Screening for depression and diabetes-related distress in a diabetes outpatient clinic.

AIMS: To investigate: (1) the willingness of patients with diabetes to participate in a screening programme; (2) the extent to which patients with diabetes who screen positive endorse need for psychosocial care; (3) the rate of referral to psychosocial care during screening vs. usual care. METHODS: Four hundred and ninety-nine patients with diabetes were invited to complete the Center for Epidemiologic Studies Depression and the Problem Areas in Diabetes questionnaires. Patients screening positive on either instrument were invited for an interview. One year after screening was withdrawn, rates of referral to psychosocial care were assessed from physician reports of patient referrals. RESULTS: In total, 349/499 (70%) patients with diabetes completed the questionnaire. Patients who did not take up the screening were younger, smoked more often and had higher HbA(1c) values. 'No-shows' for clinical appointments accounted for 74% of non-participation. Of the 104 (30% of 349) patients screening positive, 45 accepted an invitation for an interview. Finally, 36/104 (35%) would like a referral for psychological care. Seven per cent of patients were referred to psychological care during screening compared with 1% when screening was withdrawn. CONCLUSIONS: Results raise questions as to whether screening is the most efficient way to identify patients with psychological problems. Many patients did not take up the screening, especially those with low adherence to diabetes care in general. Furthermore, few patients screening positive wanted to be referred. Screening should be evaluated in the context of consideration of alternative ways to identify at-risk patients, including providing resources to deal with patients with already known adjustment and adherence problems.

Sleep and daily functioning during androgen deprivation therapy for prostate cancer.

A limited body of evidence suggests that sleep problems are common in prostate cancer patients undergoing androgen deprivation therapy, yet little is known about sleep characteristics and the effects of poor sleep on daily functioning in this population. This study assessed sleep in 60 prostate cancer patients taking androgen deprivation therapy with wrist actigraphy and daily diaries for 7 days. The Epworth Sleepiness Scale and the general version of the Functional Assessment of Cancer Therapy scale were also administered. On average, total sleep time was 5.9 (SD = 1.4) h, and sleep efficiency was 75% (SD = 12.0) as assessed by actigraphy. There was generally poor concordance between actigraphy and daily diary for most sleep metrics. Subjects reported awakening, on average, 2.7 times per night, most commonly for nocturia and hot flashes. Assessment of daily functioning showed that participants had mild daytime sleepiness, which was predicted by total sleep time (F(1,47) = 4.5, P= 0.04) General quality of life was not impaired. This study supports more research on the predictors of poor sleep in order to identify effective interventions.

Self-reported distress: analog or Ersatz depression?

Vredenburg, Flett, and Krames's (1993) conclusion that self-reported distress in college students is an appropriate analog for diagnosable depression is examined in light of a broader literature. Self-reported distress is conceptually and empirically distinct from depression and depressive symptoms. Distress has stronger correlates with common psychological and social factors. Distress in college students tends to be mild and transient, and most distressed college students are not depressed. Some other features of college life also make generalizations to clinical and community samples of adults problematic. Overall, ubiquitous misunderstandings in the literature have limited recognition of the pitfalls of studying distress as an analog for diagnosable depression. It is undesirable for reasons of science, social responsibility, and the credibility of psychological models of depression.

Issues in personality as diathesis for depression: the case of sociotropy-dependency and autonomy-self-criticism.

A congruency between personality and life stress is assumed to pose a particular risk for depression. The authors review relevant research as a way of examining broader issues entailed in diathesis-stress models of depression. Topics include the identification of distinct personality modes and the differentiation of these modes from the phenomena of depression and the influence of the social context. Diathesis-stress models face formidable conceptual and methodological challenges. More complex models are needed to accommodate the dynamics of a person's life course, involvement in significant social contexts, and fluctuations in vulnerability to depression. Base rates of key phenomena favor development of models of depression recurrence in high-risk samples rather than its onset in the general population.

Children of depressed parents: an integrative review.

This article reviews the various literatures on the adjustment of children of depressed parents, difficulties in parenting and parent-child interaction in these families, and contextual factors that may play a role in child adjustment and parent depression. First, issues arising from the recurrent, episodic, heterogeneous nature of depression are discussed. Second, studies on the adjustment of children with a depressed parent are summarized. Early studies that used depressed parents as controls for schizophrenic parents found equivalent risk for child disturbance. Subsequent studies using better-defined samples of depressed parents found that these children were at risk for a full range of adjustment problems and at specific risk for clinical depression. Third, the parenting difficulties of depressed parents are described and explanatory models of child adjustment problems are outlined. Contextual factors, particularly marital distress, remain viable alternative explanations for both child and parenting problems. Fourth, important gaps in the literature are identified, and a consistent, if unintentional, "mother-bashing" quality in the existing literature is noted. Given the limitations in knowledge, large-scale, long-term, longitudinal studies would be premature at this time.

Prognostic importance of marital quality for survival of congestive heart failure.

Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patient's concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

Depression in the family physician's office: what the psychiatrist needs to know: the Michigan Depression Project.

A rapidly growing body of research suggests that depression in primary care may differ from that in psychiatry in its nature, severity, comorbidity, and responsiveness to treatment. The Michigan Depression Project is a long-term series of studies designed to explore the twin assumptions that depressed primary care patients are similar to depressed psychiatric patients and that identical treatment will benefit both groups. Major findings are (1) criterion-based diagnosis of major depressive disorder in primary care includes many patients with mild depression and little to no impairment; (2) the onset of depression among family practice patients-but not psychiatric patients-is usually preceded by a severe life event; (3) in primary care, outcome for patients with undetected depression appears to be comparable to that for those with detected depression; and (4) family physicians appear to employ historical cues in assigning the diagnosis of depression to distressed and impaired patients. The results of the Michigan Depression Project and the recent work of other researchers suggest that the challenges facing primary care physicians in the diagnosis and treatment of depressed patients are daunting. These challenges lead to a set of consultative skills and behaviors on the part of psychiatrists that may be different than generally expected. One-time, stand-alone psychiatric consultations are often needed, because neither the primary care physician nor the patient desires the psychiatric care to be "carved out" from the continuing care of a set of chronic problems. Future intervention studies should compare subgroups of patients who appear most in need of treatment (on the basis of functional impact) with those who are mildly depressed and barely meet diagnostic criteria. These studies will help primary care physicians focus their energies and therapies where they will have the most benefit in treating what is clearly a common and important, but still poorly understood, problem in primary care medical practice.

The relationship between alcohol problems and health functioning of older adults in primary care settings.

OBJECTIVE: The purpose of this study was to determine the relationship between alcohol use and health functioning in a sample of older adults screened in primary care settings. DESIGN: A cross-sectional study. SETTING: Thirty-seven primary care clinics. PARTICIPANTS: Older adults (n = 8,578; aged 55-97) with regularly scheduled appointments in primary care clinics were screened. MEASUREMENTS: Participants were categorized based on alcohol consumption levels as abstainers, low-risk drinkers, and at-risk drinkers (women: 9 or more drinks/week; men: 12 or more drinks/week). Dependent variables were eight SF-36 health functioning scales. RESULTS: Sixty-one percent of participants were abstainers, 31% were low-risk drinkers, and 7% were at-risk drinkers. ANCOVAs found significant effects of drinking status on General Health, Physical Functioning, Physical Role Functioning, Bodily Pain, Vitality, Mental Health, Emotional Role, and Social Functioning, controlling for age and gender, with low-risk drinkers scoring significantly better than abstainers. At-risk drinkers had significantly poorer mental health functioning than low-risk drinkers. Few significant gender differences were found on SF-36 scales. CONCLUSIONS: Older adults who are at-risk drinkers may not present with poor physical health functioning. Future studies are needed to determine the relationship between drinking limits for older adults and other areas of physical and psychosocial health.

Emotional and physical intimacy in coping with lupus: women's dilemmas of disclosure and approach.

This study examined whether self-rated physical and emotional intimacy of 74 women with their heterosexual partner, during an illness episode of lupus, was related to their affect and relationship satisfaction. It was predicted that greater intimacy would be related to better psychosocial adjustment. Women who engaged in physically intimate behavior with their partner more often reported greater relationship satisfaction. Women who frequently avoided or who were often the initiators of physical intimacy, however, reported greater negative affect. Concerning emotional intimacy, women who disclosed more information about illness symptoms and women who concealed more information about their symptoms and feelings experienced the highest levels of negative affect. Results identify dilemmas that women with recurrent illness may face when trying to maintain intimacy during illness periods.

The relationship of distress to mood disturbance in primary care and psychiatric populations.

Disagreement remains as how to interpret elevated scores on measures of self-reported distress. This study compared elevated scores on the Center for Epidemiologic Studies-Depression Scale (CES-D) in 2 samples to mood disturbance as assessed in an interview. In a primary medical care sample, most distressed patients did not have a mood disturbance, and distress without mood disturbance was associated with little impairment. Primary care patients with elevated scores on the CES-D were less distressed and less likely to have mood disturbance, major depression, or impairment than distressed psychiatric patients. Few patients with mood disturbance in either sample failed to meet criteria for major depression. Implications are discussed for research on depression using self-report measures, for generalizations across clinical and nonclinical populations, and for screening for preventive interventions.

Significance of prior episodes of depression in two patient populations.

Perhaps the single best predictor of current depression is a prior episode of depression. This study examined the significance of prior depressive episodes in a weighted sample of 425 primary medical care (PC) patients. It also compared the 53 PC patients with major depression with 93 depressed psychiatric patients with respect to percentage of recurrences versus 1st episodes. PC patients with prior depression were over 8 times more likely to be currently depressed than those without such a history. Having at least 1 prior episode of depression was modestly more sensitive, but less specific, than an elevated Center for Epidemiologic Studies--Depression Scale score in predicting current depression. Most currently depressed patients in both PC (85%) and psychiatry (78%) had prior episodes of depression. These findings highlight the importance of assessing history of depression in research and clinical practice.

The relationship of self-reported distress to depressive disorders and other psychopathology.

The relationship between self-reported depression and a clinical diagnosis of depression was investigated. Within 2 weeks of completing the Center for Epidemiologic Studies Depression Scale (CES-D), a stratified sample of 425 primary medical care patients received the structured interview for the DSM-III-R. In the weighted data set, the CES-D was significantly related to a diagnosis of depression but also to other Axis I disorders. Most distressed subjects were not depressed, a fifth of the patients with major depressive disorder (MDD) had low distress, and the CES-D performed as well in detecting anxiety as in detecting depression. MDD, other depression diagnoses, and anxiety and substance use disorders were all significant predictors of CES-D score. Differences in demographic variables, treatment history, and impairment highlight the nonequivalence of the self-report scale and diagnosable depression. The use of a self-report in place of an interview-based diagnostic measure in the study of depression, as well as the use of such a report as a screening device, is discussed.

Distress and psychiatric morbidity among women from high-risk breast and ovarian cancer families.

This study assessed psychological distress and psychiatric disorder in high-risk women enrolled in a hereditary breast and ovarian cancer registry, and it evaluated the concordance between self-report data and interview-based psychiatric diagnosis. A sample of 464 women completed the Hopkins Symptom Checklist-25 and were interviewed using modules of the Structured Clinical Interview for DSM-IV. Level of psychological distress and the prevalence of psychiatric disorder were low and in the range that would be expected for a sample of community-residing women. Screening proved inefficient: Less than 10% of distressed women met criteria for a clinical disorder. High-risk women seeking genetic testing in research settings may not require extensive psychological screening and diagnostic assessment. Caution is expressed about possible self-selection biases in women enrolled in hereditary cancer registries.

Evaluating the continuity of symptomatology between depressed and nondepressed individuals.

Debate is contentious concerning whether depression should be viewed as a distinct category or as a continuum including overlapping normal and clinical phenomena. A nonparametric item response model was used to evaluate whether the probability of expressing individual symptoms differed between nondepressed and clinically depressed adults experiencing similar levels of overall severity. Even though depressed and nondepressed individuals were equated in terms of overall severity, differences on specific symptoms emerged. Depressed mood, anhedonia, and suicidality were more likely to be expressed in depressed than in nondepressed individuals, whereas hypochondriasis and middle insomnia were more likely to be expressed in nondepressed individuals at similar levels of severity. Such differences are inconsistent with the view of depression as a simple continuum.

Effects of recent and past major depression and distress on self-concept and coping.

The Self-Appraisal Questionnaire (J. C. Coyne & M. M. Calarco, 1995) was used to examine how primary care and psychiatric outpatients with recent or past major depression appraised their prospects and structured their lives. They were compared with nondistressed and distressed primary care patients. Both depressed groups scored higher than the nondistressed patients for Lack of Energy, Management of Burden on Others, Need to Maintain a Balance in Life, Fear of Taking Risks, Imposition of Limitations on Life, and Sense of Stigma. The distressed group fell between the depressed psychiatric and the nondistressed groups, and generally did not differ from the depressed primary care group. Past depression did not explain differences associated with more recent depression and distress. Distress entails a need to manage its effects on others, but depression in psychiatric patients may produce a more profound reorganization of self-concept, relationships, and coping.

Nondetection of depression by primary care physicians reconsidered.

This article examines the rates of detection for major depression and other depressive disorders by family physicians as well as the differences between detected and undetected cases in terms of a variety of demographic and clinical variables. A total of 1,580 family practice patients completed a screening form and were rated by their physician. Patients with elevated Center for Epidemiologic Studies-Depression Scale (CES-D) scores were oversampled for possible interviews using the Structure Clinical Interview for DSM-III-R (SCID). In the resulting weighted sample, family physicians detected 34.9% of cases of major depression and 27.9% of cases of any depressive disorder. Detection was associated with pharmacological and psychological intervention. However, the undetected cases tended to be mildly depressed and higher functioning. Presence of a current anxiety disorder facilitated detection. Overall, the mildness of undetected depression and associated impairment have implications for estimates of the consequences of primary care physicians' low rates of nondetection and for the development of interventional strategies to improve their performance.

Differences between detected and undetected patients in primary care and depressed psychiatric patients.

The aim of this study was to explore differences between primary care and tertiary psychiatry patients meeting DSM-III-R criteria for depressive disorders in terms of a wide range of demographic and clinical variables including psychiatric comorbidity. A weighted sample of 153 depressed primary care patients was obtained from the waiting rooms of family physicians using a two-stage selection and assessment procedure including the Structured Clinical Interview for the DSM-III-R (SCID). A measure of physician detection was also obtained. The 123 depressed psychiatric patients were seeking evaluation and treatment at a university-based depression program, and DSM-III-R diagnoses were also obtained using the SCID. Overall, fewer depressed primary care patients met criteria for major depressive disorder, and more of those who did were only midly depressed. Depressed primary care patients were more likely to be women, older, and had less education, less past treatment, and greater lifetime comorbidity. Clinical differences were greatest for the depressed patients who had gone undetected by their physicians: they were higher functioning, less distressed, and more mildly depressed. Findings are discussed in terms of the validity and acceptability of practice guidelines for depression in primary care.

Prevalence, nature, and comorbidity of depressive disorders in primary care.

This article examines the prevalence, nature, and comorbidity of depressive disorders using DSM-III-R criteria among patients recruited from the waiting rooms of family physicians. A total of 1928 family practice patients completed a screening form including the Center for Epidemiologic Studies-Depression Scale (CES-D), and patients with elevated CES-D scores were oversampled for possible interviews using the Structured Clinical Interview for the DSM-III-R (SCID). In the resulting weighted sample of 425, a prevalence of 13.5% was obtained for major depression and 22.6% for all depressive disorders. Over 40% of the patients with major depressive disorder (MDD) were only mildly depressed. Gender and other demographic variables failed to distinguish depressed patients, but a variety of self-ratings did. Depression was associated with comorbid anxiety disorders and substance abuse. Results are discussed in terms of the implications of depression in primary care as a public health problem, but also in terms of some diagnostic issues, particularly the use of an impairment criterion for major depression.

Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients.

The aims of this study were to determine whether detection of major depression in primary care was associated with improved outcome, and to compare the 4.5 month outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. Primary care patients with major depression were recruited from the practices of 50 family physicians in Southeastern Michigan using a two-stage selection procedure employing the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Structured Clinical Interview for DSM-III-R (SCID); clinician detection of depression was ascertained by response to a direct query on a rating form. Depressed patients seeking treatment in an outpatient psychiatric setting also received the CES-D and the SCID. Data on patient demographics and clinical characteristics were obtained for both primary care and psychiatric patients. Initial and 4.5 month scores on the Hamilton Depression Rating Scale (HAM-D) were obtained for 34 undetected and 25 detected depressed primary care and 55 depressed psychiatric patients. Improvement in depression over time was assessed by the change in HAM-D scores over the 4.5 months. The three groups did not differ in initial severity. Both psychiatric and undetected primary care patients showed significant improvement at 4.5 months, whereas detected primary care patients did not improve. At 4.5 months there were no differences in mean HAM-D scores between undetected, depressed primary care patients and depressed psychiatric outpatients. This result did not change after controlling for age and severity of depression at initial presentation, nor did it change after exclusion of cases of mild depression to control for a possible "floor effect." However, differences among groups in the stage of depressive episodes may have affected this comparison. These findings suggest that an exclusive focus on increasing detection of depression in primary care patients is unlikely to improve outcomes, and that undetected depression among primary care patients does not necessarily represent poor quality of care. Although depressed psychiatric patients in this study had better outcomes than detected depressed primary care patients, the presence of unmeasured differences among groups in the stage of the depressive episode makes it impossible to determine whether treatment of depression by psychiatrists is superior to that provided by primary care physicians. These findings should stimulate efforts to examine a more comprehensive model for detection and treatment of depression in primary care.