Dalene Stangl

The Implications of DSM-III Personality Disorders for Patients with Major Depression

We studied 78 inpatients with DSM-III major depression. Forty-one (53%) had a concurrent personality disorder (PD) according to a detailed structured interview for DSM-III personality disorders. The patients with depression plus PD differed from patients with depression alone on numerous measures. The PD patients had earlier onset; higher HRS scores; poorer social support; more life stressors; more frequent separation and divorce; more frequent nonserious suicide attempts, less frequent dexamethasone nonsuppression; poorer response to antidepressant medication; and higher risk for depression, alcoholism and antisocial personality among first-degree relatives. The PD subgroup shares many attributes with Winokurs subtype of depression spectrum disorder and Akiskals character spectrum disorder. An attempt to identify a subgroup of personality disorders which might be an atypical affective disorder was inconclusive. However, patients in DSM-III cluster III were similar to the patients with no-PD on the dexamethasone suppression test, response to treatment, and familial risk for depression and antisocial personality.

Use, persistence, and intensity: patterns of care for children's mental health across one year.

This paper explores the use, persistence, andintensity of services for childrens mental healthproblems across a variety of service sectors during aone year period. Data come from the Great SmokyMountains Study. Analyses focus on childrens psychiatricsymptomatology and impairment, service use, and factorsthat may influence the relationship between psychiatricproblems and service use across a one year period. Findings show that approximately 20% ofchildren used some mental health services from somesector during the year. Childs symptomatology andcharacteristics of parents were associated with use and persistence of services. Parentsperceptions of impact on the family were associated withservice use, persistence, and intensity.

Exploring Lack of Trust in Care Providers and the Government as a Barrier to Health Service Use

OBJECTIVES We examined associations between trust of health care providers and the government and health service use and outcomes. METHODS Interviews with a sample of 611 HIV-positive individuals included an attitudinal assessment measuring beliefs concerning the creation of AIDS, information being withheld about the disease, and trust of care providers. RESULTS Trust in care providers was associated with increased HIV-related out-patient clinic visits, fewer emergency room visits, increased use of antiretroviral medications, and improved reported physical and mental health. Trusting the government was associated with fewer emergency room visits and better mental and physical health. More than one quarter of the respondents believed that the government created AIDS to kill minorities, and more than half believed that a significant amount of information about AIDS is withheld from the public. Ten percent did not trust their provider to give them the best care possible. CONCLUSIONS Distrust may be a barrier to service use and therefore to optimal health. Distrust is not isolated in minority communities but also exists among members of nonminority communities and equally interferes with their use of services and health outcomes.

DSM-III personality disorders: Diagnostic overlap and internal consistency of individual DSM-III criteria

Abstract We rated the presence or absence of every DSM-III personality criteria in a cohort of 131 non-psychotic subjects. Ratings were based on the Structured Interview for DSM-III Personality Disorders (SIDP) which was administered to each patient and a knowledgable informant. Diagnositc overlap of the personality disorders (PD) was examined. Sensitivity, specificity, predictive value—positive and negative, and interrater reliability was calculated for each criteria item of each personality disorder. Problems in reliability of DSM-III personality disorders can be traced to specific criteria within those disorders that are associated with low reliability and/or low predictive value positive when compared to the other criteria used to define the personality disorder. Improvements are suggested. We were unable to demonstrate a significantly greater enhancement of reliability among criteria structures using a polythetic classification over those using monothetic classification despite a trend favoring the former. This study agrees with others that find a great deal of overlap between borderline PD and histrionic PD as defined in DSM-III. Passive-aggressive PD is very rare in the absence of some other PD. Paranoid and schizoid personality disorders were also rare though this may reflect the fact that individuals with these disorders rarely seek treatment.

How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the south

Objective: In addition to biological markers of human immunodeficiency virus (HIV) disease progression, physical functioning, and utilization of health care may also be important indicators of health status in HIV-infected patients. There is insufficient understanding of the psychosocial predictors of health-related physical functioning and use of health services among those with this chronic disease. Therefore, the current study examines how trauma, severe stressful events, posttraumatic stress disorder (PTSD), and depressive symptoms are related to physical functioning and health utilization in HIV-infected men and women living in rural areas of the South. Methods: We consecutively sampled patients from 8 rural HIV clinics in 5 southern states, obtaining 611 completed interviews. Results: We found that patients with more lifetime trauma, stressful events, and PTSD symptoms reported more bodily pain, and poorer physical, role, and cognitive functioning. Trauma, recent stressful events, and PTSD explained from 12% to 27% of the variance in health-related functioning, over and above that explained by demographic variables. In addition, patients with more trauma, including sexual and physical abuse, and PTSD symptoms were at greater risk for having bed disability, an overnight hospitalization, an emergency room visit, and four or more HIV outpatient clinic visits in the previous 9 months. Patients with a history of abuse had about twice the risk of spending 5 or more days in bed, having an overnight hospital stay, and visiting the emergency room, compared with those without abuse. The effects of trauma and stress were not explained by CD4 lymphocyte count or HIV viral load; however, these effects appear to be largely accounted for by increases in current PTSD symptoms. Conclusion: These findings highlight the importance of addressing past trauma, stress, and current PTSD within clinical HIV care. PTSD = posttraumatic stress disorder; HIV = human immunodeficiency virus; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders; OR = odds ratio; CI = confidence interval; SD = standard deviation.

Meta-Analysis in Medicine and Health Policy

Meta-Analysis: Past and Present Challenges Dalene K. Stangl and Donald A. Berry Meta-Analysis of Heterogeneously Reported Study Results: A Bayesian Approach Keith R. Abrams, Paul C. Lambert, Bruno Sanso, and Chris Shaw Meta-Analysis versus Large Trials: Resolving the Controversy Scott M. Berry A Bayesian Meta-Analysis of Randomized Mega-Trials for the Choice of Thrombolytic Agents in Acute Myocardial Infarction James Brophy and Lawrence Joseph Combining Studies with Continuous and Dichotomous Responses: A Latent-Variables Approach Francesca Dominici and Giovanni Parmigiani Computer-Modeling and Graphical Strategies for Meta-analysis William DuMouchel and Sharon-Lise Normand Meta-Analysis for 2 x 2 Tables with Multiple Treatment Groups Leon J. Gleser and Ingram Olkin A Bayesian Meta-Analysis of the Relationship between Duration of Estrogen Exposure and Occurrence of Endometrial Cancer Daniel T. Larose Modeling and Implementation Issues in Bayesian Meta-Analysis Donna K. Pauler and Jon Wakefield Meta-Analysis of Population Pharmacokinetic Data Nargis Rahman and Jon Wakefield Meta-Analysis of Individual-patient Survival Data Using Random-Effect Models Daniel J. Sargent, Benny C. Zee, Chantal Milan, Valter Torri, and Guido Francini Adjustment for Publication Bias and Quality Bias in Bayesian Meta-Analysis David D. Smith, Geof H. Givens, and Richard L. Tweedie Meta-Analysis of Clinical Trials: Opportunities and Limitations Richard Simon Research Synthesis for Public Health Policy: Experience of the Institute of Medicine Michael A. Stoto Meta-Analysis in Practice: A Critical Review of Available Software Alexander J. Sutton, Paul C. Lambert, Martin A. G. Hellmich, Keith R. Abrams, and David

Minorities, the poor, and survivors of abuse: HIV-infected patients in the US deep South

Background: The HIV/AIDS epidemic in the U.S. South is undergoing a marked shift toward a greater proportion of new HIV/AIDS cases in women, African-Americans, and through heterosexual transmission. Methods: Using consecutive sampling, 611 participants were interviewed from eight Infectious Diseases clinics in five southeastern states in 2001 to 2002. Results: Sixty four percent of participants were African-American, 31% were female, and 43% acquired HIV through heterosexual sex; 25% had private health insurance. Eighty-one percent were on antiretroviral therapy, and 46% had HIV RNA viral loads (VL) <400. Women and racial/ethnic minorities were less likely to be on antiretrovirals and to have VL <400. Probable psychiatric disorders (54%) and history of childhood sexual (30%) and physical abuse (21%) were common. Conclusions: Prevention and care systems need to address the HIV epidemic’s shift into poor, minority, and female populations. High levels of trauma and probable psychiatric disorders indicate a need to assess for and address these conditions in HIV clinical care.

Prevalence of childhood sexual abuse and physical trauma in an HIV-positive sample from the deep south

We examined prevalence and predictors of trauma among HIV-infected persons in the Deep South using data from the Coping with HIV/AIDS in the Southeast (CHASE) study. Over 50% of CHASE participants were abused during their lives, with approximately 30% experiencing abuse before age 13, regardless of gender. Caregiver characteristics were associated with childhood abuse. Abuse is related to increases in high-HIV-risk activities. The findings help explain why people engage in such high-risk activities and can provide guidance in designing improved care and prevention messages.

Four definitions of endogenous depression and the dexamethasone suppression test

We examined the relationship between the DST and 4 definitions of endogenous depression: DSM-III, Feinberg and Carroll, Newcastle and RDC. Endogenous patients had a significantly higher rate of nonsuppression than nonendogenous patients according to the DSM-III and Newcastle definitions but not according to the RDC and Feinberg and Carroll criteria. Moreover, the relationship between the DST and the DSM-III and Newcastle definitions was significant even after individually controlling for age, psychosis and weight loss. We review the literature on the relationship between the DST and the RDC definition of endogenous depression and suggest that interstudy differences in criteria application may be partially responsible for the inconsistent results across studies.

The relationship between age and post-dexamethasone cortisol: A test of three hypotheses

Previous studies report that DST nonsuppressors are older than normal suppressors. Data are presented on 188 primary unipolar major depressive inpatients and 35 healthy controls. In males, age appeared to correlate positively with post-dexamethasone cortisols in depressed patients and normal controls, although mean levels were higher in depressives. Female controls showed no consistent relationship between age and post-dexamethasone cortisol. A positive relationship did exist for depressed women. However, the association disappeared when age-of-onset was entered into the model, suggesting that in females early onset may identify a subtype of depression with normal DST suppression.