Showing papers on "Depression (differential diagnoses) published in 1996"

Cross-national epidemiology of major depression and bipolar disorder

Abstract: Objective. —To estimate the rates and patterns of major depression and bipolar disorder based on cross-national epidemiologic surveys. Design and Setting. —Population-based epidemiologic studies using similar methods from 10 countries: the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand. Participants. —Approximately 38 000 community subjects. Outcome Measures. —Rates, demographics, and age at onset of major depression and bipolar disorder. Symptom profiles, comorbidity, and marital status with major depression. Results. —The lifetime rates for major depression vary widely across countries, ranging from 1.5 cases per 100 adults in the sample in Taiwan to 19.0 cases per 100 adults in Beirut. The annual rates ranged from 0.8 cases per 100 adults in Taiwan to 5.8 cases per 100 adults in New Zealand. The mean age at onset shows less variation (range, 24.8-34.8 years). In every country, the rates of major depression were higher for women than men. By contrast, the lifetime rates of bipolar disorder are more consistent across countries (0.3/100 in Taiwan to 1.5/100 in New Zealand); the sex ratios are nearly equal; and the age at first onset is earlier (average, 6 years) than the onset of major depression. Insomnia and loss of energy occurred in most persons with major depression at each site. Persons with major depression were also at increased risk for comorbidity with substance abuse and anxiety disorders at all sites. Persons who were separated or divorced had significantly higher rates of major depression than married persons in most of the countries, and the risk was somewhat greater for divorced or separated men than women in most countries. Conclusions. —There are striking similarities across countries in patterns of major depression and of bipolar disorder. The differences in rates for major depression across countries suggest that cultural differences or different risk factors may affect the expression of the disorder.

The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome.

Abstract: The impact of maternal depression and adversity on mother-infant face-to-face interactions at 2 months, and on subsequent infant cognitive development and attachment, was examined in a low-risk sample of primiparous women and their infants. The severe disturbances in mother-infant engagement characteristic of depressed groups in disadvantaged populations were not evident in the context of postpartum mood disorder in the present study. However, compared to well women, depressed mothers were less sensitively attuned to their infants, and were less affirming and more negating of infant experience. Similar difficulties in maternal interactions were also evident in the context of social and personal adversity. Disturbances in early mother-infant interactions were found to be predictive of poorer infant cognitive outcome at 18 months. Infant attachment, by contrast, was not related to the quality of 2-month interactions, but was significantly associated with the occurrence of adversity, as well as postpartum depression.

Symptoms of Depression, Acute Myocardial Infarction, and Total Mortality in a Community Sample

Abstract: Background Depression has been shown to adversely affect the prognosis of patients with established coronary artery disease, but there is comparatively little evidence to document the role of depre...

A Multifaceted Intervention to Improve Treatment of Depression in Primary Care

Abstract: Background: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. Methods: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. Results: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. Conclusion: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Relationships of Age and Axis I Diagnoses in Victims of Completed Suicide: A Psychological Autopsy Study

Abstract: OBJECTIVE: Psychiatric illness is a potent risk factor for suicide, rates of which differ markedly with age. The purpose of this study was to examine whether the psychiatric diagnoses of suicide victims vary predictably with age. METHOD: DSM-III-R axis I diagnoses of 141 persons aged 21 to 92 years who had completed suicide were established by the psychological autopsy method. Multiple logistic regression analyses were used to determine whether age, gender, or their interaction predicted the presence of specific disorders. RESULTS: One or more axis I conditions were diagnosable in 90.1% of the suicide victims. Substance use disorders were most frequent, followed by mood disorders and primary psychotic illness. Younger age at death was a significant predictor of substance abuse or dependence and primary psychoses, while older age predicted major mood disorders. Comorbidity of substance use and mood disorders was common. Among victims with substance abuse or dependence, older age at death predicted major depression; among victims with mood disorders, younger age at death predicted comorbid substance abuse or dependence. CONCLUSIONS: The distribution of psychiatric illnesses in suicide victims differs across the life course. Age-related patterns of addictive and psychotic disorders echo their prevalence in the general population. In contrast, the relationship between age and mood disorders among suicide victims is distinctly different from that of the general population. These findings suggest that risk for suicide increases with age in individuals with major affective illness. Depressed elderly men are particular targets for suicide prevention strategies. Language: en

Depression and Risk for Onset of Type II Diabetes: A prospective population-based study

Abstract: OBJECTIVE To determine whether depression is associated with an increased risk for onset of diabetes. RESEARCH DESIGN AND METHODS In 1981, a total of 3,481 household-residing adults participated in the Epidemiologic Catchment Area (ECA) Program survey at the East Baltimore site. A follow-up of that cohort after 13 years completed 1,897 interviews, amounting to >72% of survivors. In 1981, depression was assessed with the National Institutes of Mental Health (NIMH) Diagnostic Interview Schedule and diabetes, by self-report. This prospective analysis focused on subjects at risk for onset of diabetes by removing from the analysis individuals with diabetes in 1981. RESULTS There were 89 new cases of diabetes among 1,715 individuals at risk, yielding a 13-year cumulative incidence of diabetes of 5.2%. In logistic models, major depressive disorder, but not milder forms of depression or other forms of psychiatric disorder, predicted the onset of diabetes (estimated relative risk, 2.23; 95% CI 0.90–5.55). Controlling for age, race, sex, socioeconomic status, education, use of health services, other psychiatric disorders, and body weight did not weaken the relationship. CONCLUSIONS Major depressive disorder signals increased risk for onset of type II diabetes. Limitations of the findings arise from the difficulty in determining temporal order with two chronic conditions, even when the temporal order of measurement is clear. In addition, even though control variables were introduced for the use of health services, it is possible that the treatment for depression led to an earlier diagnosis of diabetes in this sample.

The prevalence and meaning of fatigue in rheumatic disease.

Abstract: Objective. To determine the prevalence of fatigue in rheumatic disease ; to characterize the strength of associations between demographic and clinical features and fatigue ; to identify predictors of fatigue, and to determine the consequence of clinically significant fatigue. Methods. 1488 consecutive patients with rheumatic disease were assessed with the Clinical Health Assessment Questionnaire, a health status instrument with scales for fatigue, pain, global severity, sleep disturbance, gastrointestinal problems, anxiety, depression, health status, health satisfaction, and work ability. All patients underwent rheumatic disease examinations and laboratory testing. Results. Fatigue measured by visual analog scale (VAS) was present in 88-98% of patients, but clinically important levels of fatigue (≥ 2.0 on VAS) were present in more than 41% of patients with rheumatoid arthritis (RA) or osteoarthritis (OA) and 76% of those with fibromyalgia (FM). Fatigue was related to almost all demographic and clinical variables, but in multivariate analyses the strongest independent predictors of fatigue were pain, sleep disturbance, depression, tender point count and Health Assessment Questionnaire (HAQ) disability. About 90% of the R 2 of the model (all patients=0.51, RA=0.49, OA=0.45, FM=0.41) was explained by pain, sleep disturbance, and depression. In RA assessed by erythrocyte sedimentation rate, joint count and grip strength, no association of the inflammatory process with fatigue could be found in the multivariate analyses. In measuring health status, fatigue was strongly associated with work dysfunction and general measures of health (VAS of global severity, health status, and health satisfaction). Conclusion. Fatigue is common across all rheumatic diseases, associates with all measures of distress, and is a predictor of work dysfunction and overall health status. The correlates of fatigue are generally similar across RA, OA and FM. Fatigue assessment adds much to understanding and management of patients and diseases.

Comorbid depression and anxiety spectrum disorders

Abstract: The relationship between depression and anxiety disorders has long been a matter of controversy. The overlap of symptoms associated with these disorders makes diagnosis, research, and treatment particularly difficult. Recent evidence suggests genetic and neurobiologic similarities between depressive and anxiety disorders. Comorbid depression and anxiety are highly prevalent conditions. Patients with panic disorder, generalized anxiety disorder, social phobia, and other anxiety disorders are also frequently clinically depressed. Approximately 85% of patients with depression also experience significant symptoms of anxiety. Similarly, comorbid depression occurs in up to 90% of patients with anxiety disorders. Patients with comorbid disorders do not respond as well to therapy, have a more protracted course of illness, and experience less positive treatment outcomes. One key to successful treatment of patients with mixed depressive and anxiety disorders is early recognition of comorbid conditions. Antidepressant medications, including the selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors, are highly effective in the management of comorbid depression and anxiety. The high rates of comorbid depression and anxiety argue for well-designed treatment studies in these populations. Depression and Anxiety 4:160–168, 1996/1997. © 1997 Wiley-Liss, Inc.

Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community.

Abstract: Background: It remains unclear whether depression increases the risk for dementia in the elderly. We evaluated the relationship between depressed mood at baseline and the incidence of dementia, particularly Alzheimer's disease, in the elderly living in the community. Methods: A total of 1070 elderly individuals, aged 60 years or older, were identified as part of a registry for dementia in the Washington Heights community of North Manhattan, NY. In a prospective, longitudinal design with follow-up for 1 to 5 years, annual physician evaluation and neuropsychological testing were used to assess levels of cognitive impairment and to diagnose dementia. Depressive symptoms were evaluated with the 17-item Hamilton Rating Scale for Depression. Based on clinical considerations and a validity study, a positive score for the depressed mood item was used in statistical analyses. To confirm the results, the total Hamilton Rating Scale for Depression score was also evaluated as the "depression" variable. Results: Of the 1070 subjects, 218 met criteria for dementia at baseline evaluation. In the 852 subjects without dementia, depressed mood was more common in individuals with greater cognitive impairment. In a follow-up study of 478 of these subjects without dementia (mean±SD, 2.54±1.12 years of follow-up), the effect of baseline depressed mood on the end-point diagnosis of dementia (93% had possible or probable Alzheimer's disease) was evaluated in a Cox proportional hazards model. Depressed mood at baseline was associated with an increased risk of incident dementia (relative risk, 2.94; 95% confidence interval, 1.76 to 4.91;P Conclusions: Depressed mood moderately increased the risk of developing dementia, primarily Alzheimer's disease. Whether depressed mood is a very early manifestation of Alzheimer's disease, or increases susceptibility through another mechanism, remains to be determined.

Depression comorbid with anxiety: results from the WHO study on psychological disorders in primary health care

Abstract: The World Health Organization collaborative study on "Psychological Problems in General Health Care" investigated the form, frequency, course and outcome of common psychological problems in primary care settings at 15 international sites. The research employed a two-stage case-finding procedure. GHQ-12 was administered to 25916 adults who consulted health-care services. The second-stage assessment (n = 5438) consisted of the Composite international Diagnostic Interview (CIDI), the Social Disability Schedule, and questionnaires. Possible cases or borderline cases of mental disorder, and a sample of known cases, were followed up at three months and one year. Using standard diagnostic algorithms (ICD-10), prevalence rates were calculated for current disorder (one-month) and lifetime experience disorder. Well-defined psychological problems are frequent in all the general health-care settings examined (median 24.0%). Among the most common were depression anxiety, alcohol misuse, somatoform disorders, and neurasthenia. Nine per cent of patients suffered from a "subthreshold condition" that did not meet diagnostic criteria but had clinically significant symptoms and functional impairment. The most common co-occurrence was depression and anxiety. Comorbidity increases the likelihood of recognition of mental disorders in general health care, and the likelihood of receiving treatment.

Depression and Long-Term Mortality Risk in Patients With Coronary Artery Disease *

Abstract: Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p 5 years later (p 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.

Depression and multiple sclerosis

Abstract: The objective of the present study were (1) to ascertain the lifetime risk of a depression in a representative group of multiple sclerosis (MS) patients, (2) to assess the morbidity risks for depression among first-degree relatives of these MS patients, and (3) to compare these familial risks for first-degree relatives of MS patients with those for first-degree relatives of a primary depression population, i.e., depression but no MS. We psychiatrically evaluated 221 MS patients (index cases) using a structured clinical interview for the DSM-III-R and calculated the rate and lifetime risk of depression for these index cases using the product limit estimate of survival function. We obtained psychiatric histories for all first-degree relatives of index cases, and we calculated morbidity risks for depression for these relatives using the maximum likelihood approach and compared the risks using the likelihood ratio tests. Index cases had a 50.3% lifetime risk of depression. Morbidity risks for depression among first-degree relatives of index cases were decidedly lower when compared with morbidity risks among first-degree relatives of the reference population. Although there appears to be a very high rate of depression among MS patients, the data for their first-degree relatives do not support a clear genetic basis for this depression, or at least the same genetic basis that probably operates within families when depression occurs in the absence of MS.

Major depression before and after myocardial infarction: its nature and consequences.

Abstract: The prevalence and prognostic impact of previous depression, depression in the hospital, and depression after discharge were studied in 222 patients admitted for acute myocardial infarction (MI). Patients were interviewed 1 week, 6 months, and 12 months after the index MI using a modified version of the Diagnostic Interview Schedule (DIS); patients also completed the Beck Depression Inventory (BDI). Patients or family members were recontacted at 18 months to determine survival. Some 27.5% of patients had at least one episode of major depression before their MI, but only 7.7% were depressed at some point during the year preceding the infarct. Overall, 31.5% of patients experienced depression in the hospital or during the year postdischarge. Some 35 patients were depressed in the hospital, 30 became depressed between discharge and 6 months, and five more between 6 and 12 months after the MI. History of depression increased the risk of depression in the hospital and after discharge. Depression in the hospital was associated with an increased risk of mortality over 18 months. Patients who experienced a recurrent depression in the hospital were at particularly high risk. Although patients who became depressed after discharge differed from those who remained depression-free in terms of age, history of depression, BDI scores, and the number of depression symptoms on the DIS in the hospital, a model including these variables identified only 14.7% of the patients who became depressed after returning home. Post-MI depression is common and largely unrelated to medical and psychosocial factors.

Treating Major Depression in Primary Care Practice: Eight-Month Clinical Outcomes

Abstract: Background: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. Methods: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n=91) or interpersonal psychotherapy (n=93) provided within well-structured parameters, or a physician's usual care (n=92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. Results: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. Conclusions: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.

Psychodynamics and psychiatric diagnoses of pseudoseizure subjects

Abstract: Objective The goal of this study was to determine current and lifetime rates of DSM-III-R disorders in patients with pseudoseizures and to ascertain whether trauma is associated with the occurrence of pseudoseizures. Methods Adult pseudoseizure patients (N = 45) were interviewed regarding seizure course and life events, and they were given the Structured Clinical Interview for DSM-III-R--Patient Version, the Structured Clinical Interview for DSM-III-R Dissociative Disorders, the Dissociative Experiences Scale, and the Personality Diagnostic Questionnaire--Revised. The pseudoseizures were diagnosed in a tertiary-care video-EEG facility. Most of the subjects (78%) were female, and the mean age of the overall patient group was 37.5 years (SD = 9.7). Results The mean duration of the subjects' seizure history was 8.3 years (SD = 8.0). Common current psychiatric diagnoses included somatoform disorders (89%), dissociative disorders (91%), affective disorders (64%), personality disorders (62%), posttraumatic stress disorder (PTSD) (49%), and other anxiety disorders (47%). The lifetime occurrence of nonseizure conversion disorders was 82%. The mean Dissociative Experiences Scale score was 20.2 (SD = 18.2). Trauma was reported by 84% of the subjects: sexual abuse by 67%, physical abuse by 67%, and other traumas by 73%. Conclusions Pseudoseizure subjects have high rates of the psychiatric disorders found in traumatized groups; they closely resemble patients with dissociative disorders. Reclassification of conversion seizures with the dissociative disorders should be considered. Pseudoseizures often appear to express distress related to abuse reports. Clinicians should screen pseudoseizure patients for adult and childhood trauma, dissociative disorders, depression, and PTSD.

The occurrence of depression in Parkinson's disease. A community-based study.

Abstract: Objective: To investigate the frequency of major depression (MD) and the severity of depressive symptoms among patients with Parkinson's disease (PD). Design: The PD population was derived from a community-based prevalence study. Total case ascertainment and a high diagnostic accuracy of PD were attempted through a detailed community study and the use of a new clinical diagnostic classification. Major depression was diagnosed according to the criteria in theDiagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.The severity of depression in the prevalence population was scored with the Montgomery and Asberg Depression Rating Scale. The occurrence of depressive symptoms among patients with PD was compared with the occurrence among age-matched groups of patients with diabetes mellitus and of healthy elderly. In addition, the patients with PD and the control groups completed the Beck Depression Inventory. Setting: Depression among patients with PD derived from a prevalence study in the county of Rogaland, Norway. Patients: Two hundred forty-five patients with PD. Two age-matched control groups (each including 100 patients); one group included patients with diabetes mellitus and the other, healthy elderly. Results: Of the 245 patients with PD, 7.7% met the criteria for MD. Based on their Montgomery and Asberg Depression Rating score, 5.1% of the patients were moderately to severely depressed whereas another 45.5% had mild depressive symptoms. Among the patients who scored 20 or more on the Mini-Mental State Examination, 3.6% had MD compared with 25.6% of the patients with a score below 20. The frequency of patients with a Beck Depression Inventory score of 18 or more was higher in the PD group (24.1%) than among patients with diabetes mellitus (11%) and the healthy elderly controls (4%). Conclusion: This study suggests that the prevalence of MD in PD is lower than previously assumed, but a substantial proportion of patients with PD have less severe depressive symptoms.

Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch.

Abstract: Objective: To investigate the attitudes of the general public towards depression before the Defeat Depression Campaign of the Royal Colleges of Psychiatrists and General Practitioners; these results form the baseline to assess the change in attitudes brought about by the campaign. Design: Group discussions generated data for initial qualitative research. The quantitative survey comprised a doorstep survey of 2003 people in 143 places around the United Kingdom. Results: The lay public in general seemed to be sympathetic to those with depression but reluctant to consult. Most (1704 (85%)) believed counselling to be effective but were against antidepressants. Many subjects (1563 (78%)) regarded antidepressants as addictive. Conclusions: Although people are sympathetic towards those with depression, they may project their prejudices about depression on to the medical profession. Doctors have an important role in educating the public about depression and the rationale for antidepressant treatment. In particular, patients should know that dependence is not a problem with antidepressants. Key messages Before beginning its five year task the campaign sought opinions from 2003 members of the public Most of the sample (78%) thought that antidepressants were addictive, and only 16% thought that they should be given to depressed people Most patients treated with antidepressants in primary care abandon taking them prematurely; fear of dependence is one likely explanation Patients should be informed clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem

The revised monoamine theory of depression: a modulatory role for monoamines, based on new findings from monoamine depletion experiments in humans.

Abstract: The original hypothesis that brain monoamine systems have a primary direct role in depression has been through several modifications during the past 30 years. In order to test this hypothesis and more fully characterize the role of serotonin and catecholamines in the pathophysiology of depression and the mechanism of action of antidepressant treatments, our research group has conducted a series of studies evaluating monoamine depletion induced brief clinical relapse following different types of antidepressant treatment of depressed patients. We have also studied the effects of monoamine depletion (SD) on depressive symptoms in depressed and recovered patients off medication and in healthy controls. Relapse to serotonin depletion or to catecholamine depletion (CD) was found to be specific to the type of antidepressant treatment, i.e., patients responding to selective serotonin reuptake inhibilitors relapsed more frequently following SD than CD and patients responding to selective catecholamine reuptake inhibitors relapsed more frequently following CD than SD. Neither CD or SD increased depressive symptoms in clinically ill patients off treatment, or produced clinical depression in normal controls. However, recovered patients with a prior history of depression had a relapse with SD. Patients with obsessive compulsive disorder who improved on SSRI treatment, did not have an increase in OCD symptoms but those with prior depressive symptoms did have an increase in depressive symptoms with SD. The findings that relapse during treatment is specific to the type of treatment and type of depletion, that neither SD or CD produced an increase in clinical depression in healthy controls or depressed patients off medication, and that recovered patients off medication have a return of symptoms following SD, forces a major revision of the current monoamine theories of depression. The new hypothesis most consistent with this new data is that the monoamine systems are only modulating "other" brain neurobiologic systems which have a more primary role in depression. The modulatory or "antidepressant" function of the monoamine systems appears to be only necessary during drug induced recovery and the maintenance of recovery after a prior episode. These clinical studies point to the need for more fundamental research on the interaction of monoamine systems with other brain neurobiologic mechanisms relevant to depression.

The Evolution of Psychiatric Symptoms in Alzheimer's Disease: A Natural History Study

Abstract: OBJECTIVE To characterize the natural history of Alzheimer's Disease (AD); in particular, to determine the prevalence and time of onset of psychiatric symptoms. DESIGN Retrospective medical records review. SETTING Regional brain bank operated by a university hospital. PARTICIPANTS One hundred randomly selected autopsy-confirmed AD patients. MEASUREMENTS The presence of psychiatric symptoms (e.g., anxiety, wandering, agitation) was documented, and the time of onset relative to diagnosis was measured. RESULTS Irritability, agitation, and aggression were documented in 81 patients (81%) an average of 10 months after diagnosis. A total of 72% of patients experienced depression, changes in mood, social withdrawal, and suicidal ideation more than 2 years before diagnosis (26.4 months). Hallucinations, paranoia, accusatory behavior, and delusions were documented around the time of diagnosis (0.1 months after diagnosis) in 45% of patients. Patients with early-onset disease, more years of formal education, and male gender experienced psychiatric symptoms later, relative to diagnosis, than their counterparts. CONCLUSIONS Psychiatric manifestations of depression may herald a diagnosis of AD, as such behaviors occurred more than 2 years before diagnosis, on average, in this cohort. Psychotic symptoms manifested around the time of diagnosis, perhaps even prompting diagnosis, whereas agitative symptoms occurred in the first year after diagnosis. The evolution of psychiatric symptoms in this cohort differed according to age at onset of disease, years of formal education, and gender.

Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain.

Abstract: Study design This prospective, multicenter study was designed to investigate the efficacy and outcome of spinal cord stimulation using a variety of clinical and psychosocial outcome measures. Data were collected before implantation and at regular intervals after implantation. This report focuses on 70 patients who had undergone 1 year of follow-up treatment at the time of data analysis. Objectives To provide a more generalizable assessment of long-term spinal cord stimulation outcome by comparing a variety of pain and functional/quality-of-life measures before and after management. This report details results after 1 year of stimulation. Summary of background data The historically diverse methods, patient selection criteria, and outcome measures reported in the spinal cord stimulation literature have made interpretation and comparison of results difficult. Although short-term outcomes are generally consistent, long-term outcomes of spinal cord stimulation, as determined by prospective studies that assess multidimensional aspects of the pain complaint among a relatively homogeneous population, are not well established. Methods Two hundred nineteen patients were entered at six centers throughout the United States. All patients underwent a trial of stimulation before implant of the permanent system. Most were psychologically screened. One hundred eighty-two patients were implanted with a permanent stimulating system. At the time of this report, complete 1-year follow-up data were available on 70 patients, 88% of whom reported pain in the back or lower extremities. Patient evaluation of pain and functional levels was completed before implantation and 3, 6, 12, and 24 months after implantation. Complications, medication usage, and work status also were monitored. Results All pain and quality-of-life measures showed statistically significant improvement during the treatment year. These included the average pain visual analogue scale, the McGill Pain Questionnaire, the Oswestry Disability Questionnaire, the Sickness Impact Profile, and the Back Depression Inventory. Overall success of the therapy was defined as at least 50% pain relief and patient assessment of the procedure as fully or partially beneficial and worthwhile. Using this definition, spinal cord stimulation successfully managed pain in 55% of patients on whom 1-year follow-up is available. Complications requiring surgical intervention were reported by 17% (12 of 70) of patients. Medication usage and work status were not changed significantly. Conclusions This prospective, multicenter study confirms that spinal cord stimulation can be an effective therapy for management of chronic low back and extremity pain. Significant improvements in many aspects of the pain condition were measured, and complications were minimal.

Treatment Outcomes for Primary Care Patients With Major Depression and Lifetime Anxiety Disorders

Abstract: Objective : Major depression occurs with generalized anxiety disorder and panic disorder in up to 60% of psychiatric and primary care patients. This comorbidity has been associated with greater severity of depression, poorer psychosocial functioning, and poorer treatment outcomes in psychiatric samples. This study examined the clinical outcomes for depressed primary care patients with and without a lifetime anxiety disorder. Method : A total of 157 primary care patients who met criteria for major depression were randomly assigned to standardized interpersonal psychotherapy or pharmacotherapy with nortriptyline and were assessed at baseline and at 4 and 8 months on severity of depression, psychosocial functioning, and health-related functioning. Results : Depressed patients with a comorbid anxiety disorder presented with significantly more psychopathology and tended to prematurely terminate treatment more frequently than patients with major depression alone. Both standardized depression-specific treatments were effective for depressed patients with and without a comorbid generalized anxiety disorder, although time to recovery was longer for the former. Patients with lifetime panic disorder showed poor recovery in response to psychotherapy or pharmacotherapy. Conclusions : Standardized psychotherapy and pharmacotherapy are effective for patients with major depression with and without a generalized anxiety disorder. However, the longer time to recovery for the former group and lack of response to these treatments by patients with lifetime panic disorder suggest that primary care physicians should carefully assess history of anxiety disorder among depressed patients so as to select a proper intervention.

Generalized Anxiety Disorder in Stroke Patients A 3-Year Longitudinal Study

Abstract: Background and Purpose This prospective study examined the prevalence and longitudinal course of generalized anxiety disorder (GAD) after stroke and its comorbidity with major depression over time. The contributions of lesion characteristics, functional impairment, and psychosocial factors to the development of GAD after stroke were studied. Methods In a population-based cohort of 80 patients with acute stroke, we assessed GAD and comorbid major depression, functional ability, and social network at regular time points over 3 years. Cerebral atrophy and brain lesion parameters were determined from CT scans performed at the acute stage and after 3 years. Results The prevalence of GAD after stroke was 28% in the acute stage, and there was no significant decrease through the 3 years of follow-up. At 1 year, only 23% of the patients with early GAD (0 to 3 months) had recovered; those not recovered at this follow-up had a high risk of a chronic development of the anxiety disorder. Comorbidity with major depress...

The Identification and Validation of Distinct Depressive Syndromes in a Population-Based Sample of Female Twins

Abstract: Background: Depression, a clinically heterogeneous syndrome, may also be etiologically heterogeneous. Using a prospective, epidemiologic, and genetically informative sample of adult female twins, we identify and validate a typology of depressive syndromes. Methods: Latent class analysis was applied to 14 disaggregated DSM-III-R symptoms for major depression reported over the last year by members of 1029 female-female twin pairs. Results: Seven classes were identified, of which 3 represented clinically significant depressive syndromes: (1) mild typical depression , (2) atypical depression , and (3) severe typical depression . Severe typical depression was characterized by comorbid anxiety and panic, long episodes, impairment, and help seeking. Atypical depression was similar in severity to mild typical depression, but was characterized by increased eating, hypersomnia, frequent, relatively short episodes, and a proclivity to obesity. Individuals with recurrent episodes tended to have the same syndrome on each occasion. The members of twin pairs concordant for depression had the same depressive syndrome more often than expected by chance and this resemblance was greater in monozygotic than in dizygotic pairs. Conclusion: In an epidemiologic sample of female twins, depression is not etiologically homogeneous, but is instead made up of several syndromes that are at least partially distinct from a clinical, longitudinal, and familial/genetic perspective.

Cancer and depression.

Abstract: Half of all cancer patients have a psychiatric disorder, usually an adjustment disorder with depression. Anxiety about illness, such as cancer, often leads to delay in diagnosis, which has been estimated to reduce prospects of long-term cancer survival by 10% to 20%. Although earlier studies showed that depressed individuals were at higher risk for cancer incidence, later studies have not confirmed this predictive relationship. Nonetheless, effective psychotherapeutic treatment for depression has been found to affect the course of cancer. Psychotherapy for medically ill patients results in reduced anxiety and depression, and often pain reduction. In three randomised studies, psychotherapy resulted in longer survival time for patients with breast cancer (18 months), lymphoma, and malignant melanoma. The physiological mechanisms for these findings have not yet been determined, but four fundamental possibilities for psychotherapeutic effects on physiological change include health maintenance behaviour, health-care utilisation, endocrine environment, and immune function. Thus, effective treatment of depression in cancer patients results in better patient adjustment, reduced symptoms, reduced cost of care, and may influence disease course. The treatment of depression in these patients may be considered a part of medical as well as psychiatric treatment.

Change in Depression as a Precursor of Cardiovascular Events

Abstract: Objective: To determine the relationship between increasing depressive symptoms and cardiovascular events or mortality. Design: Cohort analytic study of data from randomized placebo-controlled double-blind clinical trial of antihypertensive therapy. Depressive symptoms were assessed semiannually with the Center for Epidemiological Studies— Depression (CES-D) scale during an average follow-up of 4.5 years. Setting: Ambulatory patients in 16 clinical centers of the Systolic Hypertension in the Elderly Program. Patients: Generally healthy men and women aged 60 years or older randomized to active antihypertensive drug therapy or placebo who were 79% white and 53% women and had follow-up CES-D scores and no outcome events during the first 6 months (N=4367). Main Outcome Measures: All-cause mortality, fatal or nonfatal stroke, or myocardial infarction. Results: Baseline depressive symptoms were not related to subsequent events; however, an increase in depression was prognostic. Cox proportional hazards regression analyses with the CES-D scale as a time-dependent variable, controlling for multiple covariates, indicated a 25% increased risk of death per 5-unit increase in the CES-D score (relative risk [RR], 1.25; 95% confidence interval [CI], 1.15 to 1.36). The RR for stroke or myocardial infarction was 1.18 (95% CI, 1.08 to 1.30). Increase in CES-D score was an independent predictor in both placebo and active drug groups, and it was strongest as a risk factor for stroke among women (RR, 1.29; 95% CI, 1.07 to 1.34). Conclusions: Among elderly persons, a significant and substantial excess risk of death and stroke or myocardial infarction was associated with an increase in depressive symptoms over time, which may be a marker for subsequent major disease events and warrants the attention of physicians to such mood changes. However, further studies of causal pathways are needed before widespread screening for depression in clinical practice is to be recommended. (Arch Intern Med. 1996;156:553-561)

Correlates of postnatal depression in mothers and fathers.

Abstract: BACKGROUND We compare and contrast some correlates of paternal and maternal depression after the live birth of a first child, as part of a longitudinal study. METHOD Fifty-four first-time mothers attending obstetric services in Oporto, Portugal, and 42 of their husbands or partners participated in a longitudinal study of their mental health. All subjects were given a semi-structured clinical interview (SADS) at six months antenatally and at 12 months postnatally and sub-samples were interviewed at three months postnatally. At all these times all the mothers and fathers also completed a translated version of a self-rating scale for depression, the Edinburgh Postnatal Depression Scale (EPDS) and a series of other questionnaires and interviews to measure different psychosocial variables. Profiles of risk factors associated with depression in the first postnatal year were analysed by means of logistic regressions. RESULTS In the mothers, aside from a history of depression, the only other powerful predictor of postnatal depression was the mean objective negative impact score of life events. 'Postnatal' depression in fathers was associated with a history of depression in themselves and with the presence of depression in their wives or partners during pregnancy and soon after delivery. CONCLUSION Prevention and early treatment of depression in fathers may benefit not only themselves but also their spouses and their children.