Showing papers on "Depression (differential diagnoses) published in 1991"

Traumatic events and posttraumatic stress disorder in an urban population of young adults

Abstract: \s=b\To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population. (Arch Gen Psychiatry. 1991 ;48:216-222)

Physical Activity and Depression: Evidence from the Alameda County Study

Abstract: The relation between level of physical activity and risk of subsequent depression was examined using three waves of data from the Alameda County Study. Among subjects who were not depressed at baseline, those who reported a low activity level were at significantly greater risk for depression at the 1974 follow-up than were those who reported high levels of activity at baseline. Adjustments for physical health, socioeconomic status, life events, social supports, and other health habits did not affect the association appreciably. Associations between 1965-1974 changes in activity level and depression in the 1983 follow-up suggest that the risk of depression can be altered by changes in exercise habits, although these associations were not statistically significant after adjustment for covariates. These results provide somewhat stronger evidence for an activity-depression link than do previous studies, and they argue for the inclusion of exercise programs as part of community mental health programs, as well as for further studies that focus on the relation between life-style and mental health.

Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program.

Abstract: OBJECTIVE The authors investigated patient characteristics predictive of treatment response in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program. METHOD Two hundred thirty-nine outpatients with major depressive disorder according to the Research Diagnostic Criteria entered a 16-week multicenter clinical trial and were randomly assigned to interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Pretreatment sociodemographic features, diagnosis, course of illness, function, personality, and symptoms were studied to identify patient predictors of depression severity (measured with the Hamilton Rating Scale for Depression) and complete response (measured with the Hamilton scale and the Beck Depression Inventory). RESULTS One hundred sixty-two patients completed the entire 16-week trial. Six patient characteristics, in addition to depression severity previously reported, predicted outcome across all treatments: social dysfunction, cognitive dysfunction, expectation of improvement, endogenous depression, double depression, and duration of current episode. Significant patient predictors of differential treatment outcome were identified. 1) Low social dysfunction predicted superior response to interpersonal psychotherapy. 2) Low cognitive dysfunction predicted superior response to cognitive-behavior therapy and to imipramine. 3) High work dysfunction predicted superior response to imipramine. 4) High depression severity and impairment of function predicted superior response to imipramine and to interpersonal psychotherapy. CONCLUSIONS The results demonstrate the relevance of patient characteristics, including social, cognitive, and work function, for prediction of the outcome of major depressive disorder. They provide indirect evidence of treatment specificity by identifying characteristics responsive to different modalities, which may be of value in the selection of patients for alternative treatments.

Migraine, psychiatric disorders, and suicide attempts: An epidemiologic study of young adults

Abstract: To determine the prevalence of migraine and the risks for psychiatric disorders and suicide attempts associated with it, we studied a random sample of 1,007 young adults from a large Health Maintenance Organization in the Detroit, MI area. The lifetime prevalence of migraine was 7% in males and 16.3% in females. The rate of migraine was higher in persons with lower education and was equal in whites and blacks. Persons with migraine were at increased risk for affective and anxiety disorders, nicotine dependence, and alcohol or illicit drug abuse or dependence. There was a consistent trend toward higher psychiatric comorbidity in migraine with aura than in migraine without aura. Coexisting anxiety, which generally preceded migraine, was associated with a marked increase in the odds of major depression. Persons with migraine had higher rates of suicide attempts than persons without migraine. The odds ratio for suicide attempts, adjusted for coexisting major depression and other psychiatric and substance use disorders, in migraine with aura was 3.0 (95% confidence interval, 1.4-6.6). The coexistence of migraine with major depression, anxiety disorders, and suicide attempts has important clinical and research implications.

Depression and mortality in nursing homes.

Abstract: To determine the prevalence rates of major depressive disorder and of depressive symptoms and their relationship to mortality in nursing homes, research psychiatrists examined 454 consecutive new admissions and followed them up longitudinally for 1 year. Major depressive disorder occurred in 12.6% and 18.1% had depressive symptoms; the majority of cases were unrecognized by nursing home physicians and were untreated. Major depressive disorder, but not depressive symptoms, was a risk factor for mortality over 1 year independent of selected physical health measures and increased the likelihood of death by 59%. Because depression is a prevalent and treatable condition associated with increased mortality, recognition and treatment in nursing homes is imperative.

Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variables.

Abstract: Demographic, psychiatric, social, cognitive, and life stress variables were used to determine the etiology of depression in childbearing (CB; n = 182) and nonchildbearing (NCB; n = 179) women. Hormonal variables in postpartum depression were also evaluated. In the CB group predictors of depression diagnosis were previous depression, depression during pregnancy, and a Vulnerability (V) x Life Stress (LS) interaction; predictors of depressive symptomatology were previous depression, depressive symptoms during pregnancy, life events, and V x LS. Only estradiol was associated with postpartum depression diagnosis. In the NCB group V X LS was the only predictor of depression diagnosis; depressive symptoms during pregnancy and life events were predictors of depressive symptomatology. Previous findings about depression vulnerability were replicated. The significant V x LS interactions support the vulnerability-stress model of postpartum depression.

Mental disorders in adolescent suicide. DSM-III-R axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland.

Abstract: The prevalence of mental disorders (DSM-III-R Axes I and II) among adolescent suicide victims (n = 53) was investigated in a nationwide psychological autopsy study in Finland. The data were collected comprehensively through interviews of the victims' relatives and attending health care personnel and from official records. Following independent assessment by two psychiatrists, the DSM-III-R diagnoses were assigned in consensus meetings. A large majority of the victims (94%) suffered from a mental disorder. The most prevalent disorders were depressive disorders (51%) and alcohol abuse or dependence (26%). The prevalence of adjustment disorders (21%) was higher than in most studies from other countries. Personality disorder was diagnosed in 32% of the cases. Comorbidity was found in 51% of the victims. The results indicate a strong relatedness between adolescent suicide and the presence of depression, antisocial behavior, and alcohol abuse.

Recognition, management, and course of anxiety and depression in general practice.

Abstract: • This article addresses the issues of recognition of psychiatric disorders by general physicians (GPs) and the effects of recognition on management and course. Among 1994 patients who were screened with the General Health Questionnaire and who were rated by their GP, 1450 (72.7%) had not been identified by the GP as having a psychiatric disorder in the year before the index visit. Among these "new" patients, 557 (38.4%) had positive General Health Questionnaire scores. Only 47% of the new patients who met Bedford College diagnostic criteria for anxiety, depression, or illdefined disorder had their psychiatric disorder recognized by their GP. Among patients who met Bedford College criteria, mean episode durations were longer for anxiety disorders (20 to 22 months) than for depressive disorders (9 to 10 months). Among the new patients, those with psychiatric disorders recognized by the GP were more likely to receive mental health interventions. Recognition was associated with shorter episode duration among patients with an anxiety disorder, but not among patients with depressive or illdefined disorders.

A 2-year longitudinal study of depression among Alzheimer's caregivers

Abstract: Results from a 2-year (4 waves) longitudinal study show strong evidence for patient decline and high levels of depressive symptomatology among caregivers. Female caregivers reported high, stable rates of depressive symptomatology throughout the study, whereas male caregivers exhibited significant increases in depression over time. Cross-sectional multivariate analyses revealed significant positive relationships between depression and number of patient problem behaviors, negative social support, and concern about financial resources; negative relationships were found between depression and social support, quality of prior relationship, and satisfaction with social contacts. Three significant independent predictors of change in depression were found: Lower depression scores at Time 1 were related to increases in depression over time; men were more likely than women to experience increases; and a decline in social support resulted in increased depression.

The relation of pain to depression among institutionalized aged.

Abstract: Nursing home and congregate apartment residents (N = 598) were classified on the basis of a DSM-IIIR symptom checklist as suffering possible major, minor, or no depression; they also completed the Geriatric Depression Scale (GDS) and the Profile of Mood States (POMS). Possible major depressives reported more intense pain and a greater number of localized pain complaints than did minor depressives; nondepressed individuals reported the least intense pain and fewest localized complaints. The effect remained strong even when functional disability and health status were controlled statistically. Both pain intensity and number of localized complaints were correlated with GDS and POMS factor scores, but strength and direction of associations varied with level of depression. Item-by-item examination of localized complaints again indicated that more depressed individuals were more likely to report pain, particularly where physicians had identified a physical problem that might account for the pain. Results are compared with previous research on pain among younger individuals. Implications for treatment of depressed elderly are discussed.

Trauma experiences, posttraumatic stress, dissociation, and depression in Cambodian refugees.

Abstract: OBJECTIVE The authors' goal was to determine the levels of trauma and psychiatric symptoms in a randomly selected group of Cambodian refugees and to determine the relationship between the amount of trauma experienced and subsequent psychiatric symptoms. METHOD Data on traumatic experiences and symptoms of posttraumatic stress, dissociation, depression, and anxiety were collected on 50 randomly selected Cambodian refugees who had resettled in the United States. RESULTS Subjects experienced multiple and severe traumas and showed high levels of all symptoms measured. Forty-three (86%) of the subjects met DSM-III-R criteria for posttraumatic stress disorder, 48 (96%) had high dissociation scores, and 40 (80%) could be classified as suffering from clinical depression. Correlations between trauma scores and symptom scores and among symptom scores were moderate to large. CONCLUSIONS These results indicate that a high proportion of Cambodian refugees who are not psychiatric patients suffer from severe psychiatric symptoms and that there is a relationship between the amount of trauma they experienced and the severity of these symptoms.

Personality as a Vulnerability Factor to Depression

Abstract: One hundred and forty non-depressed primiparous women in a stable relationship completed two personality measures (the EPI and the IPSM) antenatally, and were then assessed for depression at several times post-natally. The risk of depression at six months was increased up to tenfold by high interpersonal sensitivity and threefold by high neuroticism. When previously depressed women were excluded from analyses, high interpersonal sensitivity and, to a lesser extent, high neuroticism were still associated with an increased risk of being depressed. Interpersonal sensitivity, as measured, is suggested as a refined personality risk factor to both the onset and recurrence of depression.

Early sexual abuse and clinical depression in adult life.

Abstract: Sexual abuse in childhood and adolescence was studied in 286 working-class mothers living in Islington, who were contacted on three occasions over a two-year period. The sample was collected primarily to study current vulnerability factors in the onset of depression, but childhood measures were also included to look at longer-term risk factors. Twenty-five women - 9% of the sample - reported sexual abuse involving physical contact before age 17 and, of these, 64% had case depression in a three-year period (which included the year before first interview). While such abuse was related to other earlier stressful experiences such as parental indifference, violence to the child and institutional stay, it was associated with an increased risk of depression over and above these factors. Sexual abuse before age 17 also related to having been divorced/separated or never having married/cohabited.

Depression through the first year after the death of a spouse.

Abstract: OBJECTIVE This study assesses the frequency of depressive syndromes during the first 13 months after the death of a spouse. METHOD Men and women whose spouses had recently died were identified through death certificate records. These subjects completed a multidimensional questionnaire and were interviewed 7-8 weeks (2 months) after the death. Follow-up questionnaires were completed 7 and 13 months after the death. The questionnaires contained specific items corresponding to DSM-III-R criteria for depressive episodes as well as other widely used measures of depressive symptoms such as the Zung Depression Scale and the Hopkins Symptom Checklist. RESULTS Eighty-four (24%) of 350 widows and widowers met criteria for depressive episodes at 2 months, 72 (23%) of 308 did so at 7 months, and 46 (16%) of 286 did so at 13 months. At each time period, the prevalence was substantially higher than the 4% rate of depressive episodes observed in a comparison group of 126 subjects whose spouses were still living. Widows and widowers most likely to meet criteria for depressive episodes 13 months after the bereavement were younger, had past histories of major depression, were still grieving 2 months after the loss, and met DSM-III-R criteria for depressive episodes 2 and/or 7 months after the death. CONCLUSIONS Depressive episodes are common after the death of a spouse. Clinicians should maintain a high index of suspicion for the possibility of depression, particularly in young widows and widowers who have a past history of depression or who experience a full depressive syndrome soon after the loss.

Prevalence, onset, and risk of psychiatric disorders in men with chronic low back pain: a controlled study

Abstract: This study used structured diagnostic interviews and DSM-III criteria to assess lifetime prevalence and pre-morbid risk of psychiatric disorder in a sample of men with long-standing chronic back pain (CLPB) attending a primary care clinic. A control group of age and demographically matched men without history of back pain was also studied. Compared to controls, men with CLBP had significantly higher lifetime rates of major depression (32% vs. 16%), alcohol use disorder (64.9% vs. 38.8%), and a major anxiety disorder (30.9% vs. 14.3%). Almost all CLBP men ever experiencing a mood disorder reported recurrent, not single, episodes. The 6 month point prevalence of major depression, but not other disorders, was also significantly elevated for men with CLBP. In CLBP, the first episode of major depression generally (58.1%) followed pain onset. While the initial major depressive episode usually commenced within the first 2 years of established pain, late onset mood disorder was also common. By comparison in most cases (81%) onset of alcohol use disorders considerably preceded pain. When an age-matching procedure was used to gauge relative vulnerability to psychiatric illness in patients and controls, CLBP patients had significantly higher pre-pain rates of alcohol use disorder but not depression. After age of pain onset, CLBP subjects had over 9 times the risk of developing major depression, but had similar rates of developing alcoholism. We conclude that (1) alcohol use disorders rather than depression may increase risk of developing CLBP, and (2) risk of new onset and recurrent major depression remains high for men throughout their pain career. This suggests that psychological adaptation to long-standing pain may be less successful than previously thought, especially with regard to recurrent mood disorder.

Mood disorders in the year after first stroke.

Abstract: An unselected community sample of 128 patients were studied over the 12 months after their first stroke, and compared with a control sample of subjects from the general population. Psychiatric status was assessed using the PSE and BDI. Symptoms of mood disorder were commoner in the stroke patients than the controls, but the differences were not substantial and had largely disappeared by 12 months. Psychiatric problems encountered included agoraphobia, social withdrawal, apathy and self-neglect, irritability and pathological emotionalism. While there was a high cumulative incidence of psychiatric disorder, little of it persisted: only two cases of major depression were present for the whole 12 months. We believe undue emphasis has been placed in the recent literature on major depression as a specific syndrome following stroke.

Depression, the Immune System, and Health and Illness: Findings in Search of Meaning

Abstract: During the past several decades many investigators have devoted their efforts to determining whether psychosocial factors, such as stress or depression, are associated with the onset, course, or outcome of physical illness. Considerable evidence suggests that both stressful life events and depressive disorders are associated with increased morbidity and mortality. 1 A large body of research in the last few years has considered the possibility that immunologic alterations may be associated with depressive disorders and depressive symptoms accompanying stressful life events. The related immunologic alterations have been viewed as a link between depression and stress and increased risk for immune-related disease states, such as cancer, autoimmune disorders, and infections, including human immunodeficiency virus (HIV). However, there has been a lack of substantial evidence supporting the association between depression or stress and increased morbidity or mortality due to disorders involving the immune system. In a series of articles recently published in

Adult outcomes of childhood and adolescent depression: II. Links with antisocial disorders.

Abstract: Sixty-three child and adolescent patients meeting operational criteria for depression and 68 non-depressed child psychiatric controls were followed into adulthood. Twenty-one percent of the depressed group had had conduct disorder (CD) in conjunction with their index depression. Depressed children with comorbid CD did not differ from depressed children without conduct problems with respect to depressive symptom presentation or demographic characteristics. However, depressives with CD had a worse short-term outcome and a higher risk of adult criminality than depressed children without conduct problems. There was a strong trend for depressives with CD to have a lower risk of depression in adulthood than depressed children without conduct problems. The outcomes of depressives with CD were very similar to those of nondepressed children with CD. The findings are discussed in the context of current classification schemes.

Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations.

Abstract: • Using data collected in the National Institute of Mental Health (Rockville, Md) Epidemiologic Catchment Area Program, we examined the proposed hypothesis that there has been a shift in major depression to younger ages at onset, or increased prevalence in younger age periods, for recent birth cohorts. Life-table survival methods were used to examine the hazard rates for major depression as well as for other specific mental disorders. The findings are consistent with a gradual shift to increased rates for major depression between the ages of 15 and 19 years for Epidemiologic Catchment Area respondents born more recently. The findings also suggest a similar shift for drug abuse/dependence; similar but less pronounced changes were found for alcohol abuse/dependence and obsessive-compulsive disorder. However, in this study, bipolar disorder, panic disorder, and phobias did not exhibit a consistent increase in onset at younger ages. Further research is required to determine if the shifts in major depression, drug abuse/dependence, and possibly alcohol abuse/dependence are linked. It is important to note that these shifts to adolescent onset are occurring when nearly half the 31 million Americans without health insurance are aged 24 years or younger.

Depression and Mortality

Abstract: To determine the prevalence rates of major depressive disorder and of depressive symptoms and their relationship to mortality in nursing homes, research psychiatrists examined 454 consecutive new admissions and followed them up longitudinally for 1 year. Major depressive disorder occurred in 12.6% and 18.1% had depressive symptoms; the majority of cases were unrecognized by nursing home physicians and were untreated. Major depressive disorder, but not depressive symptoms, was a risk factor for mortality over 1 year independent of selected physical health measures and increased the likelihood of death by 59%. Because depression is a prevalent and treatable condition associated with increased mortality, recognition and treatment in nursing homes is imperative. ( JAMA . 1991;265:993-996)

Follow-up and family study of anxious depression

Abstract: Objective: The failure ofthe concept ofanxious depression to find its way into DSM-III-R led the authors to conclude that a further report on the occurrence of anxiety symptoms in depressed subjects is indicated. Method: The subjects were 32 7 consecutively evaluated inpatients and outpatients with primary unipolar depressive disorder at five university medical centers participating in the National Institute ofMental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies. The authors restricted their sample selection to patients with primary depressive disorder so that patients with other preexisting psychiatric disorders, especially anxiety disorders, would not contaminate the symptom picture, family studies, or follow-up. They examined six anxiety symptoms and derived a new anxiety summary score to show the effect of anxiety in depression on family data and 5-year outcome. Results: Depressed subjects with higher ratings for anxiety took longer to recover. There was also a significant relationship between anxiety in depressed probands and the risk for primary unipolar depressive disorder, but not anxiety disorders or alcoholism, among 832 blindly interviewed first-degree relatives. Conclusions: These data confirm the usefulness of subdividing depressed patients according to anxiety symptoms: psychic and somatic symptoms of anxiety, taken together, significantly predict family illness and course. The data also emphasize the wisdom ofrequiring that generalized anxiety disorder not be diagnosed in the presence of a mood disorder. Clearly, symptoms of anxiety coexist with depression and need to be recognized for the effective treatment of the underlying depressive disorder. (Am J Psychiatry 1991; 148:1512-1517)

Psychiatric History and Related Exposures as Risk Factors for Alzheimer's Disease: A Collaborative Re-Analysis of Case-Control Studies

Abstract: Data from case-control studies of Alzheimer's disease (AD) were pooled to examine the possible roles of history of depression, anti-depressant treatment and adverse life events as risk factors. History of depression was found to be associated with AD, although the effect was confined to late onset cases. The association held for episodes of depression more than 10 years before AD onset, as well as for episodes occurring within a decade of onset. No association was found with anti-depressant treatment. However, data were only available from two studies, limiting the power of the analysis. Also, no association was found with the three major life events considered in the pooled analysis: death of spouse, death of a child and divorce.

Depression and Anxiety in Relation to Social Status: A Prospective Epidemiologic Study

Abstract: • Longitudinal research in Stirling County, Atlantic Canada, indicated that during the 1950s and 1960s the prevalence of depression was significantly and persistently higher in the "low" socioeconomic status population than at other socioeconomic status levels. Anxiety was found to show a less clear picture. Incidence of depression after the study started was also higher among those who were initially in the low socioeconomic status group, supporting the view that the stress of poverty may be causally related to depression. There was also a trend for prior depression to be associated with subsequent downward social mobility, supporting the view that the concentration of depressed people at the lower end of the social hierarchy may result from handicapping aspects of the illness. Neither of these trends was statistically significant. More striking was evidence that, irrespective of socioeconomic status, depression carried a substantial risk for poor clinical course and outcome. Both depression and poverty tended to be chronic, and, accordingly, their association at the end of the study was influenced by their association at its beginning. The stability of the relationship between poverty and depression warrants the attention of caregivers and policymakers and raises new questions about strategies for the study of causal sequences.

Chronic fatigue syndrome and depression: conceptual and methodological ambiguities.

Abstract: Psychological and somatic factors contribute and interact across the spectrum of health and illness. Their relative influence varies from disorder to disorder and from case to case, and specific instances of disorder might in theory be plotted along a continuum to represent different weightings of psychological and somatic causation (Lipowski, 1986; Oken, 1987). We can criticize such a model for its implied dualism, and it is misleading to conceive of the psychological and somatic as distinct and mutually exclusive categories. Nevertheless, as levels of explanation, one may be more appropriate than the other, and it is thus legitimate to ask whether a given disorder should be understood primarily in somatic terms or whether a psychological model is more likely to advance our understanding. A disorder whose aetiology has been the subject of recent controversy is chronic fatigue syndrome (CFS), also commonly known as postviral fatigue syndrome and myalgic encephalotnyelitis. The issue of terminology is in itself controversial, and there may prove to be differences between these syndromes (Ramsay, 1988). Nevertheless, CFS will be the general term employed here; it is arguably the most appropriate at this stage of our understanding since it makes no assumptions about aetiology (Holmes et al. 1988; Lloyd et al. 1988). The central feature of the disorder is persistent and excessive fatiguability, and this may be accompanied by various other somatic and psychological symptoms, including acheing muscles and joints, headache, sore throat, painful lymph nodes, muscle weakness, sleep disturbance, mental fatigue, difficulty in concentrating, emotional lability and depression (David et al. 1988 a; Holmes el al. 1988). Its nature and causes are as yet undetermined, and the research to date suggests that it is an intriguingly complex disorder, with both biological and psychological features. On the one hand, there is accumulating evidence of biological abnormalities suggestive of viral infection and immunological dysfunction (see Archer, 1987; Bannister, 1988; David et al. 19886; Straus, 1988). However, there are inconsistencies between studies in the results obtained, no single defining factor has emerged, and the clinical significance of the abnormalities found has been questioned (Hellinger et al. 1988; Jacobson, 1988; Straus, 1988; Straus et al. 1988; Swartz, 1988). A detailed description of this body of research is beyond the scope of this paper. On the other hand, there is evidence of psychiatric disorder in a significant number of patients, with depression predominating. These findings might be taken to offer some indirect support for the hypothesis that CFS and depression are similar syndromes, with common aetiological factors. However, cross-sectional data are notoriously difficult to interpret, and there are various ways in which depression and psychological vulnerability in general could be implicated in CFS. Though depression will be the focus of this discussion, many of the arguments presented are relevant to other psychological categories, such as anxiety or somatization disorder; these have also been linked with CFS but to a lesser extent than depression.

Prevalence and correlates of postpartum depression in first-time mothers.

Abstract: The prevalence and correlates of postpartum depression were examined in a large (N = 1,033) sample of married, primiparous, middle-class mothers of full-term, healthy infants; 9.3% met modified Research Diagnostic Criteria for depression. However, 39% of the nondepressed women also reported at least 1 somatic symptom. Depressed women whose symptoms were current obtained elevated scores on the Center for Epidemiological Studies-Depression scale, as did some women who did not meet depression criteria. Depressed women different from nondepressed women on several socioeconomic status indicators and the occurrence of obstetric complications, even in this low-risk sample. These data have implications for the assessment of depression in postpartum women.

The validity of major depression with psychotic features based on a community study

Abstract: • This article reports on the evidence for the validity of psychotic major depression as a distinct subtype based on cross-sectional and 1-year prospective data from the Epidemiologic Catchment Area study. Consistent with findings from previous clinical studies, only about 14% of major depressions were accompanied by psychotic features. Psychotic as compared with nonpsychotic depression had a more severe course, as reflected in increased risk of relapse, persistence over 1 year, suicide attempts, hospitalization, comorbidity, and financial dependency. These differences could not be explained by differences in demographic characteristics or by symptom severity, as assessed by symptom profile or number of symptoms. The boundary problem with schizophrenia and bipolar affective disorder that is seen in clinical studies was also found in this sample. To our knowledge, this is the first study to examine the validity of psychotic depression in a community sample; the findings are consistent with those from clinical samples. They support the clinical significance of psychotic depression and the continuation of its inclusion as a distinct subtype in DSM-IV .

The first year's experience of an acute pain service

Abstract: The benefits, risks and resource implications of providing an Acute Pain Service were assessed during the first year of the service. Six hundred and sixty patients recovering from major surgery were treated with patient-controlled analgesia (510 patients) or extradural infusion analgesia (150 patients). The results of a prospective outcome study showed that pain control was good: more than 60% of patients scored their pain as mild during the first 24h. Only 10% of patients complained of severe postoperative pain. Eight patients developed potentially serious complications including respiratory depression and hypotension; the diagnosis and management of these problems on general wards is discussed. Retrospective analysis of the incidence of postoperative chest infection in surgical patients showed a marked reduction during the first year of the service (1.3% in 1988, 0.4% in 1989–90 (P