Assessment of state and trait anxiety in subjects with anxiety and depressive disorders.

The State-Trait Anxiety Inventory (STAI) is one of the most widely used scales for the evaluation of anxiety in medical and, to a lesser extent, psychiatric patients. Although there is a relatively large amount of STAI data about anxiety for individuals with a variety of psychiatric disorders, the results of many anxiety studies include only state or trait and many studies have been influenced by comorbidity and by variations in diagnostic criteria used. We studied state and trait anxiety and compared the revised form of the STAI (Form Y) with the original (Form X) to evaluate the anticipated improvement in the measure. In addition, we compared the STAI results with those of another self-report measure (the Symptom Checklist-90 anxiety and depression scales) and also with interviewer-rated measures of anxiety (Hamilton Rating Scale for Anxiety) and depression (Hamilton Rating Scale for Depression). Results indicate that the STAI does not clearly differentiate anxiety disorders from depressive disorders and support the use of multiple tests and of both self-report and interviewer ratings in the evaluation of anxiety and depression in psychiatric patients.

Defense styles and Personality dimensions of research subjects with anxiety and depressive disorders.

We used the Bond Defense Style and Cloninger Tridimensional Personality questionnaires to assess defense styles and personality dimensions in subjects with anxiety and depressive disorders. When measured against a comparison group, maladaptive defense style scores were significantly higher in those with major depression, panic disorder, generalized anxiety disorder, and social phobia, and higher at a trend level in the subjects with obsessive-compulsive disorder and mixed anxiety and depression. However, there were no differences in adaptive defense style scores between the subjects and the comparison group. The harm avoidance personality dimension scores were significantly higher in subjects with both anxiety and depressive disorders than in the comparison group. The harm avoidance scores correlated positively with the maladaptive defense scores, but negatively with the adaptive defense scores. These findings are discussed in terms of severity of illness, level of functioning, and relationships between Axis I and II disorders.

The ability of the Symptom Checklist SCL-90 to differentiate various anxiety and depressive disorders.

We studied the use of the Symptom Checklist-90 (SCL-90) to differentiate between specific anxiety and depressive disorders and/or their symptoms in 280 patients with 6 DSM-III-R diagnoses: major depression (MD), panic disorder (PD), generalized anxiety disorder (GAD), social phobia (SP), obsessive-compulsive disorder (OCD), and mixed anxiety and depression (MAD). Using a comparison group, we found specific patterns for some of the diagnostic categories. Both the MD and MAD subjects had significantly high paranoid ideation, interpersonal sensitivity, hostility, and psychoticism, as well as high depression subscale scores; those with PD and GAD has the highest anxiety and somatization scores; and those with SP or OCD had a mixed pattern. When ranking the severity of psychopathology, the disorders ordered from most to least were MAD, MD, PD, GAD, SP, and OCD. Subsyndromal levels of symptoms frequently were associated with the various conditions. Use of the SCL-90 subscale helps to enlarge our understanding of the various anxiety and depressive disorders.

Assessment of locus of control in patients with anxiety and depressive disorders.

We studied Levenson's Internal (I), Powerful Others (P), and Chance (C) locus of control scales in 193 patients with six DSM-III-R diagnoses: Major Depression (MD), Panic Disorder (PD), Generalized Anxiety Disorder (GAD), Social Phobia (SP), Obsessive Compulsive Disorder (OCD), and Mixed Anxiety Depressive Disorder (MAD). Compared to the comparison groups (CG), we found specific patterns for some of the diagnostic categories. There were no significant differences between the I scale scores and of those in the different anxiety and depressive disorder groups and the CG. But, patients with MD, SP, or MAD had significantly higher P scale scores than the CG. Patients with MD, PD, SP, and MAD had higher C scale scores than the CG. The OCD patients had the lowest P and C scale scores of any of the groups and not significantly different than the CG. The findings have some research and clinical implications.

Explained and unexplained medical symptoms in generalized anxiety and panic disorder: relationship to the somatoform disorders.

We have examined the numbers and types of symptoms in a sample of 90 patients with generalized anxiety disorder (GAD) and 77 patients with panic disorder (PD) collected from six different sites during the conduct of a multicenter clinical trial. This information was obtained utilizing the Health Questionnaire, a 47-item self-report list of medical symptoms, patterned after the Somatization Disorder section of the Diagnostic Interview Schedule. Although the patients in this sample had a wide variety of medically explained and unexplained physical symptoms, none of them qualified for a diagnosis of somatization disorder by DSM-III-R criteria. GAD and PD patients reported remarkably similar numbers of explained and unexplained medical symptoms. The panoply of somatic symptoms presented by these patients presents a formidable diagnostic challenge for clinicians. These findings suggest that the pattern of overutilization of medical services that is well documented for PD patients may also be found for GAD patients.

Utilization of medical specialists by anxiety disorder patients.

The purpose of this study was to determine the utilization of medical specialists by anxiety disorder patients. The setting was a university's clinical outpatient drug trails for anxiety disorders. The participants were subjects identified by advertisement and diagnosed by psychiatric interviews and, in some instances, also by structured interviews. The main outcome measures were the subject responses on a questionnaire listing medical specialists. A total of 94 subjects were surveyed. Primary care physicians (family medicine and internal medicine) were seen more often by panic disorder (PD) subjects than by obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD) subjects. Gastroenterologists were seen most frequently by the GAD subjects; dermatologists and cardiologists by the OCD subjects; and otolaryngologists, obstetricians-gynecologists, neurologists, and urologists by the PD subjects. The PD subjects saw more specialists than the subjects with the other disorders. Medical specialists need to increase identification of patients with various anxiety disorders to relieve suffering, improve health care practices, and obtain favorable cost:benefit ratios.

Consulting with anxious medical patients. Part II: Diagnostic and therapeutic considerations.

In consulting with anxious medical patients, the psychiatrist needs to consider the possibility of organic disease, differentiate anxiety and depression, and ascertain whether comorbid conditions are present. Guidelines for differential diagnosis are presented. With the anxious patient, treatment goals are to establish rapport, help the patient mobilize intellectual defenses, and enhance self-esteem. Many anxious medical patients will benefit from benzodiazepines, selective serotonin reuptake inhibitors, or doxepin. The therapeutic potential of the consultation is increased by the psychiatrist's meeting with the nursing staff and by a humanistic approach to the patient.

Consulting with the anxious patient, Part I: Complexities of the consultation process and problems of referral.

At least 20% of medical patients have anxiety disorders and are in need of treatment, but work with anxious patients is complicated by their distortions and often negative attitudes toward physicians and hospitals. Consultation is complicated by inconsistent referral patterns. Most anxious medical patients accept psychiatric consultation: only 15% to 20% have negative attitudes toward psychiatry. Guidelines for referral are presented.

Ensuring services for persons with chronic mental illness under national health care reform.

People with chronic mental illness present complex challenges for the design of health care financing reforms. In this position statement from the committee on psychiatry and community of the Group for the Advancement of Psychiatry, the authors describe chronic and severe mental illnesses as psychiatric illnesses that require acute and ongoing psychiatric assessment and treatment, as chronic medical diseases that require ongoing rehabilitative services, and as persistent disabilities that need ongoing supportive care and social services. Any proposal for health care reform must ensure parity of chronic psychiatric illnesses with other psychiatric conditions. It must also reimburse psychiatric rehabilitation at parity with other medical rehabilitation and provide equal access to and reimbursement for broad ancillary health services that reduce costs and improve quality of life.

Consultation-liaison psychiatry: a historical overview.

The author reviews the history of consultation-liaison psychiatry from its roots in the 1751 charter of the Pennsylvania Hospital in Philadelphia. The field has evolved through three distinct phases and has currently entered a fourth stage, called the consolidation phase, which is characterized by shrinkage of programs, marked reduction in liaison activities, and anxiety about its validity and future. While the survival of consultation-liaison psychiatry is threatened by inadequate financial resources, the author believes that the increasing demand for C-L psychiatrists will eventually mandate a greater investment in the special expertise they offer.

Risk for depression in families over time: a pilot epidemiologic study.

A random sample of 34 families from the general population were studied over a 15-month period to determine their risk for depression over time. Adults and children in the families were interviewed three times during the 15-month period. Risk for depression was evaluated using four screening instruments, including the Diagnostic Interview Schedule. At the original interview, 40 percent of the families contained one or more members at risk for depression. The 15-month family incidence rate for risk for depression was 26 percent and of continued good mental health 74 percent. The mental health status of 35 percent of the families changed during the 15-month period, suggesting that longitudinal studies can provide a more accurate profile of family mental health than studies of families at a single point in time.

Residency education in for-profit general hospitals.

In May, 1983, when the new University of Louisville teaching hospital was opened under the auspices of Humana Corporation, it became the first university hospital operated by a for-profit corporation. We describe the agreement that launched this venture and summarize the experiences of the Department of Psychiatry and Behavioral Sciences with Humana, Inc., during the past 3 years. We review our impressions of both the positive and negative effects that the for-profit managing style has had thus far on the teaching programs of the Department. Based on our experiences, there are financial and other benefits, but we think that there are also potential dangers for the future of psychiatric education inherent in the administration of a teaching hospital by a for-profit corporation. The "atmosphere of business" that pervades the climate of opinion in the United States in the 1980s and is merely epitomized by the increasing role of enterpreneurial groups in medicine can be antithetical to principles of psychiatry and has implications for psychiatric education in the future. Awareness of these developments is a task for psychiatric education and, when it is possible, comparative studies of residents and their programs in nonprofit and for-profit hospitals should be conducted.

Depression and internal medicine.

Although the Fathers of Internal Medicine described melancholia and wrote extensively about the affective disorders, internists continue to have difficulties diagnosing their medical patients' depressions. Consequently, it often falls to the psychiatric consultant to make the diagnosis amongst the medical population. We present current concepts of affective disorder that should be clinically relevant to the psychiatrist who works with internists and their patients. Early, accurate diagnosis of depressed medical patients requires increased awareness of depression, observation of the patient's appearance and mood, sensitivity to his or her feelings, and specific questioning about symptoms, losses, and stressors. For depressed medical patients, we present a comprehensive treatment program which often should include: 1) supportive psychotherapy, 2) antidepressant medications; and 3) resocialization or rehabilitation. We outline certain indications for psychiatric referral, and urge psychiatrists and internists to work together closely. Increasing the sensitivity of our colleagues in internal medicine toward affective illness should lead to more prompt identification and treatment of medical patients' depressions.

Anxiety in depression.

Even though anxiety in depression is a common clinical condition, there is controversy about its status. Can these patients be dichotomized as having either anxiety or depression, or are there three categories--certain anxiety states, anxiety in depression, and the specific depressive disorders? A review of the findings from four major lines of research on anxiety in depression reveals contradictory results. Anxious depression may be a distinctive entity. The guidelines for diagnosis presented here emphasize the necessity to identify anxious depressed patients and to differentiate them from those with distinctive anxiety states or depressive disorders. Tricyclic medications, such as doxepin, combined with supportive psychotherapy are the treatment of choice for patients with anxiety in depression.