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.

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.

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.

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.

Alzheimer's disease in the National Academy of Sciences-National Research Council Registry of Aging Twin Veterans. III. Detection of cases, longitudinal results, and observations on twin concordance.

OBJECTIVES: To detect cases of Alzheimer's disease (AD) in a large population of twins living throughout the United States and to examine concordance for AD in twins as a function of age and genotype for apolipoprotein E (APOE). SETTING: Nationwide survey. DESIGN: Multistage screening and field evaluation beginning with two telephone interviews and culminating with laboratory tests, longitudinal neuropsychological measures, physician examination, and diagnostic consensus among experts. PARTICIPANTS: Membership in 1990-1991 of intact pairs in the National Academy of Sciences--National Research Council Registry of veteran twins, then aged 62 to 73 years. MAIN OUTCOME MEASURES: Completeness of case detection was examined in collateral studies. Zygosity and APOE genotypes were determined by restriction mapping. Concordance was calculated by the proband method. RESULTS: Ninety subjects who screened positively for AD were studied in person, and 60 whose differential diagnoses included AD were followed up, as were their co-twins. Sensitivity of screening was estimated at greater than 99%, but 24% of subjects refused participation after initial screening. Seven of 38 diagnoses of AD have been confirmed at autopsy, and 31 other subjects eventually met criteria for probable or possible AD (prevalence estimate, 0.42%, 95% confidence interval, 0.29% to 0.56%), with good interrater reliability (intraclass r = .86). Excluding one discordant pair with unknown zygosity, concordance rates were 21.1% (4/19) for monozygotic and 11.1% (2/18) for dizygotic probands. Concordance was 50% for twins sharing the epsilon 4/epsilon 4 genotype at APOE, but there were no affected co-twins of 15 probands with onset before age 70 years, no epsilon 4 allele, and no family history of AD. The mean (SD) period of discordance in the latter pairs was 11.3 (3.3) years. CONCLUSIONS: The multistage case-detection approach achieved reliable and valid diagnoses of AD with high apparent sensitivity but substantial attrition after initial screening. Genetic influences in AD at this age are limited, except among homozygotes for allele epsilon 4 at APOE. Subjects with early-onset AD who lack the epsilon 4 allele are not rare, and their condition appears to have little genetic influence. They should be ideal for studies on environmental cause of AD.

Automated telephone screening survey for depression.

OBJECTIVE: To test the application of fully automated telephone screening using computerized digital voice recordings and touch-tone responses to assess symptoms of depression. DESIGN: A cross-sectional study of a 2-week-long telephone survey. SETTING: Toll-free telephone calls placed from home, work, or school to a central telephone/computer system at a telecommunications company in the Boston, Mass, area. PARTICIPANTS: A total of 1812 participants called the system. Of these, 278 were students and faculty at a large midwestern state university, 725 were employees of a large northeastern high-technology firm, and 809 did not identify which site they were calling from. MAIN OUTCOME MEASURES: The 20-question multiple-choice Zung Depression Scale was used to screen for depressive symptoms, and additional questions gathered demographic and caller satisfaction information. RESULTS: No technical problems were encountered during the trial. Of 1812 callers, 1597 (88.1%) completed all questions. Of these, 412 callers (25.8%) met criteria for "moderate or marked" depression and another 194 (12.1%) met criteria for "severe or extreme" depression. The majority of callers scoring positive for depression had received no previous treatment for depression. Of callers who completed the screening questionnaire, 74.6% reported the call to have been at least "moderately" helpful. CONCLUSION: Readily available low-cost technology provides a fully automated, widely accessible, and confidential method of screening for a common mental illness.

Recognizing and managing depression in primary care.

Depression is a common disorder in the primary care setting; it is associated with considerable distress and dysfunction. The management of depressed primary care patients can be complicated by the fact that these patients may lack insight into the cause of their symptoms and report only the somatic manifestations of their disorder to their physicians. Primary care patients may also be reluctant to accept a diagnosis of depression or referral to a mental health specialist. Primary care physicians may feel they lack the time or the training to adequately address their patients' depressive disorders. This paper presents a model for identifying, evaluating, and treating depression which has been specifically developed to help primary care physicians overcome these barriers.