A pilot study of needs assessment in acute psychiatric inpatients.

The needs of acute psychiatric patients have been less studied than those of long-term patients. A pilot study of needs assessment using the MRC Needs for Care Assessment Schedule is reported in 35 consecutive acute inpatients who had been in hospital for 1 month or more. Unmet clinical needs included treatment of drug side effects and dangerous and socially embarrassing behaviour. Unmet social needs were widespread and included household shopping, cooking meals, occupation and money management. Although the MRC Needs for Care Assessment was found unsuitable for assessing needs in very acutely ill patients whose mental status was rapidly changing, we did find it a useful instrument in more stable acute patients, both on an individual basis and for identifying service underprovision.

The symptomatology of depression in the elderly.

Older people may have a different pattern of depressive symptoms to that found earlier in life, in particular having more somatic symptoms and less overt low mood symptoms. Few attempts have been made to relate such differences to more general aspects of cognitive or emotional processing, such as the presence of dysfunctional attitudes or of alexithymia. Symptom differences within depression in old age have also received relatively little study, as has the ability of individual symptoms to distinguish between depressed and non-depressed elderly populations. These issues have been examined in two studies. In the first, a random sample of 700 subjects aged 65 years and over were identified through door-knocking in randomized enumeration districts in Islington, a socially deprived region of inner city London, and evaluated using a shortened version of the Comprehensive Assessment and Referral Evaluation (Short-CARE), which incorporates a depression subscale (DPDS). All 18 DPDS items distinguished significantly between depressed and non-depressed subjects (P < 0.0001). Depressed men were significantly more pessimistic than depressed women (63 versus 40%; P < 0.05); non-significant trends suggested that depressed women are more worried (39 versus 22%) and more restless (50 versus 31%), and depressed men more likely to be 'not very happy' or 'not happy at all' (53 versus 36%). There were no significant differences between older (age > 74 years) and younger subjects. Several other Short-CARE items, predominantly addressing subjective memory and disability, also distinguished significantly between the depressed and non-depressed groups. Logistic regression analysis identified eight items of the DPDS contributing significantly to the predictive ability of the total scale. In the second study, the Toronto Alexithymia Scale (TAS) and the Dysfunctional Attitudes Scale (DAS; 3) were administered to primary-care attenders aged > 64 years, and those with significant depressive symptoms were matched by age and sex to a depression-free control group. Depressed subjects had higher scores on both the TAS (Mann-Whitney U-test z = -4.71, P < 0.0001) and on the DAS (z = -2.49, P < 0.02).

Screening for alcohol misuse in older people.

OBJECTIVES: To evaluate whether the CAGE, MAST-G or an abnormally high MCV are effective screening instruments for alcohol misuse and if not to devise a new instrument. DESIGN: Questionnaire survey of randomly selected patients. SETTING: Acute admission wards of two district general hospitals. PERIOD: 9 months. SUBJECTS: Randomly selected patients, aged 65 and over, admitted as emergencies. MAIN OUTCOME MEASURES: Excessive alcohol intake, alcohol dependence. RESULTS: The sensitivities of the CAGE, MAST-G and an abnormally high MCV for excess alcohol intake and alcohol abuse are low, ranging from 0.13 to 0.54. CONCLUSION: The results confirm previous UK studies which indicate that the CAGE and an abnormally high MCV are poor screening instruments for alcohol misuse in older patients and also indicate that the MAST-G is an insensitive screening instrument. A new two-step instrument with five questions in total was generated. This requires further validation.

Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions.

One-hundred and ninety-eight elderly subjects attending their general practitioners (GPs) were asked to complete the 15 item Geriatric Depression Scale (GDS15). Analysable results were obtained from 194 (98%). Of these, 67 (34%) scored above the GDS15 cut-off (4/5) for significant depressive symptomatology. 87.6% found the questionnaire to be acceptable and only 3.6% found it very difficult or very stressful. The GDS15 had a high level of internal consistency (Cronbach's alpha = 0.80). All the individual items of the GDS15 associated significantly (P < 0.01) with total score and 'caseness'. A single question "do you feel that your life is empty?" identified 84% of 'cases'. In an attempt to devise short scales to screen elderly primary care patients for depression, the data were subjected to logistic regression analysis. Ten (GDS10), four (GDS4) and on (GDS1) item versions were generated. Agreement between these short scales and the GDS15 in the original sample was 95, 91 and 79% respectively. Cronbach's alpha was 0.72 for the GDS10 and 0.55 for the GDS4. The short scales were then validated in an independent sample of 120 patients in whom both GDS data and the results of a detailed psychiatric interview (the Geriatric Mental Status Schedule, GMS) were available. The sensitivity and specificity of the GDS10 against GMS caseness were 87 and 77% (cut-off 3/4); those of the GDS4 were 89 and 65% (cut-off 0/1) and 61 and 81% (cut-off 1/2). Sensitivity and specificity for the GDS1 were 59 and 75%. It is concluded that these short scales may be useful in helping GPs and practice staff to identify elderly patients with significant depressive symptoms.

Screening, detection and management of depression in elderly primary care attenders. II: Detection and fitness for treatment: a case record study.

Case note data were obtained for 186 elderly primary care attenders who also completed the 15 item Geriatric Depression Scale (GDS15). The presence or absence in the case notes of a current or past diagnosis of depression, of current treatment of depression, and of a number of clinical features of depression were noted. Case notes were also rated for the presence or absence of contraindications to the use of tricyclic antidepressants (TCAs) and to serotonin-specific reuptake inhibitors (SSRIs). Whereas 65 (35%) patients were rated as 'cases' of depression on the GDS15, only 28 (15%) had a current case note diagnosis of depression and 37 (20%) had one or more current symptoms of depression recorded in the case notes. Patients rated by their GP as having one or more current symptoms of depression scored higher on the GDS15 (P < 0.05) and were more likely to be categorized as a GDS case (P = 0.05). There was no significant relationship between GDS caseness and a current case note diagnosis of depression. Seventy-three patients (39%) had a past history of depression and 53 (28.5%) patients had previously been treated with antidepressants. The former was significantly associated with GDS caseness (P < 0.05). Twenty-four patients (13%) were currently on antidepressants, 19 of them receiving adequate doses (equivalent to at least 75 mg of amitriptyline). Current antidepressant treatment was not associated with GDS 'caseness'.(ABSTRACT TRUNCATED AT 250 WORDS)