Positive well-being during the menopausal transition: a systematic review.

A large body of research has investigated psychological distress during the menopause transition, but less is known about the experience of positive well-being at this time. The aim of this review is to evaluate the evidence on the relationship between menopausal factors (stage and symptoms) and indices of positive well-being including mood, satisfaction with life and eudaimonic well-being. A systematic review of the literature was conducted according to PRISMA guidelines. Nineteen relevant publications were found. Two out of 18 studies found a statistically significant association between menopausal stage and well-being, and one found a significant negative association between vasomotor symptoms and well-being. Four found menopausal symptoms measured with aggregate scales such as the Greene Climacteric Scale were associated with significantly diminished well-being, with the effect driven by the inclusion of psychological symptoms (e.g. 'crying spells') within the aggregate scales. Results indicate that there may be a dissociation, whereby menopausal stage and core vasomotor symptoms of menopause are related to negative, but not positive well-being. Positive well-being may be largely unaffected by menopause, which may mean that it is available for use as a resilience factor that women can draw on to meet the challenges that midlife presents.

Mental health issues for rural and remote Australia.

The burden of mental health problems and disorders is high and rising both in Australia and globally. In response, the Commonwealth Government has moved to implement a national mental health strategy as the basis for a coordinated national approach to underpin initiatives designed to promote mental wellbeing and address mental ill health. This article outlines the nature and extent of mental health problems, provides an overview of changes in mental health policy and service delivery in Australia over the past decade, highlights issues in these areas of particular relevance for rural and remote Australia and calls for the development of a National Rural Mental Health Strategy.

A comparison of the Composite International Diagnostic Interview (CIDI-Auto) with clinical assessment in diagnosing mood and anxiety disorders.

OBJECTIVE: Increasingly, epidemiological studies are employing computerized and highly standardized interviews, such as the Composite International Diagnostic Interview (CIDI-Auto), to assess the prevalence of psychiatric illness. Recent studies conducted in specialist units have reported poor agreement between experienced clinicians' and CIDI-Auto diagnoses. In this study we investigated the concordance rate between clinicians and the CIDI-Auto for the diagnosis of six anxiety disorders and two mood disorders, whereby the CIDI-Auto was treated as the 'gold standard'. METHOD: Subjects were 262 patients who were assessed by a clinical psychologist or psychiatrist and completed the CIDI-Auto at a tertiary referral unit for anxiety and mood disorders. Agreement between the clinicians' diagnoses and the diagnoses generated by the CIDI-Auto according to both DSM-IV and ICD-10 codes, were examined by kappa statistics. Sensitivity and specificity values were also calculated. RESULTS: Agreement between clinicians and the CIDI-Auto (DSM-IV) ranged from poor for social phobia and posttraumatic stress disorder (kappa < 0.30) to moderate for obsessive- compulsive disorder (OCD; kappa = 0.52). Agreement between clinicians and the CIDI-Auto (ICD-10) ranged from poor for major depressive episode (kappa = 0.25) to moderate for OCD (kappa = 0.57). With the CIDI diagnosis treated as the gold standard, clinicians' diagnoses showed low sensitivity (kappa < 0.70) for all the disorders except for OCD (for ICD-10), but high specificity (kappa > 0.70) for all the disorders. CONCLUSION: Poor agreements between experienced clinicians and the CIDI-Auto were reported for anxiety and mood disorders in the current study. A major implication is that if diagnosis alone directed treatment, then patients could receive different treatments, depending on whether the computer, or a clinician, made the diagnosis.

A 12-month follow up of the implementation of clinical indicators in a consultation-liaison service.

OBJECTIVES: This paper reviews the use of clinical indicators in a consultation-liaison (C-L) service over a 12-month period at the Royal Melbourne Hospital, Melbourne, Australia. METHOD: Clinical indicators and C-L data were collected during the 1999 calendar year. A review of the process was conducted during and after completion of the 12-month period. RESULTS: The system was found to be practical and useful. The use of clinical indicators led to the identification of problems and stimulated effective interventions. The use of the clinical indicators was associated with improvement in communication between C-L staff, parent units and practitioners providing follow-up. CONCLUSIONS: The implementation of a database and clinical indicators was a useful addition to the C-L service. The use of clinical indicators was effective in improving clinical performance. These benefits need to be balanced against increased administrative burden.

Improving access for rural Australians to treatment for anxiety and depression: The University of Melbourne Depression and Anxiety Research and Treatment Group-Bendigo Health Care Group initiative.

Rural Australians have limited access to care for mental health problems. We describe a collaboration between the University of Melbourne Departments of Psychology and Psychiatry and a rural Area Mental Health Service to provide a specialist anxiety and depression treatment service in rural Victoria. The clinical service and the education and training approach are described.

A comparative study of venlafaxine with a focused education and psychotherapy program versus venlafaxine alone in the treatment of depression in general practice.

The efficacy of a focused education and psychotherapy program (FEPP) plus antidepressant was compared with that of usual psychosocial treatment and antidepressant in a general practice setting. The FEPP comprised interpersonal counselling (IPC) delivered in a modified way to suit the general practice setting, together with patient education and selected cognitive behavioural techniques. All patients were treated with venlafaxine-XR. Thirty-one patients entered the study, three withdrawing before completion of the 12 week trial. Both treatments produced a statistically significant reduction in BDI and POMS scores from baseline, with greater improvement evident in the FEPP plus antidepressant group. Copyright 2001 John Wiley & Sons, Ltd.

Depressive symptoms reduced in individuals with HIV/AIDS treated with highly active antiretroviral therapy: a longitudinal study.

OBJECTIVE: The aims of this study were to investigate the stability of depressive symptoms over time, explore possible reasons for the genesis of depressive symptoms, examine psychosocial adjustment over time and examine the effects of the introduction of highly active antiretroviral therapy (HAART) in a group of HIV infected patients. METHOD: HIV seropositive outpatients were assessed at 6 monthly intervals over a 2-year period. At each assessment patients completed the Beck Depression Inventory, the Life Event Inventory, the Core Bereavement Item questionnaire and the Psychosocial Adjustment to Illness Scale. Details regarding HIV illness progression and antiretroviral treatment were recorded for each follow-up assessment. RESULTS: One hundred and sixty-three patients completed the baseline assessment and proceeded to the 2-year follow-up study. Most patients remained well over the 2-year follow-up period; mean CD4 count for the group increased over the study period. Ten patients developed AIDS and 18 patients died. Antiretroviral medications changed significantly during the follow-up, with most patients changing to combination (triple) therapy, which included the use of a protease inhibitor. Psychosocial stressors (life event distress and number of bereavements) reduced as the study progressed. Reported depressive symptoms decreased over time and psychosocial adjustment to illness tended to improve over the 2-year period. CONCLUSIONS: Over a 2-year follow-up period HIV/AIDS symptoms and illness markers and psychosocial adjustment to illness improved, psychological stressors and depressive symptoms decreased, with a temporal relationship to changes in antiretroviral therapy.

The development of clinical indicators for a consultation-liaison service.

OBJECTIVE: The aim of this paper is to describe the development and implementation of clinical indicators in the consultation-liaison service at Royal Melbourne Hospital (RMH). METHOD: A working party lead by the University of Melbourne was established in 1998 to develop clinical indicators and a database for the RMH consultation-liaison service. Core parameters for measuring service functioning and six clinical indicators were developed. The system was implemented using a data collection form and computerised database operating within a system of regular clinical reviews. RESULTS: The clinical indicators, database and review system were found to be a feasible, useful and efficient addition to a consultation-liaison service at a major general hospital. CONCLUSIONS: Clinical indicators may be used within specialist psychiatry services to enhance clinical care and aid in service development and teaching.

Secondary mania in patients with HIV infection: are antiretrovirals protective?

A case-control study of 19 patients with HIV-associated mania and 57 HIV-seropositive control patients matched by CD4 cell count, age, and year of treatment was undertaken to investigate associations with risk factors for human immunodeficiency virus (HIV) infection, treatment, and disease. There was no significant difference between groups for HIV exposure category, baseline health status, or drugs other than antiretrovirals. Zidovudine therapy provided a significant protective effect against the development of mania, whether administered at or prior to diagnosis of mania. In a 3-year follow-up study, incident AIDS dementia was significantly more common in patients with mania, despite no apparent difference in survival between cases and controls. These findings strengthen the evidence of an etiological association of HIV neuropathology with AIDS mania by demonstrating a protective effect of an antiretroviral agent able to penetrate the central nervous system.

The evaluation of depression in inpatients with HIV disease.

OBJECTIVES: The aim of this paper is: to compare the utility of four approaches to the diagnosis of depression in patients with human immunodeficiency virus (HIV) disease; to examine the utility of four rating scales to assess the presence and severity of depression; and to devise a set of substitutive criteria that would be appropriate in patients with HIV disease. METHOD: A group of inpatients was assessed using standard clinical interview. Patients found to have major depression using DSM-III-R (aetiological) criteria were assessed using inclusive, substitutive and exclusive criteria for the diagnosis of depression. Severity was assessed using the Hamilton Depression Rating Scale (HDRS), the Montgomery Asberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI), and the Centre for Epidemiological Studies Depression Rating Scale (CES-D). A group of control patients were matched for age and severity of HIV illness. RESULTS: Seventeen patients met DSM-III-R (aetiological criteria) for major depression. All were male; they had a mean age of 40.6 years and one-third had acquired immune deficiency syndrome (AIDS). Using alternative approaches to the diagnosis of depression, up to five additional 'depressed' patients were identified ('false positives'). All 17 patients meeting the DSM-III-R criteria also met the substitutive and exclusive criteria but only 15 exclusive criteria. Of the 17 controls (not meeting DSM-III-R criteria), two met substitutive, five inclusive and one exclusive criteria for depression. The mean (+/- SD) scores for the patients and controls were significantly different on all four rating scales. Analysis of individual items on the rating scales revealed that a number did not show significant differences between the depressed and nondepressed groups: on the MADRS the items lassitude and inner tension; on the HDRS the three items depicting anxiety symptoms, loss of libido, hypochondriasis, loss of weight, and maintenance of insight; on the BDI a sense of being punished, disappointed in self, being self-critical, a feeling of looking unattractive, fatigue, weight loss, worried about health and loss of libido; on the CES-D I felt just as good as others, hopeful, talk less, people unfriendly and felt people dislike me. CONCLUSIONS: The aetiological approach used by clinicians familiar with the features of HIV disease, was found to be useful. All four rating scales differentiated equally well between depressed and non-depressed groups.

Secondary mania in patients with HIV infection.

OBJECTIVE: The aim of this study was to identify a cohort of patients with mania secondary to HIV infection, to describe the clinical and radiological features of HIV-related mania, and to describe the treatment outcome of the patients. METHOD: All patients referred to the HIV consultation-liaison psychiatry service over the 29-month period from January 1993 to June 1995 were screened for the presence of manic symptoms. Diagnosis of mania was made according to DSM-III-R. Cases were defined as secondary mania if there was no clear history of mood disorder, and no family history of mood disorder. Cases were interviewed by the treating psychiatry registrar and psychiatrist to obtain information regarding present and past psychiatric history and family history of psychiatric disorder. The psychiatry registrar and consultant determined treatment. RESULTS: Twenty-three patients with mania were identified; 19 were considered to have secondary mania. The prevalence of secondary mania over the 29 months was 1.2% for HIV-positive patients, and 4.3% for those with AIDS. The clinical characteristics and response to treatment appeared to be similar to mania associated with bipolar affective disorder (primary mania). Neuroradiological abnormalities were common, occurring in 10 of the 19 patients, but did not appear to be clinically relevant. Cognitive impairment developed in five of the 15 patients where follow-up was possible. CONCLUSIONS: Mania occurring in advanced HIV disease appears to be more common than expected from epidemiological data regarding bipolar affective disorder. Differentiating secondary from primary mania has implications for the management and prognosis of mania.

HIV risk behaviour and HIV testing of psychiatric patients in Melbourne.

OBJECTIVES: Patients with chronic mental illnesses constitute an important risk group for HIV infection overseas. This study aimed to determine the prevalence of risk behaviours associated with HIV transmission and factors associated with HIV testing in psychiatric patients in Melbourne. METHODS: Inpatients and outpatients completed an interviewer-administered questionnaire which covered demographics, psychiatric diagnosis, risk behaviour, and HIV education and testing. RESULTS: Of 145 participants, 60% were male and 55.2% had schizophrenia. Injecting drug use (IDU) was reported by 15.9%, a figure approximately 10 times that found in other population surveys. Most patients reported sex in the last decade and over 20% had multiple sexual partners in the last year. Of males, 12.6% reported sex with another male (9.2% anal sex); 19.0% of females reported sex with a bisexual male. Nearly half of the males reported sex with a prostitute, 2.5 times that in a population sample. Only 15.9% reported ever having someone talk to them specifically about HIV and its transmission, although one-third had been tested for HIV. In multivariate analysis, male-male sex, paying for sex, and IDU were associated with HIV testing, but those whose primary language was not English were less likely to be tested. Those who had received HIV education were more likely to have used a condom last time they had sex (OR 4.52, 95%CI 1.49-14.0). CONCLUSIONS: This study provides evidence that those with serious mental illness in Victoria have higher rates of participation in risk behaviour for HIV infection than those in the general community. Attention to HIV education and prevention in this group has been inappropriately scant; strategies to encourage safer behaviour are urgently needed.

Liaison psychiatry in an HIV/AIDS unit.

OBJECTIVE: To provide an overview of the work of a liaison psychiatry service to an HIV/AIDS inpatient unit, and particularly to examine the identification of mood and related disorders by referring doctors. METHOD: The MICRO-CARES prospective clinical database system was used to obtain data on all patients referred to the HIV/AIDS consultation-liaison psychiatry service in an infectious diseases hospital in Melbourne. RESULTS: Three hundred and ninety-two inpatient referrals were made in the 2 years from 1993-1995: a referral rate of 16.7%. The most frequent reasons for referral were evaluation of coping problems (42%), assessment of possible depression (31%), and assessment of psychotropic medication (24.5%). The most common psychiatric diagnoses were mood disorders (36.5%), psychoactive substance use disorders (22.7%) and organic mental disorders (18.1%). Overall concordance of recognition of depression by the referring doctor and diagnosis of depression by the consultant psychiatrist was 79%; 20% false positive rate, 23% false negative rate. CONCLUSIONS: Psychiatric comorbidity is common in patients with HIV/AIDS. Reasons for referral vary from those seen in other inpatient settings. Previously noted problems such as the misdiagnosis of psychiatric disorder and the mislabelling of the syndrome recognised by psychiatrists as depression were noted here.

Depression in adults with intellectual disability. Part 1: A review.

OBJECTIVE: To examine the available literature regarding prevalence, clinical features and treatment of depression in adults with intellectual disability (ID). METHOD: A review of standard texts of ID and available literature examining psychiatric problems of individuals with ID. RESULTS: Few methodologically sound studies of prevalence have been reported. The clinical features of depression in adults with ID appear to vary with level of disability; in those with higher levels of disability in particular, irritability and anger, self-injurious and aggressive behaviour, psychomotor change and loss of activities of daily living skills may be observed rather than "classic' depressive symptoms. No systematic treatment studies have been reported; case reports support the efficacy of cognitive and behavioural strategies, antidepressants and electroconvulsive therapy. CONCLUSIONS: Well designed studies to assess the prevalence and evaluate the treatment of depression in individuals with ID are urgently needed. Design of these studies will need to address the questions of reliability and validity of diagnosis in individuals with ID and examine the appropriateness of available diagnostic criteria.

Depression in adults with intellectual disability. Part 2: A pilot study.

OBJECTIVES: To identify adults with intellectual disability (ID) with a depressive disorder referred to a tertiary consultation clinic for psychiatric assessment; to investigate common presenting features of depression in adults with ID; to assess the utility of visual analogue scale (VAS) measures of emotion/behaviour, the CORE measure of psychomotor disturbance, and substitutive diagnostic criteria in the assessment of depressive disorders in this patient group. METHOD: Over a 6-month period 47 patients were seen for psychiatric evaluation. Patients in whom a diagnosis of depression was made were further assessed using: VAS measures of depression, irritability, verbal aggression, physical aggression, temper outbursts, regressed behaviour; CORE measure of psychomotor disturbance; and substitutive diagnostic criteria designed by the authors. RESULTS: Ten patients were found to have a depressive disorder. Substitutive criteria resulted in a greater rate of diagnosis than standard DSM-IV criteria. The VAS measure of irritability was highly scored for all 10 depressed patients. All 10 depressed patients were assigned to the melancholic subgroup according to CORE score. CONCLUSIONS: Standard assessment measures and diagnostic criteria may require modification to enhance their utility in this patient group. Melancholic features require further investigation.

Diazepam versus alprazolam for the treatment of panic disorder.

BACKGROUND: Alprazolam has proven efficacy as a treatment for panic disorder, but the place of other benzodiazepines is less well established. METHOD: To compare the efficacy and tolerability of diazepam and alprazolam for the disorder, a placebo-controlled, double-blind trial was undertaken in two sites. Two hundred forty-one subjects with panic disorder or agoraphobia with panic attacks were randomly assigned to flexible doses of diazepam, alprazolam, or placebo for 8 weeks. RESULTS: At the end of the trial, over 60% of subjects taking either diazepam or alprazolam were at least moderately improved compared with less than 30% of those taking placebo. On all measures of efficacy, subjects taking diazepam and alprazolam showed an equally favorable response. Despite some sedation early in the trial, both drugs were tolerated well. More severely ill subjects responded less well to either benzodiazepine. CONCLUSION: The results indicate that diazepam is an effective alternative to alprazolam for the treatment of panic disorder.

HIV in the mentally ill.

OBJECTIVE: To review the published literature in relation to prevalence of HIV infection and risk behaviours for HIV among the mentally ill to assist in the development of appropriate strategies for public health policy, surveillance and clinical management of HIV and HIV risk in these groups. METHOD: A search of published literature was carried out using 'Medline', in association with following up appropriate papers cited in the references of journals identified. RESULTS: The North American literature shows an increased risk of HIV infection in psychiatric patients receiving treatment in both inpatient or community settings. HIV infection is associated with a number of risk behaviours, particularly male homosexual sex and injecting drug use, and being the sexual partner of a person with a history of these. Impulsivity, high levels of sexual activity during acute exacerbations of psychiatric illness, poor skills at negotiating safe sex, homelessness and drug abuse are all risk behaviours common among those affected by some mental illnesses. The mentally ill also have a comparatively poorer knowledge of HIV/AIDS. There is a dearth of published Australian data addressing the question of HIV seroprevalence or risk in the mentally ill. Although there has been development and implementation of HIV risk-reduction programs overseas, the development and evaluation of any programs in Australia has not been published. CONCLUSIONS: Arguably, Australia has developed a comprehensive program of national surveillance for HIV infection and has been relatively successful in its response to the HIV epidemic, with the high rates of infection in the early to mid-1980s substantially reduced to around 600 new diagnoses per year. However, while risk behaviours which exposed those infected with the virus are recorded, underlying conditions which predispose them to these behaviours are not. Nevertheless, there is HIV infection amongst mentally ill and intellectually disabled people in Australia. Examination of the North American experience reveals opportunities to prevent a high rate of HIV infection in those with mental illness in Australia. Such a program would require adequate risk behaviour assessment, appropriate diagnostic testing and management, and development of specific educational interventions which are properly evaluated to ensure their effectiveness.

Depressive symptoms in patients with HIV infection.

OBJECTIVE: The aim of the paper was to assess the frequency and severity of depressive symptoms amongst HIV positive patients attending an out-patient treatment clinic. METHOD: One hundred HIV positive patients attending the out-patient clinic at Fairfield Hospital, Melbourne, completed the Beck Depression Inventory (BDI). RESULTS: Forty-four patients scored 14 or more on the BDI. No significant relationship was demonstrated between BDI score and living situation, relationship status, duration of known seropositivity, current CD4 count, or Centres for Disease Control (CDC) category of illness. Significantly more patients scoring in the depressed range were unable to work because of illness. Forty patients reported suicidal ideation. CONCLUSIONS: Depressive symptoms and suicidal ideation are common amongst HIV positive patients, occurring at comparable or greater rates than those found in a variety of other medically ill populations.