Depression in elderly hospitalized patients with medical illness

Depressive symptoms and disorders were identified by structured psychiatric interview in 130 consecutively admitted male inpatients aged 70 years and over. Major depression was found in 11.5% and other depressive syndromes in 23%. While depressive symptoms and syndromes are common among the medically ill, this study demonstrated the need for careful diagnostic assessment of older patients with depressive symptoms before initiating treatment that may itself convey significant risk. Sociodemographic and health characteristics of older men at higher risk for depression were also identified. Patients more likely to be depressed were over age 75 years, had less formal education, experienced cognitive dysfunction, suffered from more severe medical illness (particularly recent myocardial infarction), and had a history of psychiatric illness. Depressive symptoms were also common among patients with renal or neurologic diseases, those having a family history of psychiatric illness, the unmarried, and the more severely disabled. Given the impact of depression on recovery from medical illness, compliance with medical therapy, and costs of extended hospital stays, detection and treatment of this disorder are imperative.     

High Levels of Concomitant Behavioral Health Disorders Among Patients Presenting for HIV Non-occupational Post-exposure Prophylaxis at a Boston Community Health Center Between 1997 and 2013

A paucity of information regarding mental health exists for patients presenting for HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed electronic medical records of 894 adult nPEP patients seen at a large Boston community health center between 1997 and 2013. Of 821 patients with consensual sexual exposures, 88.3 % were men who have sex with men, and 40.0 % had a mental health diagnosis. Diagnoses included: depression (24.4 %), anxiety (21.9 %), attention deficit disorder (7.8 %), post-traumatic stress disorder (3.3 %), and psychotic disorders (3.3 %). Of 129 patients with substance use disorders, alcohol dependence (65.9 %) and crystal methamphetamine (43.4 %) predominated. Unprotected receptive anal intercourse was associated with psychotic disorders (aOR = 4.86; 95 %CI:1.76–13.5) and substance use disorders (aOR = 1.89; 95 %CI:1.28–2.80). Substance use at the time of exposure was associated with: depression (aOR = 1.95; 95 %CI:1.36–2.80), anxiety (aOR = 2.22; 95 %CI:1.51–3.25), attention deficit disorder (aOR = 1.96; 95 %CI:1.18–3.27), and substance use disorder (aOR = 4.78; 95 %CI:3.30–6.93). Mental illness should be screened for and addressed at nPEP visits to optimize HIV risk-reduction.     

Prevalence,Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.     

The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals

Information regarding the prevalence of mental illness and substance use among HIV-infected patients and the effect of these problems on HIV treatment is needed. We conducted an observational study of patients in the University of Washington (UW) HIV Cohort to determine prevalence rates for mental illness and substance use. Cox regression analyses were used to examine the relationship between mental illness and substance use, pharmacologic treatment for depression/anxiety, and initiation of highly active antiretroviral therapy (HAART) within 9 months of becoming eligible for HAART. Among 1774 patients in the UW HIV cohort during 2004, 63% had a mental illness (including mood, anxiety, psychotic, or personality disorders), 45% had a substance use disorder, and 38% had both. There were 278 patients who met criteria for HAART eligibility. After controlling for other factors, patients with depression and/or anxiety were significantly less likely to initiate HAART compared with patients without a mental illness (hazard ratio [HR] 0.4, p = 0.02). However, patients with depression/anxiety who received antidepressant/antianxiety medications were equally likely to initiate HAART as patients without a mental illness (HR 0.9, p = 0.5). We found that patients with mental illness or substance use disorders receive HAART at lower CD4+ cell counts and higher HIV-1 RNA levels than patients without these disorders. However, HAART initiation among patients who receive treatment for depression/anxiety is associated with no delay. Screening for these disorders in primary care settings and access to appropriate treatment are increasingly important components of providing care to HIV-infected patients.     

Do HIV-Positive Women Receive Depression Treatment that Meets Best Practice Guidelines?

This study addressed whether psychopharmacologic and psychotherapeutic treatment of depressed HIV+ women met standards defined in the best practice literature, and tested hypothesized predictors of standard-concordant care. 1,352 HIV-positive women in the multi-center Women’s Interagency HIV Study were queried about depressive symptoms and mental health service utilization using standards published by the American Psychiatric Association and the Agency for Healthcare Research and Quality to define adequate depression treatment. We identified those who: (1) reported clinically significant depressive symptoms (CSDS) using Centers for Epidemiological Studies-Depression Scale scores of ≥16; or (2) had lifetime diagnoses of major depressive disorder (MDD) assessed by World Mental Health Composite International Diagnostic Interviews plus concurrent elevated depressive symptoms in the past 12 months. Adequate treatment prevalence was 46.2 % (n = 84) for MDD and 37.9 % (n = 211) for CSDS. Multivariable logistic regression analysis found that adequate treatment was more likely among women who saw the same primary care provider consistently, who had poorer self-rated role functioning, who paid out-of-pocket for healthcare, and who were not African American or Hispanic/Latina. This suggests that adequate depression treatment may be increased by promoting healthcare provider continuity, outreaching individuals with lower levels of reported role impairment, and addressing the specific needs and concerns of African American and Hispanic/Latina women.     

High prevalence of psychiatric and substance use disorders among persons seeking treatment for HIV and other STIs in Jamaica: a short report

This cross-sectional study explored the range of psychiatric and substance use disorders and unmet need for mental health care among 84 HIV-positive and 44 HIV-negative public clinic attendees in Jamaica. We used a brief interviewer-administered diagnostic tool, the Client Diagnostic Questionnaire. Two-thirds (65.6%) screened positive for at least one psychiatric disorder; 30.5% screened positive for multiple disorders. The most common disorders were post-traumatic stress disorder (PTSD) (41.4%), alcohol abuse (22.7%), and depressive disorders (21.9%). One in fourteen (7.1%) participants with at least one diagnosis received care in the last 6 months. Adjusting for age and sex, PTSD was associated with non-adherence to antiretroviral treatment (AOR?=?5.32), anxiety disorders (AOR?=?5.82), depression (AOR?=?4.29), and suicidal ideation (AOR?=?8.17). Psychiatric and substance use disorders, particularly PTSD, were common among STI/HIV clinic attendees in Jamaica. Such clinics may be efficient places to screen, identify, and treat patients with psychiatric disorders in low- and middle- income countries.     

Psychiatric disorders and symptoms in children and adolescents with sleep bruxism

Objective

This study examines state-trait anxiety, anxiety sensitivity (AS), depressive symptom levels, and psychiatric disorders in children and adolescents with sleep bruxism (SB).

Subjects and method

Thirty-five patients (aged 8–17 years) with a diagnosis of SB and 35 healthy controls were included in the study. All participants were evaluated for psychiatric disorders using a structured clinical interview and completed self-report questionnaires.

Results

At least one psychiatric disorder was present in 42.9 % of the patient group and 17.1 % of the control group (p?p?Conclusion This study suggests that SB is related to AS, regardless of the severity of anxiety or depressive symptoms.     

A comparative evaluation of substance abuse treatment IV. The effect of comorbid psychiatric diagnoses on amount of treatment, continuing care, and 1-year outcomes

Recent surveys of the substance abuse patient population have shown a striking increase in the proportion of patients with a comorbid psychiatric disorder. In this study, patients with substance abuse and psychotic, anxiety/depressive, or personality disorders were compared with patients with only substance use disorders on treatment experiences and outcomes. Regardless of dual diagnosis status, patients generally improved on both substance use and social functioning outcomes after substance abuse treatment. At the 1-year follow-up, dually diagnosed patients, and patients with only substance use disorders, had comparable substance use outcomes. However, patients with major psychiatric disorders, specifically psychotic and anxiety/depressive disorders, fared worse on psychological symptoms and employment outcomes than did patients with personality disorders and only substance use disorders. Although there were some group differences on the amount of index treatment received and continuing care, the overall pattern of relationships between treatment variables and outcomes was comparable for the patient groups. In addition, there was no diagnostic group by treatment orientation matching effects, which indicated that the dual diagnosis patient groups improved as much in 12-Step as in cognitive-behavioral substance abuse programs.     

Changes in Anxiety and Depression Symptoms Predict Sexual Risk Behaviors Among Young Men Living in Dar es Salaam,Tanzania

Young men are important targets in HIV prevention in Tanzania and throughout sub-Saharan Africa. Anxiety and depression are common among youth and may be important predictors of HIV risk behaviors; evidence of these relationships in high-risk populations is needed. Using baseline and 1 year follow-up assessments from an HIV prevention trial we assessed the association between changes in symptoms of anxiety and depression and follow-up sexual risk behaviors (condom use and sexual partner concurrency) controlling for baseline sexual risk behaviors among 1113 male members of social groups known as “camps” in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. In separate models, increases in anxiety and depression were associated with sexual partner concurrency and with lower levels of condom use. In a combined model, both anxiety and depression appeared to independently affect concurrency but only depression was independently associated with condom use, with the association between anxiety and condom use being likely attributable to covariance with depression symptoms. The results of this study indicate the importance of screening and providing treatment for depression and anxiety disorders in high HIV-prevalence contexts, and the need to develop effective HIV prevention interventions targeting young men living with anxiety and depression.     

Major depression in patients with HIV/AIDS and substance abuse

Previous research has been inconsistent in documenting a strong relationship between depression and HIV/AIDS, although a recent meta-analysis of studies examining this issue indicates that rates of depression are modestly higher for this population. For the current study, conducted from 2001-2004, we sought to examine rates and types of depressive symptoms in a cohort of patients receiving HIV care at two urban medical centers. These patients were participants in an intervention study examining adherence and mental health in persons triply diagnosed with psychiatric disorders, substance use disorders, and HIV/AIDS. Nearly three quarters of these participants were people of color, two thirds described their sexual orientation as heterosexual, and the vast majority were unemployed. We sought to examine the relationship of depression to patients' adherence to antiretroviral medication regimens (highly active antiretroviral therapy [HAART]). Results obtained from structured clinical interviews and self-report questionnaires indicated that study participants experienced high rates of depressive symptoms, and that 72.9% of participants met criteria for major depressive disorder (MDD). The results of this study offer a detailed view of the incidence and nature of MDDs and depressive symptoms for an urban sample of substance-abusing adults with HIV/AIDS. Given the degree to which depressive symptoms and MDD appear to be prevalent for this group, as well as the observation that these symptoms are amenable to treatment, future research should focus on identifying helpful strategies and interventions for treating these symptoms, effective ways of providing linkages to care, and ways in which standardized assessment and treatment protocols might be adapted to better suit this population.     

Telephone Based Cognitive Behavioral Therapy Targeting Major Depression Among Urban Dwelling, Low Income People Living with HIV/AIDS: Results of a Randomized Controlled Trial

This pilot randomized controlled trial evaluated a previously developed manualized telephone based cognitive behavioral therapy (T-CBT) intervention compared to face-to-face (f2f) therapy among low-income, urban dwelling HIV infected depressed individuals. The primary outcome was the reduction of depressive symptoms as measured by the Hamliton rating scale for depression scale. The secondary outcome was adherence to HAART as measured by random telephone based pill counts. Outcome measures were collected by trained research assistants masked to treatment allocation. Analysis was based on intention-to-treat. Thirty-four participants met eligibility criteria and were randomly assigned to receive T-CBT (n = 16) or f2f (n = 18). There was no statistically significant difference in depression treatment outcomes comparing f2f to T-CBT. Within group evaluation demonstrated that both the T-CBT and the f2f psychotherapy groups resulted in significant reductions in depressive symptoms. Those who received the T-CBT were significantly more likely to maintain their adherence to antiretroviral medication compared to the f2f treatment. None of the participants discontinued treatment due to adverse events. T-CBT can be delivered to low-income, urban dwelling HIV infected depressed individuals resulting in significant reductions in depression symptoms and improved adherence to antiretroviral medication. Trial Registry: Clinical Trial.gov identifier: NCT01055158.     

Inner-city substance abuse patterns: a study of psychiatric inpatients

Multiple studies have reported about substance abuse in Blacks and Hispanics. However, little is known about substance-abusing psychiatric patients of these ethnic groups. This study reports the prevalence and patterns of substance abuse among 171 consecutive patients (90 Blacks and 81 Hispanics) admitted to the acute psychiatric unit of an inner-city general hospital. The lifetime prevalence was 63%. Within the month prior to admission, 48% had used the following substances: cannabis, 40%; alcohol, 37%; amphetamines, 20%; cocaine, 12%; phencyclidine (PCP), 12%; barbiturates and/or sedative-hypnotics, 10%; opioids, 9%; inhalants, 1%; hallucinogens, 1%. Those who abused alcohol were more likely to abuse barbiturates and/or sedative-hypnotics, and opioids. Logistic regression analysis showed that major depression, ethnicity, and schizophrenia each were significant predictors of particular types of abuse. Patients with major depression were less likely to use PCP, Blacks were more likely than Hispanics to use hallucinogens, and schizophrenics were less likely to use opioids. In all cases in which sex, age, and personality disorder were significant, males, the young adult group, and those with personality disorder were more likely to be abusers. These three variables were all strong predictors of both multiple and extensive substance abuse. Overall, our findings suggest that in the inner-city, a substantial number of young adult psychiatric inpatients are a high risk group for multiple substance abuse. The coexistence of substance abuse and other psychiatric disorders has clinical and treatment implications, and calls attention for changes within the conventional psychiatric milieu.     

HIV symptom distress and anxiety sensitivity in relation to panic, social anxiety, and depression symptoms among HIV-positive adults

Although past work has documented relations between HIV/AIDS and negative affective symptoms and disorders, empirical work has only just begun to address explanatory processes that may underlie these associations. The current investigation sought to test the main and interactive effects of HIV symptom distress and anxiety sensitivity in relation to symptoms of panic disorder (PD), social anxiety disorder (SA), and depression among people with HIV/AIDS. Participants were 164 adults with HIV/AIDS (17.1% women; mean age, 48.40) recruited from AIDS service organizations (ASOs) in Vermont/New Hampshire and New York City. The sample identified as 40.9% white/Caucasian, 31.1% black, 22.0% Hispanic, and 6.1% mixed/other; with more than half (56.7%) reporting an annual income less than or equal to $10,000. Both men and women reported unprotected sex with men as the primary route of HIV transmission (64.4% and 50%, respectively). HIV symptom distress and anxiety sensitivity (AS) were significantly positively related to PD, SA, and depression symptoms. As predicted, there was a significant interaction between HIV symptom distress and anxiety sensitivity in terms of PD and SA symptoms, but not depressive symptoms. Results suggest that anxiety sensitivity and HIV symptom distress are clinically relevant factors to consider in terms of anxiety and depression among people living with HIV/AIDS. It may be important to evaluate these factors among patients with HIV/AIDS to identify individuals who may be at a particularly high risk for anxiety and depression problems. Limitations included recruitment from ASOs, cross-sectional self-report data, and lack of a clinical diagnostic assessment.     

Depressive disorder and HIV disease: an uncommon association

A review of data on HIV and depression fails to show any direct cause-and-effect relationships between the two, despite the fact that clinical depression is the most commonly seen psychiatric disorder in patients with HIV infection. Most of the HIV-positive individuals with depressive disorders were found to have a history of depression antedating their infection. Contradicting early reports of unusually high rates of depression among HIV patients, more recent studies show that depression levels are not higher for the seropositive versus the seronegative, nor do the levels increase over time or at different stages of the infection. Persons with HIV may be misdiagnosed as depressed because the somatic symptoms of the illness--fatigue, lethargy, weight loss, loss of appetite, and low libido--are also symptoms of depressive disorders. Practitioners are urged to distinguish loss of interest, per se, from loss of interest in activities due to medical problems. When HIV-infected patients are diagnosed as clinically depressed, they respond as well as seronegative patients to antidepressant medications, such as tricyclic antidepressants, serotonin reuptake inhibitors (SRRI's), and psychostimulants. Brief, focused psychotherapy can prove helpful for assisting HIV-positive patients through times of particular vulnerability: the confirmation of HIV infection, adjusting to the seropositive status, onset of physical symptoms, and a sudden decline in T-cell counts.     

Evaluation of the relationship between depression and fibromyalgia syndrome: why aren't all patients depressed?

OBJECTIVE: To examine the relationship between fibromyalgia syndrome (FM) and depression by determining the set of factors that differentiate FM patients with and without depressive disorders. METHODS: A sample of 69 patients with FM underwent a standardized tender point examination and a semistructured psychological interview and completed a set of self-report inventories. RESULTS: Of the sample, 39 met criteria for depressive disorder and 30 did not. Depressed patients with FM were significantly more likely to live alone, report elevated functional limitations, and display maladaptive thoughts than nondepressed patients. Nondepressed patients were significantly more likely to have received prior physical therapy than depressed patients. Pain severity, numbers of positive tender points, and pain intensity of tender points and control points did not differentiate the depressed and nondepressed patients. Discriminant analysis revealed that living status, the perception of functional limitations, maladaptive thoughts, and physical therapy treatment together identified diagnoses of depressive disorders for 78% of the patients. CONCLUSION: Concurrent depressive disorders are prevalent in FM and may be independent of the cardinal features of FM, namely, pain severity and hypersensitivity to pressure pain, but are related to the cognitive appraisals of the effects of symptoms on daily life and functional activities.     

Integrating Screening and Treatment of Unhealthy Alcohol Use and Depression with Screening and Treatment of Anxiety,Pain, and Other Substance Use Among People with HIV and Other High-Risk Persons

We review and synthesize results from a series of analyses estimating the benefit of screening for unhealthy alcohol use, depression, and tobacco to detect individuals at heightened risk for co-occurring anxiety, pain, depression, unhealthy alcohol use, and other substance use among people with HIV and HIV-uninfected individuals in the Veterans Aging Cohort Study. We also examine the potential impact of reducing unhealthy alcohol use and depressive symptoms on the incidence of co-occurring conditions. We found that screening for alcohol and depression may help identify co-occurring symptoms of anxiety, depression, and pain interference, treating unhealthy alcohol use may improve co-occurring pain interference and substance use, and improving depressive symptoms may improve co-occurring anxiety, pain interference, and smoking. We propose that an integrated approach to screening and treatment for unhealthy alcohol use, depression, anxiety, pain, and other substance use may facilitate diagnostic assessment and treatment of these conditions, improving morbidity and mortality.

     

Alcoholism, Anxiety and Depression

This paper discusses diagnostic and treatment approaches for dealing with patients who present with two or more psychiatric disorders. We emphasize the relationship between depressive and anxiety syndromes on one hand, and alcohol abuse on the other. Some reasons for diagnostic confusion are noted, such as the need to distinguish between drinking and alcoholism, sadness and depression, and anxiety feelings and major anxiety disorders. Because symptoms of sadness or anxiety and excessive drinking frequently overlap, a working hierarchy must be established–the approach suggested here is the determination of the primary disorder based on the chronology of development of symptoms. The authors point out some clinical guidelines for use in evaluating patients with primary alcohol abuse and secondary anxiety or depression. Using the data from the literature as well as clinical experience, it is concluded that alcoholism, major affective disorder and major anxiety disorder are distinct illnesses with different prognoses and treatments. Some implications for clinical practice are discussed.     

Relationship of functional gastrointestinal disorders and psychiatric disorders： Implications for treatment

This article revisits the links between psychopathology and functional gastrointestinal disorders such as irritable bowel syndrome （IBS）, discusses the rational use of antidepressants as well as non-pharmacological approaches to the management of IBS, and suggests guidelines for the treatment of IBS based on an interdisciplinary perspective from the present state of knowledge. Relevant published literature on psychiatric disorders, especially somatization disorder, in the context of [BS, and literature providing direction for management is reviewed, and new directions are provided from findings in the literature. IBS is a heterogeneous syndrome with various potential mechanisms responsible for its clinical presentations. IBS is typically complicated with psychiatric issues, unexplained symptoms, and functional syndromes in other organ systems. Most IBS patients have multiple complaints without demonstrated cause, and that these symptoms can involve systems other than the intestine, e.g. bones and joints （fibromyalgia, temporomandibular joint syndrome）, heart （non-cardiac chest pain）, vascular （post-menopausal syndrome）, and brain （anxiety, depression）. Host IBS patients do not have psychiatric illness per se, but a range of psychoform （psychological complaints in the absence of psychiatric disorder） symptoms that accompany their somatoform （physical symptoms in the absence of medical disorder） complaints. It is not correct to label IBS patients as psychiatric patients （except those more difficult patients with true somatization disorder）. One mode of treatment is unlikely to be universally effective or to resolve most symptoms. The techniques of psychotherapy or cognitive-behavioral therapy can allow IBS patients to cope more readily with their illness. Specific episodes of depressive or anxiety disorders can be managed as appropriate for those conditions. Medications designed to improve anxiety or depression are not uniformly useful for psychiatric complaints in IBS, because the p     

Depression,anxiety, post-traumatic stress,and alcohol-related problems among veterans with chronic hepatitis C

OBJECTIVE: The aim of this study was to determine the incidence of psychiatric comorbidities among veterans with chronic hepatitis C. METHODS: Depression, anxiety sensitivity, post-traumatic stress symptoms, and alcohol use were assessed using standardized questionnaires in 120 consecutive veterans with chronic hepatitis C referred to the Liver Clinic. RESULTS: Using well-established scoring criteria of the questionnaires, clinically significant levels of depression (44.2%), anxiety (38.1%), post-traumatic stress disorder (20.8%), and alcohol-related problems (26.7%) were observed. The majority of patients had a clinically significant score for at least one questionnaire, whereas 37.2% had significant scores in two or more questionnaires. Positive correlations were found between post-traumatic symptoms and depressive symptoms, anxiety sensitivity, and alcohol use problems. Depressive symptoms were also correlated with anxiety. Responses to the questionnaires, in general, correlated poorly with psychiatric histories documented in the medical record. Overall, 79 (65.8%) patients had one or more possible contraindications to antiviral therapy: coexisting unstable psychiatric disorders and/or recent substance use was found in 73.4% of these patients. CONCLUSIONS: Psychiatric comorbidities were very common among veterans with chronic hepatitis C and correlated poorly with diagnoses documented in the medical record. We recommend a multidisciplinary approach that includes psychological assessment using standardized questionnaires in the evaluation of these patients for antiviral therapy.