Psychopathological features during childhood and adolescence among adult bipolar patients: a retrospective study.

OBJECTIVE: There are still several concerns regarding the inconsistency in the diagnosis of Bipolar Disorder (BD) in children and adolescents. This study reviews the symptoms of youth admitted to The University of Texas Harris County Psychiatric Center (UT-HCPC) prior to a confirmed diagnosis of BD to elucidate patterns and target symptoms which may facilitate early recognition of BD. METHODS: This is a retrospective review of charts of adult patients with a discharge diagnosis of BD for three consecutive admissions who were also admitted to UT-HCPC as children or adolescents (N=26). The Kiddie SADS was completed based on each patient's first admission as a child and last admission as an adult. RESULTS: Most of the symptoms found in adult BD were present in the child/adolescent subjects at equivalent rates, except for mood elevation, which was less common during childhood and adolescence. In spite of the psychopathological similarity, only 6 (23%) of the subjects were diagnosed with BD as youth. CONCLUSION: BD is poorly diagnosed among children and adolescents. Difficulties in the assessment of the youth, as well as particularities in the psychopathology of mood among children and adolescents may account for the low diagnostic rate.

Third-year medical students' understanding, knowledge, and attitudes toward the use of electroconvulsive therapy: a pre-exposure and postexposure survey.

OBJECTIVES: The purpose of this study was to examine the impact of the third-year psychiatric clerkship at the University of Texas on medical students' perception about and attitudes toward electroconvulsive therapy (ECT) and to determine whether direct observation of the procedure by students impacts their attitudes differently than attendance of lectures only. METHODS: All third-year medical students were asked to complete a survey regarding their opinions about ECT before and after their third-year psychiatry rotation, and they were asked whether they received the required didactic ECT training alone or also received adjunctive observation training. RESULTS: The opinions of students in both groups (observed plus didactic vs didactic only) improved significantly from prerotation to postrotation. However, the opinions of those who observed ECT improved more than those who did not. The groups differed on only 1 item before the rotation. CONCLUSIONS: Students in the observed plus didactic group had a more positive response to the items after rotation than did their peers. Given the effectiveness of ECT, it would be beneficial for all students to have exposure to observed ECT during their psychiatric rotation. This study should be replicated in other medical school settings. Future directions will focus on replicating the study but ensuring that students do not self-select into the observation group.

Who receives antidepressants and what impact do they have? An acute-care study.

The purpose of this study was to examine characteristics associated with prescribing antidepressants in major depression and the utility of such antidepressants in an acute-care, inpatient setting. Demographic and clinical (self-report and clinician-rated scales) were obtained for 111 inpatients diagnosed with major depression. Three comparison sets were made: (1) all patients prescribed antidepressants versus those who were not; (2) those in the top quartile for length of stay (LOS) versus those in the bottom quartile; and (3) patients discharged in less than one week who were prescribed versus not prescribed, antidepressants. Overall, minimal differences were found in the three comparison sets. Those prescribed antidepressants had higher admission BDI scores, longer LOS, more previous episodes, higher education levels, and were more likely to be admitted voluntarily. At admission, there were no clear predictors of LOS. Regardless of differences between groups at admission or discharge (antidepressant versus no antidepressant, short versus long LOS), no differences were found in the length of time before patients were readmitted. These findings suggest that the traditional practice of avoiding immediate medication at hospitalization appears to have some validity.

Social isolation, impulsivity and depression as predictors of aggression in a psychiatric inpatient population.

Aggressive behavior among psychiatric inpatients remains an issue of concern for staff, families and patients themselves. At the present time, studies examining prediction of aggression among psychiatric inpatients have focused mainly on diagnostic or demographic risk factors. Unfortunately little is known about specific social functioning and personality risk factors that may help identify specific individuals at risk for aggressive behavior. Given that many individuals who have engaged in violent criminal behavior have been observed to experience a combination of social isolation, depression and impulsiveness, it is possible that this same combination of traits may function as a predictor of aggression among psychiatric inpatients. The current study examines whether psychiatric inpatients with a combination of social isolation, depression and impulsivity are significantly more likely to become aggressive than other psychiatric inpatients without that combination of factors. Results indicated that impulsivity functioned as a positive predictor of aggression, whereas depression acted as a protective factor. Perceived social support did not appear to relate strongly to aggression. Further, physicians' ratings of hostility were more predictive of aggressive incidents than were self-reports of hostility. Clinical implications of these findings are discussed.

Ratings of early major depressive disorder symptom change during a brief psychiatric hospitalization.

Ratings of change in MDD severity during a brief psychiatric hospitalization were examined across informant sources to determine the extent of change from admission to discharge and if specific symptoms are especially likely to change. Study participants were 137 inpatients with a primary diagnosis of MDD. Symptom data were collected at admission and discharge from attending psychiatrists, nurses, and patients. Global ratings of MDD severity and specific MDD symptoms significantly decreased during the course of hospitalization. This effect held across informant sources. All symptoms were equally likely to change. Females were rated as more depressed at admission and discharge by psychiatrists, but no gender differences were seen in self-report or nurse ratings. Shorter length of stay and involuntary admission status were associated with greater reduction in MDD severity. The temporal course and magnitude of the symptom reduction may result in part from unique aspects of an inpatient setting or from an underreporting of symptoms. The association between a shorter length of stay and greater symptom reduction may reflect a distinction between treatment responders and nonresponders.

Prior history of physical and sexual abuse among the psychiatric inpatient population: a comparison of males and females.

Despite increasing attention given to the high prevalence and effects of abuse in the severely mentally ill, few studies have looked at its effects among males. While both male and female psychiatric patients report greater abuse history than the general population, studies have focused on females alone. The current study compared the effects of abuse history between 271 severely mentally ill males (n = 160) and females (n = 111). The mean age of participants was 33.7 years (SD = 9.73), and included 129 Caucasians, 120 African Americans, 15 Hispanic-Americans, and 7 "Other" (i.e., Asian and native American descent). Primary Axis I diagnoses included Bipolar disorder (23.2%) major depressive disorder (27.7%) schizophrenic disorder (26.6%), substance-related disorders (10.3%), and miscellaneous disorders (12.1%). Each patient completed a comprehensive assessment, including clinician ratings, self-report measures, clinical and structured interviews. Comparisons between genders revealed that females were more likely to report both physical and sexual abuse, and males were more likely to report no history of abuse. In addition, Caucasians were more likely to report abuse than were African Americans, and voluntary patients were more likely to endorse abuse history than those admitted involuntarily. Few gender differences were found in psychological symptoms among males and females. Satisfaction with the home environment was significantly lower for abused than nonabused females. This was not true for males. However, abused psychiatric patients were perceived by the physicians, nurses, and themselves as having greater emotional disturbance than were nonabused patients, regardless of gender. Clinical implications are discussed.

Is schizoaffective disorder a stable diagnostic category: a retrospective examination.

Debate continues about whether clear nosologic boundaries can be drawn between schizoaffective disorder (SA), schizophrenia (SP), and bipolar disorder (BPD). This study attempted to clarify these boundaries. A retrospective review of the records of adult psychiatric inpatients with DSM-IV diagnoses of SA (n = 96), SP (n = 245), and BPD (n = 203) was conducted. Patients were assessed at admission and discharge using standardized rating scales (completed by physicians and nurses) and self-report inventories. Differential improvement over time also was examined. Significant differences were found for gender, legal status at admission, age, LOS, episode number, and ethnicity. Overall, SA was rated by clinicians as intermediate between SP and BPD, although SA rated themselves as the most severe. SA was similar to SP on positive symptoms, intermediate on negative symptoms, and similar to BPD on mood- and distress-related symptoms. Independent of diagnosis, differences in change scores from admission to discharge were related to severity level at admission. Although several differences were found in symptom severity across domains, no syndrome was identifiable associated with the diagnosis of SA and the diagnosis was unstable over time, thereby bringing into question the validity of SA as a diagnostic entity.

Mixed versus manic bipolar disorder: a comparison of demographic, symptomatic, and treatment differences.

This study compared patients diagnosed with Mixed versus Manic Bipolar disorder across the domains of demographic, symptom, and treatment variables. The sample included 152 patients who were admitted to an acute care psychiatric facility within an index period, whose discharge diagnosis was either Bipolar Disorder, Manic Episode (n = 109) or Bipolar Disorder, Mixed Episode (n = 43). No significant differences were found in age, race, episode number, or length of stay. There was a trend toward females being diagnosed with a Mixed Episode and males a Manic Episode. Group differences were found on physician and nurse symptom ratings, with the manic group receiving higher ratings on resistance, psychosis, and conceptual disorganization and the mixed receiving higher scores on depression and anxiety. On self-report measures, the mixed group endorsed greater severity than did the manic group. The mixed group was more likely to be prescribed antidepressants at discharge; however there were no significant differences across other medication. These differences are discussed.

Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model.

The assessment of worry among older adults typically has involved measures designed with younger cohorts. Because of special concerns in assessing older adults, modifications to existing instruments may be necessary. Addressing equivocal factor analytic data on the Penn State Worry Questionnaire (PSWQ) among younger adults, the authors conducted confirmatory factor analyses to evaluate the generalizability of previous models to older adults with generalized anxiety disorder. Data fit poorly with established single- and two-factor models. The single-factor model was modified, resulting in the elimination of 8 items, strong fit indices, high internal consistency, adequate test-retest reliability, and good convergent and divergent validity. Further psychometric work is required to assess whether the revised model is a more parsimonious method to assess late-life anxiety.

Differentiating anxiety and depression in older adults with generalized anxiety disorder.

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.

Cognitive-behavioral treatment of late-life generalized anxiety disorder.

This study addressed the efficacy of cognitive-behavioral therapy (CBT), relative to minimal contact control (MCC), in a sample of 85 older adults (age 60 years and over) with generalized anxiety disorder (GAD). All participants completed measures of primary outcome (worry and anxiety), coexistent symptoms (depressive symptoms and specific fears), and quality of life. Results of both completer and intent-to-treat analyses revealed significant improvement in worry, anxiety, depression, and quality of life following CBT relative to MCC. Forty-five percent of patients in CBT were classified as responders, relative to 8% in MCC. Most gains for patients in CBT were maintained or enhanced over 1-year follow-up. However, posttreatment scores for patients in CBT failed to indicate return to normative functioning.

'Minor GAD': characteristics of subsyndromal GAD in older adults.

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed.

Outcome assessment of the Medicaid managed care program in Harris County (Houston).

Nowadays, managed care has taken over the management of the Medicaid program in most states of the nation. The patients treated in the public sector managed care system are very vulnerable and at high risk. Thus, we decided to measure the impact of managed care in the public-sector population of Texas. To this end, we assessed the treatment outcome at the Harris County Psychiatric Center (HCPC). Our results showed that after the implementation of the Medicaid managed care program in Houston, the bed utilization at HCPC decreased by 32% and the readmission rate increased by 21%; concomitantly, the length of stay decreased from 15.6 days to 9.3 days. Additionally, African-American and Hispanic-American patients were more negatively affected than Caucasian patients. Undoubtedly, the implementation of the Medicaid managed care system in Texas has led to untoward effects in the quality of care provided to the most disadvantaged population of the state.

Measures of self-efficacy and optimism in older adults with generalized anxiety.

This study provides initial psychometric data for the Self-Efficacy Scale (SES) and the Life Orientation Test (LOT) in a sample of older adults with generalized anxiety disorder (GAD). Participants included 76 adults, ages 60 to 80, who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for GAD. Self-efficacy and outcome expectancies were lower in older adults with GAD relative to published data from younger and older community samples. Both the SES and LOT demonstrated adequate internal consistency. Confirmatory factor analysis provided evidence for optimism and pessimism factors within the LOT and exploratory factor analysis of the SES suggested threefactors that overlap with previous findings. Overall, the data support the potential utility of these instruments in late-life GAD and set the stage forfuture investigations of generalized self-efficacy expectancies and outcome expectancies (or optimism) as they relate to the prediction of affect and behavior in this group.

Determining predictors of attrition in an outpatient substance abuse program.

Determining pre-treatment variables that predict attrition in an outpatient cocaine abuse program is critically important in efforts to enhance retention and ultimately improve client outcome. Potential predictors have been identified, such as treatment history, deviant behaviors, and level of drug use; however there is not widespread agreement on their applicability across treatments and populations. This study examines the relationship of demographic, drug use severity, and psychosocial factors with treatment attrition and the time of dropout. One hundred and sixty-five individuals from the Houston area, seeking treatment for cocaine dependence, completed a pre-treatment assessment battery prior to starting 12 weeks of outpatient treatment. A series of regression analyses showed that treatment dropouts were more likely to be separated from their spouses, have poorer family/social functioning, have fewer years of education, and to be female. Those participants with higher education levels and those with poorer psychiatric functioning tended to remain in treatment longer. The implications of these findings are discussed.

Correlates of depression in chronic pain patients: a comprehensive examination.

This study examined the relations between depression and demographic, pain-related, and work-related variables in 254 chronic pain patients. Regression analyses were conducted, initially by category (i.e., demographic, pain-related, and work-related), and finally a comprehensive regression analysis was performed, containing the significant independent variables from each category. Among the demographic variables, education level and marital status were related to depression, and an interaction between age and gender was associated with depression, with younger women and older men reporting more depression. Among the pain-related variables, longer duration of pain was associated with increased depression. Among the work-related variables, unemployment was associated with depression, and there was an interaction between work status and litigation status, with working and litigating being associated with depression and not working and not litigating being associated with depression. In the comprehensive analysis, work status, education level, and marital status accounted for a significant amount of the variance in depression scores. These findings, together with future research directions, are discussed.

What does the Beck Depression Inventory measure in chronic pain?: a reappraisal.

The Beck Depression Inventory (BDI) is widely used to document the prevalence of depression in suffers of chronic pain and in research designs about this population. Williams and Richardson (1993) initially posed the question, "What does the BDI measure in chronic pain?". Results from their study found 3 independent constructs, which differed somewhat from those obtained in analyses with other non-pain subsamples. In our reappraisal of the question, we used confirmatory factor analytic procedures to assess the dimensionality of the BDI. Specifically, we questioned whether a hierarchical model in which a second-level depression construct underlies 3 constituent first-level constructs is reasonable for the data. Our results, based on a sample of 247 chronic pain patients, corroborated the adequacy of this model. The first-level constituent constructs were labeled Negative Attitudes/Suicide, Performance Difficulty, and Physiological Manifestations and were conceptually similar to first-level constructs obtained with other subsamples. Furthermore, external psychological measures and selected questionnaire items were used to assess convergent and discriminant validity of scales operationalizing the factor-analytically derived constructs. With these analyses, we clarify the constituents of depression as measured by the BDI. The findings from this study have implications for more refined epidemiologic and clinical research with chronic pain patients.