Comorbidity of Generalized Social Anxiety Disorder and Depression in a Pediatric Primary Care Sample
Background: Although comorbidity between adult social anxiety disorder and major depression is substantial, little information is available regarding this relationship among youth. Method: A sample of 190 families with children between the ages of 8 and 17 years were randomly selected from a pediatric primary care clinic. Parents responded by mail to questionnaires assessing social anxiety, social functioning, and depression and completed a semistructured diagnostic interview about their child by phone. Results: The generalized type of social anxiety disorder was highly comorbid with generalized anxiety disorder, major depression, attention-deficit/hyperactivity disorder, and specific phobias, however, little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses revealed that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (odds ratio = 5.1). Social anxiety disorder had a significantly earlier age at onset than major depression in all cases. The study was limited in that it relied on cross-sectional data and diagnoses were based on reports of child behavior by parents. Conclusions: In youth, generalized social anxiety disorder is strongly associated with depressive illness. Approaches to screening and treatment that consider both social anxiety and depressive symptoms are essential. Early treatment intervention for social anxiety disorder may help prevent subsequent depressive disorders.
(J Affect Disord 2004;80:163-171)
Efficacy of Treatment for Child and Adolescent Traumatic Stress
Background: Little is known about treatment efficacy for traumatized children and their families despite the substantial investment of public monies to lessen the impact of childhood trauma. Objective: To review the efficacy of treatment for child and adolescent traumatic stress. Data Sources: An extensive literature search identified 102 studies that addressed child and adolescent trauma treatment. Study Selection: Only 8 studies met the minimal inclusion criteria of (1) using a comparison group and (2) including symptoms of traumatic stress as a treatment outcome. The authors used formal criteria of treatment research quality to critically evaluate the studies for adherence to standards of good efficacy research. Data Synthesis: Traumatic stress treatment appears to result in greater improvement than either no treatment or routine community care. Conclusions: Research on child and adolescent posttraumatic stress disorder treatment lags behind both adult posttraumatic stress disorder treatment research and other child treatment research. The authors stress the considerable need to establish a programmatic approach to developing evidence-based child trauma treatment. Among obstacles to conducting child trauma treatment research, the authors cite sensitivity to the rights of victims and models of child service that perceive research to be intrusive for vulnerable children at critically sensitive points in their development.
(Arch Pediatr Adolesc Med 2004;158:786-791)
Are Mood Disorders and Obesity Related? A Review for the Mental Health Professional
Objective: We reviewed evidence regarding a possible relationship between mood disorders and obesity to better inform mental health professionals about their overlap. Method: We performed a MEDLINE search of the English- language literature for the years 1966-2003 using the following terms: obesity, overweight, abdominal, central, metabolic syndrome, depression, mania, bipolar disorder, binge eating, morbidity, mortality, cardiovascular, diabetes, cortisol, hypertriglyceridemia, sympathetic, family history, stimulant, sibutramine, antiobesity, antidepressant, topiramate, and zonisamide. We evaluated studies of obesity (and related conditions) in persons with mood disorders and of mood disorders in persons with obesity. We also compared studies of obesity and mood disorders regarding phenomenology, comorbidity, family history, biology, and pharmacologic treatment response. Results: The most rigorous clinical studies suggest that (1) children and adolescents with major depressive disorder may be at increased risk for developing overweight; (2) patients with bipolar disorder may have elevated rates of overweight, obesity, and abdominal obesity; and (3) obese persons seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders. The most rigorous community studies suggest that (1) depression with atypical symptoms in females is significantly more likely to be associated with overweight than depression with typical symptoms; (2) obesity is associated with major depressive disorder in females; and (3) abdominal obesity may be associated with depressive symptoms in females and males; but (4) most overweight and obese persons in the community do not have mood disorders. Studies of phenomenology, comorbidity, family history, biology, and pharmacologic treatment response of mood disorders and obesity show that both conditions share many similarities along all of these indices. Conclusion: Although the overlap between mood disorders and obesity may be coincidental, it suggests the two conditions may be related. Clinical and theoretical implications of this overlap are discussed, and further research is called for.
(J Clin Psychiatry 2004;65:634-651)
Long-Term Care Placement of Dementia Patients and Caregiver Health and Well-Being
Background: Although caregivers commonly place a relative with dementia into a long-term care facility, the transition and factors that affect caregiver health and well-being after placement of the patient are not well described. Objective: To assess the effect that placing a relative with dementia in a long-term care facility has on the health and well-being of caregivers. Design, Setting, and Participants: Prospective study from 1996 to 2000 in a sample of 1222 caregiver-patient dyads recruited from 6 U.S. sites. During the 18-month follow-up period, 180 patients were placed in a long-term care facility. Data collected before and after placement were analyzed to identify factors associated with placement, the nature of contact between caregivers and their institutionalized relatives after placement, and the relation of both factors to health outcomes among dementia caregivers. Main Outcome Measures: Caregiver depression (symptoms on the Center for Epidemiological Studies- Depression [CES-D] scale; range, 0-60) and anxiety (State Trait Inventory; range, 10-40) and use of prescription medications for depression and anxiety. Results: Caregivers who institutionalized their relative reported depressive symptoms and anxiety to remain as high as they were while the patient was being cared for at home. Overall CES-D scores for depression remained unchanged from before to after placement (median [interquartile range; IQR], 15.0 [8-24.5] and 15.0 [7.7-28]; p = .64). Overall anxiety scores on the State Trait Inventory also did not change significantly (median [IQR], 22.0 [19-27] before vs. 21.1 [18-27] after; p = .21). These effects were most pronounced among those caregivers who were spouses of the patient (p = .02 for depression), visited the patient more frequently (p = .01 for depression and p < .001 for anxiety), and were less satisfied with the help they received from others (p = .003 for depression and p < .001 for anxiety). Antidepressant use did not change significantly before (21.1%) to after (17.9%) placement (p = .16). Anxiolytic use before to after placement increased from 14.6% to 19% (p = .02), and nearly half of caregivers (48.3%) were at risk for clinical depression after the relative's placement. Conclusions: The transition to institutional care is especially difficult for spouses, almost half of whom visit the patient daily and continue to provide help with physical care during the visits. Clinical interventions that better prepare the caregiver for a placement transition and treat their depression and anxiety following institutionalization may be of great benefit to these individuals.
(JAMA 2004;292:961-967)
Attention-Deficit/Hyperactivity Disorder in Adults: A Survey of Current Practice in Psychiatry and Primary Care
Background: Many obstacles to the recognition and treatment of adult attention-deficit/hyperactivity disorder (ADHD) in psychiatry and primary care have existed. Method: Fifty psychiatrists and 50 primary care practitioners (PCPs) reviewed 537 and 317 medical records, respectively, of ADHD-diagnosed adults. Other psychiatric disorders, age at onset of ADHD, source of referral, use of referrals for diagnosis, treatment for ADHD, and drug holidays were recorded. Results: Forty-five percent of the patient records reviewed by psychiatrists and 65% reviewed by PCPs indicated previous diagnoses of ADHD. Only 25% of the adults with ADHD had been first diagnosed with the disorder in childhood or adolescence. An ADHD diagnosis was the initial cause for referral in 80% of psychiatric patients and 60% of PCP patients. Most patients with previously diagnosed and undiagnosed ADHD were self-referred. Among patients who had no prior diagnosis, 56% complained about ADHD symptoms to other health professionals without being diagnosed; PCPs were the least aggressive in diagnosing ADHD. In psychiatric and PCP settings, the use of pharmacotherapy (91% vs. 78%, respectively) and the proportion of patients taking drug holidays (24% vs. 17%, respectively) differed statistically; patients initiated most drug holidays (57%). For adult ADHD, stimulants were the treatment of choice (84% treated with stimulants). Conclusion: On the basis of this review of medical records, adult ADHD appears to be a substantial source of morbidity in both psychiatric and PCP settings.
(Arch Intern Med 2004;164:1221-1226)
Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial
Background: Although antidepressant medication and structured psychotherapy have both been proven efficacious, less than one third of individuals with depressive disorders receive effective levels of either treatment. Objective: To compare usual primary care for depression with 2 intervention programs-- telephone care management and telephone care management plus telephone psychotherapy. Design: Three-group randomized controlled trial with allocation concealment and blinded outcome assessment conducted between November 2000 and May 2002. Setting and Participants: Six hundred patients starting antidepressant treatment for depression were systematically sampled from 7 group-model primary care clinics; patients already receiving psychotherapy were excluded. Interventions: Usual primary care; usual care plus a telephone care management program that included at least 3 outreach calls, feedback to the treating physician, and care coordination; usual care plus care management combined with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone. Main Outcome Measures: Blinded telephone interviews at 6 weeks, 3 months, and 6 months to assess depression severity (Hopkins Symptom Checklist Depression Scale and the Patient Health Questionnaire), patient-rated improvement, and satisfaction with treatment. Computerized administrative data to assess use of antidepressant medication and outpatient visits. Results: Participation rates were 97% for telephone care management and 93% for telephone care management plus psychotherapy. Compared with usual care, the telephone psychotherapy intervention led to lower mean depression scores on the Hopkins Symptom Checklist Depression Scale (p = .02), a higher proportion of patients reporting that depression was "much improved" (80% vs. 55%, p < .001), and a higher proportion of patients who were "very satisfied" with depression treatment (59% vs. 29%, p < .001). The telephone care management program had smaller effects on patient-rated improvement (66% vs. 55%, p = .04) and satisfaction (47% vs. 29%, p = .001); effects on mean depression scores were not statistically significant. Conclusions: For patients in a primary care setting who are starting antidepressant treatment, a telephone program that combines care management and structured cognitive-behavioral psychotherapy can significantly improve satisfaction and clinical outcomes. According to the authors, these findings support a new public health model of psychotherapy for depression that includes active outreach and concerted efforts to improve access to and motivation for treatment.
(JAMA 2004;292:935-942)
Screening for Dementia in Primary Care: A Summary of the Evidence for the U.S.Preventive Services Task Force
Background: Dementia is a sizeable and expanding problem that often goes undiagnosed in its early stages. Screening and earlier treatment could reduce the burden associated with this syndrome. Objective: To review the evidence of benefits and harms of screening for and earlier treatment of dementia. Data Sources: MEDLINE, PsycINFO, EMBASE, the Cochrane Library, experts, and bibliographies of reviews. Study Selection: The authors formulated 8 key questions representing a logical chain between screening and improved health outcomes and gathered admissible evidence for each question by using eligibility criteria to search the data sources. Data Extraction: Two reviewers obtained relevant information using standardized abstraction forms and graded article quality according to U.S. Preventive Services Task Force criteria. Data Synthesis: No randomized, controlled trial of dementia screening has been completed. Brief screening tools can detect some persons with early dementia (positive predictive value <= 50%). Cholinesterase inhibitor treatment for 6 to 12 months modestly slows the decline of cognitive and global clinical change scores in some patients with mild-to-moderate Alzheimer disease. Function is minimally affected, and fewer than 20% of patients stop taking cholinesterase inhibitors because of side effects. Evidence indicating that any other pharmacologic or nonpharmacologic intervention slows decline in persons with early dementia is only limited. Although intensive multicomponent caregiver interventions may delay nursing home placement of patients who have caregivers, the relevance of this finding for persons who lack caregivers is uncertain. No other potential benefits and harms of screening have been studied. Conclusions: Undiagnosed dementia can be detected by screening tests. Cholinesterase inhibitors are somewhat effective in slowing cognitive decline in persons with mild-to-moderate clinically detected Alzheimer disease. The authors state that the effect of cholinesterase inhibitors or other treatments on persons with dementia detected by screening is uncertain.
(Ann Intern Med 2003;138:927-937)
Diagnosis and Treatment of Behavioral Health Disorders in Pediatric Practice
Objective: Primary care pediatricians have made concerted efforts toward the recognition and treatment of behavioral health problems in children. This study was designed to evaluate the extent of diagnosis and treatment of behavioral health problems and to identify factors that may contribute to the behavioral health practice of a sample of primary care pediatricians. Method: Forty-seven pediatricians working in primary care settings in a predominantly urban setting in North Carolina participated in a standard interview. Their responses to questions about the estimated percentage of children in their practice with a behavioral health disorder, diagnostic tools used, frequent and infrequent diagnoses made, comfort level with making a diagnosis, reasons for not making a diagnosis, psychotropic medication use, types of nonmedication interventions provided, educational background, and needs involving behavioral health issues were assessed. Results: Pediatricians estimated that the average proportion of children in their practices with a behavioral health disorder was 15%. No significant differences in perceptions related to time in practice or gender of the pediatrician were found. Attention-deficit/hyperactivity disorder (ADHD) was the most frequent behavioral health diagnosis, and the majority of pediatricians included behavioral questionnaires, expressed a high level of comfort in making the diagnosis, and frequently or occasionally prescribed stimulants. The study found variability in both practice and comfort for other behavioral health disorders; slightly fewer than half of the pediatricians frequently diagnosed anxiety and depression. Pediatric providers who diagnose anxiety and depression commonly included questionnaires and reported frequent or occasional use of selective serotonin reuptake inhibitors. Comfort with the diagnosis of anxiety was highly associated with use of selective serotonin reuptake inhibitors. The vast majority (96%) provided nonmedication interventions, including supportive counseling, education for coping with ADHD, behavior modification, and/or stress management. Diagnosis and treatment of severe behavioral health disorders were infrequent among the pediatricians. Psychopharmacology, diagnosis and treatment of depression and anxiety, and updates on ADHD were areas of greatest educational interest. The majority did not identify a need for education about several high-prevalence disorders that they infrequently diagnose or treat, including conduct disorder and substance abuse. Conclusions: Pediatric providers in this sample frequently diagnosed and treated ADHD. Pediatricians reported variability in both comfort and practice for all other behavioral health disorders. They frequently provided both pharmacologic and nonpharmacologic treatments for children and adolescents with mild-to-moderate behavioral health disorders but not for severe disorders. Although education for anxiety and depression was identified as a need, few identified educational needs for several high-prevalence behavioral health disorders, including conduct disorder and substance abuse.
(Pediatrics 2004;114:601-606)
Screening for Risk of Persistent Posttraumatic Stress in Injured Children and Their Parents
Background: Injury is a common cause of posttraumatic stress disorder (PTSD) in childhood. PTSD is neither diagnosed nor treated in most injured children who are traumatized. Objective: To develop a stand-alone screening tool for use by clinicians during acute trauma care to identify injured children and their parents who are at risk of significant, persistent posttraumatic stress symptoms. Design: The Screening Tool for Early Predictors of PTSD (STEPP) was derived from a 50-item risk factor survey administered within 1 month of injury as part of a prospective cohort study of posttraumatic stress in injured children and their parents. PTSD symptoms were assessed at least 3 months after injury. Setting and Participants: Urban, pediatric level I trauma center. A sample of 269 children aged 8 to 17 years admitted for treatment of traffic-related injuries between July 1999 and October 2001, and one parent per child, completed a risk factor survey that assessed potential predictors of PTSD outcome. One hundred seventy-one families (63%) completed a follow-up assessment. Main Outcome Measures: The Clinician-Administered PTSD Scale for Children and Adolescents and the PTSD Checklist served as criterion standards for child and parent outcomes, respectively. Those meeting criteria for at least subsyndromal PTSD with continuing impairment ("persistent traumatic stress") were defined as positive cases. Results: The STEPP comprises 4 dichotomous questions asked of the child, 4 asked of one parent, and 4 items readily obtained from the emergency medical record. STEPP sensitivity in predicting posttraumatic stress was 0.88 for children and 0.96 for parents, with negative predictive values of 0.95 for children and 0.99 for parents. The odds ratio for prediction of persistent traumatic stress was 6.5 (95% confidence interval [CI], 1.8 to 22.8) in children and 26.6 (95% CI, 3.5 to 202.1) in parents. Conclusions: The STEPP is a new method to guide evidence-based clinical decision making in the allocation of scarce mental health resources for traumatic stress. Its brevity and simple scoring rule suggest that the STEPP can be easily administered in acute care settings.
(JAMA 2003;290:643-649)
Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care for Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)
Background: Although integrated behavioral health services for older adults in primary care have recently been shown to improve health outcomes, no study has asked the opinions of clinicians whose patients experienced integrated rather than enhanced referral care for depression and other conditions. Method: The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. At each participating site, primary care clinicians were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site. Results: Almost all primary care clinicians (N = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites where the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care. Conclusions: Among primary care clinicians who cared for patients who received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.
(Ann Fam Med 2004;2:305-309)
Somatic Symptoms and Physiologic Responses in Generalized Anxiety Disorder and Panic Disorder: An Ambulatory Monitor Study
Background: In patients with anxiety disorders, physiologic responses to everyday events are poorly understood. Objective: To compare self-reports and physiologic recordings in patients with panic disorder (PD), patients with generalized anxiety disorder (GAD), and nonanxious controls during daily activities. Design: In their everyday environment, participants underwent four 6-hour recording sessions during daily activities while wearing an ambulatory monitor. Physiologic and subjective data were recorded every 30 minutes and during subject- signaled periods of increased anxiety or tension or panic attack. Participants: Twenty-six patients with PD and 40 with GAD, both without substantial comorbidity, and 24 controls. Main Outcome Measures: Recordings of heart interbeat intervals, skin conductance levels, respirations, motion, and ratings of subjective somatic symptoms and tension or anxiety. Results: Patients with anxiety disorders rated higher on psychic and somatic anxiety symptoms than did controls. Diminished autonomic flexibility throughout the day, accompanied by less precise perception of bodily states, was common to both anxiety disorders. The main differences between PD and GAD patients were a heightened sensitivity to body sensations and more frequent button presses. A trend toward heightened basal arousal in PD patients manifested itself in a faster heart rate throughout the day. Conclusions: Patients with PD or GAD are more sensitive to bodily changes than nonanxious individuals, and patients with PD are more sensitive than those with GAD. PD patients experience more frequent distress than GAD patients and controls, but their physiologic responses compare in intensity. The perception of panic attacks may reflect central rather than peripheral responses. The diminished autonomic flexibility in both anxiety conditions may result from dysfunctional information processing during heightened anxiety.
(Arch Gen Psychiatry 2004;61:913-921)