Reexamining associations between mania, depression, anxiety and substance use disorders: results from a prospective national cohort.

Separate inheritance of mania and depression together with high rates of clinical overlap of mania with anxiety and substance use disorders provide a basis for re-examining the specificity of the prospective association of manic and depression episodes that is a hallmark of bipolar disorder. We analyzed information from 34 653 adults in Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, a longitudinal nationally representative survey of US adults interviewed 3 years apart. Psychiatric disorders were assessed by a structured interview. We used logistic regression analyses to estimate the strength of associations between Wave 1 manic episodes and Wave 2 depression, anxiety and substance use disorders controlling for background characteristics and lifetime Wave 1 disorders. Corresponding analyses examined associations between Wave 1 major depressive episode with manic episodes and other psychiatric disorders. In multivariable models, Wave 1 manic episodes significantly increased the odds of Wave 2 major depressive episodes (adjusted odds ratio (AOR): 1.7; 95% confidence interval: 1.3-2.2) and any anxiety disorder (AOR: 1.8; 1.4-2.2), although not of substance use disorders (AOR: 1.2; 0.9-1.5). Conversely, Wave 1 major depressive episodes significantly increased risk of Wave 2 manic episodes (AOR: 2.2; 1.7-2.9) and anxiety disorders (AOR: 1.7; 1.5-2.0), although not substance use disorders (AOR: 1.0; 0.9-1.2). Adults with manic episodes have an approximately equivalent relative risk of developing depression episodes and anxiety disorders. Greater research and clinical focus is warranted on connections between manic episodes and anxiety disorders.

Examining heterotypic continuity of psychopathology: a prospective national study.

BACKGROUND: Individuals with one psychiatric disorder are at increased risk for incidence and recurrence of other disorders. We characterize whether the magnitude of such heterotypic continuity varies based on whether the first disorder remits or persists over time. METHOD: Cohorts were selected from participants in the National Epidemiologic Survey on Alcohol and Related Conditions wave 1 (2001-2002) and wave 2 (2004-2005) surveys with ⩾1 mood, anxiety, or substance use disorder at wave 1. Among respondents remitting (n = 6719) or not remitting (n = 3435) from ⩾1 of disorder at wave 2, the analyses compared the odds of developing new disorders. RESULTS: As compared with adults whose disorders persisted from wave 1 to wave 2, those with ⩾1 remission had lower odds of incidence or recurrence of another disorder. Remission from alcohol dependence [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3-0.5] and drug dependence (OR 0.4, 95% CI 0.3-0.6) were associated with the lowest odds of incidence of another disorder. Social anxiety disorder was associated with the lowest adjusted odds of recurrence (adjusted OR = 0.2, 95% CI 0.1-0.6). Remission of disorders within one class (mood, anxiety, substance use) was consistently associated with lower odds of incidence or recurrence of disorders from the same class than with developing disorders from the other classes. CONCLUSIONS: Remission from common psychiatric disorders tends to decrease the risk for incidence or recurrence of disorders and this effect is stronger within than across disorder classes. These results do not support the concept of heterotypic continuity as a substitution of one disorder for another.

Comparative mortality risks of antipsychotic medications in community-dwelling older adults.

BACKGROUND: All antipsychotic medications carry warnings of increased mortality for older adults, but little is known about comparative mortality risks between individual agents. AIMS: To estimate the comparative mortality risks of commonly prescribed antipsychotic agents in older people living in the community. METHOD: A retrospective, claims-based cohort study was conducted of people over 65 years old living in the community who had been newly prescribed risperidone, olanzapine, quetiapine, haloperidol, aripiprazole or ziprasidone (n = 136 393). Propensity score-adjusted Cox proportional hazards models assessed the 180-day mortality risk of each antipsychotic compared with risperidone. RESULTS: Risperidone, olanzapine and haloperidol showed a dose-response relation in mortality risk. After controlling for propensity score and dose, mortality risk was found to be increased for haloperidol (hazard ratio (HR) = 1.18, 95% CI 1.06-1.33) and decreased for quetiapine (HR = 0.81, 95% CI 0.73-0.89) and olanzapine (HR = 0.82, 95% CI 0.74-0.90). CONCLUSIONS: Significant variation in mortality risk across commonly prescribed antipsychotics suggests that antipsychotic selection and dosing may affect survival of older people living in the community.

Association between benzodiazepine receptor agonist use and mortality in patients hospitalised for COVID-19: a multicentre observational study.

AIMS: To examine the association between benzodiazepine receptor agonist (BZRA) use and mortality in patients hospitalised for coronavirus disease 2019 (COVID-19). METHODS: A multicentre observational study was performed at Greater Paris University hospitals. The sample involved 14 381 patients hospitalised for COVID-19. A total of 686 (4.8%) inpatients received a BZRA at hospital admission at a mean daily diazepam-equivalent dose of 19.7 mg (standard deviation (s.d.) = 25.4). The study baseline was the date of admission, and the primary endpoint was death. We compared this endpoint between patients who received BZRAs and those who did not in time-to-event analyses adjusted for sociodemographic characteristics, medical comorbidities and other medications. The primary analysis was a Cox regression model with inverse probability weighting (IPW). RESULTS: Over a mean follow-up of 14.5 days (s.d. = 18.1), the primary endpoint occurred in 186 patients (27.1%) who received BZRAs and in 1134 patients (8.3%) who did not. There was a significant association between BZRA use and increased mortality both in the crude analysis (hazard ratio (HR) = 3.20; 95% confidence interval (CI) = 2.74-3.74; p < 0.01) and in the IPW analysis (HR = 1.61; 95% CI = 1.31-1.98, p < 0.01), with a significant dose-dependent relationship (HR = 1.55; 95% CI = 1.08-2.22; p = 0.02). This association remained significant in sensitivity analyses. Exploratory analyses indicate that most BZRAs may be associated with an increased mortality among patients hospitalised for COVID-19, except for diazepam, which may be associated with a reduced mortality compared with any other BZRA treatment. CONCLUSIONS: BZRA use may be associated with an increased mortality among patients hospitalised for COVID-19, suggesting the potential benefit of decreasing dose or tapering off gradually these medications when possible.

Barriers to mental health treatment: results from the National Comorbidity Survey Replication.

BACKGROUND: The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population. METHOD: Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment. RESULTS: Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on one's own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions. CONCLUSIONS: Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

Stigma and treatment for alcohol disorders in the United States.

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (ß = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (ß = 1.0; P < 0.01), education (ß = 1.48; P < 0.01), and being previously married (ß = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (ß = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.

Depression in women: implications for health care research.

Epidemiologic data from around the world demonstrate that major depression is approximately twice as common in women than men and that its first onset peaks during the childbearing years. Progress has been made in understanding the epidemiology of depression and in developing effective treatments. Much remains to be learned about the basic pathogenesis of depression and the specific treatment needs of depressed women and their offspring, especially during the reproductive years.

Changing patterns of psychiatric inpatient care in the United States, 1988-1994.

Using data from the National Hospital Discharge Survey and the Inventory of Mental Health Organizations, this article examines national trends in psychiatric inpatient care from 1988 to 1994 in general hospitals and mental hospitals. We find that discharges with a primary diagnosis of mental illness in general hospitals increased from 1.4 to 1.9 million during this period. The total increase of 1.2 million days of care in general hospitals was small relative to the reduction of 12.5 million inpatient days in mental hospitals. General hospital discharges increased most in private nonprofit hospitals and declined substantially in public hospitals. Length of stay has fallen most substantially in private nonprofit hospitals. Public programs have increasingly replaced private insurance as the major source of payment. These observations suggest that psychiatric inpatient care in general hospitals can be characterized as a process in which patients who would have been clients of public mental hospitals in a prior period replace privately insured patients who, under managed care, are largely treated in community settings. Private nonprofit general hospitals increasingly treat publicly financed patients with more severe illnesses.

Offspring of depressed parents. 10 Years later.

BACKGROUND: There have been numerous studies that have shown that offspring of depressed parents are at a high risk for major depressive disorder (MDD) and impairment. None have followed up the offspring into adulthood to obtain more precise estimates of risk. METHOD: One hundred eighty-two offspring from 91 families, in which 1 or more parents had MDD (high risk) or in which neither parent was depressed (low risk), were blindly reassessed in the third follow-up, using a structured diagnostic instrument 10 years after their initial identification. RESULTS: Compared with the offspring for whom neither parent was depressed, the offspring of depressed parents had increased rates of MDD, particularly before puberty, and phobias (both at approximately a 3-fold risk), panic disorder, alcohol dependence (at a 5-fold risk), and greater social impairment. The peak age at onset for MDD in both high- and low-risk offspring ranged from 15 to 20 years. The peak age at onset for anxiety disorder was considerably earlier, especially in female offspring in the high-risk group. The onset of alcohol dependence in the offspring in the high-risk group peaked in adolescence and then after the age of 25 years. The depressed offspring of depressed parents, compared with nondepressed parents, had more serious and impairing depressions during the follow-up period but were less likely to go for treatment. CONCLUSIONS: The offspring of depressed parents are a high-risk group for onset of anxiety disorder and MDD in childhood, MDD in adolescence, and alcohol dependence in adolescence and early adulthood. The findings support the potential value of early detection in the offspring of depressed parents.

Brief screening for family psychiatric history: the family history screen.

BACKGROUND: Brief screens to collect lifetime family psychiatric history are useful in clinical practice and for identifying potential families for genetic studies. METHODS: The Family History Screen (FHS) collects information on 15 psychiatric disorders and suicidal behavior in informants and their first-degree relatives. Since each question is posed only once about all family members as a group, the administrative time is 5 to 20 minutes, depending on family size and illness. Data on the validity against best-estimate (BE) diagnosis based on independent and blind direct interviews on 289 probands and 305 relatives and test-retest reliability across 15 months in 417 subjects are presented. RESULTS: Agreement between FHS and BE diagnosis for proband and relative self-report had median sensitivity (SEN) of 67.6 and 71.1 respectively; median specificity (SPC) was 87.6 and 89.4, respectively. Marked decrease in SEN occurred when a single informant (the proband) reported on a relative (median, 37.5); however, median SPC was 95.8. Use of more than 1 informant substantially improved SEN (median, 68.2), with a modest reduction in SPC (median, 86.8). Test-retest reliability across 15 months resulted in a median kappa of 0.56. CONCLUSIONS: The FHS is a promising brief screen for collecting lifetime psychiatric history on an informant and/or first-degree relatives. Its validity is best demonstrated for major depression, anxiety disorders, substance dependence (alcohol and drug dependence), and suicide attempts. It is not a substitute for more lengthy family history if more detail on diagnosis is required.

Subthreshold psychiatric symptoms in a primary care group practice.

BACKGROUND: The authors define 6 groups of subthreshold psychiatric symptoms that do not meet the full criteria for a DSM-IV Axis I disorder and examine the clinical significance of these symptoms in an outpatient primary care sample. METHODS: The subjects were 1001 adult primary care patients in a large health maintenance organization. Data on sociodemographic characteristics and functional impairment, including scores on the Sheehan Disability Scale, were collected at the time of the medical visit, and a structured diagnostic interview for DSM-IV disorders was completed by telephone within 4 days of the visit. Subthreshold symptoms were defined for depressive, anxiety, panic, obsessive-compulsive, drug, and alcohol symptoms. RESULTS: Subthreshold symptoms were as or more common than their respective Axis I disorders: panic (10.5% vs 4.8%), depression (9.1% vs 7.3%), anxiety (6.6% vs 3.7%), obsessive-compulsive (5.8% vs 1.4%), and alcohol (5.3% vs 5.2%) and other drug (3.7% vs 2.4%) cases. Patients with each of the subthreshold symptoms had significantly higher Sheehan Disability Scale scores (greater impairment) than did patients with no psychiatric symptoms. Many patients (22.6%-53.4%) with subthreshold symptoms also met the full criteria for other Axis I disorders. After adjusting for the confounding effects of other Axis I disorders, other subthreshold symptoms, age, sex, race, marital status, and perceived physical health status, only depressive symptoms, major depressive disorder, and, to a lesser extent, panic symptoms were significantly correlated with the impairment measures. CONCLUSIONS: In these primary care patients, the morbidity of subthreshold symptoms was often explained by confounding mental, physical, or demographic factors. However, depressive symptoms and, to a lesser extent, panic symptoms were disabling even after controlling for these factors. Primary care clinicians who detect subthreshold psychiatric symptoms should consider a broad psychiatric assessment.

Antidepressant prescribing practices of outpatient psychiatrists.

BACKGROUND: The authors examined recent changes in the number and proportion of patients prescribed antidepressants by psychiatrists in outpatient private practice and characterized antidepressant prescription patterns by patient age, sex, race, payment source, and clinical diagnosis. METHODS: The authors analyzed physician-reported data from the 1985 and 1993-1994 National Ambulatory Medical Care Survey, focusing on visits to physicians specializing in psychiatry. Logistic regressions were used to examine associations between survey year and antidepressant prescription, adjusting for the presence of other variables. RESULTS: The proportion of outpatient psychiatric visits in which an antidepressant was prescribed increased from 23.1% (95% confidence interval [CI], 19.7%-26.5%) in 1985 to 48.6% (95% CI, 47.5%-49.7%) in 1993-1994. After controlling for several patient variables, psychiatric patients were approximately 2.3 (95% CI, 1.8-2.9) times more likely to receive an antidepressant in 1993-1994 than in 1985. In 1993-1994, selective serotonin reuptake inhibitors accounted for approximately half of the psychiatric visits with an antidepressant prescription. Increases in the rate of antidepressant prescription were particularly evident for children and young adults; whites; new patients; and patients with adjustment disorders, personality disorders, depression not otherwise specified or dysthymia, and some anxiety disorders. CONCLUSIONS: During the late 1980s and early 1990s, there was a significant increase in the prescription of antidepressants by office-based psychiatrists. This increase was greatest for patients with less severe psychiatric disorders.

Patterns and predictors of treatment seeking after onset of a substance use disorder.

BACKGROUND: We studied survey respondents aged 18 through 54 years to determine consistent predictors of treatment seeking after onset of a DSM-III-R substance use disorder. METHODS: Survey populations included a regional sample in Ontario (n = 6261), a national sample in the United States (n = 5388), and local samples in Fresno, Calif (n = 2874) and Mexico City, Mexico (n = 1734). The analysis examined the effects of demographics, symptoms, and types of substances on treatment seeking. RESULTS: Between 50% (Ontario) and 85% (Fresno) of people with substance use disorders seek treatment but the time lag between onset and treatment seeking averages a decade or more. Consistent predictors of treatment seeking include: (1) late onset of disorder (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.6-5.6 for late [> or =30 years] vs early [1-15 years] age at first symptom of disorder); (2) recency of cohort (OR, 3.4; 95% CI, 2.3-5.0 for most recent [aged 15-24 years at interview] vs earliest [aged > or =45 years] cohorts); (3) 4 specific dependence symptoms (using larger amounts than intended, unsuccessful attempts to cut down use, tolerance, and withdrawal symptoms), with ORs ranging between 1.6 (95% CI, 1.3-2.0) and 2.7 (95% CI, 2.1-3.6) for people with vs without these symptoms; and (4) use vs nonuse of cocaine (OR, 2.1; 95% CI, 1.6-2.7) and heroin (OR, 2.6; 95% CI, 1.1-6.0). CONCLUSIONS: Although most people with substance use disorders eventually seek treatment, treatment seeking often occurs a decade or more after the onset of symptoms of disorder. While treatment seeking has increased in recent years, it is not clear whether this is because of increased access, increased demand, increased societal pressures, or other factors.

Primary care patients who refuse specialized mental health services.

The charts of 65 patients who completed mental health care referrals were compared with those of 65 patients who failed to complete such referrals. In the year before referral, the noncompliant patients made 37% more medical visits than the compliant patients. As compared with the compliant patients, a significantly greater proportion of the noncompliant patients' medical visits were for difficult-to-explain somatic symptoms. Mental health referrals from some physicians were much more successful than referrals from other physicians. By attending to their patients' pattern of health care utilization, primary care physicians may be able to identify patients at high risk for noncompliance with mental health referrals.

Use of benzodiazepines in the community.

BACKGROUND: Although benzodiazepines are the most commonly prescribed psychotropic medications in the United States, considerable controversy surrounds their proper role in medical practice. METHODS: Data from the household section of the 1987 National Medical Expenditure Survey were analyzed to estimate the prevalence and general characteristics of adults who purchased benzodiazepines in 1987. RESULTS: An estimated 6.2% (10.9 million) of the adult population purchased benzodiazepines in 1987. In nearly half (47.0%) of the purchases, the use of benzodiazepines perceived by the patient did not correspond to a labeled or literature-supported unlabeled use. Multivariate analysis disclosed that benzodiazepine use was predicted by sociodemographic factors (white race, female gender, age older than 64 years, and unemployed work status), pharmacologic factors (use of an antidepressant), mental health factors (high levels of anxiety), and general health factors (poor general health, cardiac disease, arteriosclerosis, health-related work impairment, and trouble walking one block). CONCLUSIONS: These data indicate that benzodiazepine use is less prevalent than previously reported and suggest that there has been a recent decline in use. A marked discrepancy exists between why people perceive they purchase benzodiazepines and the recognized uses of these medications.

General hospitals and the severely mentally ill: changing patterns of diagnosis.

OBJECTIVE: The author's goal is to determine whether there has been a recent change in the number and proportion of severely ill psychiatric patients treated in general hospitals. METHOD: He analyzed the discharge data from the National Hospital Discharge Survey for the years between 1970 and 1987, focusing particularly on the discharges of patients with psychiatric versus nonpsychiatric diagnoses. The number and proportion of discharges of patients with psychiatric diagnoses in four major diagnostic groups (depression, bipolar spectrum disorders, schizophrenia, and other psychoses) were determined. RESULTS: Between 1970 and 1987, discharges of patients with psychiatric diagnoses from general hospitals increased by a factor of 0.8. The percentage of discharges of patients with the diagnoses of depression (18.0%-22.7%), schizophrenia (9.4%-13.6%), and paranoid or other nonorganic psychoses (3.1%-4.0%) remained relatively constant. The percentage of discharges of patients with the diagnosis of nondepressed bipolar disorder increased from 0.6% in 1970 to 3.2% in 1987. CONCLUSIONS: Although there has been a recent absolute increase in the number of general hospital patients with severe psychiatric diagnoses, the increase has been tempered by a concomitant increase in the number of patients with nonsevere diagnoses. Changes in classification systems (DSM-II or ICDA-8 to DSM-III or ICD-9-CM) and questions regarding the rigor with which the nosologic changes have been incorporated into practice complicate the interpretation of these findings.

Utilization of neuropsychiatric diagnostic tests for general hospital patients with mental disorders.

OBJECTIVE: The author's goal was to determine the frequency and distribution of neuropsychiatric diagnostic tests provided to general hospital patients with mental disorders. METHOD: Data from the 1989 National Hospital Discharge Survey were analyzed to determine the number, proportion, and general characteristics of 11,628 discharged patients with primary diagnoses of mental disorders who underwent computerized tomography (CT) scanning of the head, EEG, and magnetic resonance imaging (MRI) of the brain. RESULTS: Of the discharged patients with mental disorders, 5.1% had received CT scans, 2.8% had received EEGs, and 0.7% had received MRI. These rates were below the rates for patients discharged with primary diagnoses of neurological disorders but above the rates for patients discharged with primary diagnoses of other medical disorders. Among the patients discharged with mental disorder diagnoses, the likelihood of receiving a CT scan or an EEG was greater if the primary diagnosis was an organic disorder or if the secondary diagnosis was a medical disorder. Patients over age 65 were also more likely to have received a CT scan. Hospital size and location had a modest influence on the likelihood of receiving a CT scan or EEG, but the ownership of the hospital and the patient's source of payment were not significant influences. CONCLUSIONS: Neuropsychiatric diagnostic testing is selectively utilized in the routine treatment of general hospital psychiatric inpatients. Clinical variables rather than institutional or financial variables appear to be the most powerful predictors of which patients are selected to receive these tests.

Mental disorders in public, private nonprofit, and proprietary general hospitals.

OBJECTIVE: The authors' goal was to assess the effects of facility ownership on the characteristics of psychiatric inpatients treated in public, private nonprofit, or proprietary general hospitals. METHOD: Data from the 1993 National Hospital Discharge Survey were analyzed to determine the number, sociodemographic and diagnostic composition, and treatment characteristics of patients with primary mental disorders discharged from public, private nonprofit, and proprietary general hospitals. RESULTS: An estimated 1.83 million patients with a primary mental disorder diagnosis were discharged from general hospitals in 1993; the number of such discharges in the National Hospital Discharge Survey, which excluded federal general hospitals, was 13,086. These patients were unevenly distributed among public (9.4%), private nonprofit (78.9%), and proprietary (11.7%) hospitals. Psychiatric patients of public and private nonprofit hospitals were more likely to be diagnosed with schizophrenia (public: 23.4%, nonprofit: 18.8%, proprietary: 12.6%), a comorbid substance-related disorder (public: 29.9%, nonprofit: 31.0%, proprietary: 17.4%), a personality disorder (public: 11.6%, nonprofit: 11.3%, proprietary: 4.7%), or a general medical disorder (public: 62.4%, nonprofit: 57.4%, proprietary: 41.1%) than patients of proprietary hospitals. Uninsured psychiatric patients were far more common at public hospitals than at the other types of facilities (public: 17.0%, nonprofit: 9.9%, proprietary: 6.4%). CONCLUSIONS: Public general hospitals play an important role in caring for uninsured patients with severe mental illness. Before widespread closures occur in the public general hospital sector, it is critical that policy makers identify and develop resources to replace the care these institutions currently provide to poor patients with severe psychiatric disorders.

Treatment of panic attack and risk of major depressive disorder in the community.

OBJECTIVE: The authors' goal was to determine whether treatment of panic attacks has a protective effect on the risk of major depression in the community. METHOD: Data were drawn from the National Comorbidity Survey, a community-based household sample representative of the U.S. adult population. A Cox proportional hazard model was used to estimate the association between risk of first-onset major depression and panic among subjects who had or had not received treatment for panic. RESULTS: A significantly smaller proportion of individuals who received treatment for panic (19%) than those who did not receive treatment (45%) developed major depression. This difference remained significant in a Cox proportional hazard analysis adjusted for age at onset of panic and differences in demographic characteristics. CONCLUSIONS: Detection and treatment of panic may reduce the risk of developing major depression.

Trends in the prescription of antidepressants by office-based psychiatrists.

OBJECTIVE: This study was done in an effort to determine whether there was a change over the past decade in the number and proportion of patients prescribed antidepressants by psychiatrists in private practice. METHOD: The authors analyzed data from the National Ambulatory Medical Care Survey for the years 1980, 1985, and 1989, focusing on visits by adults over the age of 18 years to physicians specializing in psychiatry and psychiatric subspecialties. RESULTS: The number of visits that included prescribing an antidepressant medication grew from approximately 2.5 million in 1980 to 4.7 million in 1989, or from 17.9% to 30.4% of all office-based psychiatric visits. Fluoxetine, which first became available in 1988, accounted for 29.6% of the prescriptions for antidepressants in 1989. Increases in prescriptions for antidepressants were particularly evident for male patients, young adult patients, and patients with neurotic disorders. CONCLUSIONS: There was an increase in the 1980s in the use of antidepressants in office-based psychiatric practice. The advent of new agents and the broadening of the clinical usefulness of existing agents may have contributed to this increase.