Lawson R. Wulsin

A systematic review of the mortality of depression.

OBJECTIVE The literature on the mortality of depression was assessed with respect to five issues: 1) strength of evidence for increased mortality, 2) controlling for mediating factors, 3) the contribution of suicide, 4) variation across sample types, and 5) possible mechanisms. METHOD All relevant English language databases from 1966 to 1996 were searched for reviews and studies that included 1) a formal assessment of depressive symptoms or disorders, 2) death rates or risks, and 3) an appropriate comparison group. RESULTS There were 57 studies found; 29 (51%) were positive, 13 (23%) negative, and 15 (26%) mixed. Twenty-one studies (37%) ranked among the better studies on the strength of evidence scale used in this study, but there are too few comparable, well-controlled studies to provide a sound estimate of the mortality risk associated with depression. Only six studies controlled for more than one of the four major mediating factors. Suicide accounted for less than 20% of the deaths in psychiatric samples, and less than 1% in medical and community samples. Depression seems to increase the risk of death by cardiovascular disease, especially in men, but depression does not seem to increase the risk of death by cancer. Variability in methods prevents a more rigorous meta-analysis of risk. CONCLUSION The studies linking depression to early death are poorly controlled, but they suggest that depression substantially increases the risk of death, especially death by unnatural causes and cardiovascular disease. Future well-controlled studies of high risk groups may guide efforts to develop treatments that reduce the mortality risk of depression.

Depressive symptoms, coronary heart disease, and overall mortality in the framingham heart study

Objective: Although a substantial number of studies have shown that depressive symptoms predict worse cardiac outcome for patients with existing coronary disease, relatively few methodologically rigorous studies have examined the relation of depressive symptoms to coronary disease incidence in individuals initially free of heart disease in the community. Methods: Using multivariable-adjusted sex-stratified Cox proportional hazards regression, we examined the association between depressive symptoms and incident coronary disease and all-cause mortality in 3634 Framingham Heart Study original and offspring cohort participants (mean age 52 years, 55% women) attending a routine study examination between 1983 and 1994. Results: Over 6 years of follow-up, 83 participants had a hard coronary heart disease event (myocardial infarction or coronary death), and 133 died. Depressive symptoms (Center for Epidemiologic Studies Depression Scale (CES-D) ≥16) did not predict hard coronary disease events. All-cause mortality, however, was directly associated with depressive symptoms. Compared with the lowest tertile of CES-D score, multivariable-adjusted risks of death in the second and third tertiles were 33% and 88% higher, respectively (hazards ratio per tertile increment = 1.37, 95% confidence interval 1.10–1.71, p for trend = 0.005). Conclusion: These findings underscore the importance of further research into the pathogenesis and prevention of excess mortality experienced with depressive symptoms. 95% CI = 95% confidence interval; BMI = body mass index; CES-D = Center for Epidemiologic Studies Depression Scale; CHD = coronary heart disease; RR = relative risk.

Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain

Objective: 1) To determine whether the frequencies of panic disorder (PD) and depression (DEP) in an emergency department (ED) population were comparable to those in other primary care groups; 2) to evaluate whether patients without the clinical diagnosis of acute cardiac ischemia (ACI) had higher frequencies of these disorders; and 3) to identify characteristic clinical findings in patients with PD or DEP.Setting: An urban teaching hospital ED.Patients: Three hundred thirty-four patients with acute chest pain were evaluated prospectively over an eight-week period. The cohort participating (69%—229/334) completed psychiatric screening measures, including the Panic Disorder Self-Rating Scale, the Beck Depression Inventory, and the Zung Self-Rating Anxiety Scale.Measurements and main results: A symptom profile consistent with PD was identified in 17.5% of the patients (40/229), DEP in 23.1% (53/229), and either disorder in 35% (80/229). The prevalences of PD were similar in those with and without ACI (19.4% vs 16.6%, respectively, p>0.05). The likelihoods of one or more ED visits for chest pain in the previous year were significantly greater in those with PD (57.5% vs 36%, p<0.05) and DEP (54% vs 35%, p<0.05) than in those without these psychiatric disorders.Conclusion: This study suggests that approximately one in three patients presenting to the ED with acute pain has symptoms consistent with a psychiatric disorder. These disorders occur frequently in both those with and those without acute cardiac ischemia, and clinical variables may help identify these frequent ED utilizers.

Risk of Cerebrovascular Events Associated with Antidepressant Use in Patients with Depression: A Population-Based, Nested Case-Control Study:

Background: Given the widespread use of antidepressants and the negative consequence of cerebrovascular events (CVEs), an evaluation of the risk of CVEs associated with antidepressants is warranted. Objective: To examine the association between the use of an antidepressant and risk of CVEs among patients diagnosed with depression. Methods: A case-control study was performed using a managed care medical claims database from 1998 through 2002. A total of 1086 cases with CVEs were identified and matched with 6515 controls by age, sex, and the year ol the index date of depression Case patients were categorized by stroke type: hemorrhagic stroke, ischemic stroke, and other CVEs. Diagnoses of depression, CVEs, and other medical comorbidities were identified based on International Classification of Diseases, Ninth Revision, codes. Patients were defined as current users (antidepressant ended ≤30 days before CVE). recent users (31–60 days before CVE), past users {61–90 days before CVE), and remote/nonusers (≥91 days before CVE or nonuse). Cox proportional hazards regression analysis was conducted to estimate the risk of CVEs associated with antidepressant use. Results: A 24% increased risk of a CVE was noted in patients with current exposure to selective serotonin-reuptake inhibitors (SSRIs; adjusted hazard ratio [HR) 1.24; 95% CI 1.07 to 1.44), 34% increased risk for current exposure to tricyclic antidepressants (HR 1.34; 95% CI 1.10 to 1.62), and 43% increased risk for current exposure toother antidepressants (HR 1.43; 95% CI 1.21 to 1.69). The risk of ischemic stroke in current SSRI users was significantly higher (HR 1.55; 95% CI 1.00 to 2.39) compared with remote/nonusers. Conclusions: Current users of antidepressants may be at increased risk of a CVE. Clinicians should consider the relationship of antidepressants with the occurrence of CVEs when determining the risk-benefit profile of pharmacologic treatment in patients with depression, particularly those with existing risk factors for a CVE.

Somatic symptom disorder: An important change in DSM

This paper describes the rationale for the new diagnosis of somatic symptom disorder (SSD) within DSM5. SSD represents a consolidation of a number of previously listed diagnoses. It deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms. Data are presented concerning reliability, validity, and prevalence of SSD, as well as tasks for future research, education, and clinical practice.

Is Depression a Major Risk Factor for Coronary Disease? A Systematic Review of the Epidemiologic Evidence

&NA; My objective is to examine systematically the status of the current evidence for and against depression as an independent major risk factor for coronary disease. From English‐language reports on depression and coronary disease in MEDLINE (1966–2002) and PsycINFO (1967–2002), and from informal searches, I selected all studies that addressed the specific questions related to the established criteria for risk‐factor status: (1) strength of association, (2) prediction, (3) specificity, (4) consistency, (5) dose‐response effect, (6) biological plausibility, and (7) response to treatment. I find that the evidence for depression as a coronary disease risk factor is good for four criteria: strength of association, prediction, consistency, and dose‐response effect. The evidence on specificity and biological plausibility is fair. Due to the lack of definitive studies, there is currently insufficient evidence for cardiac risk reduction in response to treatment for depression. My conclusion is that the evidence for depressions role as an independent major risk factor for coronary disease is good in four areas, but not yet conclusive in three, pointing to the need for three types of studies: (1) prospective, observational studies that address specificity questions, (2) studies of biological mechanisms linking depression and coronary disease, and (3) clinical trials of treatments for depression in people with coronary disease or at high risk for developing coronary disease.

Screening emergency room patients with atypical chest pain for depression and panic disorder.

In response to recent reports relating atypical chest pain to normal coronary arteries and to various types of psychopathology, we developed a pilot study to investigate 1) the prevalence of depression and panic disorder among patients presenting to an emergency room with atypical chest pain, and 2) what the likelihood is of an emergency room physician recognizing the psychosocial factor. Of forty-nine subjects screened, 39 percent scored positively for depressive syndrome on the Center for Epidemiological Studies-Depression rating scale, 43 percent met criteria for panic attack and 16 percent met criteria for panic disorder by DSM-III. Although thirty subjects (61%) screened positively for depression or panic attack, only one received a psychiatric diagnosis of any kind. This pilot study suggests: 1) that the relationship between chest pain and psychopathology in emergency room patients deserves further rigorous study; 2) that depression and panic attacks in association with atypical chest pain may be underdiagnosed by the emergency room physician; and 3) that self-report screening measures as an aid to diagnosis in this population need to be more closely investigated.

An Open-Label Pilot Study of Methylphenidate in the Treatment of Cocaine Dependent Patients with Adult Attention Deficit/ Hyperactivity Disorder

Abstract A multi-site, open-label study of methylphenidate for treating patients with comorbid diagnoses of attention deficit/hyperactivity disorder and cocaine dependence was performed. Forty-one participants, who met DSM-IV criteria for adult attention deficit/hyperactivity disorder and cocaine dependence, were enrolled into this ten week outpatient study. The targeted total daily dose of methylphenidate was 60 mg (20 mg TID). Participants received individual substance abuse therapy throughout the trial. Safety measures included adverse events, vital signs, and electrocardiograms. Methylphenidates efficacy was assessed by both objective and subjective measures. Seventy percent of the participants completed final study measures. Safety measures indicated that methylphenidate was well tolerated by the participants. Subjective efficacy measures suggested that participants evidenced improvement in both cocaine dependence and adult attention deficit/hyperactivity disorder symptoms. Quantitative benzoylecgonine indicated that only those participants categorized as being compliant showed improvement. A double-blind, placebo-controlled study of methylphenidate for this population may be warranted.

Axis I Disorders in Er Patients with Atypical Chest Pain

To examine the contribution of psychopathology to emergency room (ER) visits for atypical chest pain, we administered two screening measures and the Structured Clinical Interview for DSM III-R (SCID) to thirty-five subjects within seventy-two hours of their ER visit. Follow-up SCID interviews were completed in thirty subjects at five to twelve months. Sixty percent of the sample had an initial Axis I diagnosis, predominately affective (34%) and anxiety (46%) disorders. Forty percent had multiple diagnoses initially. The most common diagnoses were panic disorder (31%) and major depression (23%). At follow-up 47 percent had Axis I diagnoses, 30 percent had multiple diagnoses, with only slightly decreased rates for panic disorder (27%) and major depression (17%). Many subjects had lost, gained, or switched diagnoses by follow-up, in spite of one consistent rater and a few subjects seeking treatment. ER physicians often do not recognize these psychiatric disorders in chest pain patients. The high risk of suicide in panic disorder and depression, and the high cost of disability in recurrent chest pain make it essential that ER physicians include these disorders in the differential of atypical chest pain.

Psychosocial Aspects of Diabetic Retinopathy

Diabetic retinopathy, particularly in the more advanced stages, poses many difficult psychosocial problems and demands major adjustments by the patient. Our review of this literature has identified specific problems relevant to patient care, future research, and public policy. For example, proliferative retinopathy often leads to at least partial visual impairment, psychiatric symptoms, and difficulties with glycemic control. Partial visual impairment appears to cause as much psychosocial disruption as severe blindness. This suggests that most rehabilitation programs that serve the legally blind may come too late in the course of this illness. This review emphasizes the paucity of past research on psychosocial aspects of diabetic retinopathy and raises some questions for future research.