Stephanie von Ammon Cavanaugh

Diagnosing depression in the hospitalized medically ill

Abstract The Beck Depression Inventory (BDI) was administered to 335 medically ill inpatients, 101 patients with major depression, and 101 normal controls to determine which of its items discriminate depression in the medically ill. Seven affective/cognitive items best discriminated depressive severity in this population: feeling like a failure, loss of interest in people, feeling punished, suicidal ideation, dissatisfaction, difficulty with decisions, and crying. The severity but not the number of somatic symptoms increased with the severity of depression. The author concludes that the BDI is useful in screening for depression in the medically ill.

Depression in the Medically Ill: Critical Issues in Diagnostic Assessment

Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed.

The prevalence of emotional and cognitive dysfunction in a general medical population: Using the MMSE, GHQ, and BDI

The Mini Mental Status Examination, General Health Questionnaire-30, and Beck Depression Inventory were administered to 335 randomly selected hospitalized medical patients. Twenty-eight percent of the population had evidence of cognitive dysfunction on the Mini Mental Status Examination, 61% showed emotional dysfunction on the General Health Questionnaire-30, and 36% were depressed as measured by the Beck Depression Inventory. Only 29% of the patients had no evidence of emotional or cognitive dysfunction. Medical resident diagnostic concordance with these tests was poor. The effects of demographic variables on these test scores were also determined.

The core symptoms of depression in medical and psychiatric patients.

The internal consistency of the Beck Depression Inventory (BDI) is assessed in 335 randomly selected medical inpatients, and in another sample of 101 depressed psychiatric inpatients with 104 interviewed normals. The data for the two samples were analyzed separately using a latent trait model. The analysis confirms that the BDI measures a single underlying dimension of depressive severity for both patient samples. Fourteen symptoms discriminate well for severity of depression in the psychiatric-normal sample, seven symptoms in the medical sample, and six symptoms in both samples. The latter six symptoms (suicidal ideation, sense of failure, sense of punishment, loss of social interest, indecision, and dissatisfaction) may represent criteria for depressive severity that are not confounded by the presence of physical illness or the attendant distress.

APPLICATION OF MODERN PSYCHOMETRIC THEORY IN PSYCHIATRIC RESEARCH

This paper describes the general statistical theory of item-response modeling as developed in the fields of statistics and education. Generalization of these procedures for application in the analysis of psychiatric rating scales is the focus of this paper. Questions of unidimensionality vs multidimensionality and choice of distributional transform (logistic vs normal) are both discussed and statistically examined using data on the Beck Depression Inventory (BDI). Application of these models to the BDI revealed two subscales that maximally differentiate high and low levels of depression in psychiatric and medically ill patients respectively. There was considerable but not complete overlap between the two subscales. These statistical models are found to have desirable properties when used to analyze psychiatric rating scales and provide a refinement over existing techniques of classical test theory and factor analysis.

PerspectiveDepression in the Medically Ill: Critical Issues in Diagnostic Assessment

Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed.

Placebo effects. Issues for clinical practice in psychiatry and medicine.

Placebo effects are integral to everyday clinical practice; therefore, they should be well understood by all health care practitioners. Despite the rich literature on the topic, placebo effects receive only passing mention in major textbooks of psychiatry and medicine. The authors clarify the placebo construct and offer a selective review of its history, definitions, mechanisms, and relation to experimental methodology and statistics. Also considered are the concept of nocebo, variation in placebo response rates, and some economic and ethical problems with placebos in clinical trials. Directions are suggested for future research.

Drug-Drug Interactions of Fluoxetine with Tricyclics

The drug-drug interactions with fluoxetine, a pure serotonergic reuptake blocker with a unique profile of side effects, have not been studied adequately. This preliminary report shows that desipramine and nortriptyline plasma levels are markedly increased at steady state (2 to 11 times) when coadministered with fluoxetine. This appears to be the result of the inhibition of the P450 enzyme system of the liver by fluoxetine, resulting in increased plasma levels of drugs metabolized by this system. Research must promptly address drug-drug interactions with fluoxetine since potentially all psychotropic drugs (except for lithium) and many medically indicated drugs could also have significant drug-drug interactions with fluoxetine.

Depression in the Hospitalized Inpatient with Various Medical Illnesses

The amount of depressive symptomatology in the medical population is high. Most of the symptomatology is, however, mild and probably represents an adjustment disorder with depression as a result of illness and hospitalization. Routine screening for depression in the hospitalized medically ill patient appears to be useful, given poor physician recognition of not only mild, but severe depressive symptomatology. Affective and cognitive symptoms of depression are the most discriminating for severe depression. Patients with bone and connective tissue disease, gastrointestinal disease, neurological disease, respiratory disease, and cancer appear to be the groups of diseases at greatest risk for serious depression in a tertiary care setting in the United States.

A successful psychiatric training program for medical residents

The psychosocial skills of 24 PGY I medical residents receiving psychiatric training every other week during the internship year were evaluated and compared to a control group of 13 PGY I residents. After the internship year, the psychiatrically trained residents showed an increase in their ability to recognize emotional problems, whereas the control group recognized less depression. Psychiatrically trained residents were more sophisticated in psychosocial problem descriptions and plan formulations, whereas the control group formulated more poor psychosocial plans.