Are psychiatrists' characteristics related to how they care for depression in the medically ill? Results from a national case-vignette survey.

The authors' goal was to examine the relationship between psychiatrists' characteristics and their decisions regarding depression care. A national sampling of 278 psychiatrists answered diagnosis and treatment questions for one of four case vignettes with depression and various degrees of medical comorbidity. They also responded to a questionnaire assessing practice and demographic characteristics. Tendency to diagnose major depression was significantly associated with being board certified, being in practice for less time, having a greater percentage of patients with managed care, and having a greater percentage of patients on psychotropic medications. Tendency to recommend an antidepressant was significantly associated with the psychiatrist being male, being less satisfied with practice, and having a greater percentage of patients on psychotropic medications. These findings remained significant even after controlling for case characteristics. Diagnostic and prescribing tendencies of psychiatrists appear to be associated with specific physician characteristics and not simply case characteristics. These findings have implications for further studies of predictors of quality of care.

Trauma history as a predictor of psychologic symptoms in women with breast cancer.

PURPOSE: To identify predictors of psychiatric problems in women with early-stage breast cancer. PATIENTS AND METHODS: One hundred sixty women with early-stage breast cancer were recruited from three treatment centers. They filled out self-report questionnaires, including a medical history and demographic survey, the Trauma History Questionnaire, Life Event Questionnaire, Brief Symptom Inventory, Beck Depression Inventory, and Duke-UNC Functional Social Support Questionnaire, and were evaluated using the Structured Clinical Interview for DSM-III-R. RESULTS: Hierarchical regression analyses indicated that four of five variable sets made a significant incremental contribution to outcome prediction, with 35% to 37% of the variance explained. Outcomes were predicted by demographic variables, trauma history variables, precancer psychiatric diagnosis, recent life events, and perceived social support. Cancer treatment variables did not predict outcome. CONCLUSION: The findings highlight the important roles of trauma history and recent life events in adjustment to cancer and have implications for screening and treatment.

Psychiatric disorders in patients with fibromyalgia. A multicenter investigation.

The authors conducted an investigation in four tertiary-care centers to determine if psychiatric comorbidity and psychological variables were predictive of functional impairment in patients with fibromyalgia syndrome (FMS). Seventy-three individuals were administered the Structured Clinical Interview for DSM-III-R, the Rand 36-item Health Survey (SF-36), and multiple self-report measures. The patients with FMS were found to have a high lifetime and current prevalence of major depression and panic disorder. The most common disorders were major depression (lifetime [L] = 68%, current [C] = 22%); dysthymia (10% [C only]); panic disorder (L = 16%, C = 7%); and simple phobia (L = 16%, C = 12%). The self-report scales revealed significant elevations in depression, anxiety, neuroticism, and hypochondriasis. Functional impairment on all measures of the SF-36 was severe (e.g., physical functioning = 45.5 and role limitations due to physical problems = 20.0). Stepwise multiple-regression analysis revealed that current anxiety was the only variable that predicted a significant proportion of the variance (29%) in SF-36 physical functioning. Thus, in this multicenter study, the persons with FMS exhibited marked functional impairment, high levels of some lifetime and current psychiatric disorders, and significant current psychological distress. Current anxiety level appears to be an important correlate of functional impairment in individuals with FMS.

Prevalence of posttraumatic stress disorder in women with breast cancer.

This study investigated whether diagnosis and treatment of breast cancer produced posttraumatic stress disorder (PTSD) in adult women. One hundred sixty women with early stage node-negative breast cancer completed self-report questionnaires and underwent a full diagnostic assessment (Structured Clinical Interview for DSM-III-R). PTSD symptoms were common; however, only 3% of the women interviewed met stringent criteria for cancer-related PTSD in the 4-12 months following the completion of their medical treatment. Thus, breast cancer produced considerable distress, but low rates of PTSD, and may not fit well as a Criterion A stressor event for PTSD. Caution is urged for an assumption of a PTSD diagnosis based on self-reported symptoms.

Excessive breast self-examination among first-degree relatives of newly diagnosed breast cancer patients. High-Risk Breast Cancer Consortium.

First-degree relatives (FDRs) of women with breast cancer may have heightened anxiety about their personal risk for developing breast cancer. Breast self-examination (BSE) is an important component of risk surveillance for all women. In this study, the authors describe a subset of FDRs who appear to excessively (> or = once per day) perform BSE. These women, who constituted 8% of 1,053 FDRs in this study, were compared with women who did not examine excessively. The excessive self-examiners were older, more frequently African American, and less educated. They were more likely to have an affected daughter and > or = two FDRs with breast cancer. They were significantly more likely to think frequently about breast cancer and to report that such thoughts affected their mood. In a multivariate analysis, three variables had significant independent associations with excessive BSE practice: ethnicity (odds ratio [OR] = 2.3), perceived risk of breast cancer compared with women without a family history (OR = 2.9), and frequency of thoughts about breast cancer (OR = 5.5). The women who practice excessive BSE would benefit from enhanced educational efforts and screening for the presence of psychiatric problems such as anxiety and hypochondriasis.

Practice patterns in the diagnosis and treatment of anxiety and depression in the medically ill. A survey of psychiatrists.

By use of a survey that assessed practice patterns and responses to case vignettes of anxiety and depression in the medically ill, 38 psychiatrists were compared with 10 national leaders in consultation-liaison psychiatry. On the case vignettes, percentage agreement with the experts varied significantly by case and by question. Fifty-eight percent of the time the psychiatrists agreed with the experts on whether to order laboratory tests as compared with an 81% agreement level on whether to use psychotherapy. Multiple regression analysis revealed that the best model to predict lower agreement with the experts was years in practice plus percentage of time spent in solo (vs. group) practice (r2 = 0.40). This study extended previous data-based pharmacoepidemiology by assessing multiple aspects of psychiatrists' practice patterns. Psychiatrists who are more distant from training years and more isolated from the current stimulation of colleagues may be particularly appropriate targets for continuing education.

Functioning and well-being of patients in a consultation-liaison psychiatry clinic.

Outpatient consultation-liaison (C-L) psychiatry clinics are valuable settings for research and teaching endeavors. However, little is known about psychiatric symptoms and health status of persons treated in such settings. In this study, 80 persons seen in an outpatient C-L psychiatry clinic were compared with 100 persons seen in a mood disorder clinic on a variety of self-report instruments. Outpatient C-L clinic patients were found to have significantly poorer health status than mood clinic patients on the following domains as measured by the RAND instrument: general health perception, pain, physical functioning, and role functioning due to physical problems. Both groups had poor role functioning due to emotional problems and poor social functioning. The groups did not differ in depressive symptoms but C-L patients were significantly less anxious. Thus, it appears that patients in an outpatient C-L setting not only have significant medical comorbidity, as expected, but have levels of psychiatric distress comparable to that seen in a traditional psychiatry outpatient setting. These findings indicate that such a clinic is a fertile area for research and training in the diagnosis and treatment of persons with comorbid physical and mental disorders.

Psychiatric aspects of the eosinophilia-myalgia syndrome.

The eosinophilia-myalgia syndrome (EMS) is a rare systemic disease caused by presumably contaminated L-tryptophan. Thirteen outpatients with EMS were found to have a high degree of depression, anxiety, and difficulty adjusting to illness. Pre-EMS history of major depression but not EMS severity predicted poor adjustment to illness.

The use of an advance directive in consultation-liaison psychiatry: a case report.

OBJECTIVE: The following case report illustrates the use of a psychiatric advance directive in a surgical setting. METHOD: The case of a woman with breast cancer and debilitating pre-operative anxiety is presented. Her anxiety was so severe that it resulted in repeated refusal to have necessary surgery. An advance directive facilitated proceeding with surgery despite her objections in the immediate pre-operative period. CONCLUSION: Consultation-Liaison psychiatrists should consider the use of an advance directive when preoperative anxiety interferes with decision-making capacity.

Outpatient consultation-liaison psychiatry: a valuable addition to the training of advanced psychiatry residents.

With current health care reimbursement conditions and recent research denoting the important relationship between mental health status and poor functioning, especially in medically ill patients, one would think that consultation-liaison (C-L) psychiatry would have an increasingly viable role in the outpatient health care sector. However, only a small number of outpatient C-L clinics are reported and recently several of these have folded. These outpatient C-L clinics can follow different clinical models and have the potential, especially at the residency and fellowship training levels, for interesting and useful educational opportunities. This paper describes a recently founded outpatient C-L clinic--the Medical Illness Clinic--in a university medical center's department of Psychiatry. We highlight the structure of the clinic, the kinds of patients seen, and focus on the unique educational residency training opportunities this setting presents. The results of clinic rotation evaluations by residents are also presented. We conclude with recommendations for more exploration of this clinical model and evaluation of its utility in psychiatric residency education.

Activation of guanylate cyclase by E. coli heat-stable enterotoxin (STa). Modulation by NAD and pertussis toxin.

The heat-stable enterotoxin (STa) of E. coli activates intestinal guanylate cyclase and leads to increased cGMP levels by an as yet undetermined mechanism. In comparing this cGMP system to other known toxin-mediated alterations in cAMP metabolism, we observed that pertussis toxin caused lower levels of intestinal cGMP synthesis in response to purified STa. Another participant in ADP-ribosylation reactions, NAD, enhanced the ability of STa to activate guanylate cyclase, yet had no effect on basal enzyme activity. Niacinamide and isoniacinamide also had no effect on basal activity, but attenuated the STa activation. These results are discussed in relation to current models of hormone/toxin-sensitive adenylate cyclase, and may suggest an involvement of guanine-nucleotide-binding proteins in intestinal cGMP metabolism.