Correlates of health-related quality of life in type 2 diabetes.

AIMS/HYPOTHESIS: We assessed the impact of medical comorbidities, depression, and treatment intensity on quality of life in a large primary care cohort of patients with type 2 diabetes. METHODS: We used the Health Utilities Index-III, an instrument that measures health-related quality of life based on community preferences in units of health utility (scaled from 0=death to 1.0=perfect health), in 909 primary care patients with type 2 diabetes. Demographic and clinical correlates of health-related quality of life were assessed. RESULTS: The median health utility score for this population was 0.70 (interquartile range 0.39-0.88). In univariate analyses, older age, female sex, low socioeconomic status, cardiovascular disease, microvascular complications, congestive heart failure, peripheral vascular disease, chronic lung disease, depression, insulin use and number of medications correlated with decreased quality of life, while obesity, hypertension and hypercholesterolaemia did not. In multiple regression analyses, microvascular complications, heart failure and depression were most strongly related to decreased health-related quality of life, independently of duration of diabetes; in these models, diabetes patients with depression had a utility of 0.59, while patients without symptomatic comorbidities did not have a significantly reduced quality of life. Treatment intensity remained a significant negative correlate of quality of life in multivariable models. CONCLUSIONS/INTERPRETATION: Patients with type 2 diabetes have a substantially decreased quality of life in association with symptomatic complications. The data suggest that treatment of depression and prevention of complications have the greatest potential to improve health-related quality of life in type 2 diabetes.

Rapid screening for major depression in post-myocardial infarction patients: an investigation using Beck Depression Inventory II items.

OBJECTIVE: To determine the ability of three questions from the Beck Depression Inventory II (BDI-II) to detect major depressive disorder (MDD) in a cohort of patients hospitalised for acute myocardial infarction (MI). DESIGN: Prospective observational study. SETTING: Coronary care unit and cardiac step-down unit of an urban academic medical centre. PATIENTS: 131 post-MI patients within 72 h of symptom onset. INTERVENTIONS: Patients were administered the BDI-II and participated in a structured diagnostic interview for MDD. Three individual BDI-II items (regarding sadness, loss of interest and loss of pleasure) were examined individually and in two-question combinations to determine their ability to screen for MDD. MAIN OUTCOME MEASURES: Sensitivity, specificity, negative and positive predictive values and proportion of patients with MDD correctly identified. RESULTS: The individual items and two-question combinations had good sensitivity (76-94%), specificity (70-88%) and negative predictive values (97-99%). Item 1 (sadness) performed the best of the individual items (48% with a positive response to the item had MDD; 3% with a negative response had MDD; over 80% of patients with MDD were correctly identified). A combination of questions about sadness and loss of interest performed best among the two-question combinations (37% with positive response had MDD v 1% with a negative response; 94% of patients with MDD were identified). CONCLUSIONS: One to two questions regarding sadness and loss of interest serve as simple and effective screening tools for post-MI depression.

What predicts suicide attempts in women with eating disorders?

BACKGROUND: Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. METHOD: In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. RESULTS: Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9%) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. CONCLUSIONS: Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial co-morbidity.

The anxiety sensitivity index: item analysis and suggestions for refinement.

Anxiety sensitivity is the fear of anxiety-related sensations, and is measured by the 16-item Anxiety Sensitivity Index (ASI). Despite the popularity and utility of the ASI in research, a number of studies have provided evidence for the inadequacy of several items, and item-to-scale correlations for the ASI have not been published. In this study, a converging set of analyses to evaluate the item adequacy and factor structure of the ASI was used. The results of these multiple analyses converged nicely suggesting that Items 1, 5, 7, 8, and 13 should be considered for removal from the instrument. The impact of removing these problematic items from the scale was explored through the reanalysis of data from 3 previously published studies that compared the original ASI with the new 11-item version (the ASI minus the 5 problematic items). The results of these analyses suggest that the 2 scales function comparably in many respects but that the new version may be a more precise measure of anxiety sensitivity. The 11-item ASI appears to tap 2 primary aspects of anxiety sensitivity: fears of somatic sensations of anxiety and fears of loss of mental control. Suggestions for further development of the ASI are offered.

The perceived clarity and understandability of the DSM-IV personality disorder criteria sets.

One of the expressed aims of the DSM-IV revision process was to "increase the clarity" and the understandability of the personality disorder (PD) criteria. This was an important goal as previous research had showed the DSM-III-R PD criteria to have problems with clarity. To assess the degree to which this goal was achieved, we had two groups (psychiatrists and lay persons) rate the clarity of the DSM-IV PD criteria and the criteria for major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). The lay group rated five of the 10 PDs criteria sets and the criteria for PTSD as being significantly more clear than did the mental health professionals. No difference was seen between the two groups on their ratings of the MDD criteria. In addition, the professional group rated two of the PD criteria sets (borderline and schizotypal) as being less clear than the MDD criteria, while the lay group rated eight of the PD criteria sets as being more clear than the MDD criteria.

Pregnancy complications and neonatal outcomes in women with eating disorders.

OBJECTIVE: This study reported pregnancy complications and neonatal outcomes for 49 live births in a group of women with eating disorders who were prospectively followed. METHOD: Subjects were recruited from 246 women participating in a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 12th year. Subjects were interviewed by trained assistants and completed a brief self-report instrument that assessed both birth statistics and birth-related complications. Medical records and/or self-report data describing the neonates' birth status were obtained. RESULTS: The majority of the women with eating disorders had normal pregnancies, resulting in healthy babies. Across the group, the mean length of pregnancy was 38.7 weeks, the mean birth weight was 7.6 lb, and mean Apgar scores at 1 and 5 minutes after birth were 8.2 and 9.0, respectively. Most outcomes were positive; however, three babies (6.1%) had birth defects, and 17 (34.7%) of the women experienced postpartum depression. The mean number of obstetric complications in the group was 1.3, and 13 (26.5%) of the women delivered by cesarean section. Women who showed symptoms of either anorexia nervosa or bulimia nervosa during pregnancy had a higher frequency of birth by cesarean section and postpartum depression than did nonsymptomatic women. CONCLUSIONS: Pregnant women with active eating disorders appear to be at greater risk for delivery by cesarean section and for postpartum depression. Pregnant women with past or current eating disorders should be viewed as being at high risk and monitored closely both during and after pregnancy to optimize maternal and fetal outcomes.

Predicting DMS-IV cluster B personality disorder criteria from MMPI-2 and Rorschach data: a test of incremental validity.

Despite their frequent conjoint clinical use, the incremental validity of Rorschach (Rorschach, 1921/1942) and MMPI (Hathaway & McKinley, 1943) data has not been adequately established, nor has any study to date explored the incremental validity of these tests for predicting Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders (PDs). In a reanalysis of existing data, we used select Rorschach variables and the MMPI PD scales to predict DSM-IV antisocial, borderline, histrionic, and narcissistic PD criteria in a sample of treatment-seeking outpatients. The correlational findings revealed alimited relation between Rorschach and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) variables, with only 5 of 30 correlations reaching significance (p <.05). Hierarchical regression analyses showed that both the MMPI and Rorschach data add incrementally in the prediction of DSM-IV borderline and narcissistic PD total criteria scores. The findings were less clear for the incremental value of Rorschach and MMPI-2 data in predicting the total number of DSM-IV histrionic PD criteria, which were best predicted by Rorschach data, and antisocial PD criteria, which were best predicted by MMPI-2 data. In addition to providing evidence of the incremental validity of Rorschach data, these findings also shed light on the psychological characteristics of the DSM-IV Cluster B PDs.

Development of a spanish version of the Schwartz Outcome Scale-10: a brief mental health outcome measure.

The lack of culturally appropriate psychometric instruments for the assessment of cognitive and emotional functioning in minority populations has been a concern often discussed in the assessment literature. With the increased focus on the measurement of outcome in mental health treatment, the lack of appropriate instruments for minorities has become readily apparent in this venue as well. We report on the Spanish translation of a brief and reliable measure of psychological health and well-being that has been shown to be sensitive to treatment outcomes. The original and Spanish translated versions of this measure are highly correlated, providing clinicians and organizations with a instrument that can be used for assessment of psychological well-being and treatment outcomes with Hispanic patients.

Alzheimer's disease: pharmacological treatment and management.

The expected rise in prevalence rates of Alzheimer's disease over the next several decades has generated a great deal of attention at all levels of society, including governmental and scientific communities. These concerns have resulted in a vast number of research studies which have yielded medications focusing primarily on the symptomatic relief of the cognitive, neuropsychiatric and behavioral alterations felt to be pathognomic of the disease. Medical and pharmacological interventions which impact the onset or delay the progression of the illness are not yet readily available. We review and discuss the medications which are currently used for the symptomatic treatment and management of the disease, as well as discuss new pharmacological strategies which are under investigation and development.

Mortality in eating disorders: a descriptive study.

OBJECTIVE: We report rates and causes of death for a cohort of 246 eating-disordered women and provide descriptive information on their eating disorder and comorbid diagnoses. METHOD: Data on mortality were collected as part of a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 11th year. Other data sources included death certificates, autopsy reports, relative interviews, and a National Death Index search. RESULTS: Seven deaths have occurred during the study, all among anorexic subjects with a history of binging and purging and with comorbid Axis I disorders. The crude mortality rate was 5.1%. The standardized mortality ratios for death (9.6) and suicide (58.1) were significantly elevated (p <. 001). CONCLUSIONS: Anorexia nervosa is associated with a substantial risk of death and suicide. Features correlated with fatal outcome are longer duration of illness, binging and purging, comorbid substance abuse, and comorbid affective disorders.

Pregnancy: outcome and impact on symptomatology in a cohort of eating-disordered women.

OBJECTIVE: This study investigates both the impact of eating disorders (ED) on pregnancy outcome and the impact of pregnancy on cognitive and behavioral symptoms of EDs. METHOD: Data on pregnancy outcome (live birth [LB], therapeutic abortion [TAB], and spontaneous abortion [SAB]) and ED symptomatology were collected as part of a large, prospective longitudinal study of anorexia nervosa (AN) and bulimia nervosa (BN). Data were gathered using a semistructured interview administered every 6 months to 246 subjects. RESULTS: We identified 54 women who reported 82 pregnancies (46 LB, 25 TAB, and 11 SAB). Pregnancy outcome was not significantly related to any of the clinical variables studied. Women with BN showed a significant decrease in the severity of their ED symptoms during pregnancy, and this decrease was sustained through 9 months postpartum. Women with AN also demonstrated a significant reduction in ED symptoms, however, these symptoms returned to prepregnancy levels by 6 months postpartum. CONCLUSIONS: Our prospective findings reveal an elevated TAB rate for ED women along with a general reduction in the severity of ED symptoms during pregnancy.

Five-factor personality traits in patients with seasonal depression: treatment effects and comparisons with bipolar patients.

BACKGROUND: Increasingly, the Five Factor Model (FFM) of personality is being used to assess personality characteristics of patients with Axis I disorders. Recent study indicates that patients with the seasonal subtype of major depression (SAD) may differ meaningfully from other depressed patients. In the present study, we further examined this finding, with attention to the stability of personality characteristics across treatment. METHODS: We used the NEO-FFM to assess the personality characteristics of two samples of depressed outpatients: patients with SAD and patients with bipolar disorder. Assessment was repeated in the SAD patients after light therapy. RESULTS: Consistent with previous research, we found elevated scores on the Openness domain in the SAD patients. SAD patients also scored significantly lower on Neuroticism and significantly higher on the Conscientiousness and Extroversion domains than patients with bipolar disorder. Scores on the Openness domain remained elevated after treatment of SAD; this occurred in the context of significant decreases in Neuroticism and increases in Extroversion scores. LIMITATIONS: These results were obtained in a relatively small-sample study. Although our sample of bipolar patients were taking mood stabilizers, it is unlikely that medication effects could explain our results. CONCLUSIONS: Our findings are consistent with those reported by Bagby et al. (Major depression and the five-factor model of personality. J. Pers. Disord. 1995;9:224-234) and suggests that Neuroticism and Extroversion are the FFM domains most responsive to treatment for depression. Our results also suggest that elevations on the Openness domain do not change with treatment and may be an enduring characteristic of patients with SAD.

A Rorschach exploration of the DSM-IV Borderline Personality Disorder.

Rorschach data has been useful in identifying the DSM Borderline Personality Disorder (BPD) and has potential for improving our understanding of this disorder. Recently, the DSM-IV BPD has been shown to be composed of 3 primary or core factors: Factor I-unstable self-other images. Factor II-deficits in affect and thought modulation, and Factor III-impulsive self-damaging actions. In a sample of outpatients with personality disorders. we explored the relationships among 6 psychoanalytically derived Rorschach scales (primitive aggression, oral dependency, self-other differentiation, splitting, devaluation, and projective identification), and the core BPD features. Significant correlations were found between 5 of the Rorschach variables and BPD total scores. Correlations between these 5 variables and the BPD core features showed that oral dependency needs were negatively associated with all 3 BPD core features, whereas the defenses of devaluation and splitting were positively associated with these core features. The clinical implications of these findings are reviewed.

Diagnostic efficiency and hierarchical functioning of the DSM-IV borderline personality disorder criteria.

This study presents information regarding the diagnostic efficiency and hierarchical functioning of the newly revised DSM-IV borderline personality disorder (BPD) criteria. Past research using the DSM-III-R version of BPD showed that the individual BPD criteria differ greatly in their diagnostic utility and that in some clinical situations, fewer than five of eight criteria could efficiently make the diagnosis. Two groups of inpatients, a BPD group (N = 33) and a non-BPD group (N = 43), were rated on the DSM-IV BPD criteria. Acceptable interrater reliability (Kappa estimates) was obtained for the presence or absence of the nine individual BPD criteria. Diagnostic efficiency statistics, sensitivity, specificity, false positive and false negative rates, positive predictive power, negative predictive power, overall classification rate and Kappa with the clinical diagnosis were obtained for all nine BPD criteria. The diagnostic efficiency data indicated that BPD criteria 1 (abandonment) and 2 (unstable relationships) functioned best in our inpatient sample, whereas criterion 9 (stress-related paranoia) performed the poorest. A stepwise logistic regression showed that the combination of BPD criteria 2, 1, 6 (unstable affect), and 3 (identity) (presented in their order of entry into the regression equation) provided the best prediction of group membership (BPD or non-BPD). The results suggest that a further refinement of both the BPD criteria set and the diagnostic decision rules may be needed.

Development and initial validation of a brief mental health outcome measure.

Using a combination of classical test theory and Rasch item analysis, we developed a short scale designed to measure the effectiveness of mental health treatment across a wide range of mental health services and populations. Item development for the scale was guided by literature review and interviews with senior clinicians and with patients. Using 3 different samples consisting of inpatients, outpatients, and nonpatients, we reduced our initial item pool from 81 to 10 items. The 10-item scale had an alpha of .96 and showed strong correlations with commonly used measures of psychological well-being and distress. Our results suggest that the scale appears to measure a broad domain of psychological health. The scale appeared to lack ceiling and floor effects, and it discriminated between inpatients, outpatients, and nonpatients, suggesting the scale has excellent potential to be broadly responsive to a variety of treatment effects. In addition, the new scale proved to be sensitive to treatment changes in a sample of 20 psychiatric inpatients. Overall, the initial data suggest that we have developed a brief, sensitive outcome measure designed to have wide application across psychiatric and psychological treatments and populations.

Establishing the psychometric properties of the DSM-III-R personality disorders: implications for DSM-V.

In this study, symptom (item) level data were used to perform a psychometric analysis of the DSM-III-R personality disorders (PDs). Determined for each PD criteria set were convergent validity, discriminant validity, and internal consistency. The results indicated that the majority of the PD criteria sets (6 of the 11 ) possessed adequate convergent validity, although discriminant validity was problematic for most of these disorders. Internal consistency was also weak for the PD criteria sets, with only 3 of the 11 exceeding a minimum cutoff score of .70. The present study employed a methodology modeled after the one reported by Morey (1988a), and the results of the two studies were highly similar. Consistent findings across the two data sets can be taken to reflect the actual psychometric properties of the DSM-III-R PDs. The success of our replication demonstrates the potential that large-scale psychometric investigations hold for aiding the development and refinement of the DSM PDs.

Identifying the unique and common characteristics among the DSM-IV antisocial, borderline, and narcissistic personality disorders.

A clinical chart-review study of the Cluster B personality disorders (PDs) was conducted to evaluate the specificity of DSM-IV criteria for the Antisocial Personality Disorder (ANPD), Borderline Personality Disorder (BPD), and Narcissistic Personality Disorder (NPD). Eight-six outpatients meeting DSM-IV criteria for a PD were identified through a retrospective chart-review procedure. Records of these 86 patients were independently rated on all of the ANPD, BPD, and NPD symptom criterion for the DSM-IV. High interrater reliabilities were obtained for the presence or absence of a PD and symptom criteria for ANPD, BPD, and NPD (all kappa > or = .80). The sample consisted of ANPD (n = 20), BPD (n = 25), NPD (n = 15), and other personality disorders (OPD; Cluster A and C; n = 26). Five ANPD criteria reliably differentiated ANPD patients from BPD and NPD patients (1, 2, 3, 6, 7), and two criteria did not differentiate this group from either intracluster category (4, 5). BPD criteria also differentiated BPD patients from ANPD and NPD patients; however, the specific criteria that effectively differentiated categories were dependent on the group comparisons. BPD criteria (1, 2, 3, 6, 7) differentiated BPD and ANPD patients. BPD and NPD patients could be discriminated on other BPD criteria (2, 3, 5, 6, 7, 8). NPD criteria showed a similar ability to differentiate patients. NPD criteria differentiated NPD and BPD patients on DSM-IV criteria of 1, 3, 4, 5, 7, and 9. NPD and ANPD patients could be differentiated on other NPD criteria (1, 2, 3, 4, 5, 9). The results of this study provide general support for the use of specific criteria for these three disorders in the differential comparison of related and unrelated PDs. The utility of items that describe essential features are discussed.

Rorschach correlates of the DSM-IV histrionic personality disorder.

Rorschach assessment data have long been rationally linked to the psychiatric condition of hysteria. This study represents the first empirical attempt to explore the associations among select Rorschach variables, the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) Histrionic Personality Disorder (HPD) criteria, and two self-report measures of hysteria. We correlated four Rorschach variables with total symptom scores for DSM-IV Cluster B Personality Disorders (Borderline, Antisocial, Narcissistic, and Histrionic). We found two Rorschach variables, FC + CF + C and T (Exner, 1993), to be significantly and meaningfully correlated with both the DSM-IV HPD total score (number of criteria) and the individual HPD criteria. Although not significantly associated with the HPD total score, Denial (DEN; Lerner & Lerner, 1980) was associated with one individual HPD criterion. Furthermore, DEN was significantly correlated with the MMPI-2 Hysteria (Hy) scale. The results are reviewed in terms of their clinical utility and the insights they offer into the psychological characteristics of the DSM-IV HPD.

Stability and predictive value of self-report personality traits pre- and post-electroconvulsive therapy: a preliminary study.

The accuracy and value of personality assessment for depressed patients receiving electroconvulsive therapy (ECT) is an underexplored and controversial area. However, there are data suggesting that personality traits and personality disorders affect the ultimate outcome of depressed patients receiving a variety of somatic treatments including ECT. Despite these data, controversy continues regarding the advisability of evaluating personality functioning in patients with severe depression. This study sought to explore the stability and predictive value of self-reported personality traits in depressed patients undergoing ECT. Sixteen subjects completed a self-report test of personality functioning and the Beck Depression Inventory (BDI) before and after ECT treatment. The results showed that the majority of self-report personality traits were stable pre- and post-ECT treatment. However, major depressive disorder did significantly affect the report of avoidant, histrionic, aggressive-sadistic, and schizotypal personality traits. Treatment did not change the overall personality profile of these subjects. Furthermore, regression analysis controlling for pretreatment depression showed pretreatment borderline personality traits to be significantly related to the posttreatment depression scores (response to treatment). These findings suggest that routine administration of a standard self-report measure of personality may aid in the evaluation of and treatment planning for patients receiving ECT.

Psychometric characteristics of the cluster B personality disorders under DSM-III-R and DSM-IV.

A stated goal for the latest revision of the DSM was improving the performance of the Axis II system. To evaluate the degree to which this goal was achieved, we performed a psychometric analysis of the Cluster B personality disorders (PD) as they are defined under the DSM-III-R and its successor the DSM-IV. Ninety-four patients with a primary PD diagnosis were rated for the presence of DSM-III-R and DSM-IV Cluster B PD criteria. From this symptom level data, the convergence, divergence, and internal consistency of the Cluster B criteria sets were determined. Also, kappa values were computed between the DSM-III-R and DSM-IV versions of these disorders as an index of coverage or agreement across the two systems. The results indicated that, in general, the DSM-IV Cluster B PDs represent an improvement over their DSM-III-R predecessors. However, some psychometric limitations, particularly regarding the convergence of the criteria sets, continue to be present.