Depression in patients referred for psychiatric consultation. A need for a new diagnosis

The Assessment and Prevalence of Affective Disorders in Advanced Cancer

The assessment of depression in patients with advanced cancer presents a difficult clinical challenge. Reported prevalence rates of depression in cancer patients range from 3.7% to 58%. Studies using structured diagnostic interviews and clearly defined diagnostic criteria are presented. The current literature suggests that among hospitalized cancer patients with significant levels of physical impairment at least 25% suffer from clinically important depression. Risk of suicide and recent literature regarding early wish to die are also discussed.

Properties of the Symptom Check List (SCL-90-R) in a Psychosomatic Consultation-Liaison Setting

The present study aimed to assess the effect of psychological screening of medical inpatients using the Symptom Check List, SCL-90-R. A sample of 630 medical inpatients who were referred to a psychosomatic consultation-liaison service was assessed using the SCL-90-R. A clinical interview was conducted with all assessed Patients. Patients referred to the consultation-liaison service showed high psychological distress. 73% of the subjects were classed as cases using the International Classification of Diseases (10th Revision) criteria and psychological impairment. The screening characteristics of the SCL-90-R were not as good as those reported for other outpatient samples. The SCL-90-R appears to have been valuable for the consultation-liaison service since subjects with mental disorders scored significantly higher on almost all the scales than subjects without mental disorders. The questionnaire can serve as a useful tool for understanding patients’ current status regarding mental health problems.

A descriptive study of adjustment disorder diagnoses in general hospital patients

Objective: A descriptive survey of the characteristics of medical and surgical patients given the diagnosis of adjustment disorder.

Method: 124 case notes of patients with adjustment disorder diagnoses seen over a one year period in a tertiary care hospital were reviewed to describe their characteristics. Patient demographic data, medical illness, hospitalisation details and psychiatric consultation notes were examined.

Results: This diagnosis represented 18.5% of consultation-liaison referrals. The length of hospitalisation for the adjustment disorder patients was more than twice that of general medical admissions. At least one psychosocial stressor was noted in 93% of all patients; in 59% of patients the medical illness was one of the stressors noted. About a third of patients had a past psychiatric history. Only 9% of patients had new courses of antidepressants recommended and in only 2% was inpatient psychiatric admission required. The diagnosis was used especially in patients with serious medical conditions, self-harm, injury and poisoning, and in cases presenting with a mixture of somatic and psychic symptoms.

Conclusions: The results suggest that this is a commonly used diagnosis in the medical consultation setting; it is largely being used in a way consistent with DSM criteria, whilst there were indications that it was also used for a range of problem behaviours that are difficult to classify.

Properties of the Symptom Check List (SCL-90-R) in a psychosomatic consultation-liaison setting

The present study aimed to assess the effect of psychological screening of medical inpatients using the Symptom Check List, SCL-90-R. A sample of 630 medical inpatients who were referred to a psychosomatic consultation-liaison service was assessed using the SCL-90-R. A clinical interview was conducted with all assessed patients. Patients referred to the consultation-liaison service showed high psychological distress. 73% of the subjects were classed as cases using the International Classification of Diseases (10th Revision) criteria and psychological impairment. The screening characteristics of the SCL-90-R were not as good as those reported for other outpatient samples. The SCL-90-R appears to have been valuable for the consultation-liaison service since subjects with mental disorders scored significantly higher on almost all the scales than subjects without mental disorders. The questionnaire can serve as a useful tool for understanding patients' current status regarding mental health problems.

Assessment of depression among cancer patients: the role of pain, cancer type and treatment

One hundred consecutive cancer patients were assessed using two structured methods for assessing major depressive disorder-Structured Clinical Interview for DSM III-R (SCID) and Endicott criteria-and using a depression rating scale-Hamilton Depression Rating Scale (HAMD). Forty-nine percent of patients were depressed using SCID (DSM III-R criteria), whereas 29% of patients were depressed using Endicott criteria. Twenty-eight percent of patients were depressed using both criteria. Age and sex did not have any influence on the assessment of major depression. Both the structured interview and the rating scale were able to identify suicide ideation. Depressed patients were not shown to have more lifetime depression than non-depressed patients using both structured methods. Patients who were depressed using both assessments of depression had more metastasis and pain than non-depressed patients.

Clinical practice issues in consultation-liaison psychiatry

OBJECTIVE

To overview and highlight the issues currently challenging and confronting consultation-liaison (C-L) psychiatry and to present them for discussion in a wider forum.

METHOD

Following preliminary discussions, the authors (members of the New South Wales C-L Interest Group) undertook to selectively review a number of issues relevant to C-L psychiatry. A preliminary paper was prepared and then presented to the membership of the interest group. Feedback from this meeting was incorporated into the final version of the paper.

RESULTS

Issues selected as a nidus for further discussion include economic issues, changing models of C-L practice, service issues as well as ethical, issues. In addition, recognition of C-L psychiatry as a true subspeciality is foreshadowed.

CONCLUSION

This paper highlights some of the challenges for C-L psychiatry both now and in the future. Intuitive beliefs in our efficacy will not suffice in this era of economic rationalisation. Disciplined and focused research substantiating our value is imperative. Subspeciality recognition is likely to ensure uniformity of standards as well as providing the structure and direction required to consolidate C-L psychiatry's future.

The recognition of depression in patients referred to a consultation-liaison service

The recognition of depression was examined in 987 medical and surgical patients referred to a consultation-liaison psychiatry service. Overall concordance of recognition of depression by the referring doctor and diagnosis of depression by the consultant psychiatrist was 74%; 41% false-positive rate, 15% false-negative rate. Concordance was higher in the Renal Unit and lower in the General Medical Unit. Patients for whom there was discordance were significantly older than those for whom there was concordance. Patients referred for depression but not diagnosed as such by psychiatrists received DSM-III-R diagnoses of Organic Mental Disorder, Somatoform and Related Disorders, Psychoactive Substance Use Disorders and Personality Disorders. On the other hand, patients diagnosed as having depression but not referred as such were referred instead for ill-defined reasons (suspected psychological component to illness, coping problems), suicide risk evaluation and routine pre-operative or pre-dialysis assessment. The results highlight the continuing misdiagnosis of psychiatric disorders, especially Organic Mental Disorders, as well as the mislabelling of the syndrome described by psychiatrists as depression. This is part of the wider problem of defining the boundaries of a clinical depressive syndrome in the physically ill.

Structured ambiguity and the definition of psychiatric illness: adjustment disorder among medical inpatients

Adjustment disorder is one of the most common psychiatric diagnoses given to patients hospitalized for medical and surgical problems. This article argues that the diagnosis, in this context, often serves strategic, non-clinical ends for consultation-liaison psychiatrists, who must negotiate their interstitial position through an essentially ambiguous diagnosis. In these cases, 'adjustment disorder' emerges from and reproduces tensions between such cultural dichotomies as mind/body and social/individual that marginalize psychiatry in medical settings.

Pharmacotherapy of depression in the medically ill: directions for future research

A common problem facing the psychiatric consultant and the medical practitioner is evaluating depression in patients with concurrent medical illnesses. Depression is difficult to recognize in the medically ill, often presenting with "masked" symptoms and organized into unique syndromes. A primary concern of the clinician is identifying those patients who are likely to benefit from an antidepressant trial. Although antidepressants have been shown to sometimes be of benefit in medical populations, the symptoms predicting antidepressant response remain poorly defined. Important directions for future research include 1) evaluating the safety and efficacy of newer antidepressants in the medically ill and 2) identifying those depressive syndromes that may be responsive to pharmacotherapy.