Assessment and Treatment of Depression Following Myocardial Infarction
Roughly 65% of patients with acute myocardial infarction report experiencing depressive symptoms, and 15% to 22% of these patients have major depressive disorder. However, only 25% of cardiac patients with major depression receive a diagnosis of the disorder, and only half of those patients receive treatment. In otherwise healthy persons, depression is an independent risk factor in the development of and mortality associated with cardiovascular disease, and depressed individuals with preexisting cardiovascular disease have a 3.5-fold greater risk of death than nondepressed individuals with cardiovascular disease. Depression in patients cardiovascular illness can be assessed using the mnemonic SIG E CAPS + mood or one of several published self-report measures (one, the Zung Self-Rating Depression Scale, is adapted and presented in this article). Treatment of depression in this population can include both psychosocial treatments (especially cognitive-behavioral therapy) and pharmacotherapeutic treatments (especially selective serotonin reuptake inhibitors [SSRIs], which have little effect on the cardiovascular system). The combination of cognitive-behavioral therapy and SSRI treatment is often the most effective treatment for depression in patients with cardiovascular disease. As an appendix to the article, the authors provide a patient information handout on depression after heart attack.
(Am Fam Physician 2001;64:641-648, 651-652)
Demographic and Clinical Features of 131 Adult Pathological Gamblers
Background: This study was constructed to detail the demographic and phenomenological features of pathological gamblers. Method: One hundred thirty-one subjects with DSM-IV pathological gambling were administered a semistructured interview to elicit demographic data and information on the phenomenology, age at onset, course, associated features, treatment history, and response to treatment of the disorder, followed by the Structured Clinical Interview for DSM-IV. Results: Seventy-eight female (59.5%) and 53 male (40.5%) (mean ± SD age = 47.7 ± 11.0 years) pathological gamblers were studied. The majority of subjects (55.7%) were married. Subjects gambled a mean of 16 hours per week. Slot machines (65%), cards (33%), and blackjack (26%) were the most popular forms of gambling. The mean length of time between first gambling behavior and onset of pathological gambling was 6.3 ± 8.9 years. Approximately one half (46%) of the subjects reported that television, radio, and billboard advertisements were a trigger to gamble. Most gamblers had severe financial, social, or legal problems. The majority of the subjects (58%) had at least 1 first-degree relative who also exhibited symptoms of problematic gambling behavior. Conclusion: Pathological gambling is a disabling disorder associated with high rates of social and legal difficulties.
(J Clin Psychiatry 2001;62:957-962)
School-Associated Violent Deaths in the United States, 1994-1999
Background: The actual incidence and characteristics of school-associated violent deaths remain shrouded in mystery, even though public alarm concerning this subject increased after several high-profile school shootings occurred in the late 1990s in the United States. This study reports trends and characteristics of school-associated violent deaths in the United States. Method: In this population-based surveillance study, data on school-related violent deaths that occurred from July 1, 1994, through June 30, 1999, were collected from state and local agencies, media databases, and police and school officials. Cases were defined as homicides, suicides, legal interventions, or unintended firearm-related deaths of students or nonstudents occurring on the campus of an elementary or secondary school, while a victim was on the way to or from school, or while a victim was at or on the way to or from an official school-sponsored event. Outcome measures included national estimates of risk of school-associated violent death, national trends in such deaths, common features of these events, and potential risk factors for perpetrating or falling victim to these violent acts. Results: 220 events leading to 253 deaths were identified between 1994 and 1999; multiple deaths occurred in 18 of these events. 172 of these 220 events were homicides, 30 were suicides, 11 were homicide-suicides, 5 were legal intervention deaths, and 2 were unintentional firearm-related deaths. Students accounted for 68.0% of these deaths (N = 172); thus, the estimated average annual incidence of school-associated violent death was 0.068 per every 100,000 students. Although the rate of single-victim student homicides decreased between 1992 and 1999 (p = .03), the homicide rates for students killed in multiple-victim events increased (p = .047). The start of the school day, the lunch period, and the end of the school day were the most common times for school-associated violent deaths to occur. Action potentially indicating risk of violence (e.g., a note or threat) occurred prior to more than half (54.5%) of the incidents. Perpetrators of homicide were more likely than victims of homicide to have exhibited suicidal behavior prior to the event (odds ratio [OR] = 6.96, 95% confidence interval [CI] = 1.96 to 24.65) and to have been bullied by peers (OR = 2.57, 95% CI = 1.12 to 5.92). Conclusions: Even though school-associated violent deaths are rare, they have occurred with sufficient frequency to allow recognition of patterns and risk factors, which may assist schools in responding to this problem.
(JAMA 2001;286:2695-2702)
Integrated Treatment of Comorbid Depression and Substance Use Disorders
Objective: The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. Method: On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. Results: Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. Conclusion: Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.
(J Clin Psychiatry 2001;62:672-677)
Prevalence of Psychiatric Disorders Among Persons Convicted of Driving While Impaired
Background: Although over a million individuals were arrested annually in the United States in the late 1990s for driving while impaired (DWI), treatment programs for DWI offenders often have disappointing results. Moreover, few data exist on the need for psychiatric treatment for DWI offenders. The aims of this study were to determine the lifetime and 12-month prevalence of DSM-III-R alcohol use and comorbid psychiatric disorders (alcohol and drug abuse and dependence, major depressive disorder, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder, and antisocial personality disorder) in DWI offenders and compare this prevalence with that in the general population. Method: Individuals (612 women and 493 men, aged 23 to 54 years) who had been convicted of DWI and had been referred to a screening program in Bernalillo County, New Mexico, were interviewed using the Diagnostic Interview Schedule between January 25, 1994, and June 30, 1997. Psychiatric diagnoses in this population were compared with findings from the National Comorbidity Survey for the western region of the United States, which was conducted between September 14, 1990, and February 6, 1992. Results: Among DWI offenders, 85% of women and 91% of men reported a lifetime alcohol-use disorder, compared with 22% of women and 44% of men in the National Comorbidity Survey sample. Drug-use disorders were reported in 32% of female and 38% of male offenders compared with 16% of women and 21% of men in the National Comorbidity Survey sample. Fifty percent of female and 33% of male offenders with alcohol-use disorders reported at least 1 additional psychiatric disorder other than drug abuse or dependence, most commonly major depression or posttraumatic stress disorder. Conclusion: DWI offenders require assessment and treatment not only for alcohol-related problems but also for drug use and other psychiatric illnesses that often accompany problems related to alcohol.
(Arch Gen Psychiatry 2001;58:943-949)
Cannabis Abuse as a Risk Factor for Depressive Symptoms
Objective: This study was designed to estimate the degree to which cannabis abuse serves as a risk factor for, as opposed to a method of self-medication of, depression. Method: Data were culled from participants in the 1980 Baltimore Epidemiologic Catchment Area study (N = 1920) who were reassessed in a follow-up study (between 1994 and 1996). Two cohorts were singled out for analysis: individuals with no depressive symptoms at baseline (N = 849) and those without a diagnosis of cannabis abuse at baseline (N = 1837). The Diagnostic Interview Schedule was used to assess symptoms of depression, cannabis abuse, and other psychiatric disorders. Results: Among those with no symptoms of depression at baseline, participants diagnosed with cannabis abuse at baseline had a 4-fold greater likelihood of having depressive symptoms at the follow-up assessment (after adjustment was made for age, gender, antisocial symptoms, and other baseline covariates) compared with those without a diagnosis of cannabis abuse. In particular, those with cannabis abuse at baseline (but no baseline depression) who were depressed at follow-up were more likely to have had anhedonia and suicidal ideation during the follow-up period. Depressive symptoms at baseline did not significantly predict cannabis abuse at follow-up among participants without a baseline diagnosis of cannabis abuse. Conclusions: Further research is needed to identify the characteristics that account for the higher risk of depression among those who abuse cannabis so that the degree of impairment resulting from their depression can be estimated.
(Am J Psychiatry 2001;158:2033-2037)
Comorbidity of Phobic Disorders With Alcoholism in a Canadian Community Sample
Objective: This study investigated the association between phobic disorders and hazardous levels of alcohol use in a community sample. Method: Data were obtained from the Mental Health Supplement of the Ontario Health Survey, in which the University of Michigan revision of the Composite International Diagnostic Interview was used to identify DSM-III-R psychiatric disorders in 8116 Canadian respondents aged 15 to 64 years. In addition to the DSM-III-R diagnoses of alcohol abuse and alcohol dependence, the World Health Organization category of “hazardous alcohol use” was included in the assessment. Odds ratios (ORs) for phobic disorders and alcohol-use diagnoses were determined using logistic regression controlling for age and sex. Results: The odds of having a phobic disorder were 2 to 3 times higher in individuals with lifetime alcohol abuse or dependence. Simple phobia and social phobia with multiple fears were significantly associated (OR range, 1.5 to 2) with hazardous alcohol use, which had a prevalence of approximately 10%. Conclusions: Because most phobic disorders have an early onset, the findings of this study suggest that these disorders increase the risk for harmful patterns of alcohol use.
(Can J Psychiatry 2001;46:733-740)
Similar Effectiveness of Paroxetine, Fluoxetine, and Sertraline in Primary Care: A Randomized Trial
Background: Although selective serotonin reuptake inhibitors (SSRIs) are, as a class, the most widely prescribed antidepressant agents, whether one SSRI is more effective than another is unknown. In this study, the effectiveness of the SSRIs paroxetine, fluoxetine, and sertraline was compared in primary care patients. Method: 573 depressed adult patients from 37 clinics in 2 U.S. primary care research networks were randomly assigned to 9 months of open-label treatment (April through November 1999) with paroxetine (N = 189), fluoxetine (N = 193), or sertraline (N = 191). Primary care physicians, who made the initial decision as to whether patients were to receive antidepressant therapy, could switch patients to a different SSRI or a non-SSRI antidepressant if patients failed to adequately respond to or tolerate their initial SSRI. The change in the Mental Component Summary score on the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), compared across treatment groups at 1, 3, 6, and 9 months, was the primary outcome measure; secondary outcomes included other depression and psychological measures, measures of work and social functioning, and other domains of health-related quality of life. Results: 94% of patients successfully completed follow-up interviews at 1 month; 87%, at 3 months; 84%, at 6 months; and 79%, at 9 months. On the SF-36 Mental Component Summary score, mean changes at 9 months were +15.8 with paroxetine, +15.1 with fluoxetine, and +17.4 with sertraline. Responses to the 3 SSRIs were comparable on all measures at all timepoints. In addition, the incidences of adverse effects and rates of discontinuation were similar with all 3 agents. Conclusions: Paroxetine, fluoxetine, and sertraline had similar effectiveness for symptoms of depression as well as for several quality-of-life domains over the 9 months of this trial.
(JAMA 2001;286:2947-2955)
Familial Psychiatric Illness and Posttraumatic Stress Disorder: Findings From a Family Study of Substance Abuse and Anxiety Disorders
Background: Aside from the possibility of a direct relationship between individual and familial posttraumatic stress disorder (PTSD), there is accumulating evidence that implicates a family history of psychiatric and substance use disorders as an important risk factor in the development of PTSD and associated symptoms. Method: The familial risk of DSM-III-R PTSD was examined within a family study of clinical- and community-ascertained probands (N = 263) and their 1206 adult first-degree relatives. Results: Although PTSD among probands was not found to significantly elevate the risk of PTSD among first-degree relatives, an elevated rate of PTSD was found among the relatives of drug abusing probands compared with the relatives of probands with alcoholism, other anxiety disorders, and normal controls. Additionally, affective disorders were significantly associated with PTSD in relatives (p < .01). When these familial and individual associations were examined according to gender, drug disorders in probands were significantly associated with PTSD only among male relatives (p < .01), while the association between PTSD and comorbid affective disorders was seen primarily among female relatives (p < .01). Conclusion: Although probands in the present family study were not selected specifically for PTSD, the data afforded a unique opportunity to examine the profile of familial psychopathology as a part of the complex picture of susceptibility for PTSD. Future family study research will be able to determine the generalizability of the present findings through more complete measurement of diverse forms of trauma.
(J Clin Psychiatry 2001;62:715-720)
Venlafaxine in the Treatment of Postpartum Depression
Background: Although postpartum depression is a highly prevalent illness, antidepressant treatment studies of postpartum depression are sparse. Incomplete recognition and treatment of puerperal illness place women at risk for chronic depression and may have adverse effects on child development. Method: An 8-week, flexible-dose, open study of venlafaxine (immediate release; mean dose = 162.5 mg/day) was performed in a group of 15 women who met DSM-III-R criteria for major depressive disorder with onset within the first 3 months postpartum. Patients were assessed at baseline and every 2 weeks across the study. Measurements of outcome included the 17-item Hamilton Rating Scale for Depression (HAM-D), the Kellner Symptom Questionnaire, and the Clinical Global Impressions scale (CGI). Results: Despite baseline scores of depression that were particularly high, response to treatment was robust. Twelve of 15 patients experienced remission of major depression (HAM-D score <= 7 or CGI score <= 2). Dramatic decrease in anxiety paralleled the decrease in depression across the sample. Conclusion: Venlafaxine is effective in the treatment of postpartum major depression. Early identification of women who suffer from postpartum mood disturbance is critical to minimize the morbidity associated with untreated mood disturbance and the effect of depression on children and families.
(J Clin Psychiatry 2001;62:592-596)
Supportive-Expressive Group Psychotherapy for Persons With Inflammatory Bowel Disease
Objective: Supportive-expressive (SE) group psychotherapy, which was originally developed for women with metastatic breast cancer, focuses on concerns and feelings related to medical illness and is designed to be helpful in other medically ill populations. SE therapy was adapted for patients with inflammatory bowel disease (IBD) in this open trial. Method: This study enrolled 30 subjects with Crohn’s disease or ulcerative colitis in 4 psychotherapy groups. Each group discussed interpersonal and emotional issues related to the illness at 20 weekly meetings. At the beginning and the end of the 20 weeks, physical and psychological variables were measured. Results: No mean group change in anxiety, depression, or quality of life was found. There was, however, a mean group reduction in maladaptive coping. Conclusion: Although interpretation of results is hampered by the small sample size and lack of a control group, the findings suggest that the intervention was ineffective. Because SE therapy has been shown to be effective in other medically ill populations, and since a null result with SE therapy in patients with IBD is consistent with results of other psychotherapy interventions in this illness population, the authors discuss characteristics of IBD that may be responsible for its resistance to psychotherapy.
(Can J Psychiatry 2001;46:622-626)
Childhood Abuse, Household Dysfunction, and the Risk of Attempted Suicide Throughout the Life Span: Findings From the Adverse Childhood Experiences Study
Background: Although suicide is one of the leading causes of death in the United States, it is difficult to identify at-risk individuals, leading the U.S. Surgeon General to make suicide prevention a national priority. Research suggests that attempted suicide among adolescents and adults is one of a variety of negative health outcomes that can stem from trauma and adverse experiences in childhood. This study examined the connection between risk of attempted suicide and adverse childhood experiences as well as the number of such experiences (adverse childhood experiences [ACE] score). Method: This retrospective study included 17,337 adult members of a health maintenance organization (mean [SD] age = 57 [15.3] years; 54% female) who attended a primary care clinic is San Diego, Calif., from 1995 through 1997 and completed a survey that included questions about childhood abuse and household dysfunction, suicide attempts, and other issues related to health. Outcome measures included self-reported suicide attempts compared by number of adverse experiences during childhood (including physical, emotional, and sexual abuse); household substance abuse, mentalillness, and incarceration; and parental separation, divorce, or domestic violence. Results: The lifetime prevalence of having at least 1 suicide attempt of was 3.8%. The risk of attempted suicide was increased 2- to 5-fold by the presence of adverse childhood experiences in any category, and a strong, graded relationship (p < .001) was found between ACE score and suicide attempts in childhood/adolescence and adulthood. The adjusted odds ratio of ever attempting suicide for individuals with 7 or more adverse experiences (35.2%) was 31.1 (95% confidence interval = 20.6 to 47.1) compared with individuals with no such experiences (who had a prevalence of attempted suicide of 1.1%). The strength of the relationship between ACE score and suicide attempts was reduced by adjustment for depressed affect, illicit drug use, and self-reported alcoholism. The population-attributable risk fractions for 1 or more adverse childhood experiences were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively. Conclusions: The relationship between adverse childhood experiences and risk of suicide attempts throughout the life span is powerful. This relationship appears to be mediated by alcoholism, depressed affect, and illicit drug use, which are strongly associated with these experiences. Prevention of these experiences and treatment of persons undergoing them may lead to progress in preventing suicide.
(JAMA 2001;286:3089-3096)
Why Do Young Women Diet? The Roles of Body Fat, Body Perception, and Body Ideal
Background: To assess the relative roles of body fat, body perception, and body ideals as motivations for dieting in college women. Method: We compared 45 college women who reported having dieted with 32 who had not, using a novel computerized test of body image called the somatomorphic matrix. Results: As expected, the difference in body fat between subjects’ “perceived body” and “ideal body” was significantly greater in dieters than in nondieters (p < .001). Remarkably, however, this difference remained highly significant even after adjusting for the subjects’ actual measured body fat (p = .002). Further analysis revealed that this difference persisted, not because dieters had unrealistic ideals of thinness, but because they had distorted perceptions of their fatness. Conclusion: Distorted body image perception, a potentially treatable condition, may play an unexpectedly large role in motivating young women to diet.
(J Clin Psychiatry 2001;62:609-611)
Neuroleptic-Related Dyskinesias in Children and Adolescents
Background: Few studies have investigated the comparative risk of neuroleptic-related dyskinesias in children and adolescents receiving typical versus newer, atypical antipsychotics. This prospective study was completed to test whether clinical use of atypical antipsychotics is associated with less risk for developing neuroleptic-related dyskinesias than clinical use of typical neuroleptics in an unselected heterogeneous population of seriously emotionally disturbed youths admitted to acute residential treatment. We also tested a novel model of predictive risk for neuroleptic-related dyskinesias in children and adolescents. Method: 102 children and adolescents receiving typical neuroleptics, atypical antipsychotics, or the combination were studied. Youths developing neuroleptic-related dyskinesias were compared with youths free of dyskinesias over a 3-month study period on demographic, diagnostic, and treatment variables. Logistic regression was utilized to develop a novel model of predictive risk. Results: Of neuroleptic-treated youths, 5.9% had probable tardive dyskinesia, a rate less than the prevalence of tardive dyskinesia in chronic neuroleptic-treated adults. Use of typical neuroleptics was significantly (p = .03) associated with dyskinesia compared with use of atypical antipsychotics. Four variables including IQ, initial Abnormal Involuntary Movement Scale score, type of antipsychotic, and cumulative number of risk factors accounted for 35.8% of the variance when predicting dyskinetic status. Conclusion: Use of atypical antipsychotics appears to be associated with less dyskinesia risk than typical neuroleptics in an unselected group of seriously emotionally disturbed children and adolescents. Results support a cumulative risk model of neuroleptic-related dyskinesia in youths.
(J Clin Psychiatry 2001;62:967-974)
Naltrexone in the Treatment of Alcohol Dependence
Background: The efficacy of naltrexone is unknown despite its approval by the U.S. Food and Drug Administration for the treatment of alcohol dependence. This study evaluated the efficacy of naltrexone when administered alongside psychosocial treatment. Method: In this multicenter, double-blind, placebo-controlled trial, 627 veterans (chiefly men) with chronic, severe alcohol dependence (DSM-IV criteria) were randomly assigned to 12 months of naltrexone (50 mg once daily), 3 months of naltrexone followed by 9 months of placebo, or 12 months of placebo. Individual counseling and programs to improve medication compliance were offered to all patients, and patients were encouraged to attend Alcoholics Anonymous meetings. Results: Each group contained 209 patients, all of whom had been sober to at least 5 days prior to assignment to study groups. No differences in number of days to relapse were found at 13 weeks between the 2 naltrexone groups (mean = 72.3 days) and the placebo group (mean = 62.4 days; 95% confidence interval for difference between groups = -3.0 to 22.8). In addition, no differences in percentage of days on which drinking occurred and number of drinks per drinking day were found among the 3 groups. Conclusions: The findings of this study do not support the use of naltrexone in treating men with chronic, severe alcohol dependence.
(N Engl J Med 2001;345:1734-1739)