Clonazepam treatment of panic disorder in patients with recurrent chest pain and normal coronary arteries.

OBJECTIVE: To examine the efficacy of clonazepam in chest pain patients with panic disorder and normal coronary arteries. METHOD: We conducted a placebo controlled, double blind, flexible dose (1-4 mg/d), six-week trial of clonazepam. All subjects (N = 27) had current panic disorder and a negative coronary angiogram or thallium exercise tolerance test within the previous year. RESULTS: Analyses show modest improvements in the clonazepam and placebo groups over the first four weeks in both primary outcome measures. Eight of twelve (67%) clonazepam treated patients responded with reduction of panic attacks by week four to zero per week or half of initial frequency, while seven of fifteen (47%) placebo treated patients responded (not significant). When response was measured by 50 percent reduction in Hamilton Anxiety total score, however, seven of twelve (58%) clonazepam treated patients responded, while two of fifteen (14%) placebo treated patients responded, (p = .038) by Fisher's exact test. Within-subject improvements over the first four weeks were not significantly greater for the clonazepam group than for the placebo group on either outcome measure. CONCLUSIONS: These results show a generally good outcome in chest pain patients with panic disorder, and they provide suggestive evidence for the efficacy of clonazepam compared to placebo. This study points to the need for larger, well-funded treatment studies of chest pain patients with panic disorder.

A systematic review of the mortality of depression.

OBJECTIVE: The literature on the mortality of depression was assessed with respect to five issues: 1) strength of evidence for increased mortality, 2) controlling for mediating factors, 3) the contribution of suicide, 4) variation across sample types, and 5) possible mechanisms. METHOD: All relevant English language databases from 1966 to 1996 were searched for reviews and studies that included 1) a formal assessment of depressive symptoms or disorders, 2) death rates or risks, and 3) an appropriate comparison group. RESULTS: There were 57 studies found; 29 (51%) were positive, 13 (23%) negative, and 15 (26%) mixed. Twenty-one studies (37%) ranked among the better studies on the strength of evidence scale used in this study, but there are too few comparable, well-controlled studies to provide a sound estimate of the mortality risk associated with depression. Only six studies controlled for more than one of the four major mediating factors. Suicide accounted for less than 20% of the deaths in psychiatric samples, and less than 1% in medical and community samples. Depression seems to increase the risk of death by cardiovascular disease, especially in men, but depression does not seem to increase the risk of death by cancer. Variability in methods prevents a more rigorous meta-analysis of risk. CONCLUSION: The studies linking depression to early death are poorly controlled, but they suggest that depression substantially increases the risk of death, especially death by unnatural causes and cardiovascular disease. Future well-controlled studies of high risk groups may guide efforts to develop treatments that reduce the mortality risk of depression.

An agenda for primary care psychiatry.

With the advent of managed care and the primary care gatekeeper, psychiatry's relationship to primary care is shifting. Four recent surveys suggest that, in general, departments of psychiatry have done little to restructure their relationships with primary care. This article proposes an agenda for developing primary care psychiatry programs in departments of psychiatry. The rationale for shifting resources toward primary care psychiatry is followed by a discussion of the goals of primary care psychiatry programs. The agenda presents specific high-priority projects in the areas of research, education, and clinical care, citing examples of existing initiatives and discussing the resources needed for funding primary care psychiatry programs.

Psychosocial adjustment to advanced proliferative diabetic retinopathy.

OBJECTIVE: To identify the major problems with adjustment to the advanced stages of proliferative diabetic retinopathy and to examine the relationship between adjustment and visual acuity. RESEARCH DESIGN AND METHODS: A cross-sectional descriptive cohort study was conducted at the referral-based eye unit at Joslin Diabetes Center in Boston, Massachusetts. We studied 47 adults with IDDM and advanced proliferative diabetic retinopathy. Thirty reported recent visual loss, and 17 had more stable vision. RESULTS: Psychosocial Adjustment to Illness Scale scores were significantly elevated relative to a normative diabetic sample (t = 2.94, P < 0.01). Our proliferative diabetic retinopathy sample reported the most difficulties in the domain of health-care orientation. No significant differences were observed in adjustment scores between those with recent partial visual loss and those with more stable vision. However, visual acuity in the best eye correlated significantly with the proliferative diabetic retinopathy sample's total adjustment score (r = -0.34, P = 0.02) and with 4 of 7 adjustment subscales. CONCLUSIONS: These results suggest that advanced proliferative diabetic retinopathy may be associated with particular difficulties in adjustment that are more related to best visual acuity than to recent visual loss. Relatively mild visual impairment may have significant psychosocial impact.

Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain.

OBJECTIVE: 1) To determine whether the frequencies of panic disorder (PD) and depression (DEP) in an emergency department (ED) population were comparable to those in other primary care groups; 2) to evaluate whether patients without the clinical diagnosis of acute cardiac ischemia (ACI) had higher frequencies of these disorders; and 3) to identify characteristic clinical findings in patients with PD or DEP. SETTING: An urban teaching hospital ED. PATIENTS: Three hundred thirty-four patients with acute chest pain were evaluated prospectively over an eight-week period. The cohort participating (69%-229/334) completed psychiatric screening measures, including the Panic Disorder Self-Rating Scale, the Beck Depression Inventory, and the Zung Self-Rating Anxiety Scale. MEASUREMENTS AND MAIN RESULTS: A symptom profile consistent with PD was identified in 17.5% of the patients (40/229), DEP in 23.1% (53/229), and either disorder in 35% (80/229). The prevalences of PD were similar in those with and without ACI (19.4% vs 16.6%, respectively, p > 0.05). The likelihoods of one or more ED visits for chest pain in the previous year were significantly greater in those with PD (57.5% vs 36%, p < 0.05) and DEP (54% vs 35%, p < 0.05) than in those without these psychiatric disorders. CONCLUSION: This study suggests that approximately one in three patients presenting to the ED with acute pain has symptoms consistent with a psychiatric disorder. These disorders occur frequently in both those with and those without acute cardiac ischemia, and clinical variables may help identify these frequent ED utilizers.

Psychiatric aspects of chest pain in the emergency department.

We estimate that a third of the patients who present to the ED with chest pain have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with a high rate of ED utilization for chest pain evaluations. Physicians in the ED recognize only a small fraction of the psychiatric disorders, so appropriate treatment or referral may be infrequent. The proportion of chest pain patients with CAD who also have a psychiatric disorder may be in the range of 20% to 30%, justifying careful assessment of psychiatric disorders in CAD patients. We conclude that the psychiatric aspects of chest pain are sufficiently prevalent, clinically significant, and a contributor to unnecessarily high utilization of medical services. We call for clinical research to address these questions by outlining three areas of study that will advance our knowledge and care of the patient with chest pain.

Psychosocial correlates of mild visual loss.

Studies of the psychosocial aspects of visual impairment have emphasized the effects of blindness, giving relatively little attention to the effects of mild or partial visual impairment. Consequently, we know little about when in the course of visual loss significant psychosocial dysfunction develops. To address this question, we assessed psychosocial functioning at three times over eight months in 31 adults with proliferative diabetic retinopathy and mild to moderate visual impairment in at least one eye. Examination of the correlations between visual and psychosocial measures revealed strong and significant correlations between visual acuity and adjustment (range of r = -0.45 to -0.68), between visual acuity and psychological symptoms (range of r = -0.39 to -0.50), and between visual acuity and emotion-focused coping (range of r = -0.38 to -0.53). The strength of these correlations and their occurrence in three independent measures of psychosocial functioning suggest a clinically meaningful relationship between visual and psychosocial functioning in the range of mild to moderate visual impairment. Psychosocial dysfunction related to visual impairment develops long before blindness. Further prospective research on the psychosocial aspects of partial visual impairment will clarify this relationship and may help justify early intervention with rehabilitation in the visually impaired who do not qualify for services for the blind.

Axis I disorders in ER patients with atypical chest pain.

To examine the contribution of psychopathology to emergency room (ER) visits for atypical chest pain, we administered two screening measures and the Structured Clinical Interview for DSM III-R (SCID) to thirty-five subjects within seventy-two hours of their ER visit. Follow-up SCID interviews were completed in thirty subjects at five to twelve months. Sixty percent of the sample had an initial Axis I diagnosis, predominately affective (34%) and anxiety (46%) disorders. Forty percent had multiple diagnoses initially. The most common diagnoses were panic disorder (31%) and major depression (23%). At follow-up 47 percent had Axis I diagnoses, 30 percent had multiple diagnoses, with only slightly decreases rates for panic disorder (27%) and major depression (17%). Many subjects had lost, gained, or switched diagnoses by follow-up, in spite of one consistent rater and a few subjects seeking treatment. ER physicians often do not recognize these psychiatric disorders in chest pain patients. The high risk of suicide in panic disorder and depression, and the high cost of disability in recurrent chest pain make it essential that ER physicians include these disorders in the differential of atypical chest pain.

Screening emergency room patients with atypical chest pain for depression and panic disorder.

In response to recent reports relating atypical chest pain to normal coronary arteries and to various types of psychopathology, we developed a pilot study to investigate 1) the prevalence of depression and panic disorder among patients presenting to an emergency room with atypical chest pain, and 2) what the likelihood is of an emergency room physician recognizing the psychosocial factor. Of forty-nine subjects screened, 39 percent scored positively for depressive syndrome on the Center for Epidemiological Studies-Depression rating scale, 43 percent met criteria for panic attack and 16 percent met criteria for panic disorder by DSM-III. Although thirty subjects (61%) screened positively for depression or panic attack, only one received a psychiatric diagnosis of any kind. This pilot study suggests: 1) that the relationship between chest pain and psychopathology in emergency room patients deserves further rigorous study; 2) that depression and panic attacks in association with atypical chest pain may be underdiagnosed by the emergency room physician; and 3) that self-report screening measures as an aid to diagnosis in this population need to be more closely investigated.

Psychosocial aspects of diabetic retinopathy.

Diabetic retinopathy, particularly in the more advanced stages, poses many difficult psychosocial problems and demands major adjustments by the patient. Our review of this literature has identified specific problems relevant to patient care, future research, and public policy. For example, proliferative retinopathy often leads to at least partial visual impairment, psychiatric symptoms, and difficulties with glycemic control. Partial visual impairment appears to cause as much psychosocial disruption as severe blindness. This suggests that most rehabilitation programs that serve the legally blind may come too late in the course of this illness. This review emphasizes the paucity of past research on psychosocial aspects of diabetic retinopathy and raises some questions for future research.

Unexpected clinical features of the Tarasoff decision: the therapeutic alliance and the "duty to warn".

The authors present a case report and discuss the clinical effects of the Tarasoff decision on the therapy of a potentially violent patient. They emphasize that the patient's ambivalence toward the intended victim can be used to foster the therapeutic alliance. The therapist's legal duty to the victim and therapeutic duty to the patient, they assert, can then be synergistically applied with an unexpected benefit: the patient's capacity to make choices is enhanced.