Screening for adjustment disorders and major depression in otolaryngology patients using the Hospital Anxiety and Depression Scale

The authors conducted a study to demonstrate the prevalence of psychiatric symptoms among 100 otolaryngology inpatients (50 with non-malignant conditions; 50 with malignancies), and to investigate the efficacy of the Hospital Anxiety and Depression Scale (HADS) as a screening test for psychiatric disorders in otolaryngology. A structured interview was conducted according to the Adjustment Disorders and Major Depressive Episodes section of DSM-N, which demonstrated that 30% of the inpatients with benign diseases met the criteria for some psychiatric disorders (one patient for major depression and 14 for adjustment disorders) and that 46% of the inpatients with malignancies met the criteria (nine patients for major depression and 14 for adjustment disorders). There were highly significant differences between the HADS scores of the patients with psychiatric disorders and those without. Comparing the sensitivity and the specificity using the HADS as a screening test, the optimal cut-off point was 12, which produced 92% sensitivity, 90% specificity and 85% positive predictive value (PPV) among not only non-malignant and malignant cases taken together but also among malignant cases only.     

Prevalence and determinants of depressive disorders in primary care practice in Spain

OBJECTIVE: Depressive disorders are considered to be a public health problem. Primary health care plays an important role in the treatment of such disorders. Our aim is to determine the prevalence and determinant factors of major depression and dysthymia in consecutive primary care attenders. METHOD: The study took place in medical consultations in 10 Primary Care Centers in Tarragona (Spain). It was designed as a two-phase cross-sectional study. In the first phase we screened 906 consecutive patients according to Zung's Self-Rating Depression Scale. In the second phase the 209 patients whose results were positive and 97 patients whose results were negative (1/7 chosen at random) were given the Structured Clinical Interview for DSM-IV Axis I Disorders, plus a series of questionnaires. We evaluated the link between major depression and dysthymia and several sociodemographic and clinical variables using non-conditional logistic regression. RESULTS: Weighted prevalence was 14.3% (CI 95%: 11.2-17.4) for major depression and 4.8% (CI 95%: 2.8-6.8) for dysthymia. Independently linked to the presence of major depression were female sex, panic disorder, generalized anxiety disorder, frequency of primary care visits, and clinical presentation in the form of explicitly psychosocial symptoms as opposed to exclusively somatic symptoms. Independently linked to the presence of dysthymia were age, generalized anxiety disorder and psychosocial symptoms. CONCLUSION: In our area, depressive disorders in primary care attenders are very common. General practitioners should be aware of this fact so that these disorders can be detected and treated correctly.     

An examination of suicidal intent in patients with multiple sclerosis

OBJECTIVE: To examine neurologic and psychiatric correlates of suicidal intent in a community sample of 140 patients with MS. METHODS: Patients with (28.6%) and without lifetime suicidal intent were compared across MS disease-related and psychiatric variables. All subjects were interviewed with 1) the Structured Clinical Interview for DSM-IV Axis 1 disorders (SCID-IV) to determine lifetime prevalence of major depression and anxiety disorders; and 2) the Social Stress and Support Interview to assess psychological stressors. Suicidal intent was documented with questions from the SCID-IV and Beck Suicide Scale. Patients also completed the Hospital Anxiety and Depression Scale and cognitive testing. RESULTS: Suicidal patients were significantly more likely to live alone, have a family history of mental illness, report more social stress, and have lifetime diagnoses of major depression, anxiety disorder, comorbid depression-anxiety disorder, and alcohol abuse disorder. By logistic regression analysis, the severity of major depression, alcohol abuse, and living alone had an 85% predictive accuracy for suicidal intent. A third of suicidal patients had not received psychological help. Two-thirds of subjects with current major depression, all suicidal, had not received antidepressant medication. CONCLUSIONS: Suicidal intent, a potential harbinger for suicide, is common in MS and is strongly associated with major depression, alcohol abuse, and social isolation. Suicidal intent is a potentially treatable cause of morbidity and mortality in MS.     

The prediction of suicidal intent in depressed patients

The aim of the present study was to examine the relationships between suicidal ideation or suicidal attempts and severity of depression, presence of personality disorders, and sociodemographic factors in a population of depressed in-patients. A total of 338 adult depressed psychiatric in-patients were examined and classified according to DSM-III criteria as having major depression with or without melancholic or psychotic features, adjustment disorder with depressed mood or dysthymic disorder. Scores on the Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI) and Zung Self-Rating Depression and Anxiety Scales (SDS and SAS) were measured. We found that suicidal ideation was significantly related to severity of depression (according to the HDRS and all self-rating scales), a lower global assessment of functioning the year before hospitalization, and previous psychiatric hospitalizations. The items with the strongest predictive value for suicidal ideation were hopelessness, depressed mood, feelings of guilt, loss of interest and low self-esteem. These symptoms predicted 43% of the variance in suicidal ideation. None of the above predictors of suicidal ideation was related to suicidal attempts. Depressed patients with a personality disorder attempted significantly more suicidal attempts and showed more suicidal ideation than depressed patients without personality disorder. No significant correlations were found between suicidal ideation or suicide attempts and gender, marital status, employment status or psychosocial stressors during the previous 6 months.     

Personality and clinical characteristics in patients with trichotillomania.

BACKGROUND: Trichotillomania, a disorder of self-directed hair pulling, has been the subject of few systematic studies. Although personality characteristics and disorders are often noted to coexist with trichotillomania, no thorough assessment of comorbidity with DSM-III-R Axis II disorders has been published. The present study was conducted to evaluate personality disorders and other personality characteristics in a large outpatient population of trichotillomanics and to compare these findings with those in a nontrichotillomanic comparison group. METHOD: Forty-eight outpatient female trichotillomanics were evaluated with the Structured Interview for DSM-III-R Personality Disorders (SIDP-R) and the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2). Personality disorders and personality cluster symptom scores from the SIDP-R and MMPI-2 scales were compared with those derived from a comparison group of 48 age-matched female outpatient psychiatric patients. RESULTS: Forty-two percent of the trichotillomanic group met criteria for a personality disorder. The only statistically significant difference in frequency of diagnoses between the trichotillomanic and comparison groups was a greater frequency of borderline personality disorder in the comparison group. Trichotillomanics demonstrated significantly less SIDP-R cluster A personality symptoms as well as less depression and better psychological adjustment on the MMPI-2. CONCLUSION: Our study suggests that no particular personality disorder or trait characterizes female trichotillomanics. Female trichotillomanics seeking psychiatric intervention appear to have better psychological adjustment and less psychopathology in general than other psychiatric outpatients.     

Usefulness of the PERI demoralization scale to screen for psychiatric disorder in a community sample

The authors gave the PERI Demoralization Scale (PERI-D), a measure of nonspecific psychological distress, to 528 subjects drawn from a larger longitudinal community survey. Respondents also were interviewed using the Schedule for Affective Disorders and Schizophrenia (SADS), a structured clinical interview. Based on the SADS, subjects were given diagnoses based on Research Diagnostic Criteria (RDC). The results corroborate earlier findings of a modest relationship between self-reported symptoms of distress and the diagnosis of clinical psychiatric disorder. There was somewhat better fit between RDC diagnoses of depression, particularly major depression, and PERI-D symptom scores, suggesting the PERI-D items may be slightly more useful for detecting cases of depression in the community than for the broader range of psychiatric disorders. In general, the authors concur with earlier writers who suggest that brief psychiatric symptom scales may be useful as screening tests in community surveys, but such instruments do not in themselves provide good estimates of the prevalence of clinical psychiatric disorder in the community.     

Somatoform dissociation discriminates among diagnostic categories over and above general psychopathology.

OBJECTIVE: The primary aim of this study was to investigate the hypothesis that somatoform dissociation would differentiate among specific diagnostic categories after controlling for general psychopathology. METHOD: The Somatoform Dissociation Questionnaire (SDQ-20), the Dissociative Experiences Scale, and the Symptom Checklist-90-R were completed by patients with DSM-IV diagnoses of dissociative disorders (n = 44), somatoform disorders (n = 47), eating disorders (n = 50), bipolar mood disorder (n = 23), and a group of consecutive psychiatric outpatients with other psychiatric disorders (n = 45), mainly including anxiety disorders, depression, and adjustment disorder. RESULTS: The SDQ-20 significantly differentiated among diagnostic groups in the hypothesised order of increasing somatoform dissociation, both before and after statistically controlling for general psychopathology. Somatoform dissociation was extreme in dissociative identity disorder, high in dissociative disorder, not otherwise specified, and increased in somatoform disorders, as well as in a subgroup of patients with eating disorders. In contrast with somatoform dissociation, psychological dissociation did not discriminate between bipolar mood disorder and somatoform disorders. CONCLUSIONS: Somatoform dissociation is a unique construct that discriminates among diagnostic categories. It is highly characteristic of dissociative disorder patients, a core feature in many patients with somatoform disorders, and an important symptom cluster in a subgroup of patients with eating disorders.     

Psychological state, quality of life, and coping style in patients with digestive cancer

The purpose of this study was to assess the relationships between psychological characteristics such as anxiety and depression, quality of life (QOL) and coping style among patients with digestive cancer. The subjects were 85 in-patients who were scheduled to undergo initial surgery for gastrointestinal cancer. The following psychological tests were administered: Japanese versions of the Hospital Anxiety and Depression Scale, Zung's Self-Rating Depression Scale, the European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 and the Coping Inventory for Stressful Situations. The first 3 tests were performed on three occasions: before surgery, before discharge and 6 months after discharge. The results showed that there was no change over the 3 test administration days for the average scores of anxiety and that the scores of depression increased from before surgery to before discharge and did not return to presurgery levels at 6 months after discharge. Changes in each subscale score of the EORTC QLQ C30 across the 3 days displayed two typical trends. Relationships between the abovementioned trends and individual coping styles showed that the higher the score of "emotion-oriented coping style," the greater the deterioration in QOL subscales. It was suggested that focusing on a patient's coping style, particularly emotion-oriented coping style, is important and that patients likely to adopt a more emotion-oriented coping style should receive special consideration.     

Scientific background of psycho-oncology]

We discussed the future direction of studies on psycho-oncology by reviewing relevant previous findings regarding treatment, early detection, and prevention of psychiatric disorders experienced by cancer patients. PSYCHIATRIC DISORDERS IN CANCER PATIENTS: It is reported that the common psychiatric disorders among cancer patients are adjustment disorder, major depression, and delirium. In addition, prevalence of adjustment disorder and major depression is higher among advanced cancer patients than that among patients with early stage cancer, and that delirium is the most common disorder among patients with terminally ill cancer. TREATMENT: Some meta-analytical studies reveal an effectiveness of psychotherapy for anxiety and depression among cancer patients however, several systematic reviews do not. Three randomized clinical trials indicate the efficacy of pharmacological treatments, anti-depressants, for major depression in cancer patients. It is suggested that delirium in advanced/terminally ill cancer patients can be ameliorated by detection and management of underlying causes of delirium and concurrent symptomatic treatment such as pharmacotherapy. EARLY DETECTION: Several brief screening instruments have been developed to detect adjustment disorder, major depression, and delirium among cancer patients. PREVENTION: One randomized clinical trial indicates the efficacy of SSRI for preventing depression occurring after interferon therapy among patients with malignant melanoma. No other effective strategy for prevention of psychiatric disorders among cancer patients has been clarified. CONCLUSION: There are not enough findings for effective treatments for ameliorating the common psychiatric disorders experienced by cancer patients, and very few studies for prevention while there are several available findings regarding early detection of their psychiatric disorders. Thus future studies on developing novel treatments including prevention and studies on mechanism should be encouraged. Psycho-oncology group in National Cancer Center are now conducting several clinical studies such as biological studies (neuro-imaging studies), studies to establish novel treatment strategy (n-3 poly unsaturated fatty acid), and multi-faceted intervention study (screening and individually tailored psychotherapy and pharmacotherapy).     

Neuropsychological screening in the psychiatric emergency room.

In a pilot study, a neuropsychological minibattery of tests consisting of Trail-Making Test A (TMA), Trail-Making Test B (TMB), and the Visual Reproduction subtest (VR) of the Wechsler Memory Scale was administered to patients with common psychiatric diagnoses in a psychiatric emergency room (ER). Patients with adjustment disorders were not distinguishable from normal controls, while patients with affective disorders and schizophrenia were more impaired than both of these samples. It is suggested that this or a similar minibattery of tests can be of use as an adjunct screening device for differential diagnosis of adjustment disorder versus more serious psychopathology in psychiatric ERs.     

Rates of depressive and anxiety disorders in a residential mother-infant unit for unsettled infants

OBJECTIVE: Depression and anxiety are known to be common among women presenting to residential mother-infant programmes for unsettled infant behaviour but most studies have used self-report measures of psychological symptomatology rather than diagnostic interviews to determine psychiatric diagnoses. The aim of the present study was to determine rates of depressive and anxiety disorders and rates of comorbidity among clients of the Karitane residential mother-infant programme for unsettled infant behaviour. METHOD: One hundred and sixty women with infants aged 2 weeks-12 months completed the Edinburgh Postnatal Depression Scale and were interviewed for current and lifetime history of depressive and anxiety disorders using the Structured Clinical Interview for DSM-IV diagnosis (Research version). RESULTS: A total of 25.1% of the sample met criteria for a current diagnosis of major depression, 31.7% had met criteria for major depression since the start of the pregnancy, and 30.5% of clients met criteria for a current anxiety disorder. Of note were the 21.6% who met criteria for generalized anxiety disorder or anxiety disorder not otherwise specified (worry confined to the topics of the baby or being a mother). High levels of comorbidity were confirmed in the finding that 60.8% of those with an anxiety disorder had experienced major or minor depression since the start of their pregnancy and 46.3% of those who had experienced depression since the start of their pregnancy also met criteria for a current anxiety disorder. CONCLUSIONS: There are high levels of psychiatric morbidity among clients attending residential mother-infant units for unsettled infant behaviour, highlighting the importance of providing multifaceted interventions in order to address both infant and maternal psychological issues.     

Reliability of psychiatric scales in patients with dementia of the Alzheimer type

For 43 patients with probable Alzheimer's disease who were screened for psychiatric disorders, the interrater reliability of the Global Deterioration Scale, BPRS, and Hamilton Rating Scale for Depression was high (intraclass correlation, 0.82-0.998). As expected, the prevalence of psychiatric symptoms in this sample was low. The score on the Zung Self-Rating Depression Scale correlated with the score on the rater-administered Hamilton depression scale in patients whose Alzheimer's disease was of low severity (N = 24) but not high severity (N = 19).     

Characteristics of depression in Parkinson's disease: evaluating with Zung's Self-Rating Depression Scale

The purpose of the study was to elucidate characteristics of depression in Parkinson's disease (PD). Fifty-eight PD patients were evaluated with Zung's Self-Rating Depression Scale (SDS) and the Unified Parkinson's Disease Rating Scale (UPDRS). Scores for "suicidal ideation" on the SDS correlated with posture and gait disturbances on the UPDRS. Twenty-six patients with spinocerebellar degeneration (SCD) were also evaluated with the SDS. SDS scores for "indecisiveness" and "constipation" were significantly higher in PD patients than SCD patients. Our results suggest that depression is common in disabled persons but PD patients might have a characteristic clinical presentation.     

Predictive validity of the physical disorders axis of the DSM multiaxial diagnostic system

This paper reports on the predictive validity of the physical disorders axis (axis III) of the DSM multiaxial diagnostic system at 3-year follow-up. A total of 515 general psychiatric patients were assessed with a semistructured procedure that covers all DSM-III diagnoses and axes, and were subsequently followed up for 3 years. Outcome was assessed with several measures of adaptive functioning. Baseline axis III was analyzed according to a) presence of any physical disorder, b) the number of these, c) presence of major chronic physical disorders (MCPD), and d) the number of these. Prediction of impairment in functioning (Strauss-Carpenter Scale), derived from baseline axis III, ranged from a correlation coefficient of .18 when expressed as the presence of any physical disorder to .35 when represented by the number of MCPD. Furthermore, within patients with specific psychiatric disorders, it was found that number of MCPD reached a predictive validity of .55 for patients with dysthymic disorders, .44 for those with anxiety disorders, and .41 for those with major depression. Comparative multiple regression analyses, controlling for demographic and clinical variables, showed that the number of MCPD at baseline was the most important predictor of functioning outcome among patients with dysthymic disorders and major depression. The number of MCPD experienced by general psychiatric patients seems to be an important predictor of future functioning, particularly for patients with certain psychiatric disorders. This points out the importance of considering the relationship between psychiatric and MCPD when conducting systematic clinical assessments towards the prediction of course and outcome.     

Psychiatric disorders in burning mouth syndrome

BackgroundPrevalence of psychiatric disorders in burning mouth syndrome (BMS) is high, but their role in the pathogenesis of BMS remains unclear.ObjectiveThe authors aimed to assess the frequency of psychiatric disorders and the severity of psychopathology in BMS.MethodsThirty BMS patients and thirty-one controls underwent a psychiatric evaluation which included a structured interview (MINI-Plus) and five psychometric scales. A Visual Analogue Scale (VAS) was used to measure the intensity of burning sensation.ResultsPatients with BMS showed a higher frequency of current major depressive disorder, past major depressive disorder, generalized anxiety disorder, hypochondria and cancerophobia (p < 0.05). In BMS patients, generalized anxiety disorder was significantly associated with current major depression and social phobia (p < 0.05). As expected, cancerophobia was significantly associated with hypochondria (p < 0.05). Patients with BMS had higher scores in Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI) and Dutch Fatigue Scale (DUFS) (p < 0.05).ConclusionBMS patients may have a particular psychological and/or psychiatric profile. Psychometric scales might be useful in screening psychiatric disorders, as well as for assessment of treatment outcomes. In the presence of clinical relevant psychiatric symptoms, patients must be treated appropriately.     

Determinants of functional disability and social adjustment in major depressive disorder: a prospective study

We examined prospectively factors influencing social and occupational disability and social adjustment among patients with major depressive disorder. The Vantaa Depression Study comprises a cohort of psychiatric inpatients and outpatients with major depressive disorder in the city of Vantaa, Finland. We prospectively interviewed 193 of 269 (72%) patients both 6 and 18 months after baseline. Axis I and II diagnoses were assessed via semistructured WHO Schedules for Clinical Assessment in Neuropsychiatry 2.0 and SCID-II interviews. Global disability and social and work adjustment were assessed. Patients' functional disability and social adjustment were alleviated concurrently with recovery from depression during the follow-up. The current level of functioning and social adjustment of a patient with depression was predicted by severity of depression, recurrence before baseline and during follow-up, lack of full remission, and time spent depressed. Comorbid psychiatric disorders, personality traits (neuroticism), and perceived social support had significant influence.     

Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease

Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease. Significantly more of the patients with irritable bowel syndrome had lifetime diagnoses of major depression, somatization disorder, generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms.     

Detection and management of depressive disorders in primary care in Spain

OBJECTIVE: Many patients with depression who attend primary care are not detected and are unaware of the benefits of therapeutic intervention. Our aim is to evaluate the recognition and management of depressed patients presenting in primary care in Spain. METHODS: This was a two-phase cross-sectional study in primary care centers in Tarragona (Spain). In the first phase, we screened 906 consecutive patients using the Zung's Self-Rating Depression Scale. In the second phase, all 209 patients whose results were positive and 97 patients whose results were negative (1/7 at random) were given the Structured Clinical Interview for DSM-IV Disorders, a series of questionnaires, and the judgment of the physician about the presence of depression was determined. In the 120 patients with major depression and/or dysthymia, predictors of detection and treatment of depression were determined. RESULTS: Seventy-two percent of depressed patients were detected. The detection was associated with educational level, severity of the depression, level of impairment, and the complaint of explicit psychological symptoms. Thirty-four percent were receiving treatment with antidepressants. Antidepressant treatment was associated with marital status, severity of and impairment from the depression, frequency of visits to the family physician, and the patients' complaint of psychological symptoms. CONCLUSION: Many depressed patients are not detected, but these are often the patients who present with the mildest forms of depression and for whom the benefits of detection are far from clear. Although treatment was associated with the severity of depression, most depressed patients, at any level of seriousness, do not receive appropriate treatment.     

Psychiatric disorders in adult‐onset focal dystonia: A case‐control study

In a single‐center, case–control study, we investigated the frequency and types of psychiatric disturbances in 89 consecutive patients with various primary focal dystonias (34 had cervical dystonia (CD), 28 blepharospasm (BPS), 16 laryngeal dystonia (LD), and 11 arm dystonia), 62 healthy control subjects and as controls for BPS, 26 patients with hemifacial spasm (HFS). Patients and controls underwent a full psychiatric evaluation. Diagnosis was based on the structured clinical interview for DSM‐IV, obsessive‐compulsive disorder (OCD) was assessed with the Yale‐Brown Obsessive‐Compulsive scale, anxiety with the Hamilton Rating Scale for Anxiety, the severity of depression with the Beck Depression Inventory. Of the 89 patients with focal dystonias studied, 51 patients (57.3%) had a diagnosis of psychiatric disorders compared with only 15 of 62 healthy subjects (24.1%) and 9 of the patients with HFS (34.6%). Depressive disorders were more frequent in the CD and BPS groups than in healthy controls, whereas the frequency of anxiety disorders, OCDs or adjustment disorders approached that of healthy subjects. No difference was found in the frequency of any specific psychiatric disorder in patients with LD and arm dystonia and healthy controls. In 35 of 51 patients who had psychiatric disorders, these started before and in 16 patients after the onset of dystonia. No differences were found in age, dystonia severity, and duration of botulinum toxin treatment between patients with and without psychiatric disturbances. The most common psychiatric features in patients with CD and BPS are depressive disorders. © 2010 Movement Disorder Society     

Determinants of self-rating and expert rating concordance in psychiatric out-patients,using the affective subscales of the CPRS

To investigate in more detail concordance between the recently developed Comprehensive Psychopathological Rating Scale (CPRS) and the recently developed Self-Rating Scale for Affective Syndromes (CPRS-S-A), a total of 101 psychiatric out-patients were assessed using these procedures and a diagnostic interview according to DSM-III-R. Depressive and anxiety syndromes were the most common diagnoses on Axis I. Approximately one-third of the patients had a diagnosis of clinical personality disorder on Axis II. The majority of the patients were assessed as predominantly manifesting either Cluster B or Cluster C traits. In general, the correlation between self-and expert-ratings was strong (0.83 for the Montgomery-Åsberg Rating Scale (MADRS) depression subscale and 0.76 for the Brief Scale for Anxiety (BSA) anxiety subscale), but it tended to be weaker in the group of patients with clinical personality disorders. The correlation between the two ratings was also weaker in the group with predominantly Cluster B character traits than in the group with predominantly Cluster C traits or the group with no predominant traits, and weaker in the depressive group than in the anxiety group. However, personality disorder diagnoses were over-represented in the depressive group. The weaker correlations in the groups mentioned above may have been attributable to psychological factors and qualitative differences in cognitive and communicative style. The CPRS-S-A is considered to be a useful and reliable instrument for quantitative rating of symptoms in out-patients. Our results highlight the potential value of using appropriate self-assessment forms as complementary tools in clinical practice and research.