Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population

Anxiety and depression-Important psychological comorbidities of COPD

Anxiety and depression are common and important comorbidities in patients with chronic obstructive pulmonary disease (COPD). The pathophysiology of these psychological comorbidities in COPD is complex and possibly explained by common risk factors, response to symptomatology and biochemical alterations. The presence of anxiety and/or depression in COPD patients is associated with increased mortality, exacerbation rates, length of hospital stay, and decreased quality of life and functional status. There is currently no consensus on the most appropriate approach to screening for anxiety and depression in COPD. Treatment options include psychological [relaxation, cognitive behavioural therapy (CBT), self-management] and pharmacological interventions. Although there is some evidence to support these treatments in COPD, the data are limited and mainly comprised by small studies. Pulmonary rehabilitation improves anxiety and depression, and conversely these conditions impact rehabilitation completion rates. Additional high quality studies are urgently required to optimise screening and effective treatment of anxiety and depression in patients with COPD, to enhance complex chronic disease management for these patients.

Lo studio internazionale multicentrico dell'Organizzazione Mondiale della Sanità sui disturbi psichici nella medicina generale: risultati relativi all'area di Verona

Objectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.

“How Much Can I Take?”: Predictors of Perceived Burden for Relatives of People with Chronic Illness

Introduction: Chronic illnesses are common and have detrimental effects not only on the affected individuals but also on their families. These negative consequences on the physical and psychological health of caregivers constitute the burden of care. We investigate the predictors of perceived burden of care among relatives of people with any chronic physical or mental illness using secondary data from a nationwide survey in Singapore. Materials and Methods: A cross-sectional household survey was conducted among adult residents of age 18 years and above and data were analysed to explore the predictors of high perceived burden of care. Two thousand four hundred and fifty-eight respondents having at least 1 close relative with any chronic physical and/or mental illness were included. Results: Majority of the respondents had at least 1 close family member with physical illness (88.3%)—the most common illnesses reported were memory problems (86.9%), physical disability (74.8%), heart problems (70.1%) and cancer (62.2%). About 30.9% (n = 723) perceived high burden resulting from their relatives’ health condition. Logistic analysis showed that women were more likely (OR 1.58, P = 0.0026) and Malays were less likely (OR 0.68, P = 0.0044) to perceive burden. Those who were able to open up to their family or friends (OR 1.65, P = 0.0162) and those who had dysthymia had higher odds (OR 4.91, respectively, P =0.0364) of perceiving burden. Conclusion: Our results suggest that regardless of the nature of the chronic illnesses, gender or ethnicity, the capacity to open up to family or friends and the mental health status of caregivers can predict their perceived burden. The results provide valuable preliminary information for planning social policies and interventions for improving the well-being of caregivers. Key words: Mental illness, Social support, Subjective burden

Gender, depression and physical impairment: an epidemiologic perspective from Aleppo, Syria

OBJECTIVE

Examine the association of physical impairment with gender, depression, and socio-demographics in the community in Aleppo, Syria.

METHOD

We conducted a cross-sectional, population-based study in Aleppo on adults aged 18-65 (N = 2,038). We used a computerized interviewer-administered structured questionnaire. Physical impairment was measured via an adapted 12-item World Health Organization, Health State Description Individual Questionnaire which includes both physical and emotional items. We used physical impairment items score to classify individuals into low, middle, and high physical impairment category. Self-report of physician-diagnosed depression and chronic diseases active in the past year and their current treatment status were obtained.

RESULTS

Sample mean age (SD) was 35.3 (12.1) years, 55% were female, and 4.5% had depression. Female gender, low socioeconomic status (SES), and depression were associated with high physical impairment. Women had more impairment (OR = 3.35, 95% CI: 2.15-5.21) with little change after controlling for depression and chronic diseases, but significantly decreased after controlling for socio-demographics (OR = 1.51, 95% CI: 0.84-2.73). The association with low (vs. high) SES was prominent (OR = 2.48, 95% CI: 1.32-4.67) after controlling for all variables. Depression's association (OR = 4.85, 95% CI: 1.93-12.15) lost significance after controlling for chronic diseases (OR = 2.81, 95% CI: 0.96-8.25), but further adjustment for socio-demographics had little effect.

CONCLUSION

Women and individuals of low SES appear more vulnerable to physical impairment in the community in Aleppo. Depression's association with physical impairment may be mediated through co-existing chronic diseases. Public health planning regarding physical impairment in Syria should encompass these as putative risk factors.

Role of depressive symptoms and comorbid chronic disease on health-related quality of life among community-dwelling older adults

OBJECTIVE

This study examined the influence of depressive symptoms on health-related quality of life (HRQOL) among community-dwelling older adults suffering from various categories of chronic comorbidity.

METHODS

A population-based survey in adults aged 60 years or more was conducted within a random sample of 1085 beneficiaries of the Mexican Institute of Social Security in Mexico City. Depressive symptoms were evaluated with the 15-item Geriatric Depression Scale, and chronic comorbidity was determined with self-reports concerning prior medical diagnoses and the HRQOL Short Form-36 health survey. We carried out a stratified analysis by comorbidity category, evaluating the impact of depressive symptoms on HRQOL through an analysis of variance and modeling the independent association of depression symptoms with HRQOL using multiple linear regression analyses adjusted for comorbidity and other covariables.

RESULTS

HRQOL scores were low in the presence of depressive symptoms, while their impact increased when chronic diseases were also present. The group with the poorest HRQOL was older adults suffering from both depressive symptoms and two or more chronic diseases (P<.05). The stratified analysis by comorbidity and multivariate analysis, adjusted for covariables, indicated that depressive symptoms and comorbidity had cumulative negative effects on HRQOL.

CONCLUSION

The HRQOL of older adults deteriorated when depressive symptoms were present and decreased even further with the simultaneous occurrence of chronic illnesses. Identifying depression symptoms-either alone or along with chronic conditions-is crucial for implementation of measures aimed at improving elderly people's HRQOL.

Associations with Changes in Level of Functional Ability. Results from a Follow-up Survey at Two and a Half Years of People Aged 85 Years and Over at Baseline Interview

This paper describes association with changes in functional ability among very elderly people who were interviewed first in 1987 when they were aged 85+, and followed-up in 1990. It focuses, in particular, on those with severe difficulties with ADL. It was notable that while those with chronic problems with disability used more health and social services, few received services specific to rehabilitation and social support (e.g. physiotherapy, occupational therapy and social work), and substantial numbers in this group (30–45%) did not receive any chiropody services; although the provision of instrumental aid with tasks of daily living was relatively high from home help services, and, in particular, from relatives.

A community study of the presence of anxiety disorder in people with epilepsy

Anxiety represents a major problem for people with epilepsy, and it is important to understand why it arises and how to reduce its potential debilitating and adverse effects. The aim of this study was to determine the prevalence of anxiety in a community-identified sample of people with epilepsy and to identify which demographic and clinical factors are most closely associated with anxiety and which factors predict the presence of anxiety among people with epilepsy. Adults with epilepsy in the community (n=515) were identified through primary care records and sent validated questionnaires, which included the Hospital Anxiety and Depression Scale (HADS). The mailout also included items on demographic and clinical variables. The prevalence of anxiety (HADS score >11) in this sample was 20.5% (95% CI: 16.9-24.1%) and was associated with a current history of depression, perceived side effects of antiepileptic medication, lower educational attainment, chronic ill health, female gender, and unemployment. It was not associated with the duration of epilepsy. The findings from this study suggest that anxiety disorders in a community population with epilepsy are most strongly predicted by factors independent of epilepsy-related variables, with the exception of patient-reported side effects. It is important to be aware of these factors when evaluating an individual with epilepsy.

Depressive Symptoms and Indicators of Maternal Health Status during Pregnancy

OBJECTIVES

Depressive symptoms are common among women, especially those who are of childbearing age or are pregnant. Prior studies have suggested that an increased burden of depressive symptoms is associated with diminished health and functional status, but these studies were primarily of middle-aged and older adults. In the current study, we investigated the relationship between depressive symptoms and health and functional status among pregnant women.

METHODS

Women were enrolled in the study at their first prenatal visit to hospital-based clinics and administered an interview that contained the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms and several questions to measure overall health status, limitations in performing moderate activities, and limitations in climbing stairs.

RESULTS

The sample included 1163 women. Women with higher levels of depressive symptoms, using cutoff points on the CES-D of either > or =16 (clinically significant) or > or =23 (major depression), had approximately twice the risk of poorer self-reported health and functional status than those with lower scores after adjustment for age, marital status, smoking, education, insurance, trimester, and race.

CONCLUSIONS

These results suggest that an increased burden of depressive symptoms during pregnancy is associated with diminished health status and may offer an explanation for the reported association between depressive symptoms and preterm birth.

Influence of patient preference and primary care clinician proclivity for watchful waiting on receipt of depression treatment

OBJECTIVE

We examined whether patients' preference for watchful waiting and their primary care clinician's proclivity for watchful waiting were associated with decreased likelihood of receiving depression treatment.

METHODS

In a quality improvement intervention for depression in primary care, patients with depressive symptoms were identified through screening in 46 clinics from June 1996 to March 1997. We analyzed baseline survey data completed by clinicians and patients using logistic regression models.

RESULTS

Of 1140 patients, 179 (16%) preferred watchful waiting over active treatment. After controlling for covariates, patients with depressive disorders who preferred watchful waiting were less likely to report use of antidepressants (OR=0.86, 95% CI=0.77-0.95). Among patients with depressive symptoms only, those who preferred watchful waiting were less likely to report antidepressant use (OR=0.84, 95% CI=0.76-0.93) or counseling (OR=0.84, 95% CI=0.77-0.95). Patients with less knowledge about depression were less likely to receive depression treatment. Clinician proclivity for watchful waiting was not associated with the likelihood that patients received depression treatment.

CONCLUSIONS

Patient preference for watchful waiting is associated with lower rates of some depression treatments, especially among patients with subsyndromal depression. Addressing patient preference for watchful waiting in primary care may include active symptom monitoring and patient education.

Prediction of depression in European general practice attendees: the PREDICT study

Background

Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation.

Methods/design

This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent.

Discussion

Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

Posttraumatic Stress Disorder and Health Status

This article examines the association between self-reported prevalence of posttraumatic stress disorder (PTSD) and health status in a sample of 2425 male Department of Veterans Affairs (VA) ambulatory care patients who participated in the Veterans Health Study. Participants were recruited at 1 of 4 VA outpatient clinics in the Boston area. They completed self-report measures of PTSD (using the PTSD Checklist and measures of exposure to traumatic events), depression (using the Center for Epidemiologic Studies--Depression scale), and health status (using the Short-Form-36) and a medical history interview assessing 22 conditions and a history of psychiatric treatment. The screening prevalence of PTSD was 20.2% among all patients (24.3% among those exposed to traumatic events); another 15.5% met the criteria for depression but not PTSD. The health status of patients with either PTSD or depression was significantly worse than that of patients with neither disorder, even after controlling for age, education, and number of comorbid medical conditions. Patients with PTSD reported more medical conditions than did other patients. Patients with PTSD currently in mental health treatment had worse health status than did those who reported no treatment; the health status of patients who reported past mental health treatment was generally comparable to that of those with no treatment. The prevalence and comorbidity of PTSD among this sample of VA ambulatory care patients were higher than previously reported among samples of community-residing adults. The association of PTSD with health status was substantial, suggesting that the burden of PTSD is at least comparable to, and may be worse than, that of depression. Mental health treatment alleviated some of this burden. The potential impact of PTSD on health status should be more widely recognized.

Bodily symptoms in moderate and severe depression

The aim of this study was to describe bodily symptoms in severe depression, testing the hypotheses that patients with depression compared with healthy controls have several specific bodily symptoms and complaints, and furthermore that changes in severity of depression correlate to changes in bodily symptoms. Inpatients (n=29) with a diagnosis of moderate to severe depression (ICD-10) and 29 matched healthy controls were included in the study. Bodily symptoms were assessed with the Body Awareness Scale (BAS) and the severity of depression with the Hamilton Depression Scale (HDS). Patients were assessed twice, i.e. when admitted to hospital and again when discharged. The patients with severe depression had more muscular tension, pain-complaints, restricted breathing, negative attitudes towards own body and lesser centring in movements compared with the healthy controls (p<0.001). Improvement in bodily symptoms was statistically significant (p<0.01), and an improvement in depression score was observed. The findings of the study may underline the importance of investigating bodily symptoms in depression and indicates a need for a specific physiotherapeutic treatment of patients with moderate to severe depression.

Primary Intensive Care: Pilot Study of a Primary Care–Based Intervention for High-Utilizing Patients

This pilot study was conducted to determine whether primary care patients with perceived inappropriate high healthcare utilization would require fewer emergency or inpatient services while enrolled in a weekly multidisciplinary clinic. Seventeen high-utilizing or difficult management patients of a primary care center were referred for the special intervention, Primary Intensive Care (PIC). Although not selected for the presence of psychopathology, 16 patients had comorbid psychiatric diagnoses. Patients followed in the PIC Clinic had significantly lower inpatient and emergency department use during their enrollment in the intervention when compared to the matched pre-enrollment time period, although the total hospital cost differences did not reach statistical significance. Patient and staff satisfaction was high, although the intervention was very difficult for the providers.

Racial/ethnic discrimination and common mental disorders among workers: findings from the EMPIRIC Study of Ethnic Minority Groups in the United Kingdom

OBJECTIVES

We measured perceived discrimination and its association with common mental disorders among workers in the United Kingdom.

METHODS

We conducted a secondary analysis of a national sample of 6 ethnic groups (n=2054). Discrimination was measured as reports of insults; unfair treatment at work; or job denial stemming from race, religion, or language. The outcome assessed was presence of common mental disorders.

RESULTS

The risk of mental disorders was highest among ethnic minority individuals reporting unfair treatment (odds ratio [OR]=2.0; 95% confidence interval [CI]=1.2, 3.2) and racial insults (OR=2.3; 95% CI=1.4, 3.6). The overall greatest risks were observed among Black Caribbeans exposed to unfair treatment at work (OR=2.9; 95% CI=1.2, 7.3) and Indian (OR=3.1; 95% CI=1.4, 7.2), Bangladeshi (OR=32.9; 95% CI=2.5, 436.0), and Irish (OR=2.9; 95% CI=1.1, 7.6) individuals reporting insults.

CONCLUSIONS

Racial/ethnic discrimination shows strong associations with common mental disorders.

Medication management of depression: the impact of comorbid chronic medical conditions

OBJECTIVE

This paper addresses the following question: Does quality of care for depression differ between depressed persons with and without chronic medical conditions (CMCs)?

METHODS

We used a population-based mental health survey to identify respondents aged 18 to 64 with the diagnosis of major depression in the past year (N = 278). In our model, the dependent variable was guideline-level medication management of depression. Determinants for guideline-level care were modeled using multivariate logistic regression.

RESULTS

Depressed persons with CMCs were significantly more likely to receive guideline-level care for depression than were the depressed persons without CMCs (OR = 1.46; 95% C.I. = 1.12-1.90). This increased likelihood did not persist when the sample excluded persons seeing physicians at more than eight visits per year (OR = 0.81; 95% CI = 0.35-1.90). Previous psychiatric hospitalization was the only other significant determinant of guideline-level care.

CONCLUSION

Depressed persons with comorbid CMCs are more likely to receive guideline-level care for depression than are depressed persons without comorbid CMCs. However, the association did not persist once we excluded respondents who were high utilizers. This finding implies that further understanding of the interaction between depression care and comorbid CMCs will require a longitudinal focus on repeated physician-patient interactions.

Effect on disability outcomes of a depression relapse prevention program

OBJECTIVE

This report evaluates the effects of a depression relapse prevention program on disability outcomes among patients treated for depression at high risk for relapse.

MATERIALS AND METHODS

Primary care patients initiating antidepressant treatment for depression were assessed 6 to 8 weeks after the initial prescription. Patients responding to initial treatment but at high risk for relapse were randomized to usual care or a relapse prevention intervention (N= 386). The 12-month relapse prevention program included systematic patient education, two psycho-educational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and ongoing monitoring of medication adherence and depressive symptoms via telephone and mail. Disability outcomes were assessed via blinded telephone assessments at 3, 6, 9, and 12 months using SF-36 and Sheehan Disability scales.

RESULTS

Usual care patients and relapse prevention program patients had high rates of use of maintenance pharmacotherapy. Both relapse prevention and usual care patients showed improved functioning over the 12-month follow-up period. One of the three disability measures (the SF-36 Social Function scale) showed a significant intervention effect because of continuing improvement at 9 and 12 month follow-up, whereas the Sheehan Disability Scale showed a nonsignificant trend toward greater improvements in disability among relapse prevention patients than among usual care controls.

CONCLUSIONS

Moderate effects of a relapse prevention intervention on depressive symptoms were associated with modest and variable effects on disability outcomes. Inconsistent effects of the intervention for disability outcomes may be because of the high rates of maintenance pharmacotherapy among usual care patients, relatively mild levels of depressive symptoms among both intervention and control patients at baseline, the absence of a specific relapse prevention effect of the intervention, and the resultant modest differences in depressive symptoms between intervention and control patients in this trial.

Chronic fatigue and sociodemographic characteristics as predictors of psychiatric disorders in a community-based sample

OBJECTIVES

To explore the roles of chronic fatigue and sociodemographic characteristics (eg, parental status, work status, socioeconomic status, sex, age, marital status, and ethnicity) as predictors of psychiatric disorders.

METHODS

A stratified random sample of 18,675 adults residing in diverse neighborhoods in Chicago completed a telephone-screening questionnaire. A control group without chronic fatigue (N = 74) and a group of individuals with chronic fatigue (N = 227) were identified and administered a semi-structured psychiatric interview. Stepwise logistic regression analyses predicting occurrence of current and lifetime psychiatric disorders according to chronic fatigue status and sociodemographics were conducted on this overall sample of 301 participants.

RESULTS

Chronic fatigue, low socioeconomic status, and unemployment were among significant predictors of overall Axis I psychiatric disorders. Chronic fatigue functioned as a predictor for mood and anxiety disorders (including posttraumatic stress disorder), but did not function as a predictor for somatoform disorders, substance abuse/dependence, and eating disorders. Low socioeconomic status and unemployment were significantly associated with current psychiatric disorder, and low socioeconomic status was also significantly associated with mood and anxiety disorders. Women were significantly more likely to experience mood disorder, and minorities (eg, African Americans, Latinos, and individuals of other ethnicity) were significantly more likely to report posttraumatic stress disorder.

CONCLUSIONS

Results support prior findings for increased rates of psychiatric disorder among individuals with chronic fatigue and highlight the roles of low socioeconomic status, unemployment, being a woman, and being classified as a minority in their association with certain psychiatric disorders.

A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses

OBJECTIVE

To determine whether type 2 diabetes contributes to the presence of depressive and anxiety disorder diagnoses in low-income adults with hypertension, asthma, and/or arthritis.

RESEARCH DESIGN AND METHODS

Using a cross-sectional design, this study administered a structured diagnostic interview to low-income primary care patients diagnosed with type 2 diabetes, hypertension, arthritis, and asthma, as well as to those with no chronic illness (n = 326), to determine the 12-month prevalence of depressive and anxiety disorders. A logistic regression (LR) model was used to assess whether a diagnosis of depression and/or anxiety was associated with type 2 diabetes after adjusting for known risk factors.

RESULTS

A high prevalence rate of depressive and/or anxiety disorders was found in the total sample (29%) and in all three illness groups: type 2 diabetes (36%), other chronic illnesses (24%), and no chronic illness (31%). Using LR, a main effect was detected for illness group when age and education were controlled (chi(2) = 22.66, df 4, P = 0.000). Specifically, the odds of occurrence of a depressive and/or anxiety disorder in those with comorbid type 2 diabetes were twice that in the nondiabetic, chronically ill comparison group (odds ratio 2.26, 95% CI 1.28-4.01, P = 0.005).

CONCLUSIONS

These results suggest a positive contribution of type 2 diabetes to increased rates of depressive and/or anxiety disorders in patients with hypertension, asthma, and/or arthritis and support prior research that type 2 diabetes may serve as an indicator of depression and anxiety in low-income adults treated in primary care clinics.

Screening for depression in medical care: pitfalls, alternatives, and revised priorities

Depression is a disorder seen commonly in general and specialty medical settings. Screening has been advocated as a means of ensuring that depressed patients are identified and receive appropriate treatment. Yet, recommendations for routine screening are frequently made without reference to empirical data demonstrating that it will have its intended effect. We examine the literature regarding screening in medical settings and suggest that screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems. We offer suggestions for how screening instruments might be used to improve the outcomes of depressed persons while minimizing negative effects on health care.

Self-reported Depressive Symptoms in Myasthenia Gravis

It is well known that patients with a chronic medical illness experience major depression at a higher rate than the general population. The purpose of this study was to determine the frequency of depression among patients with myasthenia gravis (MG) who were referred to a Muscular Dystrophy Association clinic. Forty-five patients with a diagnosis of MG were evaluated with a self-administered survey regarding various typical somatic and psychologic symptoms of depression (the Beck Depression Inventory [BDI]) and then scored according to the BDI guidelines. Thirty-three percent of these patients generated scores suggestive of depression (24% were categorized as mildly depressed, 7% as moderately depressed, and 2% as severely depressed). These results suggest that patients with MG patients experience depression at a higher rate than the general population and at a similar rate as patients with other chronic illnesses.

Determinants of the diagnosis of psychological problems by primary care physicians in patients with normal GHQ-28 scores

In studies comparing the performance of psychometric instruments and general practitioners in the identification of psychological disorders, authors usually treat the psychometric instrument as the gold standard. Some patients may have no psychiatric diagnosis and normal scores on self-report measures of distress, but still benefit from detection and treatment of their psychosocial problems. However, physicians may be spending valuable time identifying problems in patients who have no disability. The extent and implications of the discrepancy between clinician assessment and standard instruments requires further exploration. Adult patients of 40 family physicians completed the General Health Questionnaire (GHQ-28) before their visit. Immediately following the visit, physicians, who were blind to the patient's GHQ score, indicated whether they had detected any signs or symptoms of anxiety, depression, somatization, or other psychosocial problems. Of the 1,011 primary care patients that participated, 439 had normal GHQ-28 scores. Physicians detected psychological problems in 177 (38.3%) of the 439. In bivariate analyses, poorer general and mental health (as measured by SF-36) was associated with higher detection rates. The patient's belief that there was a psychological component of his or her problem (OR=2.50), being in a marital relationship (OR=1.87), and the physician's perception of the seriousness of the problem (OR=1.84) were associated with detection. Detection was less frequent when the physician did not know the patient well (OR=0.69), and when the physician was a woman (OR=0.46). For the 28% of patients who themselves perceived a psychological element of their problem, physician detection was probably appropriate. However, it is unlikely that detection of the remaining patients was beneficial to the patients.

Chronic fatigue, abuse-related traumatization, and psychiatric disorders in a community-based sample

The relationship between sexual and physical abuse history and negative health effects has been well-documented in medical facility samples. Few studies have examined the role of abuse history and its relationship with chronic fatigue and psychiatric disorders in a diverse, randomly selected community-based sample. The present study compared rates of different types of abuse events in individuals with chronic fatigue and non-symptomatic controls. Relationships between specific types of abuse and psychiatric disorders commonly associated with chronic fatigue were also explored. A stratified random sample of 18,675 adults residing in ethnically and socioeconomically diverse neighborhoods in Chicago first completed a telephone screening questionnaire. A control group and a group of individuals with chronic fatigue symptomatology were identified and administered a semi-structured psychiatric interview assessing DSM-IV Axis I psychiatric disorders and a sexual and physical abuse history questionnaire. Controlling for sociodemographic differences, fatigue outcome was significantly predicted by childhood sexual abuse and the total number of different childhood abuse events. Within the chronic fatigue group, diagnosis of posttraumatic stress disorder (PTSD) was significantly predicted by childhood sexual abuse, childhood death threat, the total number of childhood abuse events, and lifetime abuse events. Sexual abuse during adolescence or adulthood significantly predicted other anxiety disorders among individuals with chronic fatigue. These findings suggest that a history of abuse, particularly during childhood, may play a role in the development and perpetuation of a wide range of disorders involving chronic fatigue. Among individuals with chronic fatigue, PTSD and other anxiety disorders appear to demonstrate the strongest association with abuse history. The implications of these findings are discussed.

Depression and anxiety impair health-related quality of life and are associated with increased costs in general medical inpatients

Two hundred sixty-three consecutive medical inpatients were studied to assess whether depression and anxiety are associated with increased costs and reduced health-related quality of life. Seventy-three (27.8%) had depressive/anxiety disorders, 107 were "subthreshold" cases, and 83 were controls. After adjustment for severity of physical illness, using the Duke Severity of Illness Scale, cases and subthreshold cases incurred greater mean health care costs than controls over the follow-up period: $8,541 (SE = $605) versus $5,857 (SE = $859), P = 0.012. There was significant impairment of health-related quality of life (SF36 scores) in cases and, to a lesser extent, in subthreshold cases compared to controls. This impairment persisted at follow-up, as did anxiety and depression, indicating the need for future intervention studies.

Consultation-liaison psychiatrists' use of antidepressants in the physically ill

In a practice-based, prospective study of 917 inpatients referred to a consultation-liaison psychiatry service and diagnosed as depressed, 41% were prescribed an antidepressant: 40% tricyclics, 35% selective serotonin reuptake inhibitors (SSRIs), 15% monoamine oxidase inhibitors (MAOIs)/reversible inhibitors of monoamine (RIMAs) (mainly moclobemide), and 11% tetracyclics (mianserin). Factors associated with choice of antidepressant type included age, referral for pain, length and seriousness of physical illness, type of physical illness, and concurrent antipsychotics (P < 0.01). Tetracyclics and MAOI/RIMAs were used significantly more often than tricyclics in the more severely physically ill and the elderly. The percentage of patients prescribed an antidepressant increased significantly over time, which is accounted for by the greater use of SSRIs across all age groups and degrees of seriousness of illness. There is a paucity of randomized controlled trials on which to base practice guidelines. Practice-based research such as this helps inform those guidelines.

Impediments to employment under welfare reform: the importance of physical health and psychosocial characteristics

The impact of Connecticut's welfare reform program (Jobs First), physical and mental health status, personal resources and household violence on employment was examined 18 months after women were randomized to either the welfare reform or the older AFDC program. Multivariate analyses showed that although the Jobs First program was statistically significantly associated with women having worked sometime since assignment to the welfare reform program, the Jobs First program was not associated with women currently working or having worked at some point but no longer working. Rather, women were more likely to be working at the 18 month interview if they reported frequent help from their social networks (OR = 1.52; p = .009), they had at least a high school degree (OR = 1.65; p =.002) and they were in good physical health (OR = 3.41; p = .009). Women who had worked sometime since random assignment but were no longer working at the 18 month interview reported few social contacts (OR = 1.33; p = .042), did not pay rent or own their own homes (OR = 6.94; p = .025), reported receiving AFDC for 2 years or more prior to randomization (OR = 1.83; p = .035) and reported high levels of household violence (OR = 1.52; p = .035). The need for attention to be focused on the importance of health problems, household violence and personal resources for the successful transitioning from public income support to employment is discussed.

Psychological distress, unmet need, and barriers to mental health care for women

Using data from the Commonwealth Fund 1998 Survey of Women's Health, this article describes the characteristics of women in need of mental health services for depression or anxiety, and identifies factors related to why women do not get needed care. Depressive/anxiety symptoms are common and access to care for psychological distress remains a problem for many women, especially for minorities, those with less education, and those without a usual source of health care. Sources of unmet need include patient factors, clinician factors, and characteristics of the health system, such as costs of mental health care.

Mental disorders in medical inpatients and the association to severity of illness, self-rated physical disability, and health perception

In a study of 294 consecutive medical inpatients, the authors assessed a subsample of 157 patients for psychiatric diagnoses using an extensive semistructured interview, Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Patients rated their health and physical functioning, and medical consultants assessed them for chronic and life-threatening diseases. A life-threatening condition increased odds for having a psychiatric diagnosis by 3.1 times (95% Confidence Interval (CI): 1.03-9.1), while a chronic medical disease had no such impact (OR=1.1; 95% CI: 0.5-2.3). In women, mental disorders were strongly associated with self-rated disability (OR=6.7; 95% CI: 1.6-27.8) and self-rated health (OR=9.4; 95% CI: 2.7-32.4). This association was absent in men (OR(disability)=0.7; 95% CI: 0.2-2.7; OR(health)=1.6; 95% CI: 0.6-4.7). Analyses included adjustment for age and gender.

Molecular Abnormalities in Brains of Depressed Patients

Studies on the molecular pharmacology of antidepressants have lead to a reinterpretation of earlier models of the neuropathology of depression. Noradrenergic and serotonergic hypotheses of depression have been expanded to include postsynaptic intracellular signal transduction pathways and regulation of gene expression. Because much of this evidence was obtained from postmortem brain, there has been increased interest in the use of this tissue to study depression. In the following pages, we will review the postmortem brain studies in depressed individuals focusing on neurotransmitter systems, signal transduction, and structural abnormalities.

Treatment preferences among depressed primary care patients

OBJECTIVE

To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

DESIGN

Patient questionnaires and interviews.

SETTING

Forty-six primary care clinics in 7 geographic regions of the United States.

PARTICIPANTS

One thousand one hundred eighty-seven English- and Spanish-speaking primary care patients with current depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P =.001) and had greater knowledge about antidepressant medication ( OR, 2.6; 95% CI, 1.6 to 4.4; P

CONCLUSIONS

Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

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Key Words

• depression
• primary care
• patient preferences
• treatment preferences

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MESH Headings

• Adolescent
• Adult
• Depression/classification
• Depression/diagnosis
• Depression/therapy
• Female
• Humans
• Interviews as Topic
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Satisfaction
• Primary Health Care
• Socioeconomic Factors
• Surveys and Questionnaires

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Grants

• R01 HS008349 AHRQ HHS
• K12 MH00990-01-01 NIMH NIH HHS
• HS08349-02 AHRQ HHS

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Affiliation(s)

M Dwight-Johnson Department of Psychiatry, University of Southern California, Los Angeles, Calif, USA.
C D Sherbourne
D Liao
K B Wells

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Anxiety, depressive, or cognitive disorders in rehabilitation patients: effect on length of stay

OBJECTIVE

To test the hypothesis that anxiety, depressive, or cognitive disorders are associated with an increase in length of stay of physical rehabilitation inpatients.

DESIGN

Secondary analysis of a 1-yr prospective data recording. Three treatment and rehabilitation centers in the Canton of Vaud (Switzerland). Ninety-five percent of inpatients admitted from November 15, 1990, to November 14, 1991, agreed to participate. Apart from length of stay, data consisted of demographic and medical data results from the Hospital Anxiety and Depression Scale, Mini-Mental State Score, and Functional Autonomy Measurement System. Multivariate linear regression was used in the analysis.

RESULTS

The presence of anxiety or depression altered length of stay in a bivariate analysis, although all effects disappeared in a multivariate approach. Factors that had an independent association with length of stay were gender, length of stay in an acute care hospital before hospitalization, treatment and rehabilitative centers, Functional Autonomy Measurement System mobility score, and Functional Autonomy Measurement System Activities of Daily Living score. Results concerning the association between cognition abilities and length were similar.

CONCLUSIONS

Our results recognize that an influence of psychiatric disorders acted on length of stay through a relationship between the psychiatric status and the control variables. If mental state influences physical state, then early intervention studies are desirable. If somatic state induces mental alterations, then interventions directed toward the psychiatric sphere will bring mostly qualitative benefits (amelioration of well-being without remarkable effects on length of stay).

Psychiatric symptoms and distress differ between patients with postherpetic neuralgia and peripheral vestibular disease

OBJECTIVE

No previous studies have investigated the psychiatric characteristics of patients with postherpetic neuralgia (PHN). Similarly, no studies have been performed on patients with different chronic somatic symptoms due to a defined medical disease to compare the characteristics of psychiatric morbidity associated with each etiology.

METHODS

After completing the subscales of the Symptom Checklist 90-R, a psychiatrist administered the Diagnostic Interview Schedule to all subjects. The psychiatric comorbidity in 35 patients with pain due to PHN was compared with a control group of 34 patients with the nonpainful aversive symptom of vertigo due to a peripheral vestibular disorder that caused unilateral hypofunction.

RESULTS

PHN patients had significantly more symptoms of major depression and somatization disorder. No significant differences were found between groups for psychiatric diagnoses. Patients with PHN reported significantly less acutely distressing somatic symptoms.

CONCLUSION

These results suggest that the psychiatric symptoms of patients with PHN are distinct from nonspecific acute distress and may be related to the experience of suffering from chronic neuropathic pain. Patients with PHN may not meet criteria for a psychiatric diagnosis, but their psychiatric comorbidity places them at substantial risk for increased pain, suicidal ideation, sustained disability, and the numerous complications of excessive medical evaluation and treatment. Patients with PHN should be evaluated specifically for psychiatric symptoms to reduce potential negative consequences through appropriate treatment.

The psychiatric profile of patients with chronic diseases who do not receive regular medical care

OBJECTIVE

To assess the relationship between psychiatric disorders and lack of regular medical care in individuals with chronic medical diseases.

METHODS

Nine hundred sixty-three respondents to the household-based Baltimore Epidemiologic Catchment Area (ECA) Follow-Up Study were interviewed in 1981, 1982, and 1993-1996. The main outcome measures were: 1) not receiving regular care from a health professional for an active chronic medical condition in 1981, 2) persistent lack of regular medical care, and 3) leaving regular medical care.

RESULTS

In cross-sectional analyses, having a psychiatric disorder (OR 1.70, 95% CI 1.17-2.48) was associated with not receiving regular medical care. This was mostly due to individuals with phobic disorder (OR 1.57, 95% CI 1.02-2.43). In prospective analyses, depression (RR 2.4, p < 0.04) and alcohol abuse (RR 2.9, p < 0.001) predicted leaving regular medical care one year later. Phobic disorder (RR 2.8, p < 0.001) predicted leaving care thirteen years later.

CONCLUSIONS

Psychiatric disorders appear to place an individual at risk for irregular medical care. Studies of the quality and continuity of care for patients with chronic medical conditions should include measures of common psychiatric conditions.

The relationship between psychosocial parameters and outcome in irritable bowel syndrome

This article reviews the evidence that psychiatric disorders have an adverse influence on the outcome of irritable bowel syndrome (IBS) and relates this to the close relationship between psychological symptoms and severity of abdominal pain, bloating, and diarrhea. Therefore, accurate measurement of psychological symptoms may be an important aspect of trial design for IBS therapy. The importance of psychological distress and health anxiety in differentiating "consulters" and "nonconsulters" for IBS is reviewed. The consequences of excluding from a trial people with certain types of psychiatric disorder or with a known past history of sexual abuse are considered.

Depression and cancer: an appraisal of the literature for prevalence, detection, and practice guideline development for psychological interventions

This paper reviews the current literature concerning the prevalence and incidence of depression in the general population and within the population of people living with cancer where depression is defined using current standards and guidelines. Reviews of recent work where the treatment of depression was the focus of study are also presented. Finally, studies that have specifically addressed the psychological treatment of depression among cancer patients are critically reviewed. Suggestions for practice guideline development of psychological interventions are offered based on the review.

Modeling physical health and functional health status: the role of combat exposure, posttraumatic stress disorder, and personal resource attributes

This study examined associations of combat exposure and posttraumatic stress disorder (PTSD) with physical health conditions and also incorporated hardiness and social support as mediators and functional health status as an outcome. Data were derived from 1,632 male and female Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. Path analysis revealed that hardiness and social support operated primarily as intermediary variables between combat exposure and PTSD, and PTSD emerged as the pivotal variable explaining physical health conditions and functional health status. Gender-based differences in means and patterns of associations among variables were found. The results stress the importance of assessing trauma in clinical settings as a meaningful determinant of health outcomes.

Depressive symptoms and mortality in older Mexican Americans

PURPOSE

We examined the prevalence of comorbid depressive symptomatology and leading chronic medical conditions, and their influence on death rates in older Mexican Americans.

METHODS

Data from the Hispanic Established Population for the Epidemiologic Study of the Elderly (EPESE) were used. Differences in death rates across sociodemographics, self-ratings of health, and health conditions were examined with analysis of variance statistics. Logistic regression models were used to examine main effects and interaction effects of each medical condition separately and in conjunction with depressive symptomatology.

RESULTS

Bivariate analyses indicated that death rates were substantially higher when a high level of depressive symptoms was comorbid with diabetes (OR = 3.84, 95% CI = 2.55-5.78), cardiovascular disease (OR = 4.04, 95% CI = 2.36-6.91), hypertension (OR = 2.27, 95% CI = 1.57-3.27), stroke (OR = 3.00, 95% CI = 1.44-6.15), and cancer (OR = 4.46, 95% CI = 2.48-8.01). Multivariate analyses indicated a synergistic effect for comorbid diabetes and depressive symptoms such that the odds of having died among diabetics with high levels of depressive symptoms (OR = 4.03, 95% CI = 2.67-6.11) were three times that of diabetics without high levels of depressive symptoms (OR = 1.36, 95% CI = 0.89-2.06).

CONCLUSIONS

High levels of depressive symptoms concomitant with major chronic medical conditions elevate the risk for death among older Mexican Americans. Given the fact that depression is often unrecognized and undertreated in the elderly, awareness of the potential for loss of life as well as the potential for treatment may help to improve this situation not only for older Mexican Americans, but for older adults in general.

Depressive symptoms in inner-city mothers of young children: who is at risk?

OBJECTIVE

To identify factors associated with depressive symptoms in inner-city mothers of young children.

DESIGN

A cross-sectional survey was administered to a convenience sample of English-speaking mothers attending a well-child visit for a child aged 6 months to 3 years in a hospital-based, inner-city, general pediatric clinic. The maternal interview collected data on sociodemographic characteristics, and mothers' health and financial status. Mothers completed the Psychiatric Symptom Index (PSI), a 29-item checklist shown to have very good validity and reliability in a multicultural population. A total score of >/=20 represents high levels of symptoms; scores >/=30 strongly suggest major depression.

RESULTS

Two hundred seventy-nine mothers completed the PSI. Mothers ranged in age from 14 to 48 years (mean, 27 years). Seventy-one percent were unmarried; 57% received public assistance. Forty-two percent of mothers were Hispanic, 40% black, 9% white, and 10% mixed or other races. Forty-eight percent were foreign-born. Twenty-four percent reported having a medical condition; 6% had activity limitation because of illness. The mean PSI score was 19; 18% of mothers had a PSI score >/=30 and 39% scored >/=20. PSI scores did not vary by age, race, birthplace, educational level, employment, marital status, or family composition. PSI scores were higher for mothers receiving public assistance (21 vs 17), with self-reports of poor or fair financial status (22 vs 15) and poor health status (52 vs 17). Mothers with activity limitations because of illness had significantly higher PSI scores (34 vs 18). Multiple regression analyses confirmed the independent relationships of these maternal characteristics to high PSI scores.

CONCLUSIONS

Depressive symptoms in inner-city mothers of young children are common. In this population of women with many risk factors, traditional sociodemographic risk factors did not successfully identify those who are depressed. However, mothers' self-reports of poor financial status, health status, or activity limitation because of illness were associated with higher levels of depressive symptoms. These findings may assist clinicians in distinguishing which mothers are likely to be depressed when almost all are at high risk.

Is there a threshold between peak oxygen uptake and self-reported physical functioning in older adults?

PURPOSE

Few studies have examined the relationship between directly measured oxygen uptake (VO2) and self-reported physical function (PF). The purpose of this study was: 1) to examine the relationship between peak V02 and PF and 2) to determine whether a threshold or cut point exist that distinguishes between individuals reporting required assistance in the performance of functional tasks (low PF) and those who report ability to perform tasks independently (high PF).

METHODS

Participants were 161 community-dwelling adults, ages 65-90, who had a baseline evaluation for a clinical trail that included measurement of peak V02 and PF consisted of a summary score combining scores from the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire, Nagi Disability Study. Rosow-Breslau Scale, Physical Function Scale of the Medical Outcomes Study, and the Falls Efficacy Scale. Decision tree, cubic spline, and logistic regression analyses explored these relationships with age, gender, education, race, body mass index, depression, and total number of chronic diseases included as important covariates.

RESULTS

Among all covariates examined, peak V02 was most strongly associated with (P = 0.004) with PF. There was not threshold effect. Decision tree analyses indicated that 18.3 mL.kg-1.min-1 was the optimal cut point distinguishing between low PF and High PG (P < 0.0001). Between-gender differences in PF (P = 0.002) were no longer significant when peak V02 was included in the PF model (P = 0.17).

CONCLUSIONS

These data indicate that individuals with a V02 < 18 mL.kg-1min-1 report significant difficulty in the performance of daily tasks and that differences in peak V02 may explain, in part, why women report more impairment in PF.

Poverty, unemployment, and common mental disorders: population based cohort study

OBJECTIVE

To determine whether poverty and unemployment increase the likelihood of or delay recovery from common mental disorders, and whether these associations could be explained by subjective financial strain.

DESIGN

Prospective cohort study.

SETTING

England, Wales, and Scotland.

SUBJECTS

7726 adults aged 16-75 living in private households.

MAIN OUTCOME MEASURES

Common mental disorders were assessed using the general health questionnaire, a self assessed measure of psychiatric morbidity.

RESULTS

Poverty and unemployment (odds ratio 1.86, 95% confidence interval 1.18 to 2.94) were associated with the maintenance but not onset of episodes of common mental disorders. Associations between poverty and employment and maintenance of common mental disorders, however, were much smaller than those of cross sectional studies. Financial strain at baseline was independently associated with both onset (1.57, 1.19 to 2.07) and maintenance (1.86, 1.36 to 2.53) even after adjusting for objective indices of standard of living.

CONCLUSIONS

Poverty and unemployment increased the duration of episodes of common mental disorders but not the likelihood of their onset. Financial strain was a better predictor of future psychiatric morbidity than either of these more objective risk factors though the nature of this risk factor and its relation with poverty and unemployment remain unclear.

Physical fitness and functional limitations in community-dwelling older adults

BACKGROUND

Conceptual models of disability have focused on disease-specific factors as the primary cause of disability. Functional limitations in the performance of basic tasks are considered primary mediators on the causal pathway from disease to disability.

PURPOSE

The purpose of this study was to assess the association between three fitness components (cardiorespiratory, morphologic, and strength) and functional limitations.

METHODS

Analyses employed data collected upon 161 older adults (72.5 +/- 5.1 yr) who agreed to undergo baseline testing in a clinical trial.

RESULTS

After controlling for age, race, sex, education, depressive symptoms, and body mass index, all three fitness components were directly associated with functional limitations (P < 0.05). This study is the first to characterize a broad set of individual fitness components as they relate to functional limitations and the first to examine directly measured cardiorespiratory fitness within the context of existing disability models.

CONCLUSION

These findings suggest that low fitness is a risk factor for functional decline independent of disease processes.

Consultation-liaison psychiatrists management of depression

Prospective data on 1,360 consecutive inpatients referred to the consultation-liaison psychiatry service of 2 metropolitan general teaching hospitals and diagnoses as having a Depressive Illness Spectrum Disorder were collected by using the MICRO-CARES clinical database system. The distribution of DSM-III-R diagnoses was major depression (MD) 49%; dysthymia (DYS) 15%; organic or substance-induced mood disorder or depressive disorder not otherwise specified (ORG/NOS) 14%; and adjustment disorder with depressed mood (AD) 29%s. Antidepressants were prescribed in 59% of the MD cases, 40% of the DYS cases, 36% of the ORG/NOS cases, and 17% of the AD cases. In confirmed MD, antidepressants were prescribed in 69%, and significantly more often in those who were older, female, had a prior history of physical illness, had a neoplasm or a disorder of the nervous or musculoskeletal systems, had higher Axis IV scores, or were referred because of pain or terminal illness. The patients with confirmed MD prescribed antidepressants had a longer length of stay and were referred later than those not prescribed antidepressants. The results illustrate the importance of all the forms of depression in consultation-liaison psychiatry and the vigor with which all forms are treated.