Biased interpretation of evidence by mock jurors.

Predecisional distortion is jurors' biased interpretation of new evidence to support whichever verdict is tentatively favored as a trial progresses. In 2 experiments, students and prospective jurors distorted evidence from a mock trial. Further, the magnitude of prospective jurors' distortion was twice that of students. Consistent with previous research, distortion increased with juror confidence in whichever verdict was currently leading. In spite of clear instructions to ignore prior beliefs, general proplaintiff or prodefendant attitudes influenced the verdicts of prospective jurors, but not of students. These findings suggest that jury instructions should warn against not only premature decisions but also any tentative judgments, lest such opinions influence jurors' evaluations of subsequent evidence. Predecisional distortion in jury trials may lead to biased outcomes resulting from evidence order effects.

Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus.

BACKGROUND: Knowledge regarding the clinical characteristics and natural history of acute infectious mononucleosis is based largely on older, often retrospective, studies without systematic follow-up. Differences in diagnosis, methodology, or treatment between historical and current practice might affect an understanding of this illness. METHODS: Using a prospective case series design, we enrolled 150 persons with an acute illness serologically confirmed as Epstein-Barr virus infection. The goal of the study was to assess symptoms, physical examination findings, laboratory tests, and functional status measures during the acute presentation and 1, 2, and 6 months later. RESULTS: Acutely, infectious mononucleosis was characterized by the symptoms of sore throat and fatigue and substantial functional impairment. Objective physical and laboratory examination findings included pharyngitis and cervical lymphadenopathy, a moderate absolute and atypical lymphocytosis, and mildly elevated transaminase levels. The traditional signs of fever and splenomegaly were relatively uncommon. By 1 month, most symptoms and signs and all laboratory tests had returned to normal. Fatigue, cervical lymphadenopathy, pharyngitis, and functional health status improved more slowly. CONCLUSIONS: In contemporary practice most of the classical illness features of infectious mononucleosis are observed. Symptoms, signs, and poor functioning might be protracted in some patients.

Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial.

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

Depression and self-reported physical health in patients with coronary disease: mediating and moderating factors.

OBJECTIVES: The purpose of this study was to define how the relation between depression and self-reported physical health in patients with coronary disease is modified by other patient-centered factors. METHODS: We conducted a prospective cohort study of 111 patients (members of a health maintenance organization) with angiographically documented coronary disease, examining factors (physical symptoms, psychological states and traits, and spousal support) modifying the relation between depression and patient-reported physical health 5 years later using multiple hierarchical regression models. RESULTS: Five regression models (all including demographic and disease severity covariates) were constructed to predict physical health from depression only (R2 = 0.22); depression plus angina and fatigue (R2 = 0.53); depression plus positive affect and novelty seeking and their interaction (R2 = 0.48); depression plus spousal support (R2 = 0.27); and depression, angina, fatigue, positive affect, and novelty seeking (overall model) (R2 = 0.65). Depression remained significant in each model, but the proportion of variance it predicted was diminished in the presence of the other variables (bivariate r = 0.39, partial r = 0.37-0.13). CONCLUSIONS: The effect of depression on self-reported physical health is significantly mediated by physical symptoms (angina and fatigue), personality states and traits (positive affect and novelty seeking), and spousal support. Positive affect and novelty seeking had more marked effects on physical health in the presence of more depression. Thus, a broad range of factors beyond the severity of coronary disease itself affect the perceived physical health of patients with coronary heart disease.

The patient-provider relationship: attachment theory and adherence to treatment in diabetes.

OBJECTIVE: Lack of adherence to diabetic self-management regimens is associated with a high risk of diabetes complications. Previous research has shown that the quality of the patient-provider relationship is associated with adherence to diabetes treatment. This study attempts to improve understanding of both patient and provider factors involved in lack of adherence to treatment in diabetic patients by using the conceptual model of attachment theory. METHOD: Instruments that assessed attachment, treatment adherence, depression, diabetes severity, patient-provider communication, and demographic data were administered to 367 patients with type 1 and 2 diabetes in a health maintenance organization primary care setting. Glucose control, medical comorbidity, and adherence to medications and clinic appointments were determined from automated data. Analyses of covariance were used to determine if attachment style and quality of patient-provider communication were associated with adherence to treatment. RESULTS: Patients who exhibited dismissing attachment had significantly worse glucose control than patients with preoccupied or secure attachment. An interaction between attachment and communication quality was significantly associated with glycosylated hemoglobin (Hb A(1c)) levels. Among the patients with a dismissing attachment style, there was a significant difference in glycosylated hemoglobin levels between those who rated their patient-provider communication as poor (mean=8.50%, SD=1.55%) and those who rated this communication as good (mean=7.49%, SD=1. 33%). Among all patients who were taking oral hypoglycemics, adherence to medications and glucose monitoring was significantly worse in patients who exhibited dismissing attachment and rated their patient-provider communication as poor. CONCLUSIONS: Dismissing attachment in the setting of poor patient-provider communication is associated with poorer treatment adherence in patients with diabetes.

Reliability and clinical utility of DSM-IV substance-induced psychiatric disorders in acute psychiatric inpatients.

The goal of his study was to evaluate in 1,951 acute psychiatric inpatients the reliability, construct, convergent, and predictive validity of substance-induced psychiatric syndrome ratings made by clinical attending pschiatrists. The primary admitting condition for each subject was categorically rated by clinical attendings as not, mildly, moderately, or mostly substance-induced at both admission and discharge. Individual substance categories were associated with characteristic demographic, clinical treatment response, and length of stay, findings indicating good construct, predictive validity, and clinical utility. A linear dimensional approach to rating substance-induced syndromes in acute clinical populations may be preferable to the simple dichotomous approach used in DSM-IV.

Panic disorder in primary care: biopsychosocial differences between recognized and unrecognized patients.

Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in more symptomatic and impaired patients. As part of a randomized effectiveness study in primary care patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a significantly higher frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with more prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However, the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care.

Depression and diabetes: impact of depressive symptoms on adherence, function, and costs.

BACKGROUND: Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. METHODS: We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA(1c)) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA(1c) levels, functional impairment, and health care costs. RESULTS: Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). CONCLUSIONS: Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed. Arch Intern Med. 2000;160:3278-3285.

Acute infectious mononucleosis: characteristics of patients who report failure to recover.

PURPOSE: We sought to determine how often acute mononucleosis precipitates chronic illness, and to describe the demographic, clinical, and psychosocial features that characterize patients who report failure to recover. SUBJECTS AND METHODS: We enrolled 150 patients with infectious mononucleosis during the acute illness and asked them to assess their recovery at 2 and 6 months. At baseline, we performed physical and laboratory examinations; obtained measures of psychological and somatic functioning, social support, and life events; and administered a structured psychiatric interview. RESULTS: Self-assessed failure to recover was reported by 38% of patients (55 of 144) at 2 months and by 12% (17 of 142) at 6 months. Those who had not recovered reported a persistent illness characterized by fatigue and poor functional status. No objective measures of disease, including physical examination findings or serologic or laboratory markers, distinguished patients who failed to recover from those who reported recovery. Baseline predictors for failure to recover at 2 months were older age (odds ratio [OR] = 1.4, 95% confidence interval [CI]: 1.1 to 1.8, per 5-year increase), higher temperature (OR = 1.5, 95% CI: 1.1 to 2.2, per 0.5 degrees C increase), and greater role limitation due to physical functioning (OR = 1.5, 95% CI: 1.2 to 1.9, per 20-point decrease in Short Form-36 score). At 6 months, baseline predictors for failure to recover included female sex (OR = 3.3, 95% CI: 1.0 to 12), a greater number of life events more than 6 months before the disease began (OR = 1.7, 95% CI: 1.1 to 2.5, per each additional life event), and greater family support (OR = 1.9, 95% CI: 1.1 to 4.2, per 7-point increase in social support score). CONCLUSIONS: We were not able to identify objective measures that characterized self-reported failure to recover from acute infectious mononucleosis. The baseline factors associated with self-reported failure to recover at 2 months differed from those associated with failure to recover at 6 months. Future studies should assess the generalizability of these findings and determine whether interventions can hasten recovery.

Nefazodone treatment of major depression in alcohol-dependent patients: a double-blind, placebo-controlled trial.

Depression is the most common comorbid psychiatric illness in patients with alcohol dependence. This double-blind study tested the efficacy of nefazodone versus placebo for the treatment of depression in actively drinking alcohol-dependent patients who were also participating in weekly group treatment for alcoholism. Sixty-four subjects with major depression disorder and alcohol dependence with a history of at least one prior episode of depression when not drinking were randomly assigned to receive 12 weeks of either nefazodone or placebo and participated in a weekly psychoeducational group on alcoholism. Subjects were assessed every 2 weeks for depression, anxiety, side effects, and drinking frequency. Subjects taking nefazodone were significantly more likely to complete the study (62%) than those taking placebo (34%). Analyses of covariance using drinks per week as a time-dependent covariate showed lower Hamilton Rating Scale for Depression scores at week 8 for end-point analysis and at weeks 8 and 12 for completers. The endpoint analysis demonstrated a significantly greater response in the nefazodone group (48%) than in the placebo group (16%). Both groups showed a similarly significant decrease in the average number of alcoholic drinks consumed per day over the course of the study. Although the number of adverse effects was significantly greater for the nefazodone group, there were no severe adverse events, and nefazodone was well tolerated. Nefazodone is a safe and effective antidepressant to use in a population of alcohol-dependent patients with depression who have a high degree of comorbidity. Nefazodone treatment was superior to placebo in alleviating depression in these patients but did not add any advantage over the psychoeducational group in terms of drinking outcomes.

Depression, fatigue, and functional disability in patients with chronic hepatitis C.

OBJECTIVE: To examine the extent to which fatigue and functional disability correlate with severity of depressive symptoms in patients with chronic hepatitis C. METHODS: Fifty patients with chronic hepatitis C were evaluated using structured psychiatric interviews and standardized rating instruments. RESULTS: Fourteen (28%) of patients had current depressive disorders. Depressed and nondepressed patients did not differ with regard to demographics or hepatic disease severity. Severity of depressive symptoms was highly correlated with fatigue severity while measures of hepatic disease severity, interferon treatment, and severity of comorbid medical illness were not. Severity of depressive symptoms was associated with functional disability and somatization. CONCLUSIONS: Disability and fatigue are more closely related to depression severity than to hepatic disease severity. Antidepressant treatment trials in patients with hepatitis C are indicated to determine whether improvement in depressive symptoms leads to improvement in fatigue and functioning.

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care.

OBJECTIVE: The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted. METHOD: They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy. RESULTS: At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy. CONCLUSIONS: Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

Relapse of depression in primary care. Rate and clinical predictors.

OBJECTIVE: To determine the clinical predictors and rate of relapse for major depression in primary care. DESIGN: A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted. SETTING: A large primary care clinic of a staff-model health maintenance organization. PATIENTS: Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months. MAIN OUTCOME MEASURES: Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist. RESULTS: Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither. CONCLUSIONS: The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

Rapid detection of human infections with fluorine-18 fluorodeoxyglucose and positron emission tomography: preliminary results.

The purpose of this study was to evaluate the feasibility of 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) and positron emission tomography (PET) for rapid detection of human infections. Eleven patients who were known or suspected to be harboring various infections were studied with FDG-PET. Dynamic scans over the putative infection sites were performed immediately after FDG (370 MBq) injection through 60 min, and static images including multiple projection images were then obtained. FDG uptake was assessed visually into four grades (0, normal; 1, probably normal; 2, probably abnormal; 3, definitely abnormal). For the semiquantitative index of FDG uptake in infections, the standardized uptake value of FDG normalized to the predicted lean body mass (SUV-lean, SUL) was determined from the images obtained at 50-60 min after FDG injection. PET results were compared with final clinical diagnoses. Eleven lesions in eight patients, which were interpreted as grade 2 or 3 by FDG-PET, were all concordant with active infectious foci. The SUL values of infections ranged from 0.97 to 6.69. In two patients, FDG-PET correctly showed no active infection. In one patient, it was difficult to detect infectious foci by FDG-PET due to substantial normal background uptake of FDG. In total, FDG-PET correctly diagnosed the presence or absence of active infection in 10 of 11 patients. Fusion images of PET with computed tomography showed the most intense FDG uptake to be within an abscess wall. In conclusion, FDG-PET appears to be a promising modality for rapid imaging of active human infections. More extensive clinical evaluation is warranted to determine the accuracy of this method.

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital.

OBJECTIVE: The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. METHODS: A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. RESULTS: The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. CONCLUSIONS: The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.

Determinants of suicidal ideation: the role of substance use disorders.

BACKGROUND: This study tested the hypothesis that the amount of psychoactive substance consumed (frequency and/or quantity), life problems resulting from this use, and a DSM-IV diagnosis of substance abuse/dependence are independent risk factors associated with increased suicidal ideation in a population of psychiatric inpatients with major depressive disorder. METHOD: 891 hospitalized patients with a primary diagnosis of nonpsychotic major depressive disorder (MDD) received a standardized, psychiatrist-administered assessment battery. To examine the relationship between admission suicidality and demographic, psychiatric history, and admission variables, chi-square analyses were used for categorical data and one-way ANOVAs were used for continuous indices. Stepwise hierarchical multiple regression analyses were performed to determine the set of variables that was independently related to admission suicidality level. RESULTS: There was general agreement between our findings and previous literature in regard to the association between severity of Axis I diagnosis, depressed mood, hopelessness, male gender, unemployment, involuntary treatment, and alcohol/drug problems and higher suicidal ideation. In our sample of hospitalized patients with unipolar major depressive disorder, higher current drug and/or alcohol dependency and high current use of alcohol or other substances of abuse were independently associated with higher levels of suicidal ideation. CONCLUSION: This association with higher suicidal ideation lends support to the importance of treating patients for both alcohol/drug problems and depression in an effort to decrease their risk for future suicide. We hope that our findings will improve the care that patients with dual diagnoses receive.

Symptoms as a clue to otologic and psychiatric diagnosis in patients with dizziness.

Dizziness is a common symptom that often remains unexplained despite extensive medical evaluation. Psychiatric disorders are usually considered only after all medical causes of dizziness have been ruled out. Sixty-five patients referred to an otolaryngology practice received a structured psychiatric interview, an otologic evaluation, and a dizziness questionnaire modified to assess psychiatric symptoms. They were divided into four diagnostic groups: psychiatric diagnosis only, otologic diagnosis only, both diagnoses, or neither diagnosis. Eleven questionnaire items were significantly associated with diagnostic groupings. Stepwise discriminant function analysis utilizing age, gender, rapid/irregular heartbeat, extremity weakness, nausea/vomiting, and difficulty with speech resulted in correct group classification for 70% of subjects. The presence of dizziness symptoms like vertigo or lightheadedness was not significantly different between groups. This study suggests that assessment of psychiatric and autonomic symptoms should accompany, not follow, otologic evaluation of dizziness. These symptoms may be more important diagnostically than dizziness quality.

Psychiatric and medical factors associated with disability in patients with dizziness.

Dizziness is a common patient symptom and often remains medically unexplained even after an extensive work-up. The otologic disorders, psychiatric disorders, and functional disability of 75 patients presenting with dizziness to a community otolaryngology practice were assessed in 1991. The patients were classified according to the presence or absence of at least one current DSM-III-R psychiatric disorder and the presence or absence of a peripheral vestibular disorder. Decrements in mental health and role functioning, and increases in bodily pain and hypochondriacal focus were significantly associated with the presence of a psychiatric disorder and whether the etiology of dizziness was due to a peripheral vestibular dysfunction.