Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.

BACKGROUND: Primary care treatment of depression needs improvement. OBJECTIVE: To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN: Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING: Two managed care adult primary care clinics. PARTICIPANTS: A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS: For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES: For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS: Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION: Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

A comparison of psychopathology in eating disorder patients from France and the United States.

OBJECTIVE: This study compares Minnesota Multiphasic Personality Inventory (MMPI) profiles of subtypes of eating disorder patients in France and the United States. METHOD: The patients were hospitalized in psychiatric hospitals in France and the United States. Diagnoses were made by independent clinicians who reviewed the clinical material. The 550-item version of the MMPI was administered to the US subjects; and a 357-item version to the French. RESULTS AND DISCUSSION: In both the US and French subjects, more psychopathology was found in the groups diagnosed with both anorexia nervosa and bulimia nervosa than in those with either anorexia nervosa or bulimia alone, consistent with previous research. The US subjects had generally more psychopathology than the French, except in the anorexia-restrictor subgroup.

Suicidal children grow up: ego functions associated with suicide attempts.

OBJECTIVE: To evaluate the relations between suicidal behavior in children and ego functions including impulse control, reality testing, and ego mechanisms of defense. METHOD: One hundred thirty-three children were assessed initially and at a 6- to 8-year follow-up for levels of reality testing and impulse control and frequency of use of several ego mechanisms of defense. Associations between suicidal ideation and suicide attempts at the initial assessment and at follow-up were analyzed with regard to ego functions. RESULTS: Specific ego functions, such as impulsivity, poor reality testing, and ego mechanisms of defense such as projection, regression, compensation, and reaction formation were positively associated with suicide attempts. Repression was a protective factor to prevent suicide attempts in the follow-up period. CONCLUSIONS: The results suggest that ego functions are related to behavior of consequence and are useful in the identification of children at risk for suicidal behavior.

Culture shock and synergy. Academic/managed care/corporate alliances in outcomes management.

The Behavioral Health Outcomes Study is a partnership in conducting outcomes measurement involving a corporate healthcare purchaser, five managed behavioral healthcare organizations and academic researchers. The goals of this study are to: evaluate the feasibility of incorporating patient self-reported data in outcomes research; identify factors that may be predictors of outcome; and evaluate the effectiveness of an employee-sponsored aftercare program. The differing perspectives and needs of the three partners have created a number of challenges in the areas of goals, confidentiality, proprietary vs. open access issues and methodology. However, after the study's first year, it is clear not only that outcomes research can be conducted under such a partnership, but that the partnership generates a kind of synergy in problem-solving.

Suicidal children grow up: suicidal episodes and effects of treatment during follow-up.

OBJECTIVES: This paper describes risk for first recurrent suicidal episodes in follow-up of suicidal child psychiatric inpatients. It identifies relations between suicide attempts in follow-up and psychosocial and psychopharmacological treatments. METHODS: First suicidal episodes involving either suicidal ideation or a suicide attempt in a 6 to 8 year follow-up period were rated for 69 child psychiatric inpatients and 64 children selected from the community. Psychiatric treatments were determined from reports from multiple sources. RESULTS: Forty-five percent of 133 subjects reported a suicidal episode during follow-up. Children who reported suicidal ideation or a suicide attempt were greater than twice as likely to report a suicidal episode in follow-up than were children from the community. Children treated with antidepressants in follow-up were more likely to attempt suicide than were those not treated with antidepressants. CONCLUSIONS: Close follow-up of suicidal children is warranted to identity risk and to intervene to prevent suicidal episodes. Lack of efficacy of naturalistic treatments implies that controlled treatment studies are needed to determine effective intervention for suicidal children.

Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up.

OBJECTIVE: Rates and psychosocial risk factors for suicide attempts during a 6 to 8-year follow-up period were compared for 25 predominantly prepubertal inpatient suicide attempters, 28 inpatient suicidal ideators, 16 nonsuicidal inpatients, and 64 nonpatients. METHOD: Standard research instruments were used to interview subjects and parents. Cox proportional hazard regression analyses were used to identify risk factors for a suicide attempt in the follow-up. RESULTS: No deaths occurred during follow-up. Suicide attempters were six times and suicidal ideators were three times more likely than were nonpatients to attempt suicide during follow-up. Poor social adjustment and mood disorder close to a recurrent suicide attempt were the strongest risk factors. CONCLUSIONS: Risk assessment should focus on identifying symptoms of mood disorders and impaired social adjustment in children with histories of suicide attempts and psychiatric hospitalization.

The PEH. A questionnaire to assess acknowledgment of psychiatric illness.

The aim of this research project was to develop an instrument to measure acknowledgment and denial of illness in hospitalized psychiatric patients. The investigators developed a 23-item, 4-point self report scale, the Patient's Experience of Hospitalization (PEH), and collected validity data from a sample of inpatients. A total of 29 subjects completed the PEH, the Marlowe-Crowne Social Desirability Inventory (MCSD), the MMPI, and a Global Assessment Scale (GAS) report. The patients' psychotherapists also provided GAS scores. Kuder Richardson split-half reliability and point biserial correlations of 18 items were adequate. The PEH total score correlated significantly and positively with the difference between the GAS scores assigned to the patient by the patient and by the therapist, with the patient's self-report GAS score, with MCSD scores and with the MMPI L and K scales, considered to assess crude and subtle defensive denial. Correlations with MMPI clinical scales (symptom reports) were negative, further supporting the idea of the PEH as a measure of denial.

Late luteal phase dysphoric disorder in 670 women evaluated for premenstrual complaints.

OBJECTIVE: The American Psychiatric Association's DSM-IV Work Group on Late Luteal Phase Dysphoric Disorder (LLPDD) reanalyzed existing data from prospective, daily symptom ratings to evaluate the DSM-III-R criteria for LLPDD. The objectives were to 1) evaluate the individual symptoms presently required for the diagnosis and other symptoms, 2) determine the proportion of treatment-seeking women who meet the LLPDD criteria, and 3) explore the association between LLPDD and other mental disorders. METHOD: Data from over 1,000 women seeking evaluation for premenstrual complaints at five U.S. sites were examined. The data from 670 of these women were sufficiently complete to warrant evaluation by four different methods of assessing symptom change. RESULTS: Depending on the assessment method used, 14% to 45% of the women met the criteria for LLPDD. The current DSM-III-R symptoms were classified as positive for 7% to 54% of the women. Each of these symptoms was significantly more common among women with LLPDD regardless of the assessment method used. Five symptoms not presently included were also significantly more common. Women who had had mental disorders in the past, but not present, showed a significantly greater, but very small, relative risk of LLPDD. CONCLUSIONS: The variability in the frequency of LLPDD diagnosis according to method of assessing symptom change underscores the need for a uniform assessment method. The five additional symptoms with frequencies comparable to those of the DSM-III-R symptoms should be studied further for possible inclusion in the criteria.

High nocturnal body temperature in premenstrual syndrome and late luteal phase dysphoric disorder.

OBJECTIVE: Because women with late luteal phase dysphoric disorder (LLPDD) experience symptomatic affective states predictably, they can be studied to determine whether there are biological findings related solely to the clinically symptomatic state. The authors sought to answer the question, Does body temperature change with affective state? METHOD: The core body temperature and motor activity patterns of 10 women with premenstrual syndrome (PMS), six of whom also met criteria for LLPDD, and no other psychological or medical illness were compared to those of six women with chronic, noncyclic dysphoria and six asymptomatic comparison women at four phases of the menstrual cycle. RESULTS: The nocturnal temperatures of the women with PMS/LLPDD were significantly higher than those of the comparison subjects across the entire menstrual cycle, but there were no differences in nocturnal activity levels. The women with noncyclic dysphoria had a mean nocturnal temperature in the follicular phase as high as that of the women with PMS/LLPDD. The temperatures of all women were higher in the luteal phase than in the follicular phase. CONCLUSIONS: These findings suggest that in the future investigators should document menstrual cycle phase in all female subjects and, when studying body temperature, should carefully monitor symptomatic state in comparison subjects.

Suicidal children grow up: demographic and clinical risk factors for adolescent suicide attempts.

This longitudinal study reports rates and demographic and clinical risk factors for adolescent suicide attempts during a 6- to 8-year follow-up period of an initial sample of 106 preadolescent and young adolescent psychiatric inpatients and 101 preadolescent and young adolescent nonpatients. Survival analysis was used to evaluate risk for a first suicide attempt in the follow-up period for 133 subjects who were interviewed. No deaths occurred. Suicidal inpatients, compared with nonpatients, had earlier first suicide attempts in the follow-up period. Adolescents who attempted suicide in the follow-up period were seven times more likely to have a mood disorder during the follow-up period than those who did not attempt suicide. Implications for clinical practice and research are discussed.

An examination of the stability of the MMPI Personality Disorder Scales.

Recently, a set of Minnesota Multiphasic Personality Inventory (MMPI) scales for the diagnosis of personality disorders have attracted research attention. As personality disorders are thought to represent long-standing trait disturbances, any measure of these disorders should be stable over time and relatively free from state influences. This study investigated the stability of the MMPI scales in 67 subjects across a brief inpatient treatment for substance abuse. The results indicated high levels of stability across the 3-week treatment period.

The effects of haloperidol on thought disorder and IQ in schizophrenia.

The impact of haloperidol treatment on the Wechsler Adult Intelligence Scale (WAIS) and the Thought Disorder Index was investigated in a group of 19 patients with schizophrenia tested both before and after 26 days of treatment with haloperidol. Thought disorder scores declined significantly over the course of treatment and fewer patients demonstrated severe forms of thought disorder at the end of the trial. WAIS performance improved significantly but the magnitude of change was consistent with the literature on expected practice effects. Thought disorder scores were negatively correlated with IQ at baseline, but not at Day 26. The results suggest a partial dissociation of thought disorder and other cognitive functions in schizophrenia.

Spectral analysis of cyclic symptoms in late luteal phase dysphoric disorder.

Fifty-eight subjects self-referred for premenstrual difficulty were evaluated for late luteal phase dysphoric disorder through a spectral analysis technique applied to prospective symptom ratings. Data from the Schedule for Affective Disorders and Schizophrenia--Life-time Version were used to group the subjects according to the absence or presence of past or present psychiatric disorders. The two psychiatric groups were compared with regard to both patterns of significant symptom change and premenstrual symptom severity. Differences between the groups are used to discuss issues regarding the reliable identification of late luteal phase dysphoric disorder and the impact of other psychiatric disorders on this syndrome.

Frequency of reported premenstrual changes in normal and self-selected populations.

Premenstrual Assessment Form (PAF) data are presented on the prevalence of premenstrual syndrome subtypes in self-referred women (N = 60) who were requesting an evaluation for premenstrual difficulties. These data are compared to the normative data of Halbreich and Endicott (1982). The PAF offers the advantages of comprehensive symptom coverage and criteria for non-mutually exclusive subtypes of premenstrual disorder. Although the PAF relies on retrospective accounts of premenstrual difficulty, it allows the exploration of the relationships between perception of premenstrual symptoms and sample selection criteria. The present data suggest that sample characteristics such as their manner of selection for study will influence significantly the prevalence of PAF subtypes.

Psychological test signs of borderline personality disorder: a review of the empirical literature.

Recent empirical work aimed at identifying test signs of borderline personality disorder is reviewed. The review focuses on commonly employed clinical tests, including the Wechsler Adult Intelligence Scale (WAIS), the Rorschach, and the Minnesota Multiphasic Personality Inventory (MMPI). Possible test signs are considered in relation to their sensitivity to and specificity for the diagnosis and in relation to the criteria of DSM-III, which define the disorder. Although consistent patterns of potentially useful test signs have begun to appear, methodological difficulties have hampered any subsequent development of clinically useful indices. Greater attention to sample size and its composition and definition as well as demonstrations of adequate reliability and predictive utility are required for further development of these signs.

Premenstrual syndrome research: using the NIMH guidelines.

The 1983 National Institute of Mental Health (NIMH) guidelines for a premenstrual syndrome (PMS) diagnosis were applied to Daily Rating Form (DRF) data in a prospective research study. The use of two sets of criteria, each consistent with the NIMH guidelines, resulted in prevalence rates of 44% and 17%. The authors discuss other problems in defining a "syndrome": symptom patterns and the relationship between PMS and the presence of a psychiatric disorder.

Evaluation of diagnostic criteria for borderline personality disorder.

A comparison of 17 narrowly defined borderline patients with 20 nonpatient control subjects indicated that certain individual and combinations of criteria may be more highly correlated with the disorder than others. Requiring any four or certain specific combinations of two or three of the five most discriminating criteria provided the optimal balance of sensitivity, specificity, predictive power, and diagnostic efficiency considerations. Fewer than five DSM-III-R criteria adequately identified the patients.