Primary care physicians' and psychiatrists' approaches to treating mild depression.

OBJECTIVE: To measure how primary care physicians (PCPs) and psychiatrists treat mild depression. METHOD: We surveyed a national sample of US PCPs and psychiatrists using a vignette of a 52-year-old man with depressive symptoms not meeting Major Depressive Episode criteria. Physicians were asked how likely they were to recommend an antidepressant counseling, combined medication, and counseling or to make a psychiatric referral. RESULTS: Response rate was 896/1427 PCPs and 312/487 for psychiatrists. Compared with PCPs, psychiatrists were more likely to recommend an antidepressant (70% vs. 56%), counseling (86% vs. 54%), or the combination of medication and counseling (61% vs. 30%). More psychiatrists (44%) than PCPs (15%) were 'very likely' to promote psychiatric referral. PCPs who frequently attended religious services were less likely (than infrequent attenders) to refer the patient to a psychiatrist (12% vs. 18%); and more likely to recommend increased involvement in meaningful relationships/activities (50% vs. 41%) and religious community (33% vs. 17%). CONCLUSION: Psychiatrists treat mild depression more aggressively than PCPs. Both are inclined to use antidepressants for patients with mild depression.

Religiosity is an important part of coping with grief in pregnancy after a traumatic second trimester loss.

Women (n = 15) who were pregnant after a traumatic late pregnancy loss (termination because of fetal death or serious anomalies) completed psychometric screening tests and scales, including the Perinatal Grief Scale (PGS), the Impact of Event Scale (IES), the Duke Depression Inventory (DDI), the Generalized Anxiety Disorder-7 (GAD), and the Hoge Scale for Intrinsic Religiosity (IR). Despite a mean elapsed time since the prior loss of 27 (range, 7-47) months, half (7/15, 47%) of the combined groups had high levels of grief on the PGS. Multiple positive scores on psychometric tests were frequent: Sixty percent (9/15) had high scores on the PGS Active Grief subscale or on the IES. Forty percent (6/15) had a high score on the DDI, and 17% (3/15) on the GAD. IR scores significantly and negatively correlated with scores on the Despair subscale of the PGS. The results from this pilot study suggest that high levels of grief and PTS symptoms are significant problems for pregnant women who have suffered late loss of a wanted pregnancy. Religiosity may play an important part in maternal coping during these stressful pregnancies.

Antipsychotics and the risk of sudden cardiac death.

BACKGROUND: Case reports link antipsychotic drugs with sudden cardiac deaths, which is consistent with dose-related electrophysiologic effects. Because this association has not been confirmed in controlled studies, we conducted a retrospective cohort study in Tennessee Medicaid enrollees, which included many antipsychotic users; there were also computer files describing medication use and comorbidity. The study was conducted before the introduction of risperidone and, thus, did not include the newer atypical agents. METHODS: The cohort included 481,744 persons with 1,282,996 person-years of follow-up. This included 26,749 person-years for current moderate-dose antipsychotic use (>100-mg thioridazine equivalents), 31,864 person-years for current low-dose antipsychotic use, 37,881 person-years for use in the past year only, and 1 186,501 person-years for no use. The cohort had 1487 confirmed sudden cardiac deaths; from these, we calculated multivariate rate ratios adjusted for potential confounding factors. RESULTS: When current moderate-dose antipsychotic use was compared with nonuse, the multivariate rate ratio was 2.39 (95% confidence interval, 1.77-3.22; P<.001). This was greater than that for current low-dose (rate ratio, 1.30; 95% confidence interval, 0.98-1.72; P=.003) and former (rate ratio, 1.20; 95% confidence interval, 0.91-1.58; P<.001) use. Among cohort members with severe cardiovascular disease, current moderate-dose users had a 3.53-fold (95% confidence interval, 1.66-7.51) increased rate relative to comparable nonusers ( P<.001), resulting in 367 additional deaths per 10,000 person-years of follow-up. CONCLUSIONS: Patients prescribed moderate doses of antipsychotics had large relative and absolute increases in the risk of sudden cardiac death. Although the study data cannot demonstrate causality, they suggest that the potential adverse cardiac effects of antipsychotics should be considered in clinical practice, particularly for patients with cardiovascular disease.

The Spiritual History Scale in four dimensions (SHS-4): validity and reliability.

The goals of this study were to develop a valid, reliable measure of lifetime religious and spiritual experience and to assess its value in explaining late-life health. Procedures included semi-structured interviews with Duke Aging Center volunteers (n = 30), followed by structured interviews of a stratified, random sample of subjects (n = 157) from the Established Populations for Epidemiologic Studies of the Elderly at Duke University. Principal components analysis suggested four factors with favorable psychometrics. Health-impaired subjects reported a history of seeking/receiving divine aid (God Helped). At every level of impairment, Lifetime Religious Social Support and current religious attendance were positively correlated. Regardless of current attendance, subjects who reported higher Lifetime Religious Social Support received more instrumental social support. Healthy behaviors were associated with both God Helped and Lifetime Religious Social Support. Cost of Religiousness predicted depressive symptoms and impaired social support. Family History of Religiousness was unrelated to late-life health. Evaluation of the Spiritual History Scale in Four Dimensions (SHS-4) across geographical settings, cultural subgroups, age cohorts, and clinical samples is warranted.

Who/se we are: baptism as personhood.

The attempt to arrive at some consensus on precisely what qualifies a human as a persons represents one of the more persistently debated and widely significant issues in modern biomedical ethics. The attribution of personhood has been and continues to be a powerful tool in moral discourse. Biomedical and bioethical debates about personhood seem especially morally significant in late modernity given the recent trends in biomedical technology. Our attempts to formally articulate universally agreed upon criteria for personhood represent some of the last vestiges of the hope that we can achieve substantial moral agreement in an otherwise morally fragmented world. In this essay, we argue that, from the perspective of certain strands of the Christian tradition, all bioethics grounded in attempts to develop formal, objective criteria by which we may designate a given individual a person are misguided. Criteria centering on the possession of reflective mental capacity, moreover, are for Christians especially problematic. We suggest that there are no morally neutral ways of designating personhood.

Does religious attendance prolong survival? A six-year follow-up study of 3,968 older adults.

METHODS: A probability sample of 3,968 community-dwelling adults aged 64-101 years residing in the Piedmont of North Carolina was surveyed in 1986 as part of the Established Populations for the Epidemiologic Studies of the Elderly (EPESE) program of the National Institutes of Health. Attendance at religious services and a wide variety of sociodemographic and health variables were assessed at baseline. Vital status of members was then determined prospectively over the next 6 years (1986 1992). Time (days) to death or censoring in days was analyzed using a Cox proportional hazards regression model. RESULTS: During a median 6.3-year follow-up period, 1,777 subjects (29.7%) died. Of the subjects who attended religious services once a week or more in 1986 (frequent attenders), 22.9% died compared to 37.4% of those attending services less than once a week (infrequent attenders). The relative hazard (RH) of dying for frequent attenders was 46% less than for infrequent attenders (RH: 0.54, 95% CI 0.48-.0.61), an effect that was strongest in women (RH 0.51, CI 0.434).59) but also present in men (RH 0.63, 95% CI 0.52-0.75). When demographics, health conditions, social connections, and health practices were controlled, this effect remained significant for the entire sample (RH 0.72, 95% CI 0.64-.81), and for both women (RH 0.65, 95% CI 0.554-.76, p<.0001) and men (RH 0.83, 95% CI 0.69-1.00, p=.05). CONCLUSIONS: Older adults, particularly women, who attend religious services at least once a week appear to have a survival advantage over those attending services less frequently.

Use of antidepressants by nonpsychiatrists in the treatment of medically ill hospitalized depressed elderly patients.

OBJECTIVE: The purpose of this study was to examine antidepressant use by nonpsychiatrists in the treatment of depressed elderly medical inpatients. METHOD: Patients aged 60 or older who were admitted to medical services at Duke Hospital were evaluated by a geropsychiatrist who used a structured psychiatric interview to identify major or minor depressive disorder. Medical records of depressed patients were reviewed for use of antidepressants and benzodiazepines before admission, during hospitalization, and on discharge. After discharge, depressed patients were contacted four times by telephone at 12-week intervals to inquire about medication use (median follow-up time = 45 weeks). RESULTS: Of 153 depressed patients, 40.5% received antidepressants at some time during their hospital stay or follow-up period, 25.5% received only benzodiazepines, and 34.0% received neither. The most commonly prescribed antidepressant was amitriptyline (45.2% of treated patients), administered at an average maximum dose of 49 mg/day. Only 15 of 114 untreated depressed patients started antidepressant therapy during hospitalization (nine with amitriptyline). Of 91 depressed patients who did not receive antidepressants either before admission or during hospitalization, only 11% received any antidepressant therapy during the median 11-month follow-up; again, half were treated with amitriptyline at doses of 10-30 mg/day. Intensity of antidepressant therapy was predicted by severity of depressive symptoms, history of psychiatric problems, and higher income. CONCLUSIONS: A relatively low proportion of depressed older medical inpatients receive treatment with antidepressants. Patients treated with antidepressants often receive potentially dangerous tertiary tricyclics at inadequate doses. Unless depression is identified and treated during medical hospitalization, it is unlikely to be treated adequately after discharge.

A randomized trial of a consultation service to reduce falls in nursing homes.

CONTEXT: Falls are a major health problem in nursing homes, but no interventions have been shown to prevent falls in nursing home residents. OBJECTIVE: To evaluate an intervention program designed to prevent falls and associated injuries in high-risk nursing home residents. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: Seven pairs of middle Tennessee nursing homes with 1 facility in each pair randomly assigned to the intervention. Facilities had 482 (261 control, 221 intervention) residents who qualified for the study because they had high risk of falls and a potential safety problem that could be addressed by the intervention. INTERVENTION: Comprehensive structured individual assessment with specific safety recommendations that targeted suboptimal practices for environmental and personal safety, wheelchair use, psychotropic drug use, and transferring and ambulation. Facility staff were encouraged to implement the individual recommendations and to improve overall facility safety. MAIN OUTCOME MEASURES: The mean proportion of recurrent fallers and incidence rate of injurious falls in the facility in the year following the intervention. RESULTS: The mean proportion of recurrent fallers in intervention facilities (43.8%) was 19.1% (95% confidence interval, 2.4%-35.8%) lower than that in control facilities (54.1%, P=.03). Intervention facilities had a nonsignificant trend toward a lower mean rate of injurious falls (13.7 vs 19.9 per 100 person-years, reduction of 31.2%, P=.22). Subgroup analyses suggested greatest benefits for residents for whom the recommended interventions were carried out or who had 3 or more falls in the preceding year. CONCLUSION: The high rate of falls and related injuries in nursing homes should not be viewed as inevitable, but as outcomes that can be substantially improved through structured safety programs.

Predictors of antipsychotic withdrawal or dose reduction in a randomized controlled trial of provider education.

OBJECTIVES: To evaluate the effects of an educational program to reduce antipsychotic use in nursing homes that had high use rates post-OBRA-87 and to identify factors that predicted antipsychotic withdrawal or 50% or greater dose reduction. DESIGN/SETTING: A randomized controlled trial (RCT) of the educational program (nursing home the unit of randomization and analysis) was conducted in 12 Tennessee nursing homes (6 education/6 control). Cohort analysis in baseline antipsychotic users identified factors predicting withdrawal or dose reduction. SUBJECTS: The RCT analysis included 1152 patients in the homes at baseline and 6 months. The cohort analysis included 133 baseline antipsychotic users in the five education homes able to implement the recommendations of the educational program. OUTCOME MEASURES: Change in days of antipsychotic use per 100 days of nursing home residence, withdrawal from antipsychotics, reduction in antipsychotic dose by 50% or more. RESULTS: Following the educational intervention, use of antipsychotics in the six education homes decreased from 25.3 days per 100 at baseline to 19.7 days per 100 by month 6, a 23% reduction relative to control homes (P = .014). In the withdrawal analysis, 44 (33%) of 133 baseline antipsychotic users were withdrawn. Factors at baseline predicting successful withdrawal were low antipsychotic dose, no use of benzodiazepines or antidepressants, and behavioral symptoms score below the median. However, although an additional 22 patients had dose reductions > or = 50%, none of the predictors of withdrawal were associated with dose reductions. CONCLUSIONS: Focused provider education programs may facilitate antipsychotic reduction above and beyond that attributable to regulatory changes. Patients who are poor candidates for total antipsychotic withdrawal may tolerate substantial dose reductions, which should reduce their risk of adverse antipsychotic effects.

Religious coping in the nursing home: a biopsychosocial model.

OBJECTIVE: To examine psychosocial and physical health correlates of religious coping in medically ill chronically institutionalized older adults. Religious coping is defined as the extent to which persons use religious beliefs and practices to help them to cope. METHOD: This is a cross-sectional cohort study conducted in a 120 bed VA-affiliated and a 125 bed university affiliated community-based nursing home in Durham, North Carolina. Participants were 115 chronic care nursing home residents; mean age of the sample was seventy-nine years, 44 percent were women, and 17 percent were African Americans. Subjects were enrolled for a one-month period during which comprehensive psychosocial and health assessments were performed, including evaluation of cognitive function (Mini-Mental State Exam), physical function (Barthel index), severity of medical comorbidity (Cumulative Illness Rating Scale), self-reported physical pain (vertical verbal descriptor scale), depressive symptoms (Geriatric Depression Scale), social support (social network), and religious coping (Religious Coping Index). RESULTS: Over 43 percent of the sample scored in the depressed range of the Geriatric Depression Scale. Almost 60 percent reported they used religion at least to a large extent when coping with their problems; 34 percent said that it was the most important factor that enabled them to cope. Patients who used religion to cope had greater social support (p = .01), more severe medical illness (p = .04), and better cognitive functioning (p = .02). CONCLUSIONS: Religious beliefs and practices are frequently used by chronically institutionalized older adults to help them to cope. Religious coping is associated with more severe medical illness, higher social support, and better cognitive functioning.

Religious affiliation and psychiatric disorder among Protestant baby boomers.

OBJECTIVE: The authors examined the relationship between religious affiliation and psychiatric disorder among Protestant members of the baby-boom generation (those born between 1945 and 1966) who resided in the Piedmont area of North Carolina. METHODS: Data were obtained on six-month and lifetime rates of major psychiatric disorders among 853 Protestant baby boomers during wave II of the National Institute of Mental Health's Epidemiologic Catchment Area survey, conducted in 1983-1984. Participants were grouped into three categories based on religious affiliation: mainline Protestants, conservative Protestants, and Pentecostals. Rates of disorder were compared across denominational groups, controlling for sex, race, physical health status, and socioeconomic status and stratifying by frequency of church attendance. The analyses were repeated for 1,826 middle-aged and older Protestants born between 1889 and 1944, and the results were compared with the findings for baby boomers. RESULTS: Among the baby boomers, Pentecostals had significantly higher six-month and lifetime rates of depressive disorder, anxiety disorder, and any DSM-III disorder. Mainline Protestants had the lowest six-month and lifetime rates of anxiety disorder and the lowest six-month rates of any DSM-III disorder, whereas conservative Protestants had the lowest six-month and lifetime rates of depressive disorder and the lowest lifetime rates of any DSM-III disorder. These relationships among baby boomers were weaker among middle-aged and older Protestants, although a new association with alcohol abuse or dependence emerged among older Pentecostals. When analyses were stratified by frequency of church attendance, associations between psychiatric disorder and Pentecostal affiliation were strongest among infrequent churchgoers, a group also unlikely to seek help from mental health professionals. CONCLUSIONS: Young adult Pentecostals in the Peidmont area experienced high rates of psychiatric disorder, which was not generally true for Pentecostals who were middle aged or older. Infrequent churchgoers appeared to be at greatest risk, although they seldom sought professional help for their problems.

Effects of antipsychotic withdrawal in elderly nursing home residents.

OBJECTIVE: To study the effects of antipsychotic withdrawal in elderly nursing home residents. DESIGN: Longitudinal prospective study. SETTING: 12 community nursing homes that participated in a randomized controlled trial of an educational program designed to reduce antipsychotic use. SUBJECTS: 271 residents receiving antipsychotics at baseline and remaining in the home for approximately 6 months thereafter. These were placed into two groups: those with continued use of antipsychotics at follow-up (n = 207) and those with drug discontinued (n = 64). MEASUREMENTS: Change between baseline and follow-up for several standard measurements. These included behavior problems, as reported by both regular care providers (Nursing Home Behavior Problem Scale) or a blinded study rater (items from the Brief Psychiatric Rating Scale), observer-rated psychiatric symptoms (subset of the Brief Psychiatric Rating Scale), and other standard tests of function (Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, and Abnormal Involuntary Movements Scale). RESULTS: The frequency of behavior problems did not increase in residents with antipsychotics discontinued. For these residents, observer-rated psychiatric symptoms decreased by 21% (P = 0.003), which resulted from a 27% decrease in adverse affective symptoms (P = 0.0002). Residents with drug discontinued had no deterioration in any of the measures of function. CONCLUSION: In this sample, nursing home residents whose antipsychotics were discontinued had significantly improved affect and no discernable adverse effects.

Religious practices and alcoholism in a southern adult population.

OBJECTIVE: The study examined associations between religious variables and alcohol abuse and dependence among 2,969 North Carolina residents aged 18 to 97 who participated in the 1983-1984 National Institute of Mental Health Epidemiologic Catchment Area survey at its Piedmont location. METHODS: Six-month and lifetime prevalence of alcohol disorders were compared among participants reporting varying levels of religious activity. Data were collected on frequency of Bible reading, prayer, and church attendance; time spent watching or listening to religious programming on television or radio; importance of religion; religious denomination; and identification as "born-again" Christians. RESULTS: Recent and lifetime alcohol disorders were less common among weekly churchgoers and those who considered themselves born again. Recent, but not lifetime, alcohol disorders were also less common among respondents who frequently read the Bible or prayed privately. Alcohol disorders were more common among those who frequently watched or listened to religious television and radio. Lifetime, but not recent, alcohol disorders were more prevalent among members of Pentecostal denominations. CONCLUSIONS: Longitudinal study is necessary to further clarify and explain these relationships between religious practices and alcohol disorders.

Reducing antipsychotic drug use in nursing homes. A controlled trial of provider education.

OBJECTIVE: In the United States, 20% or more of nursing home residents receive antipsychotic drugs, primarily for the behavioral manifestations of dementia. This high level of use of drugs with substantial toxicity has engendered a strong and persistent controversy and recently has led to explicit regulatory measures to curtail use (Omnibus Budget Reconciliation Act of 1987). We developed and tested a comprehensive program to reduce antipsychotic use through education of physicians, nurses, and other nursing home staff. The primary elements of the program were instruction in use of behavioral techniques to manage behavior problems and encouragement of a trial of gradual antipsychotic withdrawal. DESIGN: In a nonrandomized controlled trial, the program was implemented (beginning in August 1990) in two rural Tennessee community nursing homes with elevated antipsychotic use; two other comparable homes were selected as concurrent controls. PATIENTS: Throughout the study 194 residents were in the education homes and 184 were in the control homes. Residents in both groups of homes had comparable demographic characteristics and functional status, and each group had a baseline rate of 29 days of antipsychotic use per 100 days of nursing home residence. MAIN OUTCOME MEASURES: The primary end points were postintervention changes in administration of antipsychotics and other psychotropic drugs, use of physical restraints, and frequency of behavior problems. RESULTS: Days of antipsychotic use decreased by 72% in the education homes vs 13% in the control homes (P < .001). No significant changes were noted in the use of other psychotropic drugs in either group. Days of physical restraint use decreased 36% in the education homes vs 5% in the control homes (P < .001). Behavior problem frequency did not increase in either group, even among the 48% of baseline antipsychotic users in the education homes who had antipsychotic drug regimens discontinued for 3 or more months. CONCLUSIONS: The educational program led to a substantial reduction in antipsychotic use with no increase in the frequency of behavior problems. This suggests that for many antipsychotic drug users benefits may be marginal and that programs to reduce such drug use among the 250,000 US nursing home residents receiving these drugs should have high priority.

Religious coping and depression among elderly, hospitalized medically ill men.

OBJECTIVE: The investigators examined the frequency of religious coping among older medical inpatients, the characteristics of those who use it, and the relation between this behavior and depression. METHOD: The subjects were 850 men aged 65 years and over, without psychiatric diagnoses, who were consecutively admitted to the medical or neurological services of a southern Veterans Administration medical center. Religious coping was assessed with a three-item index. Depressive symptoms were assessed by self-rating (the Geriatric Depression Scale) and observer rating (the Hamilton Rating Scale for Depression). RESULTS: One out of every five patients reported that religious thought and/or activity was the most important strategy used to cope with illness. Variables that were associated with religious coping included black race, older age, being retired, religious affiliation, high level of social support, infrequent alcohol use, a prior history of psychiatric problems, and higher cognitive functioning. Depressive symptoms were inversely related to religious coping, an association which persisted after other sociodemographic and health correlates were controlled. When 202 men were reevaluated during their subsequent hospital admissions an average of 6 months later, religious coping was the only baseline variable that predicted lower depression scores at follow-up. CONCLUSIONS: These findings suggest that religious coping is a common behavior that is inversely related to depression in hospitalized elderly men.

Religious affiliation and major depression.

Data from the Duke Epidemiologic Catchment Area survey were used to examine the relationship between religious affiliation and major depression among 2,850 adults in the community. Religious affiliations were categorized into six groups: mainline Protestant (27 percent), conservative Protestant (59 percent), Pentecostal (4.2 percent), Catholic (2.4 percent), other religions (2.6 percent), and no affiliation (4.4 percent). The six-month prevalence of major depression among Pentecostals was 5.4 percent, compared with 1.7 percent for the entire sample. Even after psychosocial factors such as gender, age, race, socioeconomic status, negative life events, and social support were controlled for, the likelihood of major depression among Pentecostals was three times greater than among persons with other affiliations. Carefully designed studies are needed to understand the complex interactions of religion and mental health.

Screening for depression in hospitalized elderly medical patients: taking a closer look.

OBJECTIVE: To re-examine the test characteristics of the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS) in elderly medical inpatients, simulating the procedure followed by clinicians when using screening instruments. DESIGN: Masked comparison of GDS and BCDRS with psychiatric interview. SETTING: Durham VA Medical Center. PARTICIPANTS: 109 consecutively admitted persons aged 70 or over. MEASUREMENTS: Screening by a social worker using GDS and BCDRS on day one, followed the next day by an investigator's structured psychiatric interview to determine the presence of major depressive disorder (MDD). RESULTS: By this method, the sensitivity and specificity of the GDS (cutoff 11) were 82% and 76%, respectively; for the BCDRS (cutoff 6), they were 73% and 79%. Among those with a negative test, the likelihood of MDD dropped from an a priori probability of 10% to an a posteriori probability of 3% with the GDS and 4% with the BCDRS. Among those with a positive test, the likelihood of MDD was 27% for the GDS and 28% for the BCDRS. Excluding patients with cognitive impairment (MMSE < or = 25) only slightly improved test characteristics. CONCLUSION: These estimates are considerably below those reported in earlier studies where concordant screening, two-stage screening, or other methods have been utilized and may impact the decision whether or not to screen for depression using these instruments.