Subsyndromal (“Mixed”) anxiety-depression in primary care

Objective: To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses. Design: Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff. Setting: Five primary care sites in the United States, France, and Australia. Patient: Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up. Methods: Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers. Results: After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders. Conclusion: The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment. Supported in part by a grant from the American Psychiatric Association.     

Clinical Interventions for Late-Life Anxious Depression

Anxiety symptoms are frequently present in patients with late-life depression. The designation “anxious depression” has been used to describe major depressive disorder (MDD) accompanied by clinically significant but subsyndromal anxiety symptoms. MDD may also present comorbid with diagnosable anxiety disorders, although this presentation is less common in late life. Diagnosis of anxious depression in the elderly is complicated by several factors (eg, their tendency to experience and report psychiatric symptoms as somatic illness) and is associated with a more severe clinical presentation, increased risk for suicidal ideation, increased disability, and poorer prognosis. Standard pharmacotherapy for depression may be sufficient but for many patients must be modified or augmented. Psychosocial interventions may also be an important component in the treatment of these patients, although no specific psychosocial treatments have been developed for late-life anxious depression.     

Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication adherence difficulties

The present study examined the frequency and correlates of self-reported symptoms of posttraumatic stress among patients with HIV and medication adherence problems. Self-report data revealed that more than half of participants met diagnostic criteria for posttraumatic stress disorder (PTSD) according to the Posttraumatic Diagnostic Scale PDS. Death anxiety was associated with overall PTSD symptom severity scores as well as severity scores for reexperiencing, avoidance, and arousal symptoms. The association between death anxiety and total PTSD severity, reexperiencing and avoidance symptom scores remained after controlling for depression and satisfaction with social support. Anxiety, as manifested by PTSD symptoms should be routinely assessed among patients with HIV, and variables such as death anxiety, social support, and depression are appropriate targets for mental health interventions.     

Prospective study of posttraumatic stress disorder and disease activity outcomes in US veterans with rheumatoid arthritis

Objective

To examine the relationship between posttraumatic stress disorder (PTSD) and disease activity in US veterans with rheumatoid arthritis (RA).

Methods

US veterans with RA were enrolled in a longitudinal observational study and were categorized as having PTSD, other anxiety/depression disorders, or neither of these psychiatric diagnoses using administrative codes. Generalized linear mixed‐effects models were used to examine the associations of the diagnostic groups with outcomes measured over a mean followup period of 3.0 years.

Results

At enrollment, 1,522 patients had a mean age of 63 years, they were primarily men (91%), and a majority (78%) reported white race. A diagnosis of PTSD was observed in 178 patients (11.7%), and other anxiety/depression diagnoses (excluding PTSD) were found in 360 patients (23.7%). The presence of a PTSD diagnosis was independently associated with higher values of self‐reported pain, physical impairment, tender joint count, and worse patient global well‐being scores compared to patients with no psychiatric diagnosis. There were no significant group differences in swollen joint count, erythrocyte sedimentation rate, or Disease Activity Score in 28 joints. There were no differences between any outcomes comparing those with PTSD and those with other anxiety/depression diagnoses.

Conclusion

In this RA cohort, the diagnosis of PTSD was associated with worse patient‐reported outcomes and tender joint counts, but not with other physician‐ or laboratory‐based measures of disease activity. These results suggest that PTSD, along with other anxiety/depression disorders, may affect RA disease activity assessments that rely on patient‐reported outcomes and the resulting treatment decisions.     

Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?

OBJECTIVES: The primary aim of this study was to assess the frequency of post-traumatic stress disorder (PTSD) in patients with the fibromyalgia syndrome (FMS). The influence of gender on measures of PTSD in fibromyalgia (FM) patients also was examined. METHODS: Seventy-seven consecutive patients (40 women and 37 men) who fulfilled the criteria for FM were asked to complete questionnaires measuring the prevalence and severity of symptoms of PTSD, anxiety, and depression. The subjects were divided in 2 groups based on the presence or absence of PTSD symptoms. RESULTS: In this study, 57% of the FM sample had clinically significant levels of PTSD symptoms. The FM patients with PTSD reported significantly greater levels of avoidance, hyperarousal, reexperiencing, anxiety, and depression than did the patients without clinically significant levels of PTSD symptoms. The prevalence of PTSD among the FM patients in this study was significantly higher than in the general population. Women with FM and PTSD reported a greater number of past traumatic events than did their male counterparts. CONCLUSIONS: The results represent the first comprehensive study applying structured clinical assessment of trauma exposure and PTSD to a group of FM patients. This study shows a significant overlap between FM and PTSD, according to the currently accepted diagnostic criteria for each.     

Mental health screening in integrated care settings: Identifying rates of depression,anxiety, and posttraumatic stress among youth with HIV

Rates of depression, anxiety, and posttraumatic stress disorder (PTSD) are greater in youth living with HIV (YLWH) than in the general population. Currently, depression screening guidelines exist for YLWH but not anxiety and PTSD. This study examined data from comprehensive mental health screenings conducted with YLWH, which included measures of depression, anxiety, and PTSD. Percentages of positive screeners were 35%, 25.7%, and 20.6% for depression, anxiety, and PTSD, respectively. Older participants reported more depression and anxiety symptoms. Participants with less education reported more PTSD symptoms. These findings support the need for universal and comprehensive mental health screenings for YLWH.     

Psychiatric morbidity among patients with cancer of the esophagus or the gastro-esophageal junction: a prospective, longitudinal evaluation

Cancer of the esophagus is often diagnosed at a late stage and is related to severe morbidity and a low 5-year survival rate. Previous studies have reported low health-related quality of life and high suicide rates for these patients. The occurrence of psychiatric morbidity and thus the potential need for psychological support may vary over time after diagnosis. This has not been adequately studied in patients with newly diagnosed cancer of the esophagus or gastro-esophageal junction. The present study therefore aimed to prospectively evaluate the prevalence of psychiatric morbidity in 94 consecutive patients (median age 66, range 45-88 years) with all stages of disease. Psychiatric morbidity was evaluated with the Hospital Anxiety and Depression Scale (HADS) questionnaire at inclusion and 1, 2, 3, 6 and 12 months later. At inclusion, 42% of the patients had HADS scores indicating possible or probable anxiety disorder and/or depression. At all follow-ups except at 3 months, proportions of patients with possible/probable anxiety disorder were significantly lower than at inclusion. Among patients with a duration of tumor-specific symptoms exceeding 6 months pre-diagnosis, larger proportions of patients with a possible/probable anxiety disorder were found at the 1- and 6-month follow ups. The prevalence of possible/probable depression was greater among patients treated with a palliative intent than among those with a curative intent at inclusion. Patients who died during the study period scored worse for depression compared to the survivors. Apart from this, the proportion of patients with possible/probable psychiatric morbidity (anxiety and/or depression) was relatively stable over time and was unrelated to patient characteristics or clinical background, including the treatment regime. In conclusion, psychiatric morbidity is common among esophageal cancer patients, both at inclusion and over time, regardless of the cancer therapy given. The findings stress the importance of monitoring the patients' mental health and of offering adequate psychological care when needed.     

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability.

OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions. METHODS: Subjects were 224 patients, aged 60 years and older, recruited from private internal medicine offices or a family medicine clinic. Validated measures of psychopathology, medical burden, and functional status were used. The subsyndromal depression group was defined by a score of more than 10 on the Hamilton Rating Scale for Depression and by the absence of major or minor depressive disorder. Analyses included multiple regression techniques to determine the presence of group differences adjusted for demographic covariates. RESULTS: Subsyndromal depression was common (estimated point prevalence of 9.9% compared with 6.5% for major depression, 5.2% for minor depression, and .9% for dysthymic disorder), associated with functional disability and medical comorbidity to a degree similar to major or minor depression, and often treated with antidepressant medications. CONCLUSIONS: Although depressive conditions are common and are associated with considerable functional and medical morbidity in older primary care patients, many patients with clinically significant depressive symptoms are not captured by criteria-based syndromic diagnostic categories. Future work should include intervention studies of subsyndromally depressed older persons as well as attention to the course and biopsychosocial concomitants of diagnosable and subsyndromal depressions in this population.     

Anxiety of Alzheimer's disease: prevalence, and comorbidity.

BACKGROUND: Anxiety may be associated with psychiatric morbidity, disability, increased health care utilization, and mortality in Alzheimer's disease (AD) patients as it is in the general adult population. However, the phenomenology of anxiety symptoms in AD and its relationship to dementia progression, comorbid depression, and the presence of other problematic behaviors have not yet been examined. METHOD: Data on anxiety symptoms and their coexistence with other factors were obtained in 523 community-dwelling AD patients through interviews with their caregivers and direct physical examination. The prevalence of anxiety symptoms and their association to patient depression, other behavioral problems, gender, and age was investigated. RESULTS: Anxiety symptoms were common, occurring in 70% of subjects. Anxiety symptoms were significantly correlated with ADL impairment and other behavioral disturbances, including wandering, sexual misconduct, hallucinations, verbal threats, and physical abuse. Comorbidity of anxiety-depression was also prevalent: 54% of the sample had both anxiety and depression symptoms. ADL impairment and problem behaviors were significantly associated with comorbidity; however, the latter association was explained entirely by the presence of anxiety. CONCLUSION: Anxiety symptoms were common and significantly related to ADL and additional neuropsychiatric problems in this sample. These results indicate the need for additional research into the phenomenology of anxiety and comorbid anxiety-depression in AD and for the development and investigation of effective assessment and treatment of anxiety in AD clinical practice.     

The quality of life of HIV-infected women is associated with psychiatric morbidity

This study evaluated the effect of clinical, demographic and psychiatric factors on the health-related quality of life of 76 women with HIV infection seen in two HIV reference centres in Brazil. The generic questionnaire for evaluation of Health-Related Quality of Life (SF-36), the Hospital Anxiety and Depression Scale (HAD) and the Clinical Interview Schedule (CIS-R) were used. The statistical tests included the covariance analysis. The patients' mean age was 37.4 years; 44.7% had less than 8 years of schooling. A total of 44.8% were asymptomatic, 28.9% symptomatic non-AIDS and 26.3% had AIDS. Most (77.6%) used two or three kinds of antiretrovirals; 36.8 and 30.3% achieved scores for anxiety and depression, respectively (HAD); and 48.7% for conspicuous psychiatric morbidity (CIS-R). The sub-group of the non-AIDS symptoms (clinical stage B) showed the worst quality of life. The variables which better explained the scoring variation on both the mental and physical components of the SF-36 were related to mental health. The more mental symptoms present, the worse the health-related quality of life. We must rethink care strategies in the area of mental health which are directed toward HIV+ patients, by virtue of the levels of mental symptoms found and the request for care which the research revealed.     

Routine Depression Screening in an HIV Clinic Cohort Identifies Patients with Complex Psychiatric Co-morbidities Who Show Significant Response to Treatment

This study described characteristics, psychiatric diagnoses and response to treatment among patients in an outpatient HIV clinic who screened positive for depression. Depressed (25 %) were less likely to have private insurance, less likely to have suppressed HIV viral loads, had more anxiety symptoms, and were more likely to report current substance abuse than not depressed. Among depressed, 81.2 % met diagnostic criteria for a depressive disorder; 78 % for an anxiety disorder; 61 % for a substance use disorder; and 30 % for co-morbid anxiety, depression, and substance use disorders. Depressed received significantly more treatment for depression and less HIV primary care than not depressed patients. PHQ-9 total depression scores decreased by 0.63 from baseline to 6-month follow-up for every additional attended depression treatment visit. HIV clinics can routinely screen and treat depressive symptoms, but should consider accurate psychiatric diagnosis as well as co-occurring mental disorders.     

Common mental disorders in postconflict settings

Research into postconflict psychiatric sequelae in low-income countries has been focused largely on symptoms rather than on full psychiatric diagnostic assessment. We assessed 3048 respondents from postconflict communities in Algeria, Cambodia, Ethiopia, and Palestine with the aim of establishing the prevalence of mood disorder, somatoform disorder, post-traumatic stress disorder (PTSD), and other anxiety disorders. PTSD and other anxiety disorders were the most frequent problems. In three countries, PTSD was the most likely disorder in individuals exposed to violence associated with armed conflict, but such violence was a common risk factor for various disorders and comorbidity combinations in different settings. In three countries, anxiety disorder was reported most in people who had not been exposed to such violence. Experience of violence associated with armed conflict was associated with higher rates of disorder that ranged from a risk ratio of 2.10 (95% CI 1.38-2.85) for anxiety in Algeria to 10.03 (5.26-16.65) for PTSD in Palestine. Postconflict mental health programmes should address a range of common disorders beyond PTSD.     

Drug intolerance due to nonspecific adverse effects related to psychiatric morbidity in hypertensive patients

BACKGROUND: Poor adherence to antihypertensive drug regimens is common and may increase the risk for cardiovascular morbidity and mortality. Adverse effects of the drugs can contribute to poor adherence, but some patients who discontinue several different antihypertensive drugs may misinterpret nonspecific symptoms as adverse effects of the drug because of psychiatric morbidity. We examined the relationship between intolerance to antihypertensive drugs and the presence of panic disorder, panic attacks, anxiety, and depression. METHODS: We included all patients with hypertension who attended a hospital hypertension clinic during 1 year with at least 2 episodes of intolerance (resulting in reduction of the dosage or stopping an antihypertensive drug) recorded on standardized problem lists and a similar number of patients with no recorded episodes of intolerance. Psychiatric morbidity, assessed by self-administered questionnaires, was analyzed against the number of episodes of nonspecific and drug-specific intolerance, verified by means of individual case-note scrutiny, and scored independently by 2 assessors masked to patient identity. RESULTS: Analyzable questionnaires were returned by 233 (84%) of 276 patients who had experienced 576 (85%) of 679 episodes of intolerance assessed. Five hundred thirty-two episodes (92%) were subjective (patient was symptomatic); of these, 284 were judged to be drug specific; 248, nonspecific. Having more episodes of nonspecific intolerance was associated with significantly higher diastolic blood pressure (P =.003). Episodes of nonspecific intolerance were associated with panic attacks (P =.008), anxiety (Hospital Anxiety and Depression Scale score, P =.04), and depression (Hospital Anxiety and Depression Scale score, P =.005). Drug-specific intolerance was not associated with psychiatric morbidity. CONCLUSIONS: Intolerance to multiple antihypertensive drugs, particularly non-drug-specific intolerance, is strongly associated with psychiatric morbidity. Physicians treating hypertensive patients need to recognize and manage the psychiatric aspects of intolerance to multiple antihypertensive drugs.     

Clinical and Neuropsychological Predictors of Posttraumatic Stress Disorder

Although acute responses to traumatic stress generally resolve within a few weeks, some individuals experience severe and persistent problems, such as posttraumatic stress disorder (PTSD). While studies have identified a variety of predictors of PTSD, not all data are consistent. This longitudinal study examined the predictive power of neurocognitive deficits with regard to PTSD severity.One hundred thirty one road traffic collision (RTC) survivors were included within 2 weeks of the RTC and followed up 3 and 6 months later to determine severity of PTSD.Impairment on tests of information processing, executive functioning, verbal learning, and motor speed predicted PTSD severity when neuropsychological, clinical, and sociodemographic factors were all taken into account. Clinical variables (initial symptoms, psychiatric diagnoses, disability, trait anxiety, perceived stress, negative cognitions, and sleep) were associated with 3 and 6-month PTSD severity, but only trait anxiety was predictive of PTSD severity. Ethnicity and education were also found to be predictive.These findings suggest implementation of a holistic approach to screening for PTSD and support a need for interventions that target neurocognitive, clinical, and social variables. Early targeted profiling of this group of trauma survivors can inform early clinical interventions and policy.     

Psychiatric disorders among veterans with hepatitis C infection

BACKGROUND & AIMS: The presence of psychiatric, drug-, and alcohol-use disorders in hepatitis C virus (HCV)-infected patients may influence their management and prognosis. The frequency and the risk for these disorders among HCV-infected patients are unknown. METHODS: We identified all HCV-infected veteran patients who were hospitalized during 1992-1999 and searched the inpatient and outpatient computerized files for predefined psychiatric, drug-, and/or alcohol-use disorders. We then performed a case-control study among Vietnam veterans; controls without HCV were randomly chosen from hospitalized patients. RESULTS: We identified 33,824 HCV-infected patients, in whom 86.4% had at least one past or present psychiatric, drug-, or alcohol-use disorder recorded. However, only 31% had active disorders as defined by hospitalization to psychiatric or drug-detoxification bed sections. There were 22,341 HCV-infected patients from the Vietnam period of service (cases) who were compared with 43,267 patients without HCV (controls). Cases were more likely to have depressive disorders (49.5% vs. 39.1%), posttraumatic stress disorder (PTSD) (33.5% vs. 24.5%), psychosis (23.7% vs. 20.9%), bipolar disorder (16.0% vs. 12.6%), anxiety disorders (40.8% vs. 32.9%), alcohol (77.6% vs. 45.0%), and drug-use disorders (69.4% vs. 31.1%). In multivariable regression analyses that adjust for age, sex, and ethnicity, drug use, alcohol-use, depression, PTSD, and anxiety remained strongly associated with HCV. CONCLUSIONS: Several psychiatric, drug-, and alcohol-use disorders are commonly found among HCV-infected veterans compared with those who are not infected. At least one third of these patients have active disorders. A multidisciplinary approach to the management of HCV-infected patients is needed.     

Psychological distress in the first year after diagnosis of HIV infection among women in South Africa

Cross-sectional studies on psychological responses associated with an HIV diagnosis are replete, but a paucity of research exists to evaluate the changes and stability of these responses, particularly among black African women. One hundred and five HIV-positive black and coloured women were studied as they reported for follow-up health management at the outpatient clinic for infectious diseases at Tygerberg Hospital in Cape Town, South Africa. They were assessed at baseline and 51 returned for a follow-up interview six months later. Assessments involved use of the Mini-International Neuropsychiatric Interview (MINI), the Carver Brief COPE, and the Sheehan Disability Scale. Negative life events and risk behaviours were also evaluated. Fifty-nine women (56.2%) were diagnosed with at least one psychiatric disorder on the MINI at baseline. The most frequent diagnosis was major depression (38.1%), followed by dysthymic disorder (22.9%). A diagnosis of HIV or AIDS exacerbated the premorbid state of 19% of the women who reported a past history of depression. Twelve women (11.4%) were at risk for suicide, while 19% met criteria for a clinical diagnosis of post-traumatic stress disorder (PTSD) and 6.7% met the diagnosis of generalised anxiety disorders. At follow-up, 26 (51%) were diagnosed with at least a psychiatric disorder. Eleven (21.6%) met the criteria for major depression, while eight (15.7%) had a past history of depression. The number of women with PTSD increased from 19% of the total sample at baseline to 29.4% of those interviewed at follow-up. Conversely, the number with dysthymia dramatically decreased from 24 women (22.9%) at baseline to just one woman at follow-up. The number displaying suicidality also decreased from 12 at baseline to four at follow-up. At both baseline and follow-up, the number and impact of negative life events significantly increased the likelihood of major depression persisting or recurring, but this association was not found for PTSD. These findings indicate that, over time, there is variability in psychiatric morbidity among coloured and black African women living with HIV and that a high number of negative life events may increase the likelihood of persistent major depression in these women.     

A prospective study of psychiatric and psychological aspects of Cushing's syndrome

OBJECTIVE Cushing's syndrome is associated with psychiatric and psychological disturbances. The aim of this study was to ascertain the extent of mental illness in patients before and after treatment for Cushing's syndrome. DESIGN AND PATIENTS Patients with Cushing's syndrome were identified for a prospective study. Control patients were selected with pituitary adenomas secreting GH or PRL. The aim was to reassess patients after Cushing's syndrome had been treated. MEASUREMENTS Psychiatric symptoms were measured and classified using the Present State Examination (PSE), and analysed on the Catego Programme. The Hamilton Rating Scale (HRS) was used to measure depression. The Crown-Crisp Experiential Index was used to measure common psychoneurotic symptoms (anxiety, phobia, obsession, somatic, depression and hysteria scales). The Eysenck Personality Inventory was used to assess extroversion and neuroticism. Cortisol, ACTH, and other hormones were measured by conventional methods. Parametric and non-parametric tests were used where appropriate. RESULTS Catego analysis of psychiatric ratings showed only 8 patients of 43 with active Cushing's syndrome (19%) were normal. Psychiatric diagnoses were obtained as follows: neurotic depression in 20 (46%), possible neurotic depression in 1 (2%), reactive depression in 6 (14%), and non-specific neurotic symptoms in 8 (19%). Additional Catego ratings of suspected other psychoses were made for 3 patients who were also depressed. None of these 43 patients with active Cushing's syndrome had ratings of schizophrenia or mania, obsessional neurosis or pathological anxiety. In the control group 13 (87%) were normal, 1 patient with acromegaly had an anxiety state and one patient with a prolactinoma had neurotic depression. It was possible to reassess the Present State Examination after treatment in 25 patients, when cortisol levels had been substantially reduced (to normal in 88%), the percentage rated as psychiatrically normal increased from 19 to 68 (χ²=11.7, 1 d.f., P<0.01). Hamilton Rating Scale scores for depression showed significant improvements after treatment for Cushing's syndrome (mean decrease from 9.2 to 2.4, n=36, P<0.001). Crown-Crisp experiential index data showed significant improvements in anxiety, somatic symptoms, and depression (n=25, P<0.05). Eysenck Personality Inventory assessments showed a significant improvement in neuroticism score (n=26 P=0.016), but no significant change in extroversion (P=0.5) or lie score (P=0.6). CONCLUSIONS Most patients with Cushing's syndrome had significant psychiatric pathology, usually depressive illness. As cortisol levels were returned to normal there were significant improvements in scores for depression and anxiety. Management of patients with Cushing's syndrome should include careful assessment of psychological and psychiatric illness.     

Post-traumatic stress disorder and other co-morbidities in a sample population of patients with irritable bowel syndrome

BACKGROUND: High rates of psychiatric co-morbidity have been reported in patients with irritable bowel syndrome (IBS) and high rates of post-traumatic stress disorder (PTSD) have been reported in fibromyalgia, a disorder also associated with IBS. The primary aim of this study was to assess the frequency of PTSD in IBS patients. METHODS: Sixty-four patients who fulfilled the Rome II diagnostic criteria for IBS were asked to complete questionnaires measuring the prevalence and severity of symptoms of PTSD and psychological distress. RESULTS: Although 86% of IBS patients reported a traumatic life experience, only 7.8% met the diagnostic criteria for PTSD. High rates of somatization, obsessive-compulsive behavior, interpersonal sensitivity, and anxiety symptoms were seen among the IBS patients. CONCLUSIONS: The results show a lower than expected prevalence of PTSD among IBS patients, which is similar to that of the general population. Thus, we did not find that PTSD is over-represented in a sample population of IBS patients.     

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.     

Posttraumatic stress disorder in first-time myocardial infarction patients

OBJECTIVES: The objectives of this study were to investigate the prevalence of posttraumatic stress disorder in patients with a first myocardial infarction compared with a random sample of healthy controls and to determine variables associated with the disorder. DESIGN: A questionnaire was distributed to 112 consecutive patients 4 to 6 weeks after infarction and to 115 healthy controls selected randomly from the general population. Objective clinical measures were obtained from the patients' medical records. RESULTS: Twenty-five (22%) patients qualified for a diagnosis of posttraumatic stress disorder (PTSD) compared with 8 (7%) controls with patients being more than a three-fold (OR: 3.84; 95% CI: 1.65 to 8.94) risk of having the disorder. When adjusting for other variables, the risk was reduced to above a two-fold risk (OR: 2.71; 95% CI: 0.99-7.41). In patients and controls, depression and neuroticism were associated with a diagnosis of PTSD adjusting for other variables. In patients, anxiety was associated with a diagnosis of PTSD adjusting for other variables. Left ventricular ejection fraction and symptoms of angina pectoris were not related to a diagnosis of PTSD in the patient group. CONCLUSIONS: Given that previous research has shown that persons with PTSD are at increased risk of cardiovascular diseases, cardiac patients with the disorder may be at a higher risk of recurrent cardiac events. Although longitudinal studies are needed to confirm such a relationship, this disorder should not be overlooked because of its potential role in reinfarctions and mortality.