Edward A. Walker

Development and validation of a brief screening version of the Childhood Trauma Questionnaire

OBJECTIVE The goal of this study was to develop and validate a short form of the Childhood Trauma Questionnaire (the CTQ-SF) as a screening measure for maltreatment histories in both clinical and nonreferred groups. METHOD Exploratory and confirmatory factor analyses of the 70 original CTQ items were used to create a 28-item version of the scale (25 clinical items and three validity items) and test the measurement invariance of the 25 clinical items across four samples: 378 adult substance abusing patients from New York City, 396 adolescent psychiatric inpatients, 625 substance abusing individuals from southwest Texas, and 579 individuals from a normative community sample (combined N=1978). RESULTS Results showed that the CTQ-SFs items held essentially the same meaning across all four samples (i.e., measurement invariance). Moreover, the scale demonstrated good criterion-related validity in a subsample of adolescents on whom corroborative data were available. CONCLUSIONS These findings support the viability of the CTQ-SF across diverse clinical and nonreferred populations.

Adult health status of women with histories of childhood abuse and neglect

PURPOSE Several recent studies have found associations between childhood maltreatment and adverse adult health outcomes. However, methodologic problems with accurate case determination, appropriate sample selection, and predominant focus on sexual abuse have limited the generalizability of these findings. SUBJECTS AND METHODS We administered a survey to 1,225 women who were randomly selected from the membership of a large, staff model health maintenance organization in Seattle, Washington. We compared women with and without histories of childhood maltreatment experiences with respect to differences in physical health status, functional disability, numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. RESULTS A history of childhood maltreatment was significantly associated with several adverse physical health outcomes. Maltreatment status was associated with perceived poorer overall health (ES = 0.31), greater physical (ES = 0.23) and emotional (ES = 0.37) functional disability, increased numbers of distressing physical symptoms (ES = 0.52), and a greater number of health risk behaviors (ES = 0.34). Women with multiple types of maltreatment showed the greatest health decrements for both self-reported symptoms (r = 0.31) and physician coded diagnoses (r = 0.12). CONCLUSIONS Women with childhood maltreatment have a wide range of adverse physical health outcomes.

Psychiatric diagnoses, sexual and physical victimization, and disability in patients with irritable bowel syndrome or inflammatory bowel disease

We compared 71 patients with irritable bowel syndrome (IBS) and 40 patients with inflammatory bowel disease (IBD) using structured interviews for psychiatric, gastrointestinal and sexual/physical victimization histories, as well as self-reported measures of personality, functional disability and dissociation. IBS patients had significantly higher lifetime prevalence rates of major depression, current panic disorder, and childhood sexual abuse. Despite the absence of organic pathology, IBS patients had significantly higher numbers of medically unexplained physical symptoms and disability ratings equal to, or greater than, those of patients with severe organic gastrointestinal disease.

Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome

Chronic pelvic pain and irritable bowel syndrome are common disorders, yet very little is known about their comorbidity. As part of an epidemiological study of patients with irritable bowel syndrome or irritable bowel disease we inquired about a history of chronic pelvic pain and related gynecological problems, and hypothesized that distress associated with either of these conditions was additive in women with both syndromes. A medically trained interviewer evaluated a sequential sample of 60 women with irritable bowel syndrome and 26 women with inflammatory bowel disease in an urban gastroenterology clinic using the National Institute of Mental Health Diagnostic Interview Schedule, the Briere Child Maltreatment Interview (emotional, physical and sexual abuse), and a structured interview to elicit a lifetime history of chronic pelvic pain that was distinct from the history of bowel distress. Chronic pelvic pain was reported in 21 (35.0%) of the irritable bowel syndrome patients vs. 4 (13.8%) of the inflammatory bowel disease group (p < 0.05). Compared to women with irritable bowel syndrome alone, those with both irritable bowel syndrome and chronic pelvic pain were significantly more likely to have a lifetime history of dysthymic disorder, current and lifetime panic disorder, somatization disorder, childhood sexual abuse and hysterectomy. Logistic regression showed that mean number of somatization symptoms was the best predictor of a history of both irritable bowel syndrome and chronic pelvic pain compared either to inflammatory bowel disease or irritable bowel syndrome alone. Many women with irritable bowel syndrome may have a history of chronic pelvic pain as well. The high rates of psychopathology associated with irritable bowel syndrome and chronic pelvic pain independently are even higher in women with both syndromes, and women who present with either irritable bowel syndrome or chronic pelvic pain should probably be evaluated for both disorders.

Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits.

In the past two decades, carefully designed studies examining the biopsychosocial causes of common physical symptoms have shown that most health care visits are made because of common symptoms for which no identified pathology is found (1). In this paper, we summarize the relationship between common medical symptoms without identified pathology and a range of psychosocial variables, such as stressful life events, psychological distress, psychiatric disorders, and predisposing emotional vulnerabilities. We also review the association between psychiatric illness and specific clusters of physical symptoms (such as the chronic fatigue syndrome) that are considered syndromes with ill-defined pathologic mechanisms. Medical symptoms without identified pathology are defined as physical symptoms appearing in patients who do not have proportional tissue abnormalities. In most studies reviewed here, a symptom was considered to have no identified pathology when a patient visited a medical physician and was told that 1) no structural changes could be found to explain the symptom or 2) the symptom was secondary to stress or psychiatric illness. Our medical language to describe these symptoms is imperfect; advances in research suggest that many medical symptoms without identified pathology may actually be caused by problems in psychophysiologic or brainbody pathways, such as abnormalities in smooth-muscle tone in the gastrointestinal tract during stress in patients with the irritable bowel syndrome (2). Recent research also suggests that links between perturbations in brain physiology and physical symptoms are bidirectional. Changes in brain physiology secondary to stressful life events cause functional abnormalities in the body (such as abnormalities in smooth-muscle tone in the gut), and these functional abnormalities in the body are also associated with changes in brain physiology (3). The identification of medical symptoms and syndromes without identified pathology may be broken down into a four-part process (4, 5). First, a person has a symptom (presumably, a neurophysiologic event brings it to awareness). Second, the person uses his or her knowledge, experience, and beliefs about the symptom and its cause to assign the symptom a level of medical importance. Most symptoms do not lead to medical visits because patients assign them a relatively low level of medical importance. Third, the person with the symptom seeks care. Whether a person will seek care can be predicted by that persons beliefs about the symptoms significance and by his or her attitude toward the medical system. The fourth and final step is the interaction of the patients beliefs and expectations with those of the physician. This step may be associated with decreased worry about the symptoms medical implications when the patientphysician interaction goes well, or it may lead to frustration and doctor-shopping when the interaction is problematic. The litigious nature of western society may also lead the physician to order tests because of anxiety about missing a medical problem. This may inadvertently reinforce the patients worry over having a medical illness. Spectrum of Severity The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has developed dichotomous classifications of patients with unexplained symptoms, such as somatization disorder, conversion disorder, hypochondriasis, and pain disorder. In general, these dichotomous diagnoses apply to only a small percentage of primary care patients and do not point to specific treatment regimens. Most primary care patients who have medical symptoms without identifiable pathology have associated stressful life events or anxiety and depressive diagnoses (or both) and do not have the severity or the chronicity needed to qualify for diagnosis with the somatoform disorders mentioned above (6-8). Several research groups have shown that there is not a sharp dichotomy between patients with multiple somatic symptoms (such as those with the somatization disorder) and patients with medical symptoms without identified pathology but actually a spectrum of severity of somatization (9). As the number of medical symptoms without identified pathology increases, the number of psychological distress symptoms, the number of anxiety and depressive diagnoses, and the degree of functional impairment increase linearly (9-13). Thus, increasing numbers of medically unexplained symptoms have been found to be proxy measures of the degree of psychological distress and functional impairment (9-11). Longitudinal studies that have examined predictors of chronicity in patients who have medical symptoms without identified pathology have found the baseline number of physical symptoms to be the best predictor of persistent impairment (14). Epidemiology Physical symptoms are common among community respondents and are responsible for approximately 50% of all physician visits (1). Epidemiologic surveys of community respondents have found high rates of such symptoms as headache (15), fatigue (16), and abdominal pain (17). One health care diary study (18) reported that participants had a new physical symptom every 5 to 7 days, and more than 90% of these symptoms were not brought to a physicians attention. Another study found that 85% to 95% of community respondents had at least one symptom every 2 to 4 days (19). People in the United States have been found to restrict activities because of symptoms an average of 9.7 days per year and to visit physicians an average of 2.7 times per year (20). Researchers have sought to understand factors predicting medical visits for common physical symptoms, such as headache or fatigue. Studies of community participants with migraine headaches (15), fatigue (16), and common gastrointestinal symptoms (17) have shown that compared with persons who do not seek health care, persons who do seek health care have significantly more stressful life events (21, 22), have psychological distress, and are significantly more likely to meet the criteria for a DSM-IV anxiety or depressive disorder. Epidemiologic studies have found that 25% to 35% of primary care patients meet the criteria for a DSM psychiatric disorder, most often an anxiety or depressive disorder (8, 23). Researchers have shown that approximately half of patients with a DSM anxiety or depressive disorder do not receive an accurate diagnosis by primary care physicians (7, 8, 23). This may be because 50% to 80% of patients with a DSM anxiety or depressive disorder initially present with physical symptoms (7, 8). Compared with patients with psychiatric illness who present with psychological symptoms, significantly more patients with psychiatric illness who present with physical symptoms do not receive an accurate diagnosis by a primary care physician (7, 8). Patients with common anxiety and depressive disorders have significantly more medical symptoms without identified pathology than do patients without psychiatric illness (24, 25). In the Epidemiologic Catchment Area study (25), 50% of community respondents with five or more medically unexplained symptoms over a 6-month period met the criteria for a DSM-III psychiatric disorder; only 5% of respondents without these symptoms met the criteria. Spitzer and colleagues, in the Primary Care Evaluation of Mental Disorders (PRIME-MD) 1000 study (26), showed that as the number of medical symptoms increased, so did the percentage of patients who met the criteria for a DSM-III-R anxiety or depressive disorder (10). This was true both for symptoms that the primary care physician rated as not explained by medical pathology and for symptoms that the physician labeled as probably due to a medical illness. Two other large primary care studies (9, 11) also found a relationship between more medical symptoms without identified pathology and a higher likelihood of a DSM-IV anxiety or depressive disorder. This relationship between the number of medical symptoms and psychiatric disorders holds true for patients with subsyndromal psychiatric disorders. Mental health researchers (27, 28) have shown that as the number of self-rated psychological symptoms increases, so does the number of self-rated physical symptoms, with a correlation of about 0.5 between psychological scales of distress and self-rated physical symptom checklists. Health Care Utilization Patients with depressive and anxiety disorders are often high utilizers of medical services, perhaps because they have an increased number of physical symptoms. In the Epidemiologic Catchment Area Study of five United States cities (29), community respondents with one or more with psychiatric disorders were significantly more likely than respondents without psychiatric disorders to be high utilizers of medical services. A study in a large health maintenance organization (HMO) (30) found that patients with depression who were treated with antidepressants incurred about twice the health care costs of age- and sex-matched patients without depression, even after adjustment for comorbid chronic medical illness. These differences in medical costs were found in every component measured, including primary care, medical specialty, and mental health visits; in-patient medical days; laboratory costs; emergency department costs; and radiography (30). Elderly patients in an HMO who had positive results on screening tests for depression were found to incur 30% to 50% more overall costs than did nondepressed elderly persons after adjustment for comorbidity (31). A retrospective casecontrol study (32) showed that patients with a specific type of anxietypanic disorderhad increased medical costs in every year over a 10-year period compared with age- and sex-matched controls. This association between psychiatric disorders and health care utilization is also evident if patients are identified by utilization patterns. High utilizers of medical services have been shown to h

The Role of the Primary Care Physician in Patientsʼ Adherence to Antidepressant Therapy

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages—1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants—were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual physical and emotional abuse and neglect.

Objective Two recent reports have found associations between fibromyalgia and sexual victimization, but had methodologic characteristics that limited their interpretation. Method We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis by using structured interviews for sexual, physical, and emotional victimization histories, as well as dimensional self-report measures of victimization severity. Results Compared with the patients with rheumatoid arthritis, those with fibromyalgia had significantly higher lifetime prevalence rates of all forms of victimization, both adult and childhood, as well as combinations of adult and childhood trauma. Although childhood maltreatment was found to be a general risk factor for fibromyalgia, particular forms of maltreatment (eg, sexual abuse per se) did not have specific effects. Experiences of physical assault in adulthood, however, showed a strong and specific relationship with unexplained pain. Trauma severity was correlated significantly with measures of physical disability, psychiatric distress, illness adjustment, personality, and quality of sleep in patients with fibromyalgia but not in those with rheumatoid arthritis. Conclusions Fibromyalgia seems to be associated with increased risk of victimization, particularly adult physical abuse. Sexual, physical, and emotional trauma may be important factors in the development and maintenance of this disorder and its associated disability in many patients.

Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression

Objective This report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. Study Design Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trial (N = 217), consulting psychiatrists provided enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153), Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologists provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. Results Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression, Collaborative Care was more costly and not more cost-effective than Usual Care. Conclusions Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.

PSYCHOSOCIAL FACTORS IN FIBROMYALGIA COMPARED WITH RHEUMATOID ARTHRITIS : I. PSYCHIATRIC DIAGNOSES AND FUNCTIONAL DISABILITY

Objective Recent studies of the relationship between fibromyalgia and psychiatric disorders have yielded conflicting findings, and many of these inconsistencies seem to result from methodological differences. Method We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis from a tertiary care clinic using physician-administered, structured psychiatric interviews and self-reported measures of illness appraisal, coping, and functional disability. Results Patients with fibromyalgia had significantly higher lifetime prevalence rates of mood and anxiety disorders, as well as higher mean numbers of medically unexplained physical symptoms across several organ systems. Ninety percent of the patients with fibromyalgia had a prior psychiatric diagnosis compared with less than half of the patients with rheumatoid arthritis. Conclusions Despite the absence of organic pathology, the patients with fibromyalgia had equal or greater functional disability and were less well adapted to their illness. Although the pathophysiology of fibromyalgia remains unclear, co-morbid psychiatric disorders and functional disability remain an important focus of treatment in this population.

Achieving Guidelines for the Treatment of Depression in Primary Care Is Physician Education Enough

OBJECTIVES The authors examine whether physician education has enduring effects on treatment of depression. METHODS Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes. RESULTS No lasting educational effect was observed consistently in any of the outcomes measured. CONCLUSIONS There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.