Laura Portera

Assessing psychiatric impairment in primary care with the Sheehan Disability Scale

Objective: Several recent studies have documented that substantial functional impairment is associated with many of the mental disorders seen in primary care. However, brief measures of mental health-related functional impairment are not commonly applied in primary care settings. The Sheehan Disability Scale (SDS), a three-item instrument for assessing such impairment, is evaluated in this study. Method: A psychometric analysis of the SDS was conducted with a sample of 1001 primary care patients at Kaiser Permanente in Oakland, California. The SDS and the Symptom Driven Diagnostic System for Primary Care assessments were completed. Results: The internal consistency reliability of the SDS is high, with coefficient alpha of 0.89. The construct validity was substantiated in two ways. A one-factor model fit the data quite well. Furthermore, patients with each of six psychiatric disorders had significantly higher impairment scores than those who did not. Finally, over 80 percent of the patients with mental disorder diagnoses had an elevated SDS score and nearly 50 percent of those with elevated SDS scores had at least one disorder. Conclusions: The psychometric properties of the SDS were evaluated in primary care. The internal consistency reliability was high. The analyses also lend empirical support for the construct validity. The scale is a sensitive tool for identifying primary care patients with mental health-related functional impairment, who would warrant a diagnostically-oriented mental health assessment.

Assessing impairment in patients with panic disorder: the Sheehan Disability Scale.

SummaryThe DSM-III-R incorporates both distress (symptoms) and disability (impairment) in the definition of a psychiatric disorder. In psychiatric research there is a wide array of instruments used to measure symptom severity, but a limited selection for the assessment of impairment. The psychometric properties of one such instrument, The Sheehan Disability Scale (Sheehan 1983), are evaluated in this paper. The data analyzed come from two studies of patients with panic disorder, the Cross National Collaborative Panic Study-Phase I and the Panic Depression Study. In this report both the alpha coefficients and factor analyses indicate that the reliability of the scale is acceptable. The factor structure of the items and the sensitivity to change of their composite demonstrate satisfactory construct validity. The criterion-related validity is substantiated by the significant relationship between symptomatology and impairment. These analyses were limited to patients with panic disorder. Further work is needed to evaluate the instrument in assessing patients with other disorders.

Childhood abuse and subsequent sexual assault among female inpatients

The relationship between a history of childhood abuse and subsequent sexual assault was assessed among 409 consecutive female inpatient admissions. A total of 45% of the sample reported a history of some form of childhood abuse and 22% reported at least one adulthood sexual assault. A hierarchical logistic regression indicated that, after controlling for sociodemographic and diagnostic variables, women with a history of childhood abuse were 3.1 times more likely to have experienced an adult sexual assault compared to those without abuse. There was a higher prevalence of adult sexual assault among women reporting only physical abuse or physical and sexual abuse than those reporting only sexual abuse, indicating the significance of physical abuse as a potential risk factor for adult sexual assault.

Fatal Injuries after Cocaine Use as a Leading Cause of Death among Young Adults in New York City

BACKGROUND Cocaine intoxication can lead to fatal cardiovascular and cerebrovascular events. In addition, the neurobehavioral effects of cocaine may increase the likelihood that a user will receive violent fatal injuries. Since New York City is a center for the importation and distribution of cocaine, we sought to determine the extent of cocaine use among city residents with fatal injuries. METHODS Among a total of 14,843 residents of New York City who received fatal injuries from 1990 through 1992, we determined the proportion who used cocaine shortly before their deaths. We also determined the population-based rates of fatal injuries that were known to follow cocaine use and the proportion of all deaths of New York City residents that was represented by these cases for each demographic stratum. For adults 15 to 44 years of age, fatal injury after cocaine use was ranked with other causes of death as though it was a separate cause. RESULTS Cocaine use, as measured by the detection of the metabolite benzoylecgonine in urine or blood, was found in 26.7 percent of all New York City residents receiving fatal injuries; free cocaine was detected in 18.3 percent. Approximately one third of deaths after cocaine use were the result of drug intoxication, but two thirds involved traumatic injuries resulting from homicides, suicides, traffic accidents, and falls. If fatal injury after cocaine use was considered as a separate cause of death, it would rank among the five leading causes of death among those 15 to 44 years of age in New York City. CONCLUSIONS Fatal injuries among cocaine users account for a substantial proportion of all deaths among young adults in New York City.

Childhood trauma as a correlate of lifetime opiate use in psychiatric patients.

Associations have been reported between childhood sexual and/or physical abuse and adult substance abuse in general. This study investigated the relationship between childhood abuse and opiate use in particular among 763 consecutively admitted psychiatric inpatients. Patients were interviewed about demographic information, alcohol and drug use, and history of interpersonal violence. Opiate users were 2.7 times more likely to have a history of childhood sexual and/or physical abuse than nonopiate users, after controlling for diagnostic and sociodemographic variables. Opiate use was higher among those reporting physical abuse alone (24.1%) or both physical and sexual abuse (27%) than among those reporting sexual abuse alone (8.8%). Implications of these findings are discussed.

Correlates of suicidal ideation in dysphoric mania

BACKGROUND Previous investigations have reported that suicidal ideation and behavior are more prevalent during mixed than pure mania. Uncertainties exist about whether suicidality in mania arises from multiple concurrent depressive symptoms, or rather, as a categorical phenomenon, reflecting dysphoria without necessarily a full major depression. To elucidate the relationship between suicidal ideation and dysphoric mania, we analyzed clinical and demographic features associated with suicidal versus nonsuicidal dysphoric manic inpatients. METHODS Records were reviewed for 100 DSM-III-R bipolar I manic inpatients at the Payne Whitney Clinic of New York Hospital from 1991-1995. All had > or = 2 concomitant depressive symptoms (other than suicidality). Affective and psychotic symptoms, past suicide attempts, prior illness, and related clinical/demographic variables were assessed by a standardized protocol. RESULTS Suicidal ideation was significantly more common among dysphoric manics who were caucasian, took antidepressant medications in the week prior to admission, had histories of alcohol abuse/dependence, and made past suicide attempts. Suicidal ideation was evident for nearly half of dysphoric manic patients with < or = 3 depressive symptoms who did not meet DSM criteria for a mixed state. No individual manic or depressive symptoms other than dysphoric mood were more common among suicidal than nonsuicidal patients. LIMITATIONS Findings from this retrospective study require confirmation using a prospective assessment. Treatments were naturalistic and may have differentially influenced hospital course and illness characteristics. Factors related to suicide attempts (rare in this cohort) or completions (not a focus of this study) may differ from those related only to suicidal ideation. CONCLUSIONS Caucasian dysphoric manic patients with past suicide attempts and substance abuse may have a significantly elevated risk for suicidality, even when full major depression does not accompany mania. Suicidality is a clinically important consideration in a majority of dysphoric manic patients.

Increase in suicide by asphyxiation in New York City after the publication of Final Exit

Coverage of suicides in the news media has been linked with a subsequent increase in suicides,1,2 but there has been some controversy about these studies3. Recently, Dr. Jack Kevorkian and others w...

A brief screen for panic disorder

Abstract Panic disorder is associated with excessive social morbidity and financial burden. Delay in its diagnosis is a serious problem confronting the health care system. Screening instruments can be used to alert clinicians to the presence of an illness. In the current study, 143 patients presenting to an outpatient anxiety disorders clinic completed both self-report scales and a structured clinical interview. The 16-item Anxiety Sensitivity Index (ASI) selectively discriminates panic disorder subjects from subjects with other anxiety disorders in an anxiety clinic population. Further analyses demonstrate that a scale composed of merely four ASI items also discriminates panic disorder patients with equal sensivity and specificity to the overall instrument. This new composite scale, named Brief Panic Disorder Screen (BPDS), will allow rapid identification of those patients who may benefit from more extensive evaluation for the presence of panic disorder.

Poverty and Fatal Accidental Drug Overdoses of Cocaine and Opiates in New York City: An Ecological Study

This ecological study examines the association of the poverty status of urban communities in New York City with their mortality rates of accidental drug overdoses. Mean annual age-adjusted rates of drug overdoses involving cocaine, opiates, or both (n = 1,684) were calculated for each of 59 residential community districts in New York City for 1990-1992. A linear regression analysis was performed to test the association of the mortality rate with the poverty status of the district as measured by the proportion of the district living below the 1989 U.S. poverty line. Poverty status accounted for 69% of the variance in the drug overdose mortality rates of communities (p < .001). This study suggests that mortality rates of overdoses involving cocaine and optiates are significantly associated with the poverty status of communities in New York City.

Psychiatric Symptomsc, Functional Impairment, and Receptivity toward Mental Health Treatment among Obstetrical Patients

Objective: To examine psychiatric symptomatology and associated functional impairment among pregnant women; and to examine the obstetrical patients receptivity to discussion of and intervention regarding emotional distress. Methods: Fifty-seven patients 16 weeks or less pregnant presenting for routine obstetrical appointments at a faculty practice at a major medical center participated in this study. Each completed a self-administered assessment packet regarding psychopathology, functional impairment and service utilization attitudes. Statistical analyses were performed using chi-square and Mann-Whitney tests. Results: Seventeen subjects (29.8 percent) screened positive for at least one anxiety disorder. Fourteen of those subjects also screened positive for depression. Those with positive screens for either anxiety and/or depression had significantly higher levels of functional impairment. Only five (29.4 percent) of the 17 subjects with positive screens reported having discussed an emotional issue with their Ob/Gyn, although 14 (82.4 percent) said that they would be willing to do so. All subjects (100 percent) reported that they would see a mental health professional if their Ob/Gyn referred them. Conclusion: Routine screens for mental disorders in early pregnancy appear to be a useful adjunct in an obstetrical setting. Although most had never discussed their emotional concerns with their Ob/Gyn, a substantial proportion of our study sample reported psychiatric symptomatology and significant levels of functional impairment that had not been recognized by their Ob/Gyn. All of the patients in our study sample reported a willingness to see a mental health professional if their Ob/Gyn referred them. Further studies investigating the benefits of antenatal diagnosis and treatment of psychiatric disorders are warranted.