Prodromal stage of major depression

AIM

The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

METHODS

Both a computerized (Medline) and a manual search of the literature were performed.

RESULTS

In a substantial proportion of patients with depression a prodromal phase can be identified. There is a relationship between residual and prodromal symptomatology (the rollback phenomenon).

CONCLUSIONS

Appraisal of prodromal phase of major depression has important implications as to pathophysiological models of disease and relapse prevention. It may allow a staging system of depressive illness that may yield more enduring results in the therapeutic efforts.

Financial conflicts of interest in psychiatry

The issue of conflicts of interest has brought clinical medicine to an unprecedented crisis of credibility. The situation of psychiatry does not appear to be different from other areas of medicine. The problems caused by the increasing financial ties between the pharmaceutical industry and researchers and clinicians can be addressed only by a complex effort encompassing both the establishment of lines of support of independent researchers who are free of substantial conflicts of interest and better disclosure policies and conduct regulations as to financial ties. Such effort requires a bold shift from current, largely inadequate strategies. In the long run it may entail, however, substantial advantages to patients, clinicians, researchers, the health industry and the civil society at large. Psychiatry, in view of its humanistic and social roots, may lead this effort.

Well-being therapy in school settings: a pilot study

BACKGROUND

There is increasing interest in the psychobiological mechanisms of resilience and psychological well-being. It is conceivable that activation of such mechanisms in the school setting may entail long-term benefits, both in terms of the developmental process and of prevention of distress. This study wants to apply and test the efficacy of a school-based intervention protocol derived from well-being therapy (WBT) compared to cognitive-behavioral strategies.

METHODS

School interventions were performed in a population of 111 students randomly assigned to: (a) a protocol using theories and techniques derived from cognitive-behavioral therapy; (b) a protocol derived from WBT. Assessment before and after interventions was performed using two self-rating scales: Kellner's Symptom Questionnaire and Ryff's Psychological Well-Being Scales.

RESULTS

Both school-based interventions resulted in a comparable improvement in symptoms and psychological well-being.

CONCLUSIONS

This new well-being-enhancing strategy could play an important role in the prevention of psychological distress in school settings and in promoting optimal human functioning among children.

Psychosocial approach to endocrine disease

In recent years, there has been growing interest in the psychosocial aspects of endocrine disease, such as the role of life stress in the pathogenesis of some conditions, their association with affective disorders, and the presence of residual symptoms after adequate treatment. In clinical endocrinology, exploration of psychosocial antecedents may elucidate the temporal relationships between life events and symptom onset, as it has been shown to be relevant for pituitary (Cushing's disease, hyperprolactinemia) or thyroid (Graves' disease) conditions, as well as the role of allostatic load, linked to chronic stress, in uncovering a person's vulnerability. After endocrine abnormalities are established, they are frequently associated with a wide range of psychological symptoms: at times, such symptoms reach the level of psychiatric illness (mainly mood and anxiety disorders); at other times, however, they can only be identified by the subclinical forms of assessment provided by the Diagnostic Criteria for Psychosomatic Research (DCPR). Indeed, in a population study, the majority of patients suffered from at least one of the three DCPR syndromes considered: irritable mood, demoralization, persistent somatization. In particular, irritable mood was found to occur in 46% of 146 patients successfully treated for endocrine conditions, a rate similar to that found in cardiology and higher than in oncology and gastroenterology. Long-standing endocrine disorders may imply a degree of irreversibility of the pathological process and induce highly individualized affective responses. In patients who showed persistence or even worsening of psychological distress upon proper endocrine treatment, the value of appropriate psychiatric interventions was underscored. As it happened in other fields of clinical medicine, a conceptual shift from a merely biomedical care to a psychosomatic consideration of the person and his/her quality of life appears to be necessary for improving effectiveness in endocrinology. The DCPR have been demonstrated to be a valuable tool for psychological assessment in the various phases of endocrine disease from diagnostic to follow-up periods.

Development of a new assessment strategy in psychosomatic medicine: the diagnostic criteria for psychosomatic research

The Diagnostic Criteria for Psychosomatic Research (DCPR) are a diagnostic and conceptual framework that was proposed a decade ago by an international group of investigators. The DCPR's rationale was to translate psychosocial variables that derived from psychosomatic research into operational tools whereby individual patients could be identified. A set of 12 syndromes was developed: health anxiety, thanatophobia, disease phobia, illness denial, persistent somatization, conversion symptoms, functional somatic symptoms secondary to a psychiatric disorder, anniversary reaction, demoralization, irritable mood, type A behavior, and alexithymia. These criteria were meant to be used in a multiaxial approach. The aim of this work is to survey the research evidence which has accumulated on the DCPR, to provide specification for their development and validation and to examine the specific DCPR clusters. Their implications for classification purposes (DSM-V) are also discussed.

The intellectual crisis of psychiatric research

The aim of this paper was to examine the intellectual crisis and the potential sources of reveille in clinical research in psychiatry. Current prevailing conceptual models in psychiatry are critically examined, with particular reference to neurobiology, clinical psychopharmacology, assessment, and the therapeutic process. Biological reductionism, neglect of individual responses to treatment, massive propaganda from the pharmaceutical industry, misleading effects of psychometric theory on clinical assessment, and lack of consideration of multiple therapeutic ingredients and of the role of psychological well-being are identified as major sources of an intellectual crisis in psychiatric research. The conceptual crisis of psychiatry is shared by other areas of clinical medicine and stems from a narrow concept of science that neglects clinical observation, the basic method of medicine. A unified concept of health and disease may yield new clinical insights in psychiatric disorders, and may result in therapeutic efforts of more enduring quality than current strategies.

Psychological aspects of primary aldosteronism

BACKGROUND

Except for 3 case reports of Conn's syndrome presenting as depression, psychosocial factors have not been explored in primary aldosteronism. We investigated psychological correlates in primary aldosteronism using methods that were found to be sensitive and reliable in psychosomatic research.

METHOD

Ten consecutive newly diagnosed patients with primary aldosteronism were studied: 5 males/5 females; mean age (+/-SD) 45.5 +/- 6.6 years, age range 34-54 years; 4 with an aldosterone-producing adenoma and 6 with idiopathic aldosteronism; systolic/diastolic blood pressure 189 +/- 20/111 +/- 7.7 mm Hg; upright plasma aldosterone 40.0 +/- 18.3 ng/dl; upright plasma renin activity (PRA) 0.2 +/- 0.1 ng/ml/h; aldosterone/PRA ratio 229.2 +/- 191.0; serum K(+) 3.5 +/- 0.5 mmol/l. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for eliciting psychiatric diagnoses, and a shortened version of the structured interview for subclinical psychological syndromes, the Diagnostic Criteria for Psychosomatic Research (DCPR), were administered.

RESULTS

Seven patients (2 with aldosterone-producing adenoma and 5 with idiopathic hyperaldosteronism) received both DSM-IV and DCPR diagnoses, while 3 had neither. As to DSM-IV, generalized anxiety disorder was detected in 6 cases (in 1 it was associated with panic disorder and in 1 with major depression) and obsessive-compulsive disorder in 1. The most frequent DCPR cluster was demoralization (5 cases), while persistent somatization occurred in 2 cases (associated with demoralization in 1) and irritable mood in 1.

CONCLUSIONS

The occurrence of anxiety disorders in patients with primary aldosteronism was much higher than that found in the general population and in primary care. Since an association between hyperaldosteronism and anxiety has also been suggested in previous animal studies, it seems worthwhile to gain further knowledge on clinical aspects by larger population studies.

Integration of Multiple Criteria for Psychosomatic Assessment of Dermatological Patients

Psychological distress has been frequently reported in the setting of skin disorders. The Diagnostic Criteria for Psychosomatic Research (DCPR) have been found to yield valuable integrative information, in addition to DSM-IV nosology, in a variety of medical diseases. The aim of this study was to verify whether this integration could also be helpful in dermatology. A consecutive series of 539 inpatients with various skin conditions was evaluated by means of structured interviews for DSM-IV and DCPR diagnoses. The prevalence of DSM-IV conditions was 38% (mostly depressive disorders and anxiety disorders), whereas that of DCPR clusters (mostly demoralization and somatization secondary to psychopathology) was 48%. Overall, DCPR diagnoses were significantly more frequent than DSM-IV categories, regardless of the presence or absence of a psychiatric disorder. Psychological assessment of patients with skin diseases needs to incorporate both clinical (DSM-IV) and subclinical (DCPR) methods of classification. The health status of these patients can be improved if their psychological problems are appropriately assessed and recognized.

Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in a Community Sample

The authors assessed the prevalence of Diagnostic Criteria for Psychosomatic Research (DCPR) clusters in a community sample and the association between these syndromes and psychosocial variables. A group of 347 consecutive subjects from the general population were administered the semistructured interview for DCPR and a self-rating scale (the Psychosocial Index). A DCPR syndrome was identified in 59% of subjects. These subjects showed more stress and distress and less well-being than those without a DCPR syndrome. Some DCPR syndromes (alexithymia, Type A behavior, irritable mood) are frequently encountered in a community sample and are associated with impairment in quality of life. Other syndromes (demoralization, persistent somatization) that have been frequently found in medically ill persons were uncommon in this general-population sample.

Irritable mood in Italian patients with medical disease

Irritability may be a mood state independent of other moods and anxiety disorders, even though it may be symptomatic of several psychiatric disorders, such as major depression. The aims of this exploratory study were to verify the presence of irritable mood in a group of medical outpatients with a variety of clinical conditions (functional gastrointestinal disorders, cardiovascular disorders, endocrine diseases and cancer) and to examine its relationship with major depression. A total of 609 consecutive outpatients recruited from different medical settings were assessed according to DSM-IV and Diagnostic Criteria for Psychosomatic Research using semistructured research interviews. Irritable mood was identified in 163 (27%) patients, while major depression was present in 113 (19%) patients. Even though there was a considerable overlap between the two diagnoses, 76 (67%) patients with major depression were not classified as irritable, and 126 (77%) patients with irritable mood did not satisfy the criteria for major depression. The findings suggest a high prevalence of irritability in the medically ill, which in most cases is independent of mood disorder. Further research may determine whether irritability, alone or in association with major depression, entails prognostic and clinical implications.

Personality characteristics and quality of life in patients treated for Cushing's syndrome

OBJECTIVE

Psychological distress does not always disappear upon proper endocrine treatment of Cushing's syndrome, and quality of life may still be compromised. Little is known on the personality correlates that may be involved. The aim of this study was to provide a controlled assessment of personality characteristics and quality of life in patients successfully treated for Cushing's syndrome.

DESIGN

A single-centred, controlled, prospective study.

PATIENTS

Twenty-four consecutive outpatients who were in remission upon proper treatment of Cushing's syndrome for at least 1 year and no more than 3 years (20 with pituitary-dependent Cushing's disease and four with a cortisol-secreting adrenal adenoma; 5 M/19 F; mean age 34.5, SD = 10.6; range 18-57 years) were compared with 24 healthy control subjects matched for sociodemographic variables.

MEASUREMENTS

Both patients and controls were administered two self-rating scales: (a) tridimensional personality questionnaire (TPQ), a 100-item inventory that yields three scales: novelty seeking, harm avoidance and reward dependence. (b) symptom rating test (SRT), a 46-item scale for assessing psychological distress and quality of life with six subscales (anxiety, depression, somatic symptoms, anger-hostility, cognitive symptoms, psychotic symptoms).

RESULTS

There were no significant differences in personality dimensions, as measured by the TPQ, between patients and controls. The results did not change when the four patients with an adrenal adenoma were excluded and only the 20 with pituitary-dependent Cushing's disease were considered. As to the SRT scale, patients with Cushing's syndrome displayed significantly higher scores in anxiety (P= 0.046), depression (P= 0.013), and psychotic symptoms (P= 0.006), with a generalized compromised quality of life (P= 0.02). Again, no differences were found in evaluating the 20 patients with Cushing's disease separately.

CONCLUSIONS

Even though personality traits other than those explored here may be involved, the results seem to exclude the presence of latent dysfunctional attitudes and beliefs contributing to long-standing psychological disturbances, even in the pituitary-dependent form of Cushing's syndrome. Data from larger populations might provide further insight in this field. The findings of a compromised quality of life are in agreement with the recent literature and have implications for the long-term management of patients.

Psychosomatic assessment of skin diseases in clinical practice

BACKGROUND

Psychiatric disorders are frequent in dermatology patients, and many studies pointed out complex, mutual relationships between psyche and skin. Our aim was to provide a systematic psychosocial evaluation of a large and heterogeneous population of patients with skin diseases, including assessments of quality of life, psychiatric status according to the DSM-IV and psychological conditions with psychosomatic relevance according to established criteria (Diagnostic Criteria for Psychosomatic Research, DCPR).

METHODS

We studied 545 dermatological inpatients aged 18-65 years, free from dementia and cognitive impairment. They completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12) and were administered the SCID-I and the Structured Interview for Psychological Conditions of Psychosomatic Relevance by a trained mental health professional blinded to questionnaire scores.

RESULTS

Overall, 38% of patients received a DSM-IV diagnosis. The most common diagnoses were mood (20%) and anxiety disorders (16%); 48% of patients also received a DCPR diagnosis. The most common were demoralisation, irritable mood, type A behaviour and various forms of abnormal illness behaviour. Adjusting for gender, age, and education, the presence of DSM-IV or DCPR diagnoses was significantly associated with high scores on the GHQ-12 and on the Functioning and Emotions scales of the Skindex-29. Also, DCPR diagnoses were significantly associated with high scores on the Symptoms scale of the Skindex-29.

CONCLUSIONS

These findings highlight the high frequency of psychosocial problems in patients with skin disease and suggest that the joint use of DSM-IV and DCPR criteria may help identify those patients in whom psychiatric issues are worthy of increased clinical attention.

Protective environments and health status: Cross-talk between human and animal studies

Although aging populations tend to have increased prevalence of a diversity of diseases and disabilities, there are substantial numbers of people who, nevertheless, maintain good health into old age. Human studies frequently demonstrate associations between environmental factors, particularly supportive social environments, and positive states of health. Identifying the pathways from protective social environments to reduced disease risk necessitates the use of animal models as a basis of explanation and a source of suggestions for further human research. We present two examples of this kind of cross-talk: (i) the possibility that the success of well-being therapy following pharmacological treatment for depression as a means of preventing recurrent depressive episodes is based on the stimulation of enrichment of dendritic networks in the hippocampus and spine retraction in the basolateral amygdala; (ii) the possibility that the release of intracerebral oxytocin is a mediating factor between persistently supportive social environments and reduced disease in later life, as exemplified by low levels of allostatic load.

Sequential treatment of mood and anxiety disorders

OBJECTIVE

Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this review was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood and anxiety disturbances.

DATA SOURCES AND STUDY SELECTION

A review of the clinical trials in which treatment components were used in a sequential order (i.e., pharmacotherapy followed by psychotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, or one psychotherapeutic technique following another) was performed. Studies were identified by using MEDLINE (English language articles published from 1967 to March 2005; keywords: sequential treatment, drugs and psychotherapy, combined treatment related to depressive disorder, bipolar disorder, depression, mania, anxiety disorders, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder) and a manual search of the literature and Index Medicus for the years 1960 to 2005.

DATA SYNTHESIS

In unipolar recurrent depression, the sequential use of pharmacotherapy was found to reduce relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already undergoing treatment with mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome.

CONCLUSION

The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, 2-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with mood and anxiety disorders. The sequential model introduces a conceptual shift in current assessment methods.

Alternatives to debriefing and modifications to cognitive behavior therapy for posttraumatic stress disorder

BACKGROUND

Psychological debriefing uses brief unsystematic exposure, and is ineffective for posttraumatic stress symptoms and disorder. Systematic exposure alone and cognitive restructuring alone are each effective. Other approaches too may be useful.

METHODS

The treatment of 3 posttraumatic stress disorder (PTSD) patients is detailed in which there was no exposure to the main traumatic event. There was exposure to related cues in case 1, exposure to related and other cues followed by well-being therapy (WBT) in case 2 and WBT in case 3.

RESULTS

The 3 patients improved enduringly, confirming earlier findings that exposure to the main trauma is not essential for PTSD to improve.

CONCLUSIONS

A study is needed of therapeutic mechanisms in PTSD and of the value of WBT in a randomized controlled trial.

A discussion on the role of clinimetrics and the misleading effects of psychometric theory

BACKGROUND

Psychometric theory is the basis for the development of assessment instruments in psychiatric research.

METHODS

It has produced a number of variable methods for improving the validity and reliability of clinical assessment. However, the psychometric model appears to be largely inadequate in the clinical setting because of its lack of sensitivity to change and its quest for homogeneous components.

RESULTS

Clinimetrics offers a viable integration to psychometrics, both from a conceptual and a methodologic viewpoint.

CONCLUSION

Without such integration, psychometric rules and methods may lead to misleading effects in clinical research both in psychiatry and medicine.

[Well-being therapy]

Well-being and quality of life are leading psychological factors that are basically independent of disease and the burdens of life. The more problems a person has to cope with, the more important they become as factors impacting upon an illness. Well-being Therapy (WBT) is a novel psychotherapeutic strategy aimed at promoting psychological well-being. WBT is based on Ryff's multidimensional model of subjective well-being which comprises six subdivisions: mastery of the environment, personal growth, purpose and meaning of life, autonomy, self-acceptance and positive relationships. The aim of this therapy is to improve the patient's performance/activities in all of these areas.

The clinical domains of psychosomatic medicine

BACKGROUND

The psychosomatic evidence that has consolidated over the past decades provides the ideal background for dealing with the new needs that emerge in current medical practice.

METHOD

A review of the psychosomatic literature, using both MEDLINE and manual searches, was performed. Search terms were psychosomatic, psychosomatic medicine, mind-body medicine, and biopsychosocial. Medical journals and books in English were also searched manually. Articles, with particular reference to review articles, which were judged to be relevant to clinical practice, were selected.

RESULTS

The following aspects were found of particular clinical interest: assessment of psychosocial factors affecting individual vulnerability (life events, chronic stress and allostatic load, well-being, and health attitudes), evaluation of psychosocial correlates of medical disease (psychiatric disturbances, psychological symptoms, illness behavior, and quality of life), application of psychological therapies to medical disease (lifestyle modification, treatment of psychiatric comorbidity, and abnormal illness behavior).

CONCLUSION

A psychosomatic approach may be crucial in managing patients with unexplained somatic symptoms and in identifying psychological distress that cannot be diagnosed by psychiatric categories. Furthermore, it may contribute to recovery and rehabilitation by specific interventions.

Assessing the community prevalence of bipolar spectrum symptoms by the mood disorder questionnaire

BACKGROUND

The goal of this study was to assess the frequency and spectrum of symptoms related to bipolar disorders in a community sample by means of a self-rating questionnaire.

METHOD

The Mood Disorder Questionnaire, a self-rating scale which evaluates DSM-IV manic/hypomanic symptoms, was administered to a community sample of 1,034 individuals recruited through advertisements. Symptom interrelationships were studied by factor analysis.

RESULTS

275 individuals (26.6%) reported moderate or severe impairment due to the symptoms. Manic/hypomanic symptoms were present in a high proportion of individuals. Factor analysis found a two-factor structure of bipolar spectrum symptoms (an elevated mood overactivity factor, and an irritable behavior factor).

CONCLUSION

The findings of this study highlight the need of complementing clinical investigations on the bipolar spectrum with community studies. Subclinical manic-hypomanic symptoms may be present also in allegedly unipolar patients and may have implications on the course of illness.

Well-being therapy of generalized anxiety disorder

BACKGROUND

There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD.

METHODS

Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken.

RESULTS

Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up.

CONCLUSIONS

These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Assessing demoralization and depression in the setting of medical disease

OBJECTIVE

The aim of this study was to assess the presence of demoralization and major depression in the setting of medical disease.

METHOD

807 consecutive outpatients recruited from different medical settings (gastroenterology, cardiology, endocrinology, and oncology) were assessed according to DSM-IV criteria and Diagnostic Criteria for Psychosomatic Research, using semistructured research interviews.

RESULTS

Demoralization was identified in 245 patients (30.4%), while major depression was present in 135 patients (16.7%). Even though there was a considerable overlap between the 2 diagnoses, 59 patients (43.7%) with major depression were not classified as demoralized, and 169 patients (69.0%) with demoralization did not satisfy the criteria for major depression.

CONCLUSIONS

The findings suggest a high prevalence of demoralization in the medically ill and the feasibility of a differentiation between demoralization and depression. Further research may determine whether demoralization, alone or in association with major depression, entails prognostic and clinical implications.