A critical review of internet information about depression.

OBJECTIVE: The source and quality of information about depression available on the Internet were examined. METHODS: Online searches using the phrase "depression and treatment" were conducted on ten major Internet search engines. The first 20 sites generated by each engine were examined. The Web sites and the individual Web pages they contained were categorized by source, target audience, and affiliation with either a for-profit or a not-for-profit organization. Each site was rated by whether it mentioned the nine symptoms and five major criteria of a major depressive episode and whether it made any of three basic treatment recommendations. Ratings were compared to determine whether treatment differences between the sites could be attributed to the site's source. RESULTS: The search generated a total of 178 active sites. Overall, the quality of information was poor. Only half of the sites mentioned any DSM-IV diagnostic symptom or criteria in their descriptions of depression, and only a quarter listed 11 to 14 symptoms or criteria. Almost half of the sites made no mention of medications, psychotherapy, or professional consultation as suggested treatments for depression. Almost two-thirds of the pages were found on for-profit sites. Documents from these sites scored lower on diagnostic accuracy and treatment recommendations than those from not-for-profit sites. CONCLUSIONS: The quality of information on the Internet produced by the search was quite low. For-profit Web sites appeared much more frequently than not-for-profit sites among the first 20 sites generated by each search engine, and they contained poorer information.

Clinician attributions for symptoms and treatment of Gulf War-related health concerns.

BACKGROUND: Several clinical syndromes are defined solely on the basis of symptoms, absent an identifiable medical etiology. When evaluating and treating individuals with these syndromes, clinicians' beliefs might shape decisions regarding referral, diagnostic testing, and treatment. To assess clinician beliefs about the etiology and treatment of "Gulf War illness," we surveyed a sample of general internal medicine clinicians (GIMCs) and mental health clinicians (MHCs). METHODS: Clinicians (77 GIMCs and 214 MHCs) at the Veterans Affairs Puget Sound Health Care System, Seattle, Wash, and the Veterans Affairs Medical Center in Portland, Ore, responded to a mailed survey of their beliefs about Gulf War illness. RESULTS: Compared with GIMCs, MHCs were more likely to believe that Gulf War illness was the result of a "physical disorder" and that symptoms resulted from viruses or bacteria, immunizations, exposure to toxins, chemical weapons, or a combination of toxins and stress (P <.05). Conversely, GIMCs were more likely than MHCs to believe that Gulf War illness was a "mental disorder" and that symptoms were due to stress or posttraumatic stress disorder (P <.05). In addition, MHCs were more likely to endorse biological interventions to treat Gulf War illness (P <.01), whereas GIMCs were more likely to endorse psychological interventions. CONCLUSIONS: Clinicians' beliefs about the etiology and effective treatment of Gulf War illness vary and thus might contribute to the multiple referrals often reported by Gulf War veterans. Health care models for Gulf War veterans and others with symptom-based disorders necessitate collaborative interdisciplinary approaches.

The case against physician assisted suicide.

Physician assisted suicide (PAS) engenders debate about the meaning of professional identity, what is proper in the doctor/patient relationship, and the physician's appropriate role in society. Polarization on PAS largely arises from different views on what defines compassion in relieving pain and suffering, and the proper balance between individual autonomy and social imperatives. This paper discusses the ethical, social and economic arguments against PAS, including a historical perspective on other socially-sanctioned inappropriate uses of medical technology and expertise. This paper maintains that a truly dignified death does not come at the hand of a physician-healer, despite compelling arguments that it is a compassionate act.

A cross-cultural study of reactivation of posttraumatic stress disorder symptoms: American and Cambodian psychophysiological response to viewing traumatic video scenes.

A physiological hyperarousal state, which can be reactivated by traumatic stimuli, occurs frequently in patients with posttraumatic stress disorder (PTSD). The goals of this study were to determine whether physiological hyperarousal measured by increased heart rate is a specific response to reminders of a patient's own traumatic events or a more generalized hyperarousal state. Five brief videotape scenes of traumatic events (hurricane, auto accident, Cambodian refugee camp, domestic violence, and Vietnam War) were shown to two patient groups with PTSD (Vietnam veterans and Cambodian refugees) and three control groups (Vietnam veterans, Cambodian refugees, and nonpatient Americans). Observations of subjects' behavior, subjective ratings of distress, and heart rate change were recorded and evaluated. The results indicated that Cambodians with PTSD had the most reactions as measured by behavior and heart rate changes. These tended to occur during all scenes, not just the specific Cambodian scene, indicating a general nonspecific arousal. The Vietnam veterans had the fewest changes implying an inhibition of response. The control groups were intermediate in physiological response. The response in PTSD patients to reactivation scenes is complex and probably relates to type and degree of trauma, as well as to culture.

A comparative study of family functioning among Vietnamese and Cambodian refugees.

This study was designed to determine the extent of family problems among a clinic population of Cambodian and Vietnamese refugees, and to identify similarities and differences between the two groups. All 107 patients with adolescent children from a total clinic population of 298 were interviewed using a semistructured questionnaire, results were tabulated, and statistical methods were applied. The types of problems with children described by parents were classified into the dimensions of communication, personal behaviors, school performance, social behaviors, and antisocial behaviors. There were significantly more problems described by Vietnamese parents as compared with Cambodian parents. Vietnamese parents reported significantly more dissatisfaction with life in the United States. For both ethnic groups, parents' relationships with their adolescent children were a major source of concern and had a major impact on parents' perceptions of their own health. Yet, there were important ethnic differences between these refugee groups in how patients perceived their problems.

Medical ethics, cultural values, and physician participation in lethal injection.

Capital punishment by lethal injection has been discussed in the literature, but there has been no consideration of the sociocultural foundations of the ethical issues related to medical aspects of capital punishment. Lethal injection represents the inappropriate medicalization of a complex social issue whereby medical skills and procedures are used in ways that contradict established medical practice. Although physicians are socialized to their healing role during medical education and training, their behavior is influenced by social and cultural values that both precede and coexist with their professional life. Because of this dynamic interplay between professional and sociocultural values, physicians can neither exempt themselves from societal debate by merely invoking professional ethics, nor can they define their professional role exclusively in terms of societal values that potentially diminish personal and collective professional responsibility. It is essential that physicians have a broad historical perspective on the development of the profession's standards and values in order to deal effectively with present and future complex ethical issues.

Characterization of esterase and alcohol dehydrogenase activity in skin. Metabolism of retinyl palmitate to retinol (vitamin A) during percutaneous absorption.

Retinyl palmitate, a widely used ingredient in cosmetic products, is promoted for its beneficial effects on the appearance of skin. Previous studies suggest that enzymes are available in skin to metabolize this ingredient during skin absorption. Esterase activity hydrolyzes retinyl palmitate to retinol (vitamin A), which is oxidized in many tissues to retinoic acid primarily by alcohol dehydrogenase. The activities of esterase and alcohol dehydrogenase were characterized in hairless guinea pig skin by using flow-through diffusion cells and radiolabeled model compounds (methyl salicylate and benzyl alcohol) previously shown to be metabolized by these enzymes. Methyl salicylate was hydrolyzed by esterase to a greater extent in viable skin than in nonviable skin. Glycine conjugation of salicylic acid and benzoic acid occurred only in viable skin. The metabolism of methyl salicylate and benzyl alcohol occurred to a greater extent in male guinea pig skin than in female guinea pig skin. The percutaneous absorption of both radiolabeled compounds was similar in viable and nonviable skin. About 30 and 18% of topically applied retinyl palmitate were absorbed from an acetone vehicle by hairless guinea pig skin and human skin, respectively. Less than 1% of the applied dose of this lipophilic compound diffused from skin into the receptor fluid. Retinol was the only detectable metabolite of retinyl palmitate in both hairless guinea pig and human skin. In human skin, 44% of the absorbed retinyl palmitate was hydrolyzed to retinol. The use of retinyl palmitate in cosmetic formulations may result in significant delivery of retinol into the skin.

A prospective study of the natural course of alcoholism in a Native American village.

This study examines the natural course of alcoholism in a Native American village. We found that the remission rates of alcoholism were quite similar despite the different methods used: life histories (SADS-L interview) showed a 63% remission rate; a 19-year follow-up prospective showed 60% in remission; and following a cohort of all those who developed alcoholism in the village over the previous 19 years revealed a 60.9% remission rate. The data also showed vast differences in drinking problems between men and women. In the span of 19 years, the differences of point prevalence rates of alcoholism between men and women have jumped from that of two times (52% vs 26%) to five times (36.4% vs 7%). Furthermore, the results showed women had a higher rate of alcohol abuse (8.4% vs 3.6%) and a far higher remission rate (82% vs 52%) when compared to men. Three-fourths of the men in the studied sample had a lifetime history of alcohol dependence. They usually began drinking in their teens and developed dependency by their early twenties. About half stopped after an average of 15 years of drinking. The majority (83%) of the subjects who stopped drinking did so spontaneously or for specific personal-related reasons rather than because they received alcohol treatment.

Criterion validity of the Center for Epidemiologic Studies Depression Scale in a population sample from an American Indian village.

The criterion validity of the Center for Epidemiologic Studies Depression Scale (CES-D) is examined in 120 adult Northwest Coast American Indians. The criterion was a DSM-III-R diagnosis derived from the Lifetime version of the Schedule for Affective Disorders and Schizophrenia. Sensitivity for major depression was 100% (95% confidence limits 36%, 100%); specificity was 82.1% (75.1%; 89%). For a broad category of depressive disorders (n = 9), sensitivity was 77.8% and specificity was 84.7%. Cut points based on receiver operating characteristic analyses did not greatly improve the performance of the CES-D. The use of factor scores instead of total scores made little difference.

Group therapy with WWII ex-POW's: long-term posttraumatic adjustment in a geriatric population.

In this assessment of group therapy with WWII ex-POWs, the small cohort limits generalizations; however, we offer a longitudinal perspective on group process. Posttraumatic suppression and denial of emotions appears to be adaptive for time-limited periods but is not a long-term solution. More lasting changes in self-esteem and social interaction may be partially achieved through a supportive group environment that fosters cognitive synthesis and reorganization.

Psychotherapy of the victims of massive violence: countertransference and ethical issues.

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.

The natural history of medical and psychiatric disorders in an American Indian community.

In 1969, a Pacific Northwest American Indian community cohort (n = 100) was interviewed for the presence of physical and psychiatric illnesses. The same community was studied again in 1988. This study describes the outcome among the original 100 subjects. The schedule for Affective Disorders and Schizophrenia Lifetime Version (SADS-L) served as the basic interview instrument, supplemented by data from medical records, death certificates, and medical and community informants. Twenty-five subjects had died, 13 from cardiovascular disorders and seven from alcohol-related illnesses. Among the 46 subjects re-interviewed, hypertension, heart disease, and diabetes had become significant sources of medical morbidity. Alcoholism was the most significant cause of psychiatric morbidity, particularly among males. This study indicates that greater attention should be focused upon prevention and treatment of alcoholism, cardiovascular disorders, and diabetes in this community and in other American Indian populations.

Use of the CES-D in an American Indian village.

In this paper, we examine the performance of a pencil-and-paper screening questionnaire on depressive symptoms (the Center for Epidemiologic Studies Depression Scale, or CES-D) in a sample of 120 adult American Indians belonging to a single Northwest Coast tribe. Results of factor analyses suggest that somatic complaints and emotional distress are not well differentiated from each other in this population. CES-D scores (which have shown good sensitivity and specificity for depressive disorders in this sample) also show weak and apparently nonsignificant trends to be elevated in the presence of other psychiatric diagnoses (including alcoholism) or general impairment. However, because of the use of a convenience sample (rather than a probability sample), analyses of associations between study factors--including comorbidity--are liable to produce spurious results due to selection bias (including Berkson bias). On this basis, we suggest that the use of probability samples should assume a high priority in cross-cultural studies. The study of the entire population of interest is another solution to the sampling problem, particularly in small communities.

Psychiatric epidemiology of an Indian village. A 19-year replication study.

This 1988 study reports the point and lifetime prevalence of psychiatric disorders, using DSM-III-R criteria, of a sample (approximately 25%) of adult members of an Indian village previously studied in 1969. The basic instrument was the Schedule for Affective Disorders and Schizophrenia, augmented by available medical information and administered by experienced psychiatrists. Subjects were interviewed and results were weighed for the age- and sex-distributed population. The results indicated a high point prevalence of alcohol dependence (32.8%), with a lifetime prevalence of 72.8%, among males. The lifetime prevalence of affective disorders among women was also high (36.8%), but less so among men (19.3%). When compared with the DSM-III-R diagnoses of the 1969 study, the point prevalence rates of alcohol dependence and abuse disorders fell from 39% to 21%. Also, fewer subjects were judged to be psychiatrically impaired. Even though the prevalence of psychiatric disorders was lower in the current study, the rates for alcohol disorders and affective disorders were still far higher than those reported in Epidemiologic Catchment Area studies. Alcohol dependence (especially among young men) and affective disorder (among women) were major problems.

Posttraumatic stress disorder, depression, and somatic symptoms in U.S. Mien patients.

This report describes treatment over a period of 6 years of Mien refugees from highland Laos in the Indochinese Psychiatric Program of the Oregon Health Sciences University (Portland, OR). The medical and psychiatric problems of 84 patients were presented through somatic symptoms such as headache, dizziness, or musculoskeletal pain. Primary care medical problems were identified and treated, with the major focus on the two most common psychiatric diagnoses: major depression and posttraumatic stress disorder. Cultural beliefs about illness and medication interfered with adherence to prescribed treatment. A marked sensitivity to side effects of certain antidepressants also resulted in subtherapeutic doses. Patients rarely volunteered their traumatic histories, psychiatric problems, or dissatisfaction with medications. However, the effective use of medication for somatic complaints, along with the continuing recognition of Mien health beliefs in psychosocial treatments, allowed for the development of a trusting doctor-patient relationship and continued psychiatric care.

Treating psychiatric disorders among Mien refugees from highland Laos.

The Mien, a Southeast Asian hill people, have immigrated to various countries throughout the world since the mid-1970s. They have brought their ancient culture with them, including beliefs and practices related to health, illness, and healing. During the last several decades they have suffered much war-related trauma, including extensive human, material and symbolic losses. This report describes our clinical experience with Mien refugees in the Indochinese Psychiatric Program of the Oregon Health Sciences University. We discuss symptom presentation among this group of patients, diagnostic and treatment issues, and the impact of cultural health beliefs upon illness and treatment. Major depression and post-traumatic stress disorder have been the most commonly encountered psychiatric diagnoses, usually revealed through somatic symptoms. Not only must clinicians take careful medical and psychiatric histories, but they must also be alert to the high probability of an extensive history of trauma. Clinical improvement in response to psychotropic medications has been limited. As a result, psychosocial and psychotherapeutic approaches to treatment have been developed and expanded and now are commonly employed, effectively combining support and education in the creation of a holding environment that includes both individual and group formats. Two case histories are presented which describe symptom presentation, health belief systems and therapeutic issues involved in treating Mien patients. They also illustrate that traditional and Western healing approaches can co-exist in the optimal care of these patients.