Jennifer D. Lish

Diagnostic interviewing for family studies: Comparing telephone and face-to-face methods for the diagnosis of lifetime psychiatric disorders

Family studies require assessment of large numbers of family members, many of whom are geographically dispersed, live in different time zones, are not available during working hours, live in neighborhoods which are unsafe, or do not wish to have attention drawn to them by the presence of an interviewer in their home. For these reasons, telephone interviews are a potentially valuable and economical method. We present a comparison of results from telephone and face-to-face interviews conducted with 435 relatives of 193 probands from a family study. No significant differences were found between telephone versus face-to-face interviewed relatives in rates of RDC or of DSM-III-R diagnoses. Nor were differences found in the length of interviews; number of family history reports completed; or number of relatives requiring consensus diagnoses due to diagnostic disagreement. We conclude that telephone and face-to-face interviews yielded comparable diagnostic information in this family study and that telephone interviewing is an acceptable and valuable alternative method for the diagnosis of lifetime psychiatric disorder in relatives.

Family psychiatric screening instrument for epidemiologic studies: pilot testing and validation

Family history, a risk factor for psychiatric disorders, is infrequently assessed in epidemiologic studies due to time and cost constraints. We designed a brief computer-scorable instrument, the Family History Screen for Epidemiologic Studies (FHE), which collects a pedigree and screens for 15 DSM-III diagnoses in an informant and in his family members. The FHE was administered to one informant in 77 families in which we had collected pedigrees, interviewed 77 informants and 239 relatives using the Lifetime Anxiety version of the schedule for Affective Disorders and Schizophrenia or the Epidemiologic version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, and performed best-estimate diagnoses. We evaluated the accuracy with which the FHE predicted best-estimate diagnoses. For adults reporting on themselves, the FHE demonstrated high levels of sensitivity and specificity for depression (67.4, 75.0) and panic (92.5, 89.2), and low sensitivity and high specificity for substance abuse (33.3, 93.6). For informants reporting on adult relatives, sensitivity was low and specificity was high for depression (35.2, 84.9), panic (20.0, 91.7), and substance abuse (42.1, 93.4). For informants reporting on children, perhaps due to lower prevalence, sensitivity and specificity were poor. The FHE is a good screen for psychiatric disorders in adult informants, but it is not useful for family history. It may be useful in primary care medical settings as a screen for psychiatric history.

Suicide Screening in a Primary Care Setting at a Veterans Affairs Medical Center

Seven-hundred and three patients from a general medical outpatient clinic at a Veterans Affairs hospital completed the SCREENER, a brief self-report questionnaire that screens for psychiatric disorders. The authors found that 7.3% of the patients had suicidal ideation. The younger and white patients were at increased risk. The risk was increased twelvefold in those patients with subjectively fair or poor mental health, sevenfold in the patients with a history of mental health treatment, and fourfold in the patients with fair or poor perceived physical health. When major depression was controlled for, anxiety and substance abuse disorders continued to show an association with suicidal ideation. The suicidal patients made more visits to their primary care physician. Screening patients for anxiety disorders and drug abuse, as well as depression, is a better approach for identifying suicidal ideation in primary care settings than screening for depression alone and may help prevent suicide and suicide attempts.

Suicidal ideation among urban medical outpatients.

The prevalence of current suicidal ideation among urban primary care outpatients was assessed, and suicidal and non-suicidal patients were compared with regard to their demographic characteristics and their attitudes toward mental health screening. Twenty (3.3%) patients reported having thoughts of killing themselves. The patients who had suicidal ideation were significantly younger and more frequently divorced. Almost all (97.6%) of the patients indicated that their physicians should inquire about emotional health issues at some time, and the suicidal patients were nonsignificantly more likely to recommend inquiry about psychiatric symptoms at every visit (55.0% vs 37.0%, p<0.11). Only half of the suicidal patients reported lifetime histories of mental health treatment. The majority (70.2%) of the patients believed that it would be easy to discuss mental health problems with their medical physicians. Among the patients who had previously received psychiatric treatment, the suicidal patients were nearly three times more likely to anticipate that it would be difficult or very difficult to talk to their physicians about psychiatric problems. In contrast, among the patients who had no history of mental health treatment, there was no association between suicidal ideation and anticipated discomfort in talking with their physicians about emotional health.

Screening for depression in medical patients: Is the focus too narrow?

There is growing consensus that depression is a major public health problem causing significant psychosocial morbidity and mortality which should be addressed by case-finding effects in primary care settings. A large amount of literature has examined the ability of self-report questionnaires to detect depression in medical patients and the results have been encouraging. However, studies of general population and psychiatric patient samples indicate that depression is frequently comorbid with other psychiatric disorders, and that psychiatric disorders other than depression are also associated with significant morbidity and mortality. Consequently, we believe that psychiatric screening in primary care should be broad based. We administered a newly developed, multidimensional questionnaire (the SCREENER), that simultaneously screens for a range of DSM-III-R psychiatric disorders, to 508 medical outpatients attending a VA general medical clinic. Compared with nondepressed cases, the depressed patients significantly more often reported all of the nondepressive symptoms. Nine of the ten nondepressive disorders screened for by the SCREENER were significantly more frequent in the depressed group. Most patients who screened positive for depression also screened positive for at least one nondepressive disorder. Compared with patients who only screened positive for depression, those who screened positive for both depression and a nondepressive disorder rated their physical and emotional health more poorly and made more visits to the doctor. Compared with patients who did not screen positive for any disorder, those who only screened positive for a nondepressive disorder rated their physical and emotional health more poorly, and more frequently had a history of mental health treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Segregation analysis of panic disorder

We performed a simple segregation analysis of panic disorder, using 30 two- and three-generation pedigrees. Pedigrees were singly ascertained, either through the Epidemiologic Catchment Area study (seven probands), or as a consecutive series from an anxiety disorders clinic (23 probands). All probands were required to meet DSM-III panic disorder criteria, without comorbid major depression. Relatives (n = 189) were required to meet DSM-III criteria for panic disorder, with or without comorbid major depression. We fitted a single major dominant and a single major recessive model to the data, allowing for an age-of-onset distribution. Under the dominant model, we obtained the following parameter estimates: gene frequency = 0.01; (lifetime) susceptibility for gene carriers = 0.5; susceptibility for non-gene carriers = 0.01. Under the recessive model, we obtained the following parameter estimates: gene frequency = 0.2; susceptibility for gene carriers = 0.7; susceptibility for non-gene carriers = 0.01. The best-fitting dominant and best-fitting recessive models had equally high likelihoods. Discrepancies between our results and earlier reports are discussed, as are implications of these results for linkage analyses of panic disorder.

Prenatal exposure to diethylstilbestrol (DES): childhood play behavior and adult gender-role behavior in women.

Data from lower mammals suggest a masculinizing or defeminizing influence of pre- or perinatal diethylstilbestrol (DES) exposure on various aspects of the sex-dimorphic behavior (including juvenile rough-and-tumble play) of genetic females. However, three previous studies on childhood play and adult gender-role behavior in human females have led to ambiguous results. In a follow-up study of 60 women with prenatal exposure to DES and 26 controls, we used psychometrically well-designed multi-item scales based on self-report inventories for the assessment of these aspects of behavior. No effects of DES could be demonstrated. We conclude that, at the doses studied, prenatal DES exposure in human females has not led to behavioral masculinization or defeminization of childhood play and adult gender-role behavior.

Psychiatric screening in primary care: What do patients really want?

Psychiatric disorders are common in primary care, but underdiagnosed. U.S. physician reluctance to diagnose psychiatric illnesses is partly attributable to the belief that patients do not want their primary care physician to assess mental health. Six hundred one patients in a U.S. general internal medicine practice completed the SCREENER, a self-report questionnaire which screens for 15 psychiatric disorders, and another questionnaire about the SCREENER. Patients were predominantly female, unmarried, black, high school graduates. Only 3% thought that their physician should never evaluate their mental health. More than 60% desired periodic mental health screening, and one third wanted psychiatric assessment only when a problem was suspected. Attitudes toward questionnaire screening were less positive than toward physician interview. Patients were more likely to want screening if they were female, unmarried, young, had a history of mental health treatment, reported psychiatric symptoms, or were in fair-poor subjective physical or mental health.

Psychiatric Screening in Geriatric Primary Care: Should It Be for Depression Alone?

Depression in the elderly is highly prevalent, associated with functional disability and increased medical costs, and treatable; however, it is infrequently recognized and treated. The Agency for Health Care Policy and Research has advocated, therefore, increased case-finding efforts for depression in primary geriatric care. Anxiety, substance, and somatoform disorders in the elderly are similarly prevalent, associated with disability and cost, treatable, and also infrequently detected and treated. We believe that psychiatric case-finding in geriatric primary care should attend to these disorders, therefore, as well as to depression. In the present study, we examined whether the association between depressive and nondepressive forms of psychopathology was similar in geriatric and nongeriatric medical patients. We also examined the relationship between each type of pathology and health care utilization and global ratings of physical and mental health. In a VA hospital general medical outpatient clinic, 508 patients completed the SCREENER, which is a brief self-report questionnaire that screens for a range of psychiatric disorders, along with a self-report questionnaire regarding subjective health and medical care utilization. Of these patients, 98% were male, and the median age was 63 years. Patients aged 63 and over were compared to younger patients. In both geriatric and younger adult patients, we found substantial comorbidity between depressive and nondepressive forms of pathology. Moreover, in both age groups, there were significant associations between both depressive and nondepressive symptoms and fair-to-poor self-rated physical and mental health and increased medical care utilization. Approximately half of the cases of nondepressive disorders in the elderly were not comorbid with depression, and thus would not have been detected by screening for depression alone. Therefore, psychiatric case finding in primary care of geriatric males should be directed at anxiety, substance, and somatoform disorders, as well as at depression, for treatment resources to be triaged to maximally decrease morbidity and cost.

Primary Care Patients' Reactions to Mental Health Screening

Objective: The authors examined whether there is empirical support for the notion that medical patients are upset by being asked questions about psychiatric disorders. Method: Six hundred and one patients attending a primary care clinic completed the SCREENER—a newly developed, brief self-administered questionnaire that surveys a broad range of psychopathology. In addition, they completed a second questionnaire that assessed their attitudes toward the SCREENER. Results: We found a high level of acceptance by patients. The questions were judged easy to answer, and they rarely aroused significant negative affect. Fewer than 2 percent of the patients judged the questions difficult to answer, and fewer than 3 percent were “very much” embarrassed, upset, annoyed, or uncomfortable with the questions. Individuals with a history of psychiatric treatment and poorer current mental health reacted more unfavorably to the questionnaire. Conclusions: From the patients perspective, it is feasible and acceptable to use self-administered questionnaires for routine screening of psychiatric problems in primary care settings.