Screening for depression and diabetes-related distress in a diabetes outpatient clinic.

AIMS: To investigate: (1) the willingness of patients with diabetes to participate in a screening programme; (2) the extent to which patients with diabetes who screen positive endorse need for psychosocial care; (3) the rate of referral to psychosocial care during screening vs. usual care. METHODS: Four hundred and ninety-nine patients with diabetes were invited to complete the Center for Epidemiologic Studies Depression and the Problem Areas in Diabetes questionnaires. Patients screening positive on either instrument were invited for an interview. One year after screening was withdrawn, rates of referral to psychosocial care were assessed from physician reports of patient referrals. RESULTS: In total, 349/499 (70%) patients with diabetes completed the questionnaire. Patients who did not take up the screening were younger, smoked more often and had higher HbA(1c) values. 'No-shows' for clinical appointments accounted for 74% of non-participation. Of the 104 (30% of 349) patients screening positive, 45 accepted an invitation for an interview. Finally, 36/104 (35%) would like a referral for psychological care. Seven per cent of patients were referred to psychological care during screening compared with 1% when screening was withdrawn. CONCLUSIONS: Results raise questions as to whether screening is the most efficient way to identify patients with psychological problems. Many patients did not take up the screening, especially those with low adherence to diabetes care in general. Furthermore, few patients screening positive wanted to be referred. Screening should be evaluated in the context of consideration of alternative ways to identify at-risk patients, including providing resources to deal with patients with already known adjustment and adherence problems.

Sleep and daily functioning during androgen deprivation therapy for prostate cancer.

A limited body of evidence suggests that sleep problems are common in prostate cancer patients undergoing androgen deprivation therapy, yet little is known about sleep characteristics and the effects of poor sleep on daily functioning in this population. This study assessed sleep in 60 prostate cancer patients taking androgen deprivation therapy with wrist actigraphy and daily diaries for 7 days. The Epworth Sleepiness Scale and the general version of the Functional Assessment of Cancer Therapy scale were also administered. On average, total sleep time was 5.9 (SD = 1.4) h, and sleep efficiency was 75% (SD = 12.0) as assessed by actigraphy. There was generally poor concordance between actigraphy and daily diary for most sleep metrics. Subjects reported awakening, on average, 2.7 times per night, most commonly for nocturia and hot flashes. Assessment of daily functioning showed that participants had mild daytime sleepiness, which was predicted by total sleep time (F(1,47) = 4.5, P= 0.04) General quality of life was not impaired. This study supports more research on the predictors of poor sleep in order to identify effective interventions.

Treatment of atypical depression: post-hoc analysis of a randomized controlled study testing the efficacy of sertraline and cognitive behavioural therapy in mildly depressed outpatients.

OBJECTIVE: Atypical features are common among depressed primary care patients, but clinical trials testing the efficacy of psychopharmacological and/or psychotherapeutic treatment are lacking. This paper examines the efficacy of sertraline and cognitive behavioural therapy (CBT) among depressed patients with atypical features. SUBJECTS AND METHODS: Analyses involve a double-blind comparison of sertraline versus placebo (N=47) and a single-blind comparison between CBT versus a guided self-help group (GSG) (N=48), with primary efficacy endpoints being the Inventory of Depressive Symptomatology (IDS(C)) and Hamilton Depression Scale (HAMD-17). RESULTS: In intent-to-treat (ITT) analyses, the decrease on the IDS(C) scale (and HAMD-17) was greater after CBT compared to GSG: p=0.01 (HAMD-17: p=0.01). The difference between selective serotonin reuptake inhibitors (SSRI) versus placebo was not significant: p=0.22 (HAMD-17: p=0.36). LIMITATIONS: The number of cases in each treatment group was small, thereby limiting statistical power. Patients medicated with sertraline were 10 to 15 years younger than those included in the other groups of treatment. CONCLUSIONS: CBT may be an effective alternative to GSG for mildly depressed patients with atypical features. Although SSRI were not superior to placebo, it would be premature to rule out SSRI as efficacious in atypical depression.

Personal characteristics associated with consistency of recall of depressed or anhedonic mood in the 13-year follow-up of the Baltimore Epidemiologic Catchment Area survey.

OBJECTIVE: Our study addressed two primary questions: (1) How reliable is long-term recall of lifetime history of episodes of depressed mood? (2) What characteristics are associated with consistent recall of this history? METHOD: Psychiatric symptoms were assessed in a population-based longitudinal survey of 1498 persons twice, in 1981 and 1994. Respondents whose reports of history of depressed affect were discordant after a 13-year follow-up interval were compared with those whose reports were concordant. RESULTS: Absence of a reported history of episode of depressed mood was more consistently recalled than presence of such an episode. The kappa of reported lifetime history of episode of depressed mood was 0.32. Several personal characteristics predicted consistency of recall. CONCLUSION: If assessment of past episodes of depressed mood is used as guide for identifying cases at risk for depression, account must be taken of the personal factors that might influence recall.

Prognostic importance of marital quality for survival of congestive heart failure.

Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patient's concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

Validity and efficiency of screening for history of depression by self-report.

Because of the recurrent nature of depression, there is a need for a rapid means of screening for history of depression that is either valid in itself or an efficient means of identifying respondents needing further assessment. This study examined the validity and efficiency of assessment of lifetime history of depression by self-report screening questions in comparison with the results of a structured interview assessment conducted a year earlier. Self-reported lifetime 2-week mood disturbance was unrelated to the results of the earlier interview. Self-report of treated episodes of mood disturbance were related to interview-assessed history of depression, but too modestly for practical applications. Self-report of past depression was more strongly related to concurrent distress than to the earlier interview assessment of history of depression. Implications of these findings for screening and assessment of history of depression are discussed.

The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study.

The PROSPECT (Prevention of Suicide in Primary Care Elderly - Collaborative Trial) Study evaluates collaborative care for the treatment of current depressive disorders in older primary care patients. Using screening data, we evaluate implications of expanding the focus to additional patients who report taking psychotropic medication or having a history of depression. Some 13.8% of the patients screened were taking a psychotropic medication and 7.3% were both taking an antidepressant and had a Center for Epidemiologic Studies - Depression Scale (CES-D) score of > 15. Patients who reported current antidepressant use and those with a history of depression also had elevated CES-D scores. Conversely, most patients having an elevated CES-D score also reported taking an antidepressant or having a history of depression. These latter criteria for potential caseness yielded a larger number of patients than those identified by the CES-D alone. More comprehensive approaches to the management of depression should attend to patients already taking psychotropic medication and symptomatic patients with a history of depression, as well as those with current syndromal depression.

Evaluating the continuity of symptomatology between depressed and nondepressed individuals.

Debate is contentious concerning whether depression should be viewed as a distinct category or as a continuum including overlapping normal and clinical phenomena. A nonparametric item response model was used to evaluate whether the probability of expressing individual symptoms differed between nondepressed and clinically depressed adults experiencing similar levels of overall severity. Even though depressed and nondepressed individuals were equated in terms of overall severity, differences on specific symptoms emerged. Depressed mood, anhedonia, and suicidality were more likely to be expressed in depressed than in nondepressed individuals, whereas hypochondriasis and middle insomnia were more likely to be expressed in nondepressed individuals at similar levels of severity. Such differences are inconsistent with the view of depression as a simple continuum.

Examining symptom expression as a function of symptom severity: item performance on the Hamilton Rating Scale for Depression.

Despite widespread use of the Hamilton Rating Scale for Depression (HRSD; M. Hamilton, 1960), questions have been raised concerning its psychometric properties. A nonparametric item response model was used to examine how the probability of observing a specific symptom of depression changes with increases in depressive severity in a sample of depressed adults. Results showed that options from a number of items on the HRSD did not vary as a function of severity and therefore should not be viewed as indicators of depressive severity. The extent to which symptoms are expressed as a function of depressive severity carries important implications for the use of the HRSD as a measure of severity and for the debate concerning construction of depression as a continuum. Results argue against viewing depression as a simple continuum.

Distress and psychiatric morbidity among women from high-risk breast and ovarian cancer families.

This study assessed psychological distress and psychiatric disorder in high-risk women enrolled in a hereditary breast and ovarian cancer registry, and it evaluated the concordance between self-report data and interview-based psychiatric diagnosis. A sample of 464 women completed the Hopkins Symptom Checklist-25 and were interviewed using modules of the Structured Clinical Interview for DSM-IV. Level of psychological distress and the prevalence of psychiatric disorder were low and in the range that would be expected for a sample of community-residing women. Screening proved inefficient: Less than 10% of distressed women met criteria for a clinical disorder. High-risk women seeking genetic testing in research settings may not require extensive psychological screening and diagnostic assessment. Caution is expressed about possible self-selection biases in women enrolled in hereditary cancer registries.

How men view genetic testing for prostate cancer risk: findings from focus groups.

OBJECTIVE: To determine the values, beliefs, and attitudes that influence a man's intention to undergo or defer genetic testing for prostate cancer risk. DESIGN: Qualitative, using focus group interviews 12 focus groups were conducted to identify key values and beliefs about genetic testing for prostate cancer risk in anticipation of its future availability. SETTING: Medium-sized, mid-west, US city. PARTICIPANTS: Community sample of 90 lay men of diverse educational, ethnic, and age backgrounds. ANALYSIS: Descriptive statistics and immersion/crystallization to identify themes and sub-themes. RESULTS: The major areas of concern were distilled into the following. THEMES: beliefs about consequences, expectations, benefits for patients, beliefs about barriers, and susceptibility concerns. CONCLUSION: Identifying these men's values will help health professionals anticipate the informational and ethical needs of patients in the informed consent process. Men will need to understand how such testing may affect their planning regarding future prostate health, and how medical information is used outside of the physician patient relationship.

The relationship between alcohol problems and health functioning of older adults in primary care settings.

OBJECTIVE: The purpose of this study was to determine the relationship between alcohol use and health functioning in a sample of older adults screened in primary care settings. DESIGN: A cross-sectional study. SETTING: Thirty-seven primary care clinics. PARTICIPANTS: Older adults (n = 8,578; aged 55-97) with regularly scheduled appointments in primary care clinics were screened. MEASUREMENTS: Participants were categorized based on alcohol consumption levels as abstainers, low-risk drinkers, and at-risk drinkers (women: 9 or more drinks/week; men: 12 or more drinks/week). Dependent variables were eight SF-36 health functioning scales. RESULTS: Sixty-one percent of participants were abstainers, 31% were low-risk drinkers, and 7% were at-risk drinkers. ANCOVAs found significant effects of drinking status on General Health, Physical Functioning, Physical Role Functioning, Bodily Pain, Vitality, Mental Health, Emotional Role, and Social Functioning, controlling for age and gender, with low-risk drinkers scoring significantly better than abstainers. At-risk drinkers had significantly poorer mental health functioning than low-risk drinkers. Few significant gender differences were found on SF-36 scales. CONCLUSIONS: Older adults who are at-risk drinkers may not present with poor physical health functioning. Future studies are needed to determine the relationship between drinking limits for older adults and other areas of physical and psychosocial health.

Never the Twain shall meet? Closing the gap between coping research and clinical intervention research.

Two distinct literatures have contributed to a tremendous growth of interest in coping. The 1st consists of descriptive studies that have used coping checklists. This literature is in crisis because of its failure to yield substantive findings concerning the role of coping in adaptation that cannot be dismissed as truisms, trivia, or the product of a confounding of stress, coping, and distress. The 2nd literature concerns interventions to improve adaptation by enhancing coping. It provides evidence of the efficacy of intervention but provides little understanding of crucial ingredients, mechanisms of change, or barriers to maintaining gains. Both literatures would benefit from cross-fertilization. Process studies of interventions designed to improve coping provide an alternative to fruitless and potentially misleading correlational studies using checklists. Such studies might also aid in understanding and refining intervention strategies.

Living with a depressed spouse.

The depressed mood and specific burdens experienced by spouses of patients in treatment for depression were examined. Forty-nine wife-depressed couples and 30 husband-depressed couples were administered the Structured Clinical Interview for DSM-IV (M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1995), and spouses completed measures of depressed mood and burden. Overall, spouses living with a depressed patient reported significantly more depressed mood than general population norms and numerous specific burdens. Regression analyses showed that these burdens as well as gender of the spouse accounted for the spouses' depressed mood that would otherwise be attributed to mood contagion. It is suggested that as an alternative to an exclusive therapeutic focus on patient outcomes, attention might profitably be directed to the distress and burden experienced by spouses.

The role of competing demands in the treatment provided primary care patients with major depression.

OBJECTIVE: To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit. DESIGN: A cross-sectional patient survey. PARTICIPANTS AND SETTING: Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders. MAIN OUTCOME MEASURES: In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients. RESULTS: Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05). CONCLUSIONS: The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.