Ralph Swindle

Life stressors, social resources, coping, and the 4-year course of unipolar depression.

Little is known about the effects of psychosocial factors on the long-term course of unipolar depression. This article examines the 4-year stability and change in life stressors, social resources, and coping, and their effect on the course of treated unipolar depression among 352 men and women. Depressed patients were assessed at treatment intake and at 1-year and 4-year follow-ups. Over the 4 years, patients improved in symptom outcomes, the quality of social resources, and coping responses; there were some declines in life stressors. Life stressors, social resources, and coping were related to patient functioning concurrently, after controlling for demographics, initial treatment, and initial dysfunction severity. Preintake medical conditions and family conflict consistently predicted poorer long-term outcomes. The findings imply that medical conditions and family conflict are important risk factors that predict poorer long-term outcome of depression.

A Symptom Checklist to Screen for Somatoform Disorders in Primary Care

Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.

Validation of the Adult Attention-Deficit/Hyperactivity Disorder Quality-of-Life Scale (AAQoL): A Disease-Specific Quality-of-Life Measure

Introduction: A growing body of evidence suggests that symptoms of attention-deficit/hyperactivity disorder (ADHD) persist into adulthood and are associated with ongoing impairment and co-morbidity. The absence of a conceptually sound and well-validated ADHD-specific quality-of-life measure has been an obstacle to understanding this impact. To address this gap, the Adult ADHD Quality-of-Life Scale (AAQoL) was developed based on well accepted methods for designing patient reported outcomes. The purpose of this study was to validate the AAQoL. Methods: Nine Hundred and Eighty Nine adults in a retrospective cohort study were administered the AAQoL and psychometric validation was conducted according to an a priori statistical analysis plan. Results: A 29-item AAQoL was found to have robust scale structure with four domains: Life Productivity, Psychological Health, Relationships and Life outlook. Internal consistency was adequate (0.93 for overall, 0.75–0.93 for subscales), and construct and known-groups validity were supported. Conclusion: The AAQoL appears to be a valid measure of quality of life for adults with ADHD and can be considered for incorporation into future studies. The ability to quantify the quality-of-life consequences of adult ADHD should facilitate future research, assist clinicians in identifying appropriate treatment targets and contribute to the ultimate goal of improving the well-being and functioning of adults with ADHD.

Efficacy of duloxetine and selective serotonin reuptake inhibitors: comparisons as assessed by remission rates in patients with major depressive disorder.

It has been proposed that serotonin and norepinephrine reuptake inhibitors (SNRIs) may result in higher remission rates of major depressive disorder than therapy with selective serotonin reuptake inhibitors (SSRIs). To test this hypothesis, a meta-analysis of individual patient data (N = 1833) was performed for the complete set of 6 phase II/III studies that compared duloxetine (fixed doses; range, 40-120 mg/d) with 2 SSRIs (paroxetine or fluoxetine; 20 mg/d) in outpatients with major depressive disorder. Remission was defined as an end point score of less than or equal to 7 on the 17-item Hamilton Rating Scale for Depression (HAMD17); alternate outcome criteria were also examined, as were remission rates among the 1044 patients with moderate-to-severe depression (HAMD17 total score greater than or equal to 19). The HAMD17 remission rates were 40.3% (351/871), 38.3% (162/423), and 28.4% (144/507) for duloxetine, the 2 SSRIs, and placebo, respectively. Both active treatments were superior to placebo; the difference between duloxetine and SSRIs was not statistically significant. Similar findings were observed for alternate outcomes. Duloxetine therapy was significantly more effective than therapy with the 2 SSRIs for patients with more severe depression, with remission rates of 35.9% (183/510) versus 28.6% (70/245) (P = 0.046). A secondary analysis of dose-response relationships indicated that this advantage was not attributable to the studies using higher doses of duloxetine. Thus, whereas duloxetine and the 2 SSRIs were comparably efficacious overall, therapy with the serotonin and norepinephrine reuptake inhibitor resulted in a significantly higher remission rate among patients with moderate-to-severe depression.

Severity of premenstrual symptoms in a health maintenance organization population.

OBJECTIVE To describe severity of emotional and physical symptoms in a large diverse sample; to examine demographic, health status, and behavioral correlates of symptom severity; and to describe use of medications and alternative remedies for premenstrual symptoms. METHODS A total of 1194 women, ages 21–45, selected from members of a large northern California health maintenance organization, completed daily ratings of symptom severity for two menstrual cycles. An empirically derived algorithm defined symptom severity groups as minimal (n = 186), moderate (n = 801), severe (n = 151), or premenstrual dysphoric disorder (n = 56). Symptom severity as a continuous variable was defined by the two‐cycle mean symptom ratings in the luteal phase. Demographic, health status, and behavioral factors and use of treatments for premenstrual symptoms were assessed by self‐report. RESULTS Luteal phase symptom‐specific ratings were generally significantly greater in the premenstrual dysphoric disorder group than in the other groups (P < .001). Symptom severity score increased with each comorbidity and decreased with each year of age. Symptom severity was also inversely associated with oral contraceptive use (emotional symptoms) and better perceived health (physical symptoms). Hispanics reported greater severity of symptoms, and Asians less, relative to whites. Use of herbal and nutritional supplements for premenstrual symptoms steadily increased from 10.8% in the minimal group to 30.4% in the premenstrual dysphoric disorder group (P < .01). CONCLUSION The degree of premenstrual symptom severity varies in the population, is relatively constant within each woman over two consecutive cycles, particularly for emotional symptoms, and is influenced by age, race/ethnicity, and health status.

The Psychological and Interpersonal Relationship Scales: Assessing psychological and relationship outcomes associated with erectile dysfunction and its treatment

Erectile dysfunction (ED) is associated with complex psychological and interpersonal issues. A new measure of treatment outcome, the Psychological and Interpersonal Relationship Scales (PAIRS), was developed to evaluate the broader psychological and interpersonal outcomes associated with erectile dysfunction and its treatment. Initial items were generated based on literature review, focus groups and market research, interviews with patients and partners, and consultation with expert clinicians. Domains of Sexual Self-Confidence, Spontaneity, and Time Concerns were identified and subsequently confirmed by factor analysis. A series of validation studies was performed with four separate samples, including assessment of internal consistency and test-retest reliability, convergent and discriminant validity, and treatment responsiveness. Samples for these studies included men recruited from clinical trials for ED in several countries (N =413) and a community sample (N =801). Findings from these studies indicate that PAIRS demonstrates adequate psychometric properties and appears well suited for use in further clinical studies of treatments for ED. It provides a broader assessment of treatment outcome than current measures of erectile function.

Life circumstances and personal resources as predictors of the ten-year course of depression.

A 10-year naturalistic study of 313 patients who entered treatment for unipolar depression and a community comparison group of 284 nondepressed adults was conducted. We compared life stressors, social resources, personal resources, and coping among patients who were remitted (N = 76), partially remitted (N = 146), or nonremitted (N = 91). Compared with the controls and the remitted patients, the partially remitted and nonremitted patients consistently experienced more life stressors and fewer social resources, were less easygoing, and relied more on avoidance coping. A less easygoing disposition, fewer close relationships, and more reliance on avoidance coping were associated with higher odds of experiencing a course of partial remission or nonremission. In addition, more depressive symptoms and medical conditions predicted nonremission.

Responses to nervous breakdowns in America over a 40-year period. Mental health policy implications.

The 1957 and 1976 Americans View Their Mental Health surveys from the Institute of Social Research were partially replicated in the 1996 General Social Survey (GSS) to examine the policy implications of peoples responses to feeling an impending nervous breakdown. Questions about problems in modern living were added to the GSS to provide a profile of the publics view of mental health problems. Results were compared for 1957, 1976, and 1996. In 1957, 19% of respondents had experienced an impending nervous breakdown; in 1996, 26% had had this experience. Between 1957 and 1996, participants increased their use of informal social supports, decreased their use of physicians, and increased their use of nonmedical mental health professionals. These findings support policies that strengthen informal support seeking and access to effective psychosocial treatments rather than current mental health reimbursement practices, which emphasize the role of primary care physicians.

PREMENSTRUAL SYMPTOM SEVERITY: IMPACT ON SOCIAL FUNCTIONING AND TREATMENT SEEKING BEHAVIORS

Our purpose was to understand premenstrual symptomatology and treatment-seeking behaviors by examining three subjective measurement approaches for premenstrual syndrome (PMS), their relationship to social functioning interference, and the role of symptom severity in a broader model of help seeking for PMS. Cross-sectional data were obtained from 1022 mail survey respondents who were derived from a nationally representative random sample of women, aged 18-49, experiencing regular menstrual cycles. Statistical analyses included Pearson correlations, chi-square tests, t tests, and logistic regression. The three symptom severity measures (a global self-appraisal, summative symptom counting, and categorical-configural) were strongly intercorrelated, ranging from .60 to .78 (p < 0.001), and were correlated with interference in social and occupational functioning domains, ranging from .44 to .77 (all p < 0.001). A global self-report measure identified 4.9% of women with severe symptoms, whereas a DSM-IV-adapted ...

Measuring substance abuse program treatment orientations: The drug and alcohol program treatment inventory

Abstract Assessment of therapeutic orientation is a significant problem in substance abuse program evaluation. This study reports the initial results of a new approach to measuring treatment orientation through a self-report survey that focuses on distinctive features of substance abuse treatment orientations. The Drug and Alcohol Program Treatment Inventory (DAPTI) assesses treatment goals and activities specific to eight orientations: AA/12 Step, Therapeutic Community, Cognitive-Behavioral, Insight/Psychodynamic, Rehabilitation, Dual Diagnosis, Medical, and Marital/Family Systems. We present findings from a nationwide assessment of 327 Veterans Administration (VA) Substance Abuse treatment programs that demonstrate promising subscale internal consistency, discriminant validity, and concurrent validity. In addition, the DAPTI distinguishes between programs with independently verified orientations and between inpatient, extended care, outpatient, and methadone maintenance programs. The DAPTI may be helpful in systematically assessing differences in treatment orientations between different types of programs, such as inpatient, community residential, and outpatient care.