Depression following myocardial infarction.

OBJECTIVE: Although many investigators have studied mood disorders following myocardial infarction, the prevalence, severity, and persistence of depression have been disputed, and standard rating scales and criteria for depressive disorders have infrequently been utilized. The authors' goal was to determine how frequently depressive disorders occur after myocardial infarction, and to investigate predisposing factors for such disorders. METHOD: Structured clinical interviews were administered to 129 inpatients within ten days of myocardial infarction. Patients were also evaluated using standardized rating scales for depression, social function, cognition, and physical impairment. DSM-III diagnoses were derived from the structured interview. RESULTS: Major depressive syndromes were present in 19 percent (n = 25) of the patients and were associated with prior history of mood disorder, female sex, large infarcts, and functional physical impairment. CONCLUSION: Major depression is common in the acute post-myocardial infarction period. Such disorders confer significant psychiatric morbidity and, if sustained, require psychiatric intervention.

An experiment to change detection and management of mental morbidity in primary care.

A randomized clinical trial was conducted in a group practice for the primary care of adult patients to address the effect of feedback to providers of information from a psychiatric screening questionnaire, the General Health Questionnaire (GHQ). The practice is staffed by faculty, residents, and health care extenders of The Johns Hopkins University School of Medicine's Division of Internal Medicine. The patient population was drawn mainly from the inner city community in Baltimore that surrounds the hospital, where the practice is physically based. The GHQ was administered at the time of a regular visit to the practice and results made available to the clinicians for randomly allocated subsamples of their patients. The study results showed that feedback of GHQ information led to only marginal effects on overall detection of mental health problems among the patients in general. However, marked increases in detection occurred among the elderly, blacks, and men, subgroups that ordinarily have relatively low rates of detection of mental morbidity by primary care practitioners. Feedback of GHQ information did not affect management.

Detection and management of mental health problems of older patients by primary care providers.

Evidence is accruing that older individuals receive little attention for mental health problems and that any attention that is given is most often within the primary care setting. A randomized clinical trial was carried out at a primary care clinic of The Johns Hopkins University, Baltimore, testing the ability of feedback of the results of a screening instrument (the General Health Questionnaire) to increase awareness in clinicians of the emotional and psychological problems of their patients. This report contrasts those aged 65 years and older with younger patients. Detection and management of mental morbidity were lower for older individuals, but the feedback intervention increased the likelihood of attention to these problems. This was not true for younger patients. Detection was significantly higher for older patients when screening data were made available, as was management, although the latter difference was not statistically significant. There was evidence as well that the intervention moved clinicians to greater congruence with their older patients in the perception that current mental health problems existed. These findings have important implications for primary care.

Doubts about being of value: an important aspect of countertransference in consultation-liaison psychiatry.

Doubts about being of value to medically ill patients and their referring physicians is not an uncommon emotional reaction of consultation-liaison psychiatrists to the medical environment. Both realistic perceptions of negative attitudes of non-psychiatric physicians as well as unrealistic doubts about their potential usefulness, which may be projected upon and attributed to their non-psychiatric colleagues, can contribute to this unsettling response. This reaction may interfere with effective collaboration between consultation-liaison psychiatrists and their non-psychiatric colleagues and needs to be understood and mastered.

Patients with medically unexplained symptoms: DSM-III diagnoses and demographic characteristics.

This study reports DSM-III diagnoses and demographic characteristics of 100 patients consecutively referred to a university hospital consultation-liaison service for evaluation of medically unexplained symptoms suggesting physical disorders. Thirty-seven percent of patients received diagnoses of somatoform, dissociative, or factitious disorders, and 14% were felt to have psychologic factors affecting physical conditions. Although black and male patients were less often referred for medically unexplained symptoms, once referred they were more likely than white and female patients to receive diagnoses of somatoform, dissociative, or factitious disorders. Among patients with somatoform disorders, those with conversion disorder and somatization disorder tended to be young women, whereas those with psychogenic pain disorder were older and equally likely to be male or female.