ABSTRACT
OBJECTIVE: The authors' objectives were to determine 1) whether major depressive disorder diagnosed according to DSM-IV criteria modified for the medically ill predicted in-hospital mortality better than major depressive disorder diagnosed according to inclusive DSM-IV criteria and 2) whether a history of depression and current depression predicted mortality independent of severity of physical illness. METHOD: Of 392 consecutive medical inpatients, 241 were interviewed within the first 3 days of admission and 151 were excluded from the study. Chart review and a clinical interview that included the Schedule for Affective Disorders and Schizophrenia were used to determine demographic variables, past psychiatric history, psychiatric diagnoses, and illness measures. Diagnoses included major depressive disorder and minor depression diagnosed according to DSM-IV criteria that included all symptoms regardless of etiology and according to criteria modified for the medically ill (hopelessness, depression, or anhedonia were used as the qualifying affective symptoms; depressive symptoms were eliminated if easily explained by medical illness, treatments, or hospitalization). The Charlson combined age-comorbidity index was used to measure severity of illness. RESULTS: A diagnosis of major depressive disorder based on criteria modified for patients with medical illness better predicted mortality than a diagnosis based on inclusive criteria. A past history of depression and the Charlson combined age-comorbidity index predicted in-hospital mortality, but demographic variables, pain, discomfort, length of stay, medical diagnoses, and minor depression did not. In the final multivariate logistic regression model, the Charlson combined age-comorbidity index, a modified diagnosis of major depressive disorder, and a history of depression were independent predictors of in-hospital death. CONCLUSIONS: Severity of medical illness, a diagnosis of major depressive disorder based on modified criteria, and a past history of depression independently predicted in-hospital mortality in medical inpatients.
Subject(s)
Depressive Disorder/epidemiology , Hospital Mortality , Hospitalization/statistics & numerical data , Comorbidity , Depressive Disorder/diagnosis , Depressive Disorder/mortality , Female , Humans , Inpatients/statistics & numerical data , Logistic Models , Male , Mental Disorders/diagnosis , Mental Disorders/epidemiology , Middle Aged , Multivariate Analysis , Psychiatric Status Rating Scales/statistics & numerical data , Recurrence , Risk Factors , Severity of Illness IndexABSTRACT
The authors interviewed a consecutive series of medical inpatients (N = 241) using the Schedule for Affective Disorders and Schizophrenia to determine which depressive symptoms are associated with in-hospital mortality. Fifteen depressive symptoms, pain, and physical discomfort were assessed along with medical comorbidity. Twenty patients died in-hospital (8.3%). Logistic regression showed that anhedonia, hopelessness, worthlessness, indecisiveness, and insomnia predicted in-hospital death after adjusting for physical comorbidity and age. Clinicians should be aware that these depressive symptoms may predict mortality in medical inpatients. Future studies should address which treatment modalities lead to better outcomes.
Subject(s)
Chronic Disease/psychology , Depression/mortality , Depressive Disorder, Major/mortality , Hospital Mortality , Sick Role , Adult , Aged , Brazil , Cause of Death , Chronic Disease/mortality , Depression/psychology , Depressive Disorder, Major/psychology , Female , Humans , Male , Middle Aged , Prognosis , Survival AnalysisABSTRACT
Placebo effects are integral to everyday clinical practice; therefore, they should be well understood by all health care practitioners. Despite the rich literature on the topic, placebo effects receive only passing mention in major textbooks of psychiatry and medicine. The authors clarify the placebo construct and offer a selective review of its history, definitions, mechanisms, and relation to experimental methodology and statistics. Also considered are the concept of nocebo, variation in placebo response rates, and some economic and ethical problems with placebos in clinical trials. Directions are suggested for future research.
Subject(s)
Mental Disorders/drug therapy , Placebo Effect , Placebos/therapeutic use , Affect , Cognition , Conditioning, Classical , Homeostasis , Humans , Physician-Patient Relations , Treatment OutcomeABSTRACT
Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed.
Subject(s)
Depressive Disorder/diagnosis , Neurocognitive Disorders/diagnosis , Sick Role , Adjustment Disorders/diagnosis , Adjustment Disorders/psychology , Depressive Disorder/psychology , Diagnosis, Differential , Humans , Neurocognitive Disorders/psychology , Psychiatric Status Rating Scales , Substance-Related Disorders/diagnosis , Substance-Related Disorders/psychologyABSTRACT
The drug-drug interactions with fluoxetine, a pure serotonergic reuptake blocker with a unique profile of side effects, have not been studied adequately. This preliminary report shows that desipramine and nortriptyline plasma levels are markedly increased at steady state (2 to 11 times) when coadministered with fluoxetine. This appears to be the result of the inhibition of the P450 enzyme system of the liver by fluoxetine, resulting in increased plasma levels of drugs metabolized by this system. Research must promptly address drug-drug interactions with fluoxetine since potentially all psychotropic drugs (except for lithium) and many medically indicated drugs could also have significant drug-drug interactions with fluoxetine.
Subject(s)
Depressive Disorder/drug therapy , Desipramine/adverse effects , Fluoxetine/adverse effects , Nortriptyline/adverse effects , Desipramine/administration & dosage , Desipramine/pharmacokinetics , Drug Synergism , Drug Therapy, Combination , Fluoxetine/administration & dosage , Humans , Metabolic Clearance Rate/drug effects , Nortriptyline/administration & dosage , Nortriptyline/pharmacokineticsABSTRACT
Consultation-liaison psychiatry in the United States has had to reassess its priorities with the change in health care economics in the 80 s. Liaison programs and educational programs for primary care staff are jeopardized. The emphasis has shifted from liaison to reimbursable consultation activities. Hospital stays are shorter with emphasis on outpatient and prepaid settings. Less expensive health care professionals are often asked to see patients previously evaluated by psychiatrists. This paper will discuss the need for focused cost-effective liaison services in this climate. Funding strategies for consultation-liaison programs, models of staffing consultation-liaison services, continuity of care from inpatient to outpatient services, integration of consultation-liaison psychiatrists in prepaid health care settings, primary-care educational programs, and psychosocial intervention programs for high-risk primary-care patients will be discussed.
Subject(s)
Forecasting , Psychiatry/trends , Psychophysiologic Disorders/therapy , Referral and Consultation/trends , Humans , United StatesABSTRACT
The psychosocial skills of 24 PGY I medical residents receiving psychiatric training every other week during the internship year were evaluated and compared to a control group of 13 PGY I residents. After the internship year, the psychiatrically trained residents showed an increase in their ability to recognize emotional problems, whereas the control group recognized less depression. Psychiatrically trained residents were more sophisticated in psychosocial problem descriptions and plan formulations, whereas the control group formulated more poor psychosocial plans.
