Measuring depressive symptoms in the naturalistic primary-care setting.

BACKGROUND: The majority of individuals with major depressive disorder are diagnosed and treated in the primary-care setting. A quantifiable critical objective in the management of depression is to achieve and sustain full symptomatic remission. The HAMD-7 is a depression metric validated in both tertiary and primary-care settings. METHODS: Herein, we further characterise the psychometric properties of the HAMD-7 in depressed patients treated in primary-care settings. Several cut-scores were evaluated for maximum agreement; diagnostic efficacy statistics with the original HAMD-7 items were also evaluated. We compared performance of the HAMD-7 in primary care to a previously characterised tertiary sample. RESULTS: The depressive symptoms most frequently endorsed (>or=70%) and most sensitive to change during antidepressant treatment in depressed primary-care patients were depressed mood, guilt, work and activities, psychic and somatic anxiety and fatigue. LIMITATIONS: This is a post hoc analysis of a primary-care database; assumptions regarding the definition of symptomatic remission in depression affect interpretation. CONCLUSION: Measurement-based care with the HAMD-7 quantifies the severity of commonly reported depressive items and their responsivity to treatment. The HAMD-7, inclusive of the suicide item, is capable of tracking symptom progress, with a validated remission cut-score.

Predictors of success and satisfaction in the practice of psychiatry: a preliminary follow-up study.

BACKGROUND: Few studies have examined the predictors of psychiatrists' perceived success and personal satisfaction with their careers. The present study examines self-reported success and personal satisfaction with their careers in a cohort of psychiatrists followed for more than 20 years. METHODS: A total of 29 psychiatrists, all of whom had participated in a study during their residency 21 to 24 years earlier, completed a self-report questionnaire. The first set of questions addressed the type and characteristics of their professional practice; the second set assessed aspects of their nonprofessional practice; and the third set assessed aspects of their nonprofessional, personal lifestyles. The personality traits of neuroticism and extraversion were assessed during the residency years and were used as predictors. Composite measures of self-perceived external success and personal satisfaction were computed. Regression models were constructed to determine the best predictors of these composite measures. RESULTS: Neuroticism proved to be a significant predictor of external success but not of personal satisfaction, with higher scores predicting a lower rating of perceived external success. There were 2 practice characteristics--involvement with research and practising from an orientation other than psychoanalytic--that predicted perception of success. One personal lifestyle characteristic--the perception that one's nonprofessional life sustained professional life--also predicted perception of success. The best predictor of personal satisfaction was overall satisfaction with nonprofessional aspects of life. CONCLUSIONS: Personality, nonprofessional social support, and engaging in research are associated with greater perceived success and personal satisfaction with a career in psychiatry.

Antidepressant-induced sexual dysfunction during treatment with moclobemide, paroxetine, sertraline, and venlafaxine.

BACKGROUND: Recent reports suggest that adverse effects on sexual function occur in up to 50% of patients who are treated with selective serotonin reuptake inhibitor (SSRI) antidepressants. Previously cited low rates were more likely a function of underreporting than underoccurrence. There is less evidence about rates of dysfunction with serotonin-norepinephrine reuptake inhibitor (SNRI) and reversible inhibitor of monoamine oxidase A (RIMA) antidepressants. The purpose of this report is to evaluate disturbances in sexual drive/desire and arousal/orgasm in 107 patients who met criteria for major depressive disorder and received treatment with either moclobemide, paroxetine, sertraline, or venlafaxine. METHOD: All consenting eligible patients who met DSM-IV criteria for major depressive disorder completed the Sexual Functioning Questionnaire, version 1 (SFQ) and were assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D) prior to and after 8 or 14 weeks of antidepressant therapy. Analyses were carried out to examine the effect of gender, drug type, pretreatment level of sexual dysfunction, and drug response on reported sexual dysfunction. RESULTS: Compared with women, men experienced a significantly greater level of drug-related impairment in drive/desire (p < .05), whereas there were no statistically significant differences in levels of arousal/orgasm impairment between men and women. The reported impairment in drive/desire items for men ranged from 38% to 50% and from 26% to 32% for women. No differences were found across the 4 antidepressants in men, whereas in women, rates of dysfunction were generally higher with sertraline and paroxetine, but only significantly so in comparison with moclobemide on some measures (p < .03). Rates of sexual dysfunction with venlafaxine tended to fall between those of SSRIs and the RIMA agent. An unexpected relationship was found between favorable drug response and a decreased level of drug-induced sexual dysfunction. CONCLUSION: Antidepressant-induced sexual dysfunction occurs in approximately 30% to 70% of patients who are treated with sertraline or paroxetine. Lower rates are reported with moclobemide and venlafaxine. Clinicians should evaluate the various aspects of sexual dysfunction before and during antidepressant therapy.

Sexual dysfunction before antidepressant therapy in major depression.

BACKGROUND: Decreased sexual interest and function both occur as a consequence of antidepressant medication use, and are especially associated with serotonin reuptake inhibitors (SRIs). However, few investigators have reported the base rate for disturbances in sexual desire, arousal and orgasm or ejaculation in patients with major depression (MD) prior to antidepressant treatment. The purpose of this report is to define the frequency of sexual dysfunction (SD) in 134 patients with MD and examine the relationship between SD and demographic, clinical and personality variables. METHOD: A consecutive series of 55 male and 79 female MD patients diagnosed by SCID-DSM IV assessment completed a series of psychometric measures including a Sexual Function Questionnaire, which asked about change in sexual interest and function as well as sexual activity during the preceding month. RESULTS: Only 50% of women and 75% of men reported sexual activity during the preceding month. Over 40% of men and 50% of women reported decreased sexual interest. Reduced levels of arousal were more common in both men and women (40-50%) than ejaculatory or orgasm difficulties (15-20%). In women, problems with arousal and orgasm correlated with higher neuroticism and lower extraversion. There was no relationship between SD and personality measures in men. While age at onset of depression and number of prior episodes showed a modest correlation with SD measures, there were no correlations with severity of depression or specific symptoms clusters. LIMITATIONS AND CONCLUSIONS: Although limited by a relatively small sample of drug free patients with MD, and by the absence of a non-depressed comparison sample, these results emphasize the importance of factors beyond specific drug effects in the assessment of antidepressant related sexual dysfunction.

Self-report ratings and informants' ratings of personalities of depressed outpatients.

OBJECTIVE: This study sought to determine whether personality traits of depressed patients could be assessed similarly by informants and self-reports of the patients themselves. METHOD: Forty-six depressed outpatients completed the self-report (first-person) version of the Revised NEO Personality Inventory and nominated informants who knew them well to complete the third-person version of that instrument. RESULTS: Agreement between the self-ratings and informants' ratings on the five factors of the inventory--neuroticism, extraversion, openness-to-experience, agreeableness, and conscientiousness--was high. The only significant difference between the self-ratings and informants' ratings was on the extraversion scale, where the patients rated themselves as significantly more introverted than did the informants. CONCLUSIONS: Informants' ratings of personality are similar to self-report ratings of depressed patients. Depressed mood may not influence the self-report of personality traits.

Personality and symptom profiles of the angry hostile depressed patient.

Fava, Rosenbaum, McCarthy, Pava, Steingard and Bless (1991) have recently proposed the existence of a subtype of depressed patients who experience anger attacks. The aim of this study was to assess if depressed patients categorized as high angry hostile have symptoms and personality profiles distinct from depressed patients categorized as low angry hostile. From a sample of 125 depressed outpatients, 26 patients were classified as high angry hostile and 25 patients as low angry hostile. The symptom profiles of these tow groups were remarkably similar, with the high angry hostile patients exhibiting more interpersonal sensitivity. The high angry hostile patients were rated as less interpersonally agreeable and less conscientious than low angry hostile patients. These results provide only partial support for the angry hostile subtype of depression.

Differential pharmacological treatment response in high angry hostile and low angry hostile depressed patients: a retrospective analysis.

Fava et al., Am. J. Psychiatry 150 (1993)1158-1163, have recently proposed the existence of a sub-type of depressed patients who experience anger attacks. These investigators hypothesized that patients who experience anger attacks will respond better to a specific selective serotonin reuptake inhibitor (SSRI) medication than will depressed patients who do not experience anger attacks. Using a non-randomized, archival treatment methodology, 158 patients were classified as either high angry hostile (n = 83) or low angry hostile (n = 75). These patients had been treated with either a primarily noradrenergic reuptake inhibitor (desipramine) a SSRI (sertraline or paroxetine), or the combined serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine. A 2 (high angry hostile/low angry hostile) x 3 (medication type) analysis of variance (ANOVA) was non-significant, indicating no differential treatment effects.

Bipolar disorder, unipolar depression and the Five-Factor Model of personality.

We examined differences between personality characteristics of euthymic bipolar disorder patients (BD) (n = 34) and recovered unipolar depressed patients (UD) (n = 74) using the taxonomy of the Five-Factor Model of personality (FFM) as measured by composite scales derived from the NEO Personality Inventory (NEO PI) and the revised NEO PI (NEO PI-R). Euthymic BD patients scored significantly higher on the Openness (O) dimension and the Positive Emotions facet of the E dimension than did recovered UD patients. For O, euthymic BD patients scored higher on the Feelings facet. These results suggest not only that euthymic BD patients are more likely to experience positive affects than recovered UD patients, but also that euthymic BD patients are more receptive to their positive and negative feelings than are recovered UD patients.

Faking specific disorders: a study of the Structured Interview of Reported Symptoms (SIRS).

An untested assumption of malingering research is that persons who feign mental illness will not attempt to fake a particular disorder, but will be content to fabricate non-specific and possibly global psychiatric impairment. We tested the effectiveness of the Structured Interview of Reported Symptoms (SIRS) to detect feigning of three diagnostic groupings: schizophrenia, mood disorders, and PTSD on 45 psychologically knowledgeable correctional residents. We found that the SIRS maintained its powers of discrimination with respect to clinical samples. Similar research on faking specific disorders is needed on the MMPI-2 and other psychological measures.

Decision making in psychiatric civil commitment: an experimental analysis.

OBJECTIVE: Legislation in Canada and the United States that was intended to decrease the use of civil commitment has resulted in a paradoxical increase in involuntary hospital admissions. To elucidate the reasons for this increase, this study was designed to assess the relative importance of various factors involved in the decision to commit a patient. METHOD: All psychiatrists in Ontario were sent a questionnaire asking them to make commitment decisions based on hypothetical case vignettes. Four factors were systematically varied in the vignettes: the patients' legal commitability, clinical treatability, alternative resources, and psychotic symptoms. Completed questionnaires, with three vignettes each, were returned by 495 respondents. RESULTS: All four variables were statistically significant in the expected direction; legal commitability (i.e., dangerousness to self and/or others, inability to care for self) and presence of psychotic symptoms accounted for the majority of the variance in the final decision to commit. CONCLUSIONS: These results suggest that psychiatrists in Ontario rely primarily on legally mandated factors (i.e., psychosis and dangerousness) in making their decisions to commit, although a considerable amount of individual variation is also evident.