstract: Objective: The consultation-liaison psychiatrist is frequently confronted with the consultees' lack of adherence to the consultants' recommendations. The aim of this study was to investigate the question if and how the C-L psychiatrist's diagnoses and recommendations are mentioned in the consultee's final medical report and thus communicated to the physician responsible for the aftercare. Method: Psychiatric consult reports of a consecutive sample of 144 patients of the departments of neurology, internal medicine, and gynecology and obstetrics at the University Hospital of Zurich were compared to the content of the respective discharge letters. Results: Some kind of information about the psychiatric consultation was found in 84 percent of the discharge letters (consultation as such: 71.5%; psychiatric diagnosis: 66.7%; recommendations : 76.2%). Length of stay, timing of the consultation, length of the consult report and type of recommendation correlated significantly with the mention of psychiatric aspects in the final medical report. Psychotropic medication and psychiatric hospitalization were the recommendations most reliably mentioned. Conclusions: Psychiatric consultation seems to be taken seriously by attending physicians and is communicated in a high percentage to the physicians responsible for the aftercare. Nevertheless, in patients where active post-discharge management is needed the C-L psychiatrist should actively manage referral to outpatient settings and/or instruct primary care providers.

Self-reported allergy-related symptoms and psychological morbidity in primary care.

Abstract: Objective:To examine the relationship between allergy-related symptoms, food intolerance and psychological distress in primary care.Methods:Two thousand three hundred and thirty two adults in five ...

Psychological distress in HIV-1 disease in relationship to hypocholesterolemia.

Abstract: Objective:Altered levels of serum cholesterol, which are prevalent in early HIV-1 infection, have been associated with disturbances in mood state and behavior. The objective of this study was to evaluate the relationship of serum cholesterol status and psychological distress in HIV-1 seropositive and seronegative men.Method:The association between serum cholesterol level and psychological distress, measured with the Profile of Mood States (POMS), was examined in 169 individuals (117 HIV-1 seropositive and 52 seronegative homosexual men), controlling for negative life events, social support, coping style, and HIV-1 serostatus.Results:Individuals with hypocholesterolemia (serum cholesterol levels 150 mg/dL (p = 0.01). HIV-1 seropositive men had significantly lower cholesterol levels (p = 0.0001) and higher levels of distress than the seronegative men (p = 0.03). A significant interaction bet...

Cost-benefit & cost-effectiveness analysis of the rapid onset of selective serotonin reuptake inhibitors by augmentation.

Abstract: Objective: This article describes a method for evaluating the value of the increased cost of pharmacologic augmentation of an antidepressant. Method: Data to illustrate the method and interpretation of results were derived from a randomized, placebo controlled double blind trial. Eighty outpatients meeting ICD-10 criteria for depressive disorder and scoring > 18 on the Montgomery-Asberg Depression Rating Scale (MADRS) were recruited from a primary care population. All patients received SSRI antidepressant and either augmenting agent or placebo. The trial period was six weeks, during which the patients were monitored for changes in depressive symptoms using the MADRS. The economic analysis is based only on direct costs of treatment. The analytic approach includes decision analysis, cost-effectiveness and cost-benefit techniques, and a sensitivity analysis. Results: The economic analysis was performed on both the intention-to-treat population and the per-protocol population. Intention-to-treat and per-protocol results show that the direct cost of six weeks' treatment with the combination of augmenting agent and SSRI antidepressant, if the acceleration effect is taken into account, was more cost effective than the SSRI antidepressant and placebo. Conclusion: The direct costs of treatment are higher than those of previous pharmacoeconomic studies, but the rate of onset of antidepressant action must be taken into account. The application of the evaluative model appears valid and useful. The model is pragmatic and should be expanded for generalizability.

Psychogeriatrics and General Practice in Australia

Abstract: We describe the interface between general practice and psychogeriatrics in Australia. While aged care services are complex and there are serious deficiencies in the management of the elderly, several initiatives appear set to improve the level of care. Economic considerations, mutual education of general practitioners and psychogeriatricians, and social factors are strong determinants of good primary care of the mental health needs of older people.

Mental health and health care utilization in geriatric primary care patients.

Abstract: Objective This study examines the effect of mental health factors on health care utilization in a group of community dwelling elderly subjects followed in a primary care setting. Method Data on utilization was obtained prospectively from computerized billing records for a one-year period following completion of a structured survey. Relationships between variables were characterized by Spearman's rank correlation. Multivariate linear regression modeling was employed to relate health care utilization, as measured by total cost, to the baseline variables. Results No significant relationship was found between mental health measures and health care utilization as measured by total costs in this elderly population. However, total costs were found to be related to medical comorbidity and total daily medication use. Conclusion The present study did not find the relationship of psychiatric distress and increased use of health care services to apply to a group of community dwelling elderly. Future research will need to focus on larger data sets and improvement of models that attempt to examine the relationships between mental health and health care utilization in the elderly.