Does trauma type relate to posttraumatic growth after war? A pilot study of young Iraqi war survivors living in Turkey.

Positive personal gain after adverse life events and traumas is known as posttraumatic growth (PTG). Several factors are suggested to promote PTG after stressful events, including type of trauma, in addition to younger age and female gender. Although conflicting findings exist, studies suggest that there may be less growth associated with personal traumas (i.e., physical or sexual assault, accidents) and more growth associated with shared traumas (i.e., disasters, loss). We examined whether certain types of war-related traumas are associated with more PTG in a sample of 203 Iraqi students living in Turkey who had experienced severe war-related traumatic events. They were assessed in group sessions, using a self-report battery that included the Post-Traumatic Growth Inventory and War Trauma Questionnaire. War experiences were categorized into three types of trauma: trauma to self, trauma to loved ones, and adversity. Growth was measured by the Turkish version of the Post-Traumatic Growth Inventory. Adversity-type events positively predicted growth, whereas trauma to self predicted growth negatively. Males and females showed a different pattern of relationship with growth. Correlations of growth with younger age and adversity observed in females were not seen in males. Our results show that different trauma types may lead to differing levels of growth, and this difference may be more pronounced when gender is taken into account.

Diagnostic performance of the PTSD checklist and the Vietnam Era Twin Registry PTSD scale.

AIMS: Self-report questionnaires are frequently used in clinical and epidemiologic studies to assess post-traumatic stress disorder (PTSD). A number of studies have evaluated these scales relative to clinician administered structured interviews; however, there has been no formal evaluation of their performance relative to non-clinician administered epidemiologic assessments such as the Composite International Diagnostic Interview (CIDI). We examined the diagnostic performance of two self-report PTSD scales, the PTSD checklist (PCL) and the Vietnam Era Twin Registry (VET-R) PTSD scale, compared to the CIDI. METHODS: Data were derived from a large epidemiologic follow-up study of PTSD in 5141 Vietnam Era Veterans. Measures included the PCL, VET-R PTSD scale and CIDI. For both the PCL and VET-R PTSD scale, ROC curves, areas under the curve (AUC), sensitivity, specificity, % correctly classified, likelihood ratios, predictive values and quality estimates were generated based on the CIDI PTSD diagnosis. RESULTS: For the PCL and VET-R PTSD scale the AUCs were 89.0 and 87.7%, respectively. Optimal PCL cutpoints varied from the 31-33 range (when considering sensitivity and specificity) to the 36-56 range (when considering quality estimates). Similar variations were found for the VET-R PTSD, ranging from 31 (when considering sensitivity and specificity) to the 37-42 range (when considering quality estimates). CONCLUSIONS: The PCL and VET-R PTSD scale performed similarly using a CIDI PTSD diagnosis as the criterion. There was a range of acceptable cutpoints, depending on the metric used, but most metrics suggested a lower PCL cutpoint than in previous studies in Veteran populations.

Procedural and methodological issues in telepsychiatry research and program development.

OBJECTIVE: The authors reviewed the literature related to telepsychiatry-applications of videoconferencing technology for mental health care-which offers hope for an affordable means of solving long-standing workforce problems, particularly in geographical areas where specialist providers are not readily available. METHODS: To conduct a comprehensive review of the telepsychiatry literature, the authors searched the MEDLINE database (1970 to February 2000), using the keywords telepsychiatry, telemedicine, and videoconferencing. Studies were selected that included the use of videoconferencing technology for the provision of any form of mental health care services. RESULTS AND CONCLUSIONS: Psychiatric interviews conducted by telepsychiatry appear to be generally reliable, and patients and clinicians generally report high levels of satisfaction with telepsychiatry. A significant limitation of the literature is the lack of empirical research on telepsychiatry, especially cost analyses and clinical outcome studies. The authors outline a research agenda addressing the procedural and methodological issues that should shape future research: study design, outcome measurement, consideration of patient characteristics, and program design.

Public health consequences of different thresholds for the diagnosis of mental disorders.

The acceptance of subthreshold disorders in psychiatry is a controversial topic with multiple implications for public health policy. Using subthreshold depression as an example, we provide documentation based on data from epidemiologic and clinical studies suggesting that subthreshold conditions are not uncommon, there is significant associated disability (with significant societal costs), and the course of illness often leads to the development of the full-blown disorder. The potential societal benefits of developing and testing low-cost, low-risk, and nontraditional treatments are considered. The recommendations are to match treatment intensity and cost with severity level in a staged approach.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment.

OBJECTIVE: This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options. METHODS: In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability. RESULTS: Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent). CONCLUSIONS: In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.

Development of a brief screening instrument: the HANDS.

BACKGROUND: The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience. METHODS: We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30. RESULTS: The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist. CONCLUSION: The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?

We assessed whether a coexisting anxiety disorder predicts risk for persistent depression in primary care patients with major depression at baseline. Patients with major depression were identified in a 12-month prospective cohort study at a University-based family practice clinic. Presence of an anxiety disorder and other potential prognostic factors were measured at baseline. Persistent depressive illness (major depression, minor depression, or dysthymia) was determined at 12 months. Of 85 patients with major depression at baseline, 43 had coexisting anxiety disorder (38 with social phobia). The risk for persistent depression at 12 months was 44% greater [Risk Ratio (RR) = 1.44, 95% confidence interval (CI) 1.02-2.04] in those with coexisting anxiety. This risk persisted in stratified analysis controlling for other prognostic factors. Patients with coexisting anxiety had greater mean depressive severity [repeated measures analysis of variance (ANOVA), p < 0.04] and total disability days (54.9 vs 19.8, p < 0.02) over the 12-month study. Patients with social phobia had similar increased risk for persistent depression (RR = 1.40, 95% CI 0.98-2.00). A coexisting anxiety disorder indicates risk for persistent depression in primary care patients with major depression. Social phobia may be important to recognize in these patients. Identifying anxiety disorders can help primary care clinicians target patients needing more aggressive treatment for depression.

Structural issues and policy in the primary care management of depression.

This article reviews problems in the primary care management of depression at the patient, provider, and practice levels. These problems make it difficult for physicians to deliver proven treatments optimally and for patients to adhere optimally. Potential structural and policy solutions are proposed, suggesting that modifications addressed at multiple levels will make it possible to deliver existing treatments more effectively in primary care settings.

The classification of mental disorders in primary care: a guide through a difficult terrain.

BACKGROUND: Primary care physicians traditionally have a strong interest in the mental health of their patients. Three classification systems are available for them to diagnose, label, and classify mental disorders: 1) The ICD-10 approach with three options, 2) The DSM-IV approach with two options, and 3) the ICPC approach with two options. This article lists important similarities and differences between the systems to help potential users choose the option that best meets their needs. METHODS: Definitions for depressive disorder, anxiety disorder, and somatization disorder are compared on five characteristics of classification: 1. the domain, 2. the scope, 3. the nature of the definitions, 4. focus on episodes of care, and 5. clinical guidelines. RESULTS: Primary care physicians and psychiatrists have different perspectives, reflected in different classifications. Each system has specific possibilities and limitations with regard to the diagnosis of mental disorders. For common mental disorders it is possible, however, to choose codes from one system while maintaining compatibility with the other two. Comparability as to the diagnostic content of the different classes, however, is more difficult to establish. The available classification systems give both primary care physicians and psychiatrists options to diagnose, label, and to classify mental disorders from their own perspective, but once a system has been chosen the clinical comparability of a patient with the same diagnosis in other systems is limited. CONCLUSION: Compatibility among systems can be optimized by strictly following a number of rules. The conversion between ICPC and ICD-10 (and consequently DSM-IV) allows simultaneous use of ICPC and ICD-10 as a classification and DSM-IV as the standard nomenclature. This is of particular interest for computer based patient records in primary care. The clinical comparability of the same diagnosis in different systems however is limited by the characteristics of the different system.

Effectiveness of community-based screening for depression.

OBJECTIVE: The effectiveness of a voluntary depression screening program was assessed by determining 1) whether participants in the 1994 National Depression Screening Day went for recommended follow-up examinations and 2) the characteristics that differentiated those who did and did not return. METHOD: Randomly selected participants (N = 1,169) from 99 facilities completed a follow-up telephone survey. RESULTS: Of 805 people for whom follow-up was recommended, 56.5% (N = 455) went for an appointment. The severity of depressive symptoms in these subjects ranged from severe (33.4%, N = 152) and marked (41.3%, N = 188) to minimal (17.1%, N = 78) and normal (8.1%, N = 37). Subjects with marked or severe depression were more likely to respond to the screening recommendation than were those with minimal depressive symptoms. However, at each level of symptom severity, subjects who had received previous treatment were more likely to adhere to the screening recommendation than were those with no previous treatment. Of those who returned for a recommended follow-up, 72.1% were diagnosed with depression. Of those who did not return, 29.5% cited lack of insurance, under insurance, or inadequate finances, and 38.0% felt they could "handle" depression on their own. CONCLUSIONS: Voluntary screening for depression is an effective way to bring certain untreated depressed individuals to treatment. Inadequate insurance and the belief that individuals can manage depression on their own continue to be barriers to seeking treatment among some depressed individuals who attend a depression screening program.

Major depression in primary medical care practice. Research trends and future priorities.

This paper reviews recent developments in assessing and treating major depression in primary care practice and proposes needed research directions for the coming years. Topics warranting attention include the predictive validity of psychiatric nomenclatures specific to general medical settings; the impact of patient, clinician, and system factors on the physician's assessment of major depression; the relationship between diagnostic and treatment decisions; and the course of this disorder when treated in primary care facilities by generalists or specialists.

Psychotherapy of depression. Implications for reform of the health care system.

This article reviews the empirical evidence supporting the role of psychotherapy and psychosocial interventions in the treatment of patients with depression. Treatment models and the evidence for their effectiveness in the acute-and maintenance-treatment phases are reviewed. Whereas the sophistication of research designs and data analysis for the study of psychotherapy have substantially improved, the review highlights current gaps in our knowledge. Most important for reform of the health care system is the need for studies of efficacy to lead to large-scale investigations of effectiveness.

Who comes to a voluntary depression screening program?

OBJECTIVE: The purpose of this study was to describe who comes to a voluntary depression screening program by analyzing findings from the 1992 National Depression Screening Day. METHOD: Survey results from 5,367 adult volunteers at 345 facilities were analyzed. The authors examined the prevalence of depression detected at the screening test and sociodemographic characteristics and treatment history of the respondents. They also estimated the percentage of these individuals who would actually have a diagnosis of major depression (positive predictive value). The main assessment measure was the Zung Self-Rating Depression Scale. RESULTS: Of all participants, 76.6% (N = 4,109) had at least minimal depressive symptoms (score of at least 50 on the Zung depression scale), 53.3% (N = 2,859) had at least moderate symptoms (score of at least 60), and 22.6% (N = 1,214) had severe symptoms (score of at least 70). Few of the depressed respondents were currently in treatment for a mental health problem. The positive predictive value of a screening test diagnosis of depression was between 92.5% and 95.5% when a cutoff score of 60 was used to indicate depression and between 88.7% and 92.3% when a cutoff score of 50 was used. CONCLUSIONS: Voluntary screening tests, as exemplified by results from the National Depression Screening Day, provide a good opportunity for identifying previously unidentified and untreated individuals with depression.