Diagnosing depression in the medically ill: validity of a lay-administered structured diagnostic interview.

Understanding the validity of structured psychiatric diagnostic interviews in medically ill patients will advance the ability to conduct research into the treatment and management of these disorders in general medical settings. We compared the University of Michigan version of the CIDI (Composite International Diagnostic Interview) for major depression to a clinical gold standard, derived through Spitzer's Longitudinal, Expert, All Data (LEAD) criteria based on the SCID-III-R. A convenience sample of medical inpatients was administered the SCID-III-R and the CIDI for major depression in random order. A physician panel reviewed the SCID interview and other pertinent data and determined whether patients had a lifetime or current (past month) diagnosis of major depression. The CIDI was scored with and without hierarchical exclusions for mania, hypomania, substance use, or medical illness. When the UM-CIDI was scored for a lifetime diagnosis of major depression without hierarchical exclusions, agreement above chance (kappa) was very good (kappa = 0.67) between the CIDI and the physician panel and good (kappa = 0.46) when the UM-CIDI was scored with exclusions. Agreement above chance for diagnosis of a recent disorder was better for UM-CIDI scoring with exclusions (kappa = 0.51) compared to scoring without exclusions (kappa = 0.43). Predictive value-positive was excellent in both scoring versions for a lifetime diagnosis (82%) and good to very good for current depression (46% and 62%). In all cases predictive value-negative was very good to excellent (77-93%). Discordant cases were almost uniformly due to difficulties in attribution of symptoms to medical illnesses. We conclude that the CIDI can perform acceptably as a research instrument to diagnose major depression in medically ill patients, potentially supplemented by clinician review of cases identified by the CIDI with current disorder.

NF-Y activates mouse tryptophan hydroxylase transcription.

Tryptophan hydroxylase catalyses the rate-limiting step in the biosynthesis of serotonin, a neurotransmitter which has been implicated in the etiologies of clinically important psychiatric illnesses. Tryptophan hydroxylase is expressed in a tissue-specific manner, but little is known about its transcriptional regulation. By analysing transcriptional activities of a set 5'-deletion constructs of promoter-reporter plasmids in P815-HTR mastocytoma cells, we found that transcription was activated by sequences between nucleotides -343 and -21. DNase I footprint analysis, using nuclear protein extracts from P815-HTR cells, revealed a protein-DNA interaction between nucleotides -77 and -46. A double stranded oligonucleotide, representing this binding site, specifically bound nuclear protein in a gel shift assay. Methylation interference analysis of this complex revealed that nuclear protein interacted with an inverted GGCCAAT element, which is a high-affinity binding motif for the transcription factor NF-Y (also known as CP1 or CBF). An NF-Y specific antibody abolished protein binding in a gel shift assay. Mutagenesis of specific base pairs abolished protein binding in vitro, and mutagenesis of the same base pairs in a reporter gene construct resulted in a 65% decrease in transcriptional activity. Our results suggest that the transcription factor NF-Y binds to a GGCCAAT motif in the tph proximal promoter and activates transcription.

Diagnosis and management of substance use disorders among inpatients with schizophrenia.

OBJECTIVE: The study examined the extent of clinical recognition of comorbid substance use disorders and the clinical management of these disorders among inpatients hospitalized for an acute exacerbation of schizophrenia. METHODS: Medical records of 42 inpatients who met research diagnostic criteria for both schizophrenia and a current substance use disorder were reviewed for information about admission evaluation, inpatient management, discharge diagnosis, and disposition. RESULTS: Alcohol use disorders were the most frequent co-occurring substance-related diagnoses, found for 86 percent of the dually diagnosed inpatients. Twenty-four patients (57 percent) did not receive a diagnosis of a substance-related disorder at admission, and 19 (45 percent) did not receive a substance-related diagnosis at discharge. Referral to inpatient or outpatient substance abuse treatment was documented for a minority of subjects. CONCLUSION: The results suggest that improvements are needed in the process of clinical care for inpatients with schizophrenia who have co-occurring substance-related disorders. They highlight a need for education of health care providers and continuous quality improvement in this area.

Short-term course of drinking in an untreated sample of at-risk drinkers.

OBJECTIVE: We know little about the short-term course of drinking, particularly the stability or instability of at-risk drinking in untreated drinkers. Because few at-risk drinkers obtain help for their drinking, it is important to understand the short-term fluctuations between at-risk drinking and full-fledged alcohol use disorders, as well as remission of at-risk drinking. METHOD: We used four waves of data (each 6 months apart) from a probability community sample of 733 at-risk drinkers in six states in the southern United States to determine variation in abstinence, drinking patterns and alcohol use disorders over a 2-year period. For this analysis, we excluded those who reported receiving services for drinking during the 2-year study period (retrospectively at baseline), leaving a sample size of 664 (444 male); 479 (306 male) completed all four interviews. RESULTS: Although the majority (88%) of the sample was nonabstinent throughout the study, we found significant decreases in average number of drinks per drinking day and recent (past 6 months) alcohol disorders, and an increase in 6-month abstinence. Almost 30% of those with no recent alcohol disorder at baseline (n = 280) later met diagnostic criteria in at least one interview. Of those with a recent alcohol disorder at baseline (n = 199), one third met criteria in at least two subsequent interviews. CONCLUSIONS: There is some evidence for short-term progression from at-risk drinking to alcohol disorder. However, there is stronger evidence for declining problems and a fluctuation in and out of recovery and relapse, which may reflect an effort to maintain controlled drinking. Understanding this short-term course is important for primary and secondary prevention efforts and for screening of at-risk drinking in primary care and in the workplace.

Predictors of patient entry into alcohol treatment after initial diagnosis.

To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry, must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance-use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included age younger than than 60 (odds ratio [OR] = 4.6), not married (OR = 1.7), primary diagnosis of an alcohol-related disorder (OR = 7.7), diagnosis of a comorbid drug (OR = 4.3) or psychiatric disorder (OR = 3.6), diagnosis by a medical as opposed to a surgical specialty (OR = 6.0), and African American (OR = 1.7).

Recognition and management of depression in a substance use disorder treatment population.

This study examines the association between depressive symptomatology and return to substance use among a sample of 126 veterans consecutively admitted to treatment at a VA intensive outpatient program for substance use disorders. Controlling for numerous demographic and health-related covariates, depressive symptomatology measured at treatment exit with a Beck Depression Inventory (BDI) was significantly predictive of substance use at three-months post-treatment (p < .05). Analysis with a recoded BDI showed that the moderately-to-severely symptomatic (BDI = 20+) were 4.1 times more likely to have returned to substance use than those with a BDI score of under 20.

Correlates and 6-month outcomes for co-occurring cannabis use in rural and urban at-risk drinkers.

We know little about the functional correlates of recent cannabis use when such use is additional to an "alcohol disorder" in non-treatment populations. We report on data from a prospective study of a large probability community survey of 733 at-risk drinkers in six Southern U.S. states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee) conducted from 1995 to 1996. Twenty-one percent reported cannabis use during the past six months at the baseline interview. These cannabis users were significantly less likely to be married, employed, or a high school graduate (p < .05). They were also more likely to have a diagnosis of "antisocial personality disorder" or "panic disorder." Recent cannabis users also reported more negative consequences of their alcohol use, including more frequent recent diagnoses of an "alcohol disorder," legal difficulties associated with their drinking, and more social consequences attributed to drinking. At the six-month follow-up interview, negative alcohol outcomes were associated with concurrent cannabis use, including higher frequency and quantity of alcohol consumption, greater frequency of recent "alcohol abuse" and "dependence," and greater social consequences of drinking. These results all point to substantially poorer functioning and experiences of individuals with concurrent at-risk alcohol and cannabis use. We suggest that cannabis use may be a marker for greater impairment associated with at-risk drinking.

Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose.

OBJECTIVE: This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. DESIGN, SETTING, PARTICIPANTS: The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. MAIN OUTCOME MEASURE: The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. RESULTS: At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n = 69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. CONCLUSIONS: Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.