Depression symptom trends and health domains among lung cancer patients in the CanCORS study.

OBJECTIVES: Among lung cancer patients depression symptoms are common and impact outcomes. The aims of this study were to determine risk factors that contribute to persistent or new onset depression symptoms during lung cancer treatment, and examine interactions between depression symptoms and health domains that influence mortality. MATERIALS AND METHODS: Prospective observational study in five healthcare systems and 15 Veterans Affairs medical centers. Patients in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium with lung cancer were eligible. The 8-item Center for Epidemiologic Studies Depression (CES-D) scale was administered at baseline and follow-up. Scores ≥4 indicated elevated depressive symptoms. Health domains were measured using validated instruments. We applied logistic regression and Cox proportional hazards modeling to explore the association between depression symptoms, health domains, and mortality. RESULTS: Of 1790 participants, 38% had depression symptoms at baseline and among those still alive, 31% at follow-up. Risk factors for depression symptoms at follow-up included younger age (OR=2.81), female sex (OR=1.59), low income (OR=1.45), not being married (OR=1.74) and current smoking status (OR=1.80); high school education was associated with reduced odds of depression symptoms at follow-up, compared with lesser educational attainment (OR=0.74) (all p values <0.05). Patients with depression symptoms had worse health-related quality of life, vitality, cancer-specific symptoms, and social support than patients without depression symptoms (all p<0.001). The association between depression symptoms and increased mortality is greater among patients with more lung cancer symptoms (p=0.008) or less social support (p=0.04). CONCLUSIONS: Patient risk factors for depression symptoms at follow-up were identified and these subgroups should be targeted for enhanced surveillance. Patients with depression symptoms suffer across all health domains; however, only more lung cancer symptoms or less social support are associated with worse mortality among these patients. These potentially modifiable health domains suggest targets for possible intervention in future studies.

The prevalence of tardive dyskinesia in neuroleptic-treated diabetics. A controlled study.

In a controlled study, we compared the prevalence of tardive dyskinesia in 38 neuroleptic-treated diabetics with the prevalence of tardive dyskinesia in a group of 38 nondiabetic neuroleptic-treated controls, matched for age, sex, psychiatric diagnosis, and dose and duration of neuroleptic treatment. Members of each group were evaluated for movement disorders by a rater who used standard rating scales and was "blind" to all diagnoses and treatments. Neuroleptic-treated diabetics had a significantly higher prevalence and severity of tardive dyskinesia. There were no differences between groups on other possible risk factors for tardive dyskinesia, including parkinsonism, anticholinergic drug treatment, or cognitive function. These data suggest that diabetes mellitus should be examined further as a risk factor for tardive dyskinesia.

Misdiagnosing delirium as depression in medically ill elderly patients.

BACKGROUND: Delirium, a common and often overlooked syndrome in acutely ill elderly patients, may present with signs and symptoms of depression. OBJECTIVE: To determine (1) how often health care providers mistake delirium for a depressive disorder in older hospitalized patients referred to a psychiatric consultation service for depressive symptoms and (2) which signs and symptoms of depression and delirium characterize these patients. SUBJECTS: Patients older than 60 years, admitted to a Veterans Affairs teaching hospital, and consecutively referred to a psychiatric consultation service for evaluation and treatment of a depressive disorder. METHODS: The diagnosis of delirium was based on two independent assessments: (1) a clinical interview by a member of the psychiatric consultation service and (2) a structured bedside evaluation performed by one of the investigators, who was not a member of the psychiatric consultation service. The investigator administered the Confusion Assessment Method Instrument, Mini-Mental State Examination, digit span forward, and months of year backward. The investigator also administered the Diagnostic Interview Schedule items for depression to elicit depressive symptoms. RESULTS: Twenty-eight (41.8%) of the 67 subjects referred for evaluation or treatment of a depressive disorder were found to be delirious. Compared with nondelirious subjects, the delirious subjects were older and more impaired in activities of daily living. The delirious subjects often endorsed depressive symptoms, such as low mood (60%), worthlessness (68%), and frequent thoughts of death (52%). The referring health care provider had considered delirium in the differential diagnosis of the mood disturbance in only three subjects. CONCLUSION: Health care providers should consider the diagnosis of delirium in hospitalized elderly patients who appear to be depressed.

The prevalence of metoclopramide-induced tardive dyskinesia and acute extrapyramidal movement disorders.

BACKGROUND: Metoclopramide hydrochloride, a neuroleptic dopamine receptor antagonist used to treat gastric ailments, is reported to cause extrapyramidal movement disorders. The goals of this study were (1) to determine the prevalence and severity of tardive dyskinesia and acute extrapyramidal movement syndromes including akathisia, acute dystonia, and drug-induced parkinsonism in metoclopramide-treated patients and (2) to compare the prevalence and severity of tardive dyskinesia in metoclopramide-treated diabetics and nondiabetics. METHODS: From a list of metoclopramide-treated patients received from the Portland (Ore) Veterans Affairs Medical Center pharmacy, 53 patients met inclusion criteria and 51 (96%) agreed to participate. Controls consisted of a convenience sample drawn from the Portland Veterans Affairs Medical Center Outpatient Clinic who were matched to subjects on age (+/- 10 years), gender, and presence or absence of diabetes. Of 61 potential controls contacted, 51 (84%) agreed to participate. Metoclopramide-treated subjects and controls were seen by a rater who was "blind" to all diagnoses and treatments. The rater performed a standardized examination used to elicit signs and symptoms of tardive dyskinesia and acute extrapyramidal movement syndromes. RESULTS: The relative risk for tardive dyskinesia was 1.67 (95% confidence interval, 0.93 to 2.97), and the relative risk for drug-induced parkinsonism was 4.0 (95% confidence interval, 1.5 to 10.5). Metoclopramide-treated patients had significantly greater severity of tardive dyskinesia, drug-induced parkinsonism, and subjective akathisia than controls. Use of metoclopramide was associated with impairment in ambulation and increased use of benzodiazepines. Metoclopramide-treated diabetics had significantly greater severity of tardive dyskinesia than metoclopramide-treated nondiabetics. CONCLUSIONS: Metoclopramide use is associated with a significantly increased prevalence and severity of several extrapyramidal movement disorders.

Attitudes of Oregon psychiatrists toward physician-assisted suicide.

OBJECTIVE: After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide. METHOD: An anonymous questionnaire was sent to all 418 Oregon psychiatrists. RESULTS: Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide. CONCLUSIONS: Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low.

Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists.

OBJECTIVE: Mental health evaluation of competence to consent has been proposed as an important safeguard for patients requesting assisted suicide, yet mental health professionals have not developed guidelines or standards to aid in such evaluations. The authors surveyed a national sample of forensic psychiatrists in the United States regarding the process, thresholds, and standards that should be used to determine competence to consent to assisted suicide. METHOD: An anonymous questionnaire was sent to board-certified forensic psychiatrists between August and October 1997. RESULTS: Of the 456 forensic psychiatrists who were sent the questionnaire, 290 (64%) responded. Sixty-six percent believed that assisted suicide was ethical in at least some circumstances, and 63% thought that it should be legalized for some competent persons. Twenty-four percent indicated that it was unethical for psychiatrists to determine competence; however, 61% thought such an evaluation should be required in some or all cases. Seventy-eight percent recommended a very stringent standard of competence. Seventy-three percent believed that at least two independent examiners were needed to determine competence, and 44% favored requiring judicial review of a decision. Fifty-eight percent believed that the presence of major depressive disorder should result in an automatic finding of incompetence. Psychiatrists with ethical objections to assisted suicide advocated a higher threshold for competence and more extensive review of a decision. CONCLUSIONS: The ethical views of psychiatrists may influence their clinical opinions regarding patient competence to consent to assisted suicide. The extensive evaluation recommended by forensic psychiatrists would likely both minimize this bias and assure that only competent patients have access to assisted suicide, but the process might burden terminally ill patients.

The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy.

OBJECTIVE: This study was undertaken 1) to test the hypothesis that remission of depression results in an increase in desire for life-sustaining medical therapy and 2) to characterize patients whose desire for life-sustaining treatment increases substantially following depression therapy. METHOD: Elderly patients, suffering from major depression, were interviewed on admission to a psychiatric inpatient unit and at discharge about their desire for specific medical therapies in their current state of health and in two hypothetical scenarios of medical illness. A psychiatrist rated the impact of depressive thinking on the subject's response to these questions. Forty-three subjects completed the study, and 24 were in remission from depression at the time of discharge. RESULTS: In the majority of patients, remission of depression did not result in an increase in desire for life-sustaining medical therapy. However, a clinically evident increase in desire for life-sustaining medical therapies followed treatment of depression in subjects (N = 11 [26%]) who had been initially rated as more severely depressed, more hopeless, and more likely to overestimate the risks and to underestimate the benefits of treatment. CONCLUSIONS: In major depression of mild to moderate severity, a patient's desire to forgo life-sustaining medical treatment is unlikely to be altered by depression treatment. On the other hand, severely depressed patients, particularly those who are hopeless, overestimate the risks of treatment, or underestimate the benefits of treatment, should be encouraged to defer advance treatment directives. In these patients decisions about life-sustaining therapy should be discouraged until after treatment of the depression.

Correlates of suffering in amyotrophic lateral sclerosis.

OBJECTIVES: 1) To determine the prevalence of pain, suffering, poor quality of life, depression, and hopelessness in people with ALS, and the correlates of suffering and poor quality of life; 2) to analyze the relationship between pain, suffering, quality of life, and attitudes toward life-sustaining medical treatment and physician-assisted suicide; and 3) to determine concordance between patients with ALS and their caregivers in rating the patients' pain, quality of life, and suffering. METHODS: Subjects completed a single interview. We measured the subject's pain, quality of life, suffering, hopelessness, depression, social support, perception of burden to others, level of disability, desire for life-sustaining medical treatment, and interest in assisted suicide. Caregivers also rated the patient's quality of life, pain, and suffering. RESULTS: A total of 100 subjects with ALS and 91 caregivers participated. Suffering was rated as 4 or greater on a six-point scale by 20% of subjects with ALS, and 19% rated their pain as 4 or greater on a six-point scale. Eleven percent had clinical depression. Physicians frequently failed to recognize and treat pain and depression. The correlates of suffering were increasing pain, hopelessness, and level of disability. The correlates of poor quality of life were poor social support and increasing hopelessness. The correlation between subjects' and caregivers' rating of the patient's suffering was r = 0.47. There was no relationship between subjects' ratings of pain, suffering, and quality of life, and their interest in life-sustaining treatment or physician-assisted suicide. CONCLUSION: Many patients with ALS suffer, and their suffering is correlated to pain and hopelessness. Physicians caring for patients with ALS frequently fail to recognize and treat their patients' pain and depression.

Depression in the elderly: effect on patient attitudes toward life-sustaining therapy.

OBJECTIVE: To determine the effect of depression on preferences for life-sustaining therapy in older persons. DESIGN: A survey comparing depressed, older veterans and a similar, but non-depressed, control group. SETTING: A 490-bed Veterans Affairs teaching hospital. PATIENTS: Medical inpatients over 65 years of age were potential subjects. Patients who were in intensive care, cognitively impaired, unable to communicate, abusing alcohol or drugs, or unable to return for outpatient care were excluded. Ninety-five eligible subjects (29%) refused to participate. Depressed subjects scored >14 on the Geriatric Depression Scale (GDS) and were diagnosed as depressed by a psychiatrist who was blind to the GDS results. Complete data were collected on 50 depressed and 50 control subjects. MAIN OUTCOME MEASURES: A self-administered questionnaire quantified patients' preferences regarding life-saving interventions in their current state of health and in four hypothetical scenarios of serious illness. RESULTS: Depressed subjects desired fewer interventions than control subjects in their current health and in hypothetical scenarios with a good prognosis (P < or = 0.05). There were no differences between groups in poor prognosis scenarios. However, depression did not explain more than 5% of the variance in decision-making in any situation. In good prognosis scenarios, subjects' assessment of quality of life was the most powerful predictor of desire for life-saving interventions, accounting for 9%-17% of the variance (P <0.01). CONCLUSIONS: These results suggest that depression is associated with treatment refusal in situations with a good medical prognosis. Depression, however, is only a weak predictor of treatment refusal. Further research is needed to define which patients would accept medical treatment if effectively treated for depression.

Screening for alcohol use disorders in the nursing home.

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM-III-R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM-III-R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST-G, and the two-question instrument developed by Cyr and Wartman. DESIGN: A cross-sectional design, with DSM-III-R criteria determined by the alcohol module of the Diagnostic Interview Schedule (DIS) as the criterion standard. PATIENTS: Patients older than age 50 admitted consecutively to a VA NH, n = 117. MAIN OUTCOME MEASURES: Sensitivities, specificities, positive predictive values for the CAGE, MAST-G, and Cyr and Wartman Screening questionnaires; receiver operating characteristic (ROC) curves for the CAGE and MAST-G. MAIN RESULTS: Forty-nine percent of study participants met DSM-III-R criteria for lifetime alcohol abuse or dependence (18% active, 31% inactive). The sensitivities and specificities of the three screening questionnaires were as follows: CAGE-82% and 90%; MAST-G-93% and 65%; Cyr and Wartman-70% and 92% respectively. The area under the ROC curve was 0.94 for the CAGE and 0.90 for the MAST-G. CONCLUSIONS: The prevalence of lifetime alcohol abuse and dependence was high in this VA NH population. Both the CAGE and MAST-G are sensitive to AUDs in this setting. The areas under the ROC curves were not significantly different and indicate both tests discriminated well between NH residents with and without AUDs.

Depression and mortality in medically ill older adults.

OBJECTIVE: To determine if major depressive disorder influences the survival of older, medically ill veterans. DESIGN: Thirty month follow-up of an inception cohort. SETTING: An academically-affiliated Veterans Affairs Medical Center. PARTICIPANTS: One hundred veterans, half of whom have a depressive disorder, recruited from inpatient medical and surgical units in 1990-1991. At initial evaluation all participants were older than age 65, cognitively intact, and medically but not terminally ill. MEASUREMENTS: Severity of medical illness, functional status, social support and presence of depression were measured at initial evaluation, presence of depression was measured 4 to 6 months after initial evaluation, and survival status was determined at 30 months. Retrospective medical record review was used to determine if patients received depression treatment and to explore whether depressed persons received life-sustaining medical treatment less often than nondepressed persons. RESULTS: At 30 months, 36 of the 100 subjects had died. Only two factors predicted mortality: severity of medical illness and depression. The survival of subjects who had recovered from depression at 4 to 6 months was intermediate to never depressed and continuously depressed subjects. Somatic treatment of depression did not alter outcome. There was no significant difference between depressed and nondepressed in how often life-sustaining medical treatments were withheld or withdrawn. CONCLUSION: Presence of major depression in medically-ill older hospitalized veterans continues to be a risk factor for death 30 months after diagnosis.

Caring for medical students as patients: access to services and care-seeking practices of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Healthcare.

PURPOSE: The personal health care of medical students is an important but neglected issue in medical education. Preliminary work suggests that medical student-patients experience special barriers to health care services and report problematic care-seeking practices that merit further inquiry. METHOD: A self-report questionnaire was piloted, revised, and distributed to students at nine medical schools in 1996-97. The survey included questions regarding access to health services, care-seeking practices, and demographic information. RESULTS: A total of 1,027 students participated (52% response rate). Ninety percent reported needing care for various health concerns. Fifty-seven percent did not seek care at times, in part due to training demands, and 48% had encountered difficulties in obtaining care. A majority had received treatment at their training institutions, and students commonly pursued informal or "curbside" care from medical colleagues. Almost all participants (96%) were insured. Differences in responses were associated with level of training, gender, and medical school. CONCLUSION: Medical schools shoulder the responsibility not only of educating but also of providing health services for their students. Students encounter barriers to care and engage in problematic care-seeking practices. Greater attention to issues surrounding medical student health may benefit students and their future patients.

Drug-induced mania in the elderly.

Mania is a rare complication of prescribed drug use in elderly persons. The drugs most likely to produce mania include corticosteroids and dopamine agonists. It is uncertain if antidepressants cause mania or only increase the propensity for latent bipolar mania to be expressed. Drug-induced mania may promote poor judgment, risk-taking behaviours and medical noncompliance. The majority of episodes of drug-induced mania are short-lived and respond to discontinuation of the drug. Antipsychotic agents may hasten resolution of this psychiatric syndrome. Lithium may prevent corticosteroid-induced mania, but the role of lithium in the treatment of other drug-induced manic episodes has not been studied adequately.

Drug-induced depression in the aged. What can be done?

Over 10% of medically ill elderly persons have concurrent major depression, and medical illness is the most influential stressor contributing to depression in old age. The contribution of prescribed medications to depression in the medically ill is poorly understood. Most information on drug-induced depression is derived from case reports; 43 classes of medications have been implicated, including reserpine, beta-blockers, levodopa, corticosteroids, and antipsychotics. However, large rigorously performed studies of some drugs, particularly antihypertensives, suggest that drug-induced depression is uncommon and idiosyncratic. There is no evidence that age is an independent risk factor for drug-induced depression. However, elderly persons are the largest consumers of prescribed drugs, and the burden of drug-induced depression is carried by the old. Because of the frequency of atypical presentations of mental disorders in the elderly, drug-induced depression is often misdiagnosed. Nevertheless, basic principles of geriatric medicine offer useful guidance to clinicians in evaluating the complex interrelationships between prescribed medications and depression. We recommend an approach that includes regular inquiry into the common symptoms of mood disorders, vigilance in assessing the contribution of drugs in their development, but scepticism in assessing a depressive episode as caused only by medication.

Neuropsychiatric adverse effects of antiparkinsonian drugs. Characteristics, evaluation and treatment.

Parkinson's disease (PD) is a progressive neurological condition that causes considerable disability in the elderly. Drugs used to treat PD, such as levodopa, offer symptomatic relief but often have neuropsychiatric adverse effects, most prominently psychosis and delirium. Aged patients and those with dementia are particularly vulnerable to these adverse effects. Evaluating PD patients with drug-induced neuropsychiatric adverse effects is made difficult by their complex clinical presentations. The treatment of drug-induced psychosis and delirium begins with manipulating the antiparkinsonian drug regimen, but this frequently worsens motor function. Atypical antipsychotics such as clozapine have been successfully employed to treat the psychosis without worsening the motor disability. Patient intolerance of clozapine therapy has prompted open-label studies with newer agents such as risperidone, remoxipride, zotepine, mianserin and ondansetron.

Acute extrapyramidal syndromes in neuroleptic-treated elders: a pilot study.

The incidence, morbidity, and risk factors for acute extrapyramidal syndromes (EPS) such as akathisia and drug-induced parkinsonism (DIP) in neuroleptic-treated elders have not been systematically explored. This study presents data on 17 elderly patients who were prospectively examined for up to 4 weeks for acute EPS, functional and cognitive status, and behavioral disturbances. Seventy-one percent of subjects developed DIP, and 18% developed akathisia. Predictors of DIP included pre-neuroleptic treatment parkinsonian signs and neuroleptic dose, despite use of low doses of neuroleptics. Development of acute EPS was associated with failure to improve behaviorally. New-onset urinary incontinence was the most common functional abnormality.

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

An interdisciplinary mental health consultation team in a nursing home.

The Mental Health Consultation Team (MHCT) at the Portland Veterans Affairs Medical Center nursing home is an interdisciplinary group of mental health professionals and primary care providers established to triage mental health consultations, improve communication between consultants and primary care providers, help staff translate consultants' recommendations into patient care, and furnish education in the management of mental health problems. The MHCT has decreased the demands for formal psychiatry and psychology consultations while increasing mental health services through innovative use of existing staff.

A program for teaching psychiatric residents to provide integrated psychiatric and primary medical care.

The Psychiatry Primary Medical Care program of the Portland Veterans Affairs Medical Center teaches psychiatric residents to provide integrated psychiatric and medical care in a primary care setting. During the program's first year of operation, 34 patients received ongoing integrated care from seven residents. Patients, psychiatric residents, and medical faculty reported a high degree of satisfaction with the program. The duration and frequency of visits reflected the substantial mental health and primary care needs of the population. Patients frequently missed appointments. Barriers to starting and maintaining the program included space constraints and the amount of supervision required.

Attitudes of Oregon psychologists toward physician-assisted suicide and the Oregon Death With Dignity Act.

Since the passage of the Oregon Death With Dignity Act (ODDA), psychologists have been grappling with how to fulfill their legally specified role in the process of physician-assisted suicide. We surveyed Oregon psychologists to elicit their views on assisted suicide and the process of assessing patients who request such assistance. There was a high degree of support for assisted suicide and the ODDA, but also a minority who were highly opposed. Most survey respondents raised ethical or practical concerns with their role as assessors. Many important questions about how evaluations in the complex area should be conducted remain unanswered.