Depressive symptoms associated with scleroderma.

OBJECTIVE: To examine the prevalence and correlates of depressive symptoms among patients with systemic sclerosis (SSc; scleroderma). METHOD: Fifty-four outpatients with scleroderma were administered the Beck Depression Inventory, the Neuroticism-Extraversion-Openness Personality Inventory, the Health Assessment Questionnaire, and the Psychosocial Adjustment to Illness Scale. In addition, patients underwent a comprehensive clinical assessment, and pulmonary function tests were obtained. RESULTS: Nearly half of the patients had mild depressive symptoms, and an additional 17% had symptoms in the moderate-to-severe range. Younger patients, those with digital ulceration, and those with more self-rate functional impairment had more depressive symptoms, but there were few other relationships between depressive symptoms and either demographic or physician-rated medical variables. In contrast, there were highly significant relationships between depression and aspects of personality, psychosocial adjustment to illness, and social support. CONCLUSION: Depressive symptoms in patients with SSc are more strongly related to personality, self-rated disability, and adequacy of emotional support than to objective medical indices of illness severity. Depression in scleroderma is a debilitating comorbid condition that should be recognized and treated in its own right.

Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial.

BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

Posttraumatic adaptation and distress among adult burn survivors.

OBJECTIVE: The purpose of this study was to examine the prevalence, natural history, and psychosocial impact of posttraumatic symptoms in adult burn survivors. METHOD: Forty-three adult inpatients at a regional burn center were assessed at discharge with standardized instruments to determine the presence of psychiatric disorder, assess personality, and quantify depression. Thirty-one patients were evaluated 4 months after discharge. RESULTS: Posttraumatic stress disorder was diagnosed in 7% of patients at discharge and in over 22% of patients at follow-up. Symptoms of avoidance and emotional numbing (DSM-III-R criterion C symptoms) tended to emerge after discharge from the hospital. While posttraumatic symptoms were associated with symptoms of depression, they were not strongly associated with psychosocial adjustment to illness; psychosocial adjustment was more strongly related to aspects of personality, the injury itself, and its treatment. CONCLUSIONS: Since adult burn survivors often develop new symptoms of posttraumatic distress after leaving the hospital, longitudinal surveillance is required to detect new cases and provide appropriate treatment. Survivors at risk for poor psychosocial adjustment after discharge may be identifiable during hospitalization, and preventive treatment strategies should be developed and tested for this population.

Geropsychiatry in long-term care: a nurse-centered approach.

High prevalence rates of psychiatric disorders and disruptive behaviors in nursing home residents create the need for structured programs of psychiatric consultation and teaching in the long-term care setting. Over 40 months, 473 residents were evaluated by a psychiatric consultation-liaison clinical nurse specialist; 100 of these cases were reviewed in detail. Apparent depression was the most common reason for referral, and depressive and adjustment disorders were the most common diagnostic conclusions of the consultation team. Behavioral complications of dementia were also frequently diagnosed. Treatment recommendations usually included the development of a behavioral management plan, but the institution of psychotropic medications, usually antidepressants, was indicated in about one-fifth of the 100 cases. Treatment interventions were effective in the majority of cases. About one-half of the problems prompting referral were within the expertise of the nurse specialist and did not require the direct involvement of the geropsychiatrist. This nurse-centered consultation model proved effective, well accepted, and easy to implement.

Psychogeriatric assessment and treatment in urban public housing.

A psychogeriatric outreach team provides in-home evaluation and treatment for elderly persons living in high-rise public housing in Baltimore. During the first ten months of the team's operation, housing staff referred 9.5 percent of the elderly residents of four public housing sites for evaluation. Evaluations were completed for 85 residents, 25 percent of whom were age 80 or older. Twenty-one percent of the residents evaluated were unable to perform at least one basic activity of daily living such as eating, bathing, or dressing without assistance, and 54 percent needed help with cooking, cleaning, and other instrumental activities of daily living. Eighty-nine percent of the residents who were evaluated by the team met criteria for at least one DSM-III-R diagnosis; 63 percent of the disorders had not been previously diagnosed. The most prevalent diagnoses were dementia, depressive syndromes, schizophrenic and delusional disorders, and alcohol abuse or dependence.

Thyroid hormone elevations during acute psychiatric illness: relationship to severity and distinction from hyperthyroidism.

Acute psychiatric illness may be accompanied by transient hyperthyroxinemia. The mechanism of this phenomenon was examined by determining the role of thyrotropin (TSH) in the genesis of this state. Serial measurements of TSH, thyroxine (T4), free T4 index (FT4I), triiodothyronine (T3), and free T3 index (FT3I) were performed in 45 acutely hospitalized patients with major psychiatric disorders. Twenty-two (49%) patients exhibited significant elevations (greater than or equal to 2 SD above mean value of controls) of one or more thyroid hormone (or index) levels. Among depressed patients with elevated FT4I, TSH was higher (p less than .05) on the day of the peak FT4I than on the day of the FT4I nadir. There were significant positive correlations between psychiatric symptom severity and levels of FT4I among both depressed (p less than .01) and schizophrenic (p less than .025) patients. These data show that elevations of T4, FT4I, T3, and FT3I are common among psychiatric inpatients, especially early in their hospitalization, and that levels of thyroid hormones are correlated with severity of psychiatric symptomatology. TSH is higher early in the acute phase of illness and is not suppressed in the face of elevated thyroid hormone levels, a finding that distinguishes this phenomenon from ordinary hyperthyroidism. Elevations of peripheral thyroid hormone levels, particularly among depressed patients, may result from a centrally-mediated hypersecretion of TSH.

Medical care of chronic psychiatric outpatients.

Chronic psychiatric patients often fail to receive adequate general medical care. In a study of 42 outpatients in a psychosocial rehabilitation program, 93 percent were found to have at least one problem warranting assessment, treatment, or follow-up. Minor gynecologic disease was the most common problem among women and gross dental disease among men. Only 11 percent of the men's and 26 percent of the women's problems were receiving appropriate care. Seventy-seven percent of the previously unrecognized problems were found just by routine physical examination and hematocrit determination. Medical care for chronic psychiatric patients would improve if psychiatric clinics provided simple medical screening and if therapists were aware of their patients' general health needs.

Diagnosing dementia. Univariate and multivariate analyses of the mental status examination.

Investigators have reported poor recognition of dementia by primary physicians. For this reason, mental status examinations were performed on 72 demented and 144 nondemented medical inpatients to assess the sensitivity, specificity, and predictive value of components of this examination in the diagnosis of dementia. Sensitivity of individual level-of-orientation items was low (15.3 to 56.9%), though specificity was high (91.7 to 100%). Sensitivity of several nonorientation items was high (80.6 to 100%), though specificity was low. A multivariate discriminant equation using both orientation and nonorientation items achieved high sensitivity (89.6% test cases, 87.5% validation cases) and specificity (78.1% test cases, 87.5% validation cases). Adding the easily obtained patient characteristic of age to the equation further increased sensitivity (95.8%, 91.3%), while maintaining specificity (82.3%, 85.4%). From these results, it is concluded that the level-of-orientation screening examination used by clinicians to detect dementia is unacceptably insensitive. In contrast, a composite decision rule including nonorientation items achieves high sensitivity with relatively high specificity.

Recognition of dementia among medical patients.

To determine how accurately dementia was diagnosed among medical inpatients, we compared the judgments of medical interns with diagnoses based on standard criteria. Fifty-seven interns rendered opinions regarding the presence of dementia in 380 medical inpatients who were simultaneously examined by physician-investigators applying criteria derived from DSM III. The sensitivity and specificity of diagnosis by interns were 79% and 80%, respectively. Patients who were misdiagnosed as demented were less likely to be high school graduates than their correctly classified nondemented counterparts, and those with unrecognized dementia were more likely to be younger than 65 years than patients whose dementia was recognized by house staff. It is concluded that misdiagnosis is related to age and educational status and that attention to these factors may improve diagnostic accuracy.

Primary skeletal infections in heroin users: a clinical characterization, diagnosis and therapy.

Experience with 24 patients and 101 cases reported in the English literature demonstrate that primary skeletal infections occur in heroin users. In young individuals with no significant underlying disease, predominant involvement in the lumbar vertebrae and sternoclavicular joint, Pseudomonas aeruginosa was the dominant pathogen. Clinical manifestations, except for pain or local tenderness, and laboratory findings were of limited value. Diagnosis ultimately depended on isolation of the pathogens from either bone or joint fluid. The treatment, as indicated, was prolonged parenteral antibiotics, generally with an aminoglycoside, incision and drainage, and immobilization.