Interrater reliability of the Psychiatric Research Interview for Substance and Mental Disorders in an HIV-infected cohort: experience of the National NeuroAIDS Tissue Consortium.

The interrater reliability of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was assessed in a multicentre study. Four sites of the National NeuroAIDS Tissue Consortium performed blinded reratings of audiotaped PRISM interviews of 63 HIV-infected patients. Diagnostic modules for substance-use disorders and major depression were evaluated. Seventy-six per cent of the patient sample displayed one or more substance-use disorder diagnoses and 54% had major depression. Kappa coefficients for lifetime histories of substance abuse or dependence (cocaine, opiates, alcohol, cannabis, sedative, stimulant, hallucinogen) and major depression ranged from 0.66 to 1.00. Overall the PRISM was reliable in assessing both past and current disorders except for current cannabis disorders when patients had concomitant cannabinoid prescriptions for medical therapy. The reliability of substance-induced depression was poor to fair although there was a low prevalence of this diagnosis in our group. We conclude that the PRISM yields reliable diagnoses in a multicentre study of substance-experienced, HIV-infected individuals.

Factors in prison suicide: one year study in Texas.

UNLABELLED: The goal of the study was to examine psychopathology and stressors suffered by suicide victims, and to describe the characteristics of the suicides in the Texas Department of Criminal Justice between June of 1996 to June of 1997. Data on 25 completed suicides were collected from the records department. RESULTS: The authors identified 60% of the suicide victims with a history of psychiatric disorders. Seventy-six percent had been diagnosed with psychiatric disorders while incarcerated. The most frequent psychiatric disorders were mood disorders (64%), psychotic disorders (44%), personality disorders (56%), and comorbidity with a history of presentencing alcohol and drug abuse was common. Most of the victims experienced chronic and/or acute stressors of acute trauma, disrupted relationship, sentence hearing, and/or medical condition. We concluded that important factors associated with increased risk of prison suicide include psychiatric disorders, comorbid substance abuse, a history of suicide attempt, and chronic and/or acute stressors.

The prevalence of mental illness in prison.

Over the last decade state prisons have experienced unprecedented growth and many demographic changes. At the same time, courts are requiring states to provide mental health screening and treatment to prisoners. Findings from recent studies indicate that the prevalence of mental illness is higher in prisons than in the community, and comorbidity is common. Our ability to generalize from these studies is limited, however, because of major shifts in the demographic mix in prisons during the past decade. New studies on the prevalence of mental illness in prisons, which consider these recent changes would help planners allocate funds and staff to more effectively meet the needs of these individuals.

Comparison of DSM-III-R chronic major depression and major depression superimposed on dysthymia (double depression): validity of the distinction.

The nosology of chronic depression has become increasingly complex since the publication of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987), but there are few data available to evaluate the validity of the distinctions between the subtypes of chronic depression. The validity of the distinction between DSM-III-R chronic major depression (CMD) and major depression superimposed on dysthymia (double depression, DD) was examined. Participants were 635 patients with chronic depression in a 12-week trial of antidepressant medications. Patients with CMD, DD, and a 3rd group with a chronic major depressive episode superimposed on dysthymia (DD/CMD) were compared on demographic and clinical characteristics, family history, and response to treatment. Few differences were evident, although the depression of patients with DD/CMD tended to be more severe.

Prevalence of dyslexia among Texas prison inmates.

Approximately 80% of prison inmates are reported to be functionally illiterate. We hypothesized that poor single word decoding (the chief feature of dyslexia) accounts for a significant percentage of that rate. We studied 253 subjects selected randomly from more than 130,000 Texas prison inmates. Among them, we conducted a cross-sectional sample survey of recently admitted Texas inmates, beginning with social and educational background and followed by an educational test battery that included measures of word attack skill and reading comprehension. Deficient performance was defined primarily as single word decoding performance that measured below the 25th percentile on the Woodcock Reading Mastery Test. We found that 47.8% of the inmates were deficient in word attack skills. Word attack skills were detected in each group defined by gender and ethnicity. Nearly two thirds of the subjects scored poorly in reading comprehension.

National distribution of child and adolescent psychiatrists.

OBJECTIVE: To describe the national distribution of child and adolescent psychiatrists by state, community, and youth population. METHOD: Data on child and adolescent psychiatrists were compiled for states and counties and compared by state, county characteristics, number of youth, percentage of youth living in poverty, and child and adolescent psychiatry residents. RESULTS: The number of child and adolescent psychiatrists per 100,000 youth varied greatly by state and county. Child and adolescent psychiatrists were significantly more likely to be located in metropolitan counties and counties with a low percentage of children living in poverty. The distribution of child and adolescent psychiatrists was not significantly related to the distribution of child and adolescent psychiatry residency training programs. CONCLUSIONS: The shortage of child and adolescent psychiatrists is accentuated for nonmetropolitan areas and youth at greatest risk for mental disorders by the current pattern of distribution.

Ethnic and sex bias in primary care screening tests for alcohol use disorders.

BACKGROUND: The use of self-report screening tests for alcohol use disorders in the primary care setting has been advocated. OBJECTIVE: To test for ethnic and sex bias in three self-report screening tests for alcohol use disorders in a primary care population. DESIGN: Cross-sectional study with patients randomly selected from appointment lists. SETTING: University-based family practice clinic. PATIENTS: Probability sample of 1333 adult family practice patients stratified by sex and ethnicity. MEASUREMENTS: Patients completed 1) a diagnostic interview to determine the presence of a current alcohol use disorder and 2) three screening tests: the CAGE questionnaire, the Self-Administered Alcoholism Screening Test (SAAST), and the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: The areas under the receiver-operating characteristic (ROC) curves for the CAGE questionnaire and the SAAST ranged from 0.61 to 0.88 and were particularly poor for African-American men and Mexican-American women. For the AUDIT, the area under the ROC curves was greater than 0.90 for each patient subgroup. The sensitivity of the CAGE questionnaire and the SAAST at standard cut-points was lowest for Mexican-American women (0.21 and 0.13, respectively). Positive likelihood ratios for the AUDIT were similar to or higher than those for the other screening tests, whereas negative likelihood ratios were lowest for the AUDIT (<0.33), indicating the superiority of this test in ruling out a disorder. CONCLUSIONS: A marked inconsistency in the accuracy of common self-report screening tests for alcohol use disorders was found when these tests were used in a single clinical site with male and female family practice patients of different ethnic backgrounds. The AUDIT does not seem to be affected by ethnic and sex bias.

Administrative update: utilization of services. II. Utilization of mental health services in a tri-ethnic sample of adolescents.

In our study of a tri-ethnic sample of 2528 junior and high school students, we examined utilization of outpatient mental health services in relation to a number of variables cited in the literature as leading to potential biases and barriers to care. These include: age, gender, ethnicity, socioeconomic status, family size and composition, and linguistic fluency in Hispanic youth. The impact of service availability was examined through differences between the two regions studied: a well-served region of coastal southeast Texas and the markedly under served lower Rio Grande Valley. The impact of symptomatology was evaluated using the total problem score on the Youth Self Report by Achenbach. Hispanic youth had significantly lower mean service utilization than non-Hispanic whites. Multiple regression analyses demonstrated that socioeconomic status and family composition had a greater relative impact on utilization than all other non-clinical factors, both for the total sample as well as for the Hispanic sample. Ethnicity may play a significant role in child mental health services utilization through its close association to socioeconomic status.

The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different racial/ethnic backgrounds.

This study examined the operating characteristics of the Alcohol Use Disorders Identification Test (AUDIT) as a screen for "at-risk" drinking in a multi-ethnic sample of primary care patients, from a family practice center located in the southwestern United States. A probability sample of 1,333 family medicine patients, stratified by gender and racial/ethnic background (white, African-American and Mexican-American) completed the AUDIT, followed by the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) to determine ICD-10 diagnoses. Indicators of hazardous alcohol use and alcohol-related problems were included as measures of "at-risk" drinking. Despite differences in the spectrum of alcohol problems across patient subgroups, there was no evidence of gender or racial/ethnic bias in the AUDIT as indicated by Receiver Operating Characteristic Curve analysis. Excluding abstainers from the analysis and little impact on screening efficacy. In this population, the AUDIT appears to be an unbiased measure of "at-risk" drinking.

The demographics of disability in the south.

A major issue for health reform is the equitable distribution of health services. Equity in the use of services depends in large part on the distribution of need for services, in addition to availability, accessibility, affordability, and acceptability of the services. The present paper focuses on one set of indicators of need, the disability data reported in the 1990 U.S. Census of Population and Housing for 14 southern states. The Census data on work limitation, inability to work, physical mobility, and ability to perform routine personal care show differentials for subpopulations defined by rural versus urban areas within levels of poverty, age, sex, education, and ethnic group. Highest rates of work disability are found for rural, female, elderly, less educated, African-American, and below poverty level populations. The implications of such findings for health care reform suggest that there should be greater access to services by populations of greater identified need. Historically, the opposite has been true, perhaps exacerbating the observed differentials in need.

Symptomatology in dysthymic and major depressive disorder.

The lists of associated symptoms included in the DSM-III, DSM-III-R, and DSM-IV criteria for dysthymic disorder have been criticized for lacking content and discriminant validity. The literature on the content and discriminant validity of dysthymic symptoms was reviewed and relevant data from the DSM-IV Mood Disorders Field Trial were presented. These data indicate that cognitive and social-motivational symptoms are much more characteristic of dysthymic disorder than are vegetative and psychomotor symptoms. In addition, subjects with major depressive disorder exhibit higher rates of most depressive symptoms than do subjects with dysthymic disorder, but there is little evidence of qualitative distinctions in symptomatology between these conditions. Finally, after taking course and exclusion criteria into account, variations in the symptom criteria do not have a major effect on case definition.

Reliability of diagnosis in mood disorders.

The reliability of diagnosing mood disorders is reviewed for previous and current versions of the American Psychiatric Association's DMS. Reliability is shown to improve with the increasing specificity of diagnostic criteria. The new specifiers for the course of major depression in relation to dysthymia also are shown to be reliable.

Medically serious suicide attempts in a jail with a suicide-prevention program.

A suicide prevention program was implemented at the Galveston County Jail in 1986, reducing the number of suicides to only one from that time until the present. In the ten years prior to the implementation of the program, there had been seven suicides. Nevertheless, there have been a number of cases of medically serious suicide attempts that have occurred since implementation of the program. Thirteen cases of suicide attempts severe enough to warrant transfer to an emergency room for medical attention were identified through jail incident reports as occurring between 1989, when improvements were made in record-keeping at the jail, and July of 1994, when this study was initiated. Hospital records, jail medical records, jail administrative records and, in some cases, competency evaluations were obtained for each case. The cases were examined regarding demographic data, psychiatric history, circumstances surrounding the act, and results of psychiatric evaluation performed after the act. The findings were then compared to studies of suicides and near-suicides in the literature. Examination of these cases has provided information that should render the suicide prevention program even more effective as well as provide useful information to other jails interested in implementing or improving a suicide-prevention program.

Inconsistencies in psychosocial assessment of children after severe burns.

Health care providers usually except children with severe burns to have psychosocial problems due to the severity of the injuries and resulting deformities. To test the validity of that expectation, 72 children (43 boys, 29 girls) who had suffered severe burns were assessed at least 1 year after burn injury for behavior problems and competence, by use of the 1991 Achenbach questionnaires: Child Behavior Checklist (CBCL), Youth Self-Report, and Teacher Report Form. The scores on each questionnaire then were compared by use of paired t tests. Also, the scores of the patient population were compared with those of the nonreferred reference populations provided by Achenbach. Compared with the Teacher Report Form and Youth Self-Report, the CBCL revealed a statistically significant (p < 0.05) greater number of behavior problems and lower level of competence for all age groups and both sexes. Item analysis revealed in most instances excess endorsement of specific items on all scales for the patient population compared with their respective reference populations, but more items were endorsed on the CBCL. These results could be explained by increased parental sensitivity to problem behavior or decreased competence of their children after severe burns. Further studies are needed to understand the discrepancies between the CBCL and the other scales.

Depressive personality disorder: clinical implications.

Although the concept of a depressive personality has a long and rich tradition in psychiatry, it has only recently been included in any official nomenclature. Those afflicted with depressive personality have been subsumed under a variety of mood disorders and other personality disorders. This article presents criteria for depressive personality disorder that were developed for the DSM-IV Task Force. A framework for validating a personality disorder, including that of depressive personality disorder, is presented. Results of the DSM-IV Mood Disorders Field Trial relevant to this issue are reported in the article. Results show that DSM-IV depressive personality disorder identifies a group of patients whose diagnosis does not overlap substantially with major depression, dysthymia, or early-onset dysthymia; the patients have significant social and occupational morbidity. These results provide significant evidence to justify the validity of depressive personality disorder.

Hispanic Americans and the state mental hospitals in Texas: ethnic parity as a latent function of a fiscal incentive policy.

This paper examines patterns of utilization of the state mental hospitals in Texas by Hispanics compared to Anglos over a 5-year period from FY 1984 to FY 1988. Historically, Hispanics have been underrepresented in public mental health client populations in the United States. In the mid-1980s in Texas, the ethnic gap in use of psychiatric facilities was expected to widen as Hispanic population growth outpaced the capacity of the public system to provide accessible mental health services for persons with serious and persistent psychiatric illnesses. But in the inpatient sector, the gap narrowed significantly in the second half of the decade, due to a policy-driven sharp reduction in the overall census of the state mental hospitals. A fiscal incentive program to stimulate the development of community-based mental health services had a markedly different effect on subsequent inpatient utilization by Anglos compared to Hispanics, most notably in counties that were less urban and less affluent and counties with a relatively high proportion of Hispanic residents. The context and mixed implications of these developments are explored.

A binational school survey of depressive symptoms, drug use, and suicidal ideation.

New findings are presented from a survey of depressive symptoms, illicit drug use, and suicidality among 4,157 adolescents attending school in six border cities in Texas and neighboring Tamaulipas, Mexico. Among the Texas youth, 48.08% scored above 16 on the Center for Epidemiologic Studies' Depression Scale (CES-D); 21% reported illicit drug use in the past month; and 23.43% said they had thought about killing themselves during the past week. Rates were lower among the Mexican youth: 39.41% had high CES-D scores; 4.95% reported drug use and 11.57% reported current suicidal ideation. Multivariate models are presented to show the linkage between psychological distress, drug use, and suicidality in this sample of border youth.

Long-term Evaluation of a Psychiatry Clerkship.

For over 14 years, students completing a psychiatry clerkship were asked to rate their educational experience. Comparisons were made across clinical assignment, length of rotation (6 vs. 8 weeks), and teaching modes. Consultation and acute services were rated higher than open adult or child/adolescent services. General units were rated higher than specialty units. Ratings were higher for 8-week rotations, and case conferences were preferred to lecture formats. Ratings were not significantly correlated with National Board of Medical Examiners examination scores, which were higher during years with 8-week rotations and case conferences. There was a tendency for students on the consultation and acute services to enter psychiatry residencies at a higher rate.