Joseph J. Gallo

Depression, Psychotropic Medication, and Risk of Myocardial Infarction Prospective Data From the Baltimore ECA Follow-up

BACKGROUND There is suggestive evidence that depression increases risk of myocardial infarction (MI), but there are no prospective studies in which the measure of depression corresponds to clinical criteria. This study examines prospectively whether a major depressive episode increases the risk of incident MI and evaluates the role of psychotropic medication use in this relationship. METHODS AND RESULTS The study is based on a follow-up of the Baltimore cohort of the Epidemiologic Catchment Area Study, a survey of psychiatric disorders in the general population. A history of major depressive episode, dysphoria (2 weeks of sadness), and psychotropic medication use were assessed in 1981, and self-reported MI was assessed in 1994. Sixty-four MIs were reported among 1551 respondents free of heart trouble in 1981. Compared with respondents with no history of dysphoria, the odds ratio for MI associated with a history of dysphoria was 2.07 (95% CI, 1.16 to 3.71), and the odds ratio associated with a history of major depressive episode was 4.54 (95% CI, 1.65 to 12.44), independent of coronary risk factors. In multivariate models, use of barbiturates, meprobamates, phenothiazines, and lithium was associated with an increased risk of MI, whereas use of tricyclic antidepressants and benzodiazepines was not. Among individuals with no history of dysphoria, only lithium use was significantly associated with MI. CONCLUSIONS These data suggest that a history of dysphoria and a major depressive episode increase the risk of MI. The association between psychotropic medication use and MI is probably a reflection of the primary relationship between depression and MI.

The acceptability of treatment for depression among African-American, hispanic, and white primary care patients

Background. Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. Methods. A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. Results. African Americans (adjusted OR, 0.30; 95% CI 0.19–0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26–0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35–1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08–9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. Conclusions. African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients’ cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Depression and Risk for Onset of Type II Diabetes: A prospective population-based study

OBJECTIVE To determine whether depression is associated with an increased risk for onset of diabetes. RESEARCH DESIGN AND METHODS In 1981, a total of 3,481 household-residing adults participated in the Epidemiologic Catchment Area (ECA) Program survey at the East Baltimore site. A follow-up of that cohort after 13 years completed 1,897 interviews, amounting to >72% of survivors. In 1981, depression was assessed with the National Institutes of Mental Health (NIMH) Diagnostic Interview Schedule and diabetes, by self-report. This prospective analysis focused on subjects at risk for onset of diabetes by removing from the analysis individuals with diabetes in 1981. RESULTS There were 89 new cases of diabetes among 1,715 individuals at risk, yielding a 13-year cumulative incidence of diabetes of 5.2%. In logistic models, major depressive disorder, but not milder forms of depression or other forms of psychiatric disorder, predicted the onset of diabetes (estimated relative risk, 2.23; 95% CI 0.90–5.55). Controlling for age, race, sex, socioeconomic status, education, use of health services, other psychiatric disorders, and body weight did not weaken the relationship. CONCLUSIONS Major depressive disorder signals increased risk for onset of type II diabetes. Limitations of the findings arise from the difficulty in determining temporal order with two chronic conditions, even when the temporal order of measurement is clear. In addition, even though control variables were introduced for the use of health services, it is possible that the treatment for depression led to an earlier diagnosis of diabetes in this sample.

Depression without sadness: Functional outcomes of nondysphoric depression in later life

OBJECTIVES: We hypothesized that depressive symptoms not meeting full standard criteria for Major Depression would be associated with significant functional impairment among older adults over the course of a 13‐year follow‐up interval. Specifically, we developed criteria for a form of depression whose core symptoms did not include sadness or dysphoria.

Mental health service utilization by African Americans and whites: The Baltimore Epidemiologic Catchment Area Follow-Up

OBJECTIVE To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s. DESIGN Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996. SETTING The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up. SUBJECTS Subjects included 1,662 adults (590 African Americans and 1,072 whites). MAIN OUTCOME VARIABLE Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview. RESULTS In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites. CONCLUSIONS Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.

Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland

BACKGROUND Utilizing a prospectively designed community sample, we set out to estimate the rate of newly-incident suicidal ideation and attempts (non-fatal suicide behaviour) in a community sample, to evaluate antecedent sociodemographic characteristics and psychiatric disorders, and to assess use of mental health services in relation to non-fatal suicide behaviour. METHOD Prospectively-gathered data was utilized from 3481 continuing participants in the 13-year follow-up of the Baltimore sample of the NIMH Epidemiologic Catchment Area survey interviewed in 1981, 1982 and 1993/6. RESULTS The incidence of suicide attempts was estimated at 148.8 per 100,000 person-years and ideation at 419.9 per 100,000 person-years. Persons in the youngest age group, in the lowest socioeconomic status, and previously married persons were at increased risk for non-fatal suicide behaviour during the follow-up interval. Persons who reported suicidal ideation at baseline were more likely to report having attempted suicide at follow-up (RR = 6.09, 95% CI 2.58-14.36). Psychiatric disorders, especially depression and substance abuse, were associated with new-onset of non-fatal suicidal behaviour. While persons who reported newly-incident suicidal behaviour were more likely to report use of mental health services, few said that suicidal ideation or attempts were the reason for the visits. CONCLUSIONS Suicidal ideation is a common and important antecedent to suicide attempts and deserves more attention in community and general medical settings.

Filters on the pathway to mental health care, II. Sociodemographic factors

This study uses the prospectively gathered data of the Epidemiologic Catchment Area Program, a multi-site interview survey of mental disturbances among adult household residents in the United States, to compare health services use by individuals with different sociodemographic characteristics, accounting for the first-time occurrence of psychiatric disorder, over the course of a 1-year follow-up interval. Case ascertainment was by means of a standardized interview method, the Diagnostic Interview Schedule. In the present investigation, 13,400 continuing participants in the household sample who reported no contact with mental health services in the 6 months prior to the initial interview were studied with regard to health services use and sociodemographic characteristics. Separately, and before the mental health assessments were made, respondents were asked about their use of health and mental health services. African-Americans were significantly less likely than whites to have consulted with a specialist in mental health (estimated relative odds, 0.22, 95% confidence interval 0.10 to 0.52), even accounting for coincident psychiatric disorder, gender, and other covariates known to be associated with differential use of health care services. Hispanics and other minorities were also less likely to have consulted a specialist in mental health (estimated relative odds, 0.37 and 0.26, respectively). This large community study extends previous work on mental health services and ethnicity.

Suicidal and Death Ideation in Older Primary Care Patients With Depression, Anxiety, and At-Risk Alcohol Use

The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race.

The driving habits of adults aged 60 years and older

OBJECTIVES: We describe the driving habits of adults aged 60 years and older who were interviewed in the context of a community survey focused on mental disturbances. Our goal was to identify clinical cues that might signal driving difficulty in older adults who might present to the primary care physician for health care.

Hopelessness, depression, substance disorder, and suicidality--a 13-year community-based study.

Most earlier studies of hopelessness as a risk factor for suicidal behavior were based on either clinical or restricted samples. Using a longitudinal study design with a community sample of more than 3,000 participants, we aimed to examine if hopelessness was a long-term predictor of suicidal behaviors. Using longitudinal data from the Baltimore Epidemiologic Catchment Area (ECA) Program, we assessed the association of hopelessness at baseline and incident suicidal behaviors in the 13-year follow-up period, adjusting for the presence of depression and substance use disorders. Suicide behaviors studied included completed suicide, self-reported attempted suicide, and suicide ideation. Hopelessness was predictive of all three types of suicidal behaviors in the follow-up period, even after adjustment. Persons who expressed hopelessness in 1981 were 11.2 times as likely to have completed suicide over the 13-year follow-up interval (95% confidence interval [1.8, 69.1]). The association between suicidality and hopelessness was stronger and more stable than the association of suicidality with the presence of depression and substance use disorders. Hopelessness was an independent risk factor for completed suicide, suicide attempts, and suicidal ideation. Intervention strategies that lower hopelessness may be effective for suicide prevention.