Biomedical subjects

W Katon

Publications and source records attributed to W Katon.

At least 73 records · Page 4Linked to original sources

PubMed1994

Subsyndromal ("mixed") anxiety--depression in primary care.

OBJECTIVE: To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses. DESIGN: Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff. SETTING: Five primary care sites in the United States, France, and Australia. PATIENT: Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up. METHODS: Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers. RESULTS: After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders. CONCLUSION: The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment.

Anxiety↗

PubMed1994

Coping and marital support as correlates of tinnitus disability.

Although there is increasing awareness that depression can add significantly to the disability associated with chronic medical illness, it is not clear whether all of the impact of psychosocial factors upon medical disability are mediated by or moderated by depression. It has not been determined whether treating depression alone is an adequate strategy for addressing psychosocial magnification of medical disability. We analyzed data collected at initiation of a treatment trial from 92 subjects with chronic severe tinnitus to assess the role of coping, and 49 subject-spouse pairs to assess the role of marital interaction in tinnitus-related role dysfunction. Three multiple regression models were developed. After accounting for gender, tinnitus loudness, and depressive severity among the 92 subjects, greater role dysfunction was associated appraisal of tinnitus as salient, and less role dysfunction with coping through avoidance or seeking social support. Marital interaction was assessed from patient and spouse perspectives. In the patient-rated set, less marital cohesion was associated with greater tinnitus-related role dysfunction. In the spouse-rated set, more punishing responses to subject illness behavior were associated with greater tinnitus-related role dysfunction. In each case the disabling effect was greater in the face of high levels of subject depression. This study provides evidence for the oft-stated analogy between chronic tinnitus and chronic pain, and provides justification for a similar multimodal treatment strategy. Reducing depression is an important means to reduce medical disability but should be supplemented by clinical attention to appraisal of the illness, modes of coping with the illness, and spousal response to the illness.

Adaptation, Psychological↗

PubMed1994

The predictors of persistence of depression in primary care.

164 patients in primary care who were recognized as depressed by their physicians and started on antidepressants were interviewed at 1 and 4 months after initiation of treatment. Ten factors hypothesized to be related to persistence of depressive symptoms were entered into a multivariate analysis to determine predictors of persistence of affective symptoms. Patients with minor depression were significantly older, more likely to be married or cohabitating, more likely to have serious medical illness, and had significantly less comorbid panic disorder, recurrent depression and lower neuroticism scores compared to patients with major depression. Approximately half of the patients in this primary care sample with major depression and one-third of those with minor depression were still distressed at 4 months, although few met criteria for major depression. Severity of depression and high neuroticism scores were the best predictors of persistent depressive symptoms.

Adolescent↗

PubMed1994

Psychiatric comorbidity and length of stay in hospitalized AIDS patients.

OBJECTIVE: The purpose of this study was to assess the effect of psychiatric comorbidity on specific measures of hospital utilization, including length of stay, among hospitalized AIDS patients. METHOD: Data collection involved medical record abstraction for AIDS patients admitted to any one of 19 hospitals in Washington State during 1990. Psychiatric comorbidity was defined by the presence of an ICD-9 code reflecting psychiatric illness. Medical/surgical admissions of AIDS patients with psychiatric diagnoses were compared to those of AIDS patients without psychiatric diagnoses on measures of mean length of stay for the first admission in 1990, total number of hospitalizations in 1990, and total number of hospital days in 1990. Medical morbidity was addressed using CD4+ cell count and current and previous AIDS-defining illnesses as markers of disease severity. RESULTS: Of 357 patients hospitalized with AIDS, 49 (14%) had at least one psychiatric diagnosis. Patients with psychiatric illness were hospitalized an average of 6.6 days longer than AIDS patients without such illnesses. Differences in medical morbidity did not account for the longer length of stay. CONCLUSIONS: Psychiatric comorbidity increased the average length of stay among hospitalized AIDS patients. Future research needs to address the possible effects of this phenomenon on quality and cost of care received by AIDS patients.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study.

OBJECTIVE: The purpose of this study was to compare use of minor tranquilizers and antidepressant medications by depressed outpatients across different treatment settings. METHOD: The study subjects were 634 patients with current depressive disorder or depressive symptoms who visited general medical clinicians, psychiatrists, psychologists, or other therapists. Data on use of medication in different types of clinical practices with different types of payment plans were gathered from structured interviews by study clinicians and from surveys of patients. RESULTS: Of the depressed patients, 23% had recently used an antidepressant medication and 30% had used a minor tranquilizer. The level of use was similar for different types of depression. Patients of psychiatrists were the most likely to use medications. In the practices of physicians, but not nonphysicians, the more severely distressed patients were more likely to use antidepressant medications. Of the patients taking an antidepressant medication, 39% used an inappropriately low dose. Patients in prepaid health care plans were twice as likely as those in fee-for-service care to use minor tranquilizers. CONCLUSIONS: Less than one-third of the depressed outpatients used antidepressant medications, and the probability of use was similar for major depression and other types of depression for which efficacy is less well established. Use of antidepressant medications among patients of nonphysicians was unrelated to the level of psychological sickness, suggesting the need for more cooperation among provider groups. Minor tranquilizers were used more often than antidepressants, particularly among patients in prepaid plans, despite controversy over their efficacy.

Adult↗

PubMed1994

The DSM-IV field trial for mixed anxiety-depression.

OBJECTIVE: This field trial was designed to answer four questions. First, are patients presenting with anxious or depressed symptoms that are associated with significant impairment but do not meet DSM-III-R definitional thresholds for axis I anxiety or mood disorders? Second, is the impairment experienced by these patients simply the consequence of the severity of their medical conditions? Third, what percent of these patients present with depressive symptoms only, anxious symptoms only, and a mixture of both? Fourth, how should the operational criteria for the syndrome(s) presented by these patients be defined? METHOD: A total of 666 patients from five primary care medical sites and two outpatient mental health sites were administered a semistructured psychiatric interview. RESULTS: Patients presenting with affective symptoms that did not meet definitional thresholds for DSM-III-R axis I disorders were at least as common as patients with several of the already established anxiety and mood disorders in each of the seven sites, and their disorders were associated with significant distress or impairment. A nonspecific pattern of anxious and depressed symptoms was the modal presentation among these patients with currently subdefinitional threshold disorders, and they could be significantly differentiated in terms of current symptoms from patients presenting with a principal diagnosis of generalized anxiety disorder, major depressive episode, or panic disorder with agoraphobia. CONCLUSIONS: The authors recommend that a mixed anxiety-depression category be included in the DSM-IV appendix for proposed diagnostic categories that need further study. A criteria set is proposed.

Ambulatory Care↗

PubMed1994

Anxiety and depression in an outpatient clinic in Lesotho, Africa.

OBJECTIVE: Past studies of psychiatric disorders in primary care in developing countries have utilized measures to determine conspicuous psychiatric morbidity (CPM) rather than diagnoses. Our goal was to determine the prevalence of DSM-III major depression (DEP), panic disorder (PD), and generalized anxiety disorder (GAD) in an outpatient clinic in Lesotho, Africa. METHODS: As part of a larger community study, we utilized a translated version of the N.I.M.H. Diagnostic Interview Schedule to determine the prevalence of DEP, PD, and GAD in 126 randomly selected outpatients (response rate = 77%) attending a general hospital clinic. We compared these data to information about demographics and symptom presentation. RESULTS: We found twenty-nine (23%) patients with DEP, thirty (24%) with PD, and thirty-six (29%) with GAD. Forty-six (36%) had either DEP or PD, with thirteen (45%) having concurrent illness. Patients with DEP and/or PD presented with a significantly higher number of physical symptoms, and a higher percentage of symptoms that were pain or autonomic nervous system related than patients with no disorder ever. CONCLUSION: There is significant psychiatric morbidity of common diagnoses in outpatient clinic in Lesotho, and patients present primarily with somatic symptoms, as in developed countries. There is a need for better elucidation of cross-cultural phenomenology, medical co-morbidity as a confounder, and help-seeking and treatment patterns in the developing world.

Africa↗

PubMed1993

A randomized trial of nortriptyline for severe chronic tinnitus. Effects on depression, disability, and tinnitus symptoms.

OBJECTIVE: To determine whether the antidepressant, nortriptyline, is effective for treatment of depression, tinnitus-related disability, and tinnitus symptoms in patients with severe chronic tinnitus. DESIGN: A 12-week, double-blind, randomized controlled trial. SETTING: A university otolaryngology clinic. PATIENTS: Ninety-two subjects with severe chronic tinnitus: 38 with current major depression and 54 with depressive symptoms and significant tinnitus-related disability. INTERVENTION: Nortriptyline (maintained at 50 to 150 mg/mL for 6 weeks) or placebo. MAIN OUTCOME MEASURES: Hamilton Depression Rating Scale, Tinnitus Disability Measures, and Audiometric Measures. RESULTS: Nortriptyline was superior to placebo by multivariate analysis of covariance for depression (10.6 vs 14.3 final Hamilton Depression score), for tinnitus-related disability (1.8 vs 2.4 final MPI Tinnitus Interference), and tinnitus loudness (13.6 vs 20.0 dB final loudness match [in worst ear at tinnitus frequency]). When major depression and depressive symptoms groups were considered separately, nortriptyline was superior to placebo on these same measures but differences did not achieve statistical significance. CONCLUSIONS: The antidepressant nortriptyline decreases depression, functional disability, and tinnitus loudness associated with severe chronic tinnitus. What appears to be irreversible disability of otologic origin may, in part, be reversible disability of psychiatric origin.

Aged↗

PubMed1993

Depressive symptoms and measures of disability: a prospective study.

OBJECTIVE: The purpose of this study was to test the hypothesis that decreases in severity of depressive symptoms in patients with chronic tinnitus would correlate with reductions in measures of functional disability. METHOD: This study describes the correlations between several measures of functional disability and Hamilton depression scores in two groups of patients with major depression and depressive symptoms (D-NOS) who were patients enrolled in a 12-week placebo-controlled, double-blind trial of nortriptyline. These patients had chronic severe tinnitus which was associated in most patients with high frequency hearing loss. The effect of whether affective symptoms improved and the patient's initial depression status (major depression versus depressive symptoms) are examined in order to increase understanding about the correlations between depressive symptoms and functional disability. RESULTS: Most measures of functional disability decreased synchronously with Hamilton Depression Scale scores in both patients with major depression and those with subclinical depressive symptoms. Patients whose depression improved had a significantly greater change in each disability measure than patients whose depression did not improve. This significant decrease in functional disability was seen in 11 of 13 scales in the improved D-NOS group, versus only 3 of the 13 scales in the unimproved D-NOS group; 9 of 13 scales of functional disability significantly decreased in the improved major depression group, versus 3 of 13 scales in the unimproved major depression group. CONCLUSIONS: The results suggest that there was a significant correlation between improvement in both major depression and depression-NOS symptoms, and decreases in measures of functional disability in an aging population with a chronic medical illness.

Adaptation, Psychological↗

PubMed1993

Posttraumatic stress disorder symptoms and precombat sexual and physical abuse in Desert Storm veterans.

The purpose of this research was to study the association between precombat sexual and physical abuse and combat-related posttraumatic stress disorder (PTSD) symptoms in a clinical sample of male and female Desert Storm veterans. Two hundred ninety-seven veterans provided data on precombat sexual and physical abuse, precombat psychiatric problems, sociodemographics, Desert Storm combat exposure, and PTSD symptomatology using the Mississippi Scale. Men reported significantly higher levels of combat exposure, and women described significantly more frequent precombat abuse. Precombat-abused veterans reported more frequent precombat psychiatric histories. Analysis of covariance revealed that gender significantly modified the impact of precombat abuse on combat-related and other PTSD symptomatology after adjusting for precombat psychiatric history and level of combat exposure. Specifically, females describing precombat abuse reported much greater PTSD symptomatology than did females denying precombat abuse. These results in conjunction with previous research suggest that a relationship between precombat abuse and combat-related PTSD may exist. Prospective, longitudinal studies of both men and women are needed.

Adult↗

PubMed1993

Depression, anxiety, and social disability show synchrony of change in primary care patients.

OBJECTIVES: The purposes of this study were to (1) characterize the social disability associated with the common psychiatric illnesses of primary care patients in terms of role dysfunction (self-care, family role, social role, occupational role) and (2) establish whether severity of psychiatric illness and disability level show synchrony of change. METHODS: A two-stage sample design was employed. In the first stage, 1994 consecutive attenders of 25 general practitioners were screened on psychiatric illness by their physicians and with the General Health Questionnaire. A stratified random sample (n = 285) with differing probabilities was selected for a second-stage interview. Patients with psychiatric symptoms were reinterviewed 1 and 3.5 years later (n = 143). RESULTS: (1) Disability level among patients was increased (moderately for depression, mildly for anxiety) and was associated with severity of psychiatric illness. (2) Most disability was found in occupational and social roles. (3) Change in severity of psychiatric illness was concordant with change in level of disability and was largely invariant across diagnosis (depression, anxiety, mixed anxiety/depression). At follow-up, disability among improved patients had returned to normal levels. CONCLUSIONS: Psychiatric illness in primary care patients is associated with mild to moderate disability, and severity of psychiatric illness and disability show synchrony of change.

Activities of Daily Living↗

PubMed1992

Chronic fatigue syndrome criteria. A critique of the requirement for multiple physical complaints.

OBJECTIVE: The purpose of this study was to test the hypothesis that the patients with chronic fatigue who have the highest number of medically unexplained physical symptoms over their lifetime would also have the highest prevalence of current and lifetime affective and anxiety disorders, lifetime affective symptoms, and the most functional disability. A further goal was to use this information to modify the current case definition to better identify a subgroup of patients with chronic fatigue syndrome who are less likely to have psychiatric illness. DESIGN: Two hundred eighty-five consecutive patients with chronic fatigue were interviewed with the National Institute of Mental Health Diagnostic Interview Schedule and completed four self-rating questionnaires measuring psychologic distress, functional disability, and the tendency to amplify symptoms. Based on previously published data, patients were divided into four groups with a progressively higher number of lifetime medically unexplained physical symptoms. The prevalence of current and lifetime psychiatric disorders, lifetime psychologic symptoms, and extent of functional impairment was then compared in these four groups of patients. MAIN RESULTS: The prevalence of current and lifetime psychiatric diagnosis and lifetime depressive symptoms increased linearly with the number of lifetime physical symptoms that the patient experienced. The extent of impairment in activities of daily living and the tendency to amplify symptoms also increased linearly with the number of medically unexplained physical symptoms. CONCLUSION: The patients with the highest numbers of medically unexplained physical symptoms had extraordinarily high rates of current and lifetime psychiatric disorders. These data suggest that the current case definition for chronic fatigue syndrome inadvertently selects for patients with the highest prevalence of lifetime psychiatric diagnoses. A recommendation based on these results is to modify the case criteria for chronic fatigue syndrome to include patients with fatigue and few physical symptoms and to identify and consider excluding patients with high numbers of physical complaints.

Anxiety Disorders↗

PubMed1992

Disability and depression among high utilizers of health care. A longitudinal analysis.

We evaluated, among depressed medical patients who are high utilizers of health care, whether improved vs unimproved depression is associated with differences in the course of functional disability. At baseline, 6 months, and 12 months, depression and disability were assessed among a sample of enrollees in health maintenance organizations (N = 145) in the top decile of users of ambulatory health care who exceeded the 70th percentile of health maintenance organization population norms for depression. Improved depression was defined as a reduction of at least one third in depressive symptoms averaged across the two follow-up times. At the 12-month follow-up, persons with severe-improved depression experienced a 36% reduction in disability days (79 days per year to 51 days per year) and a 45% reduction in disability score. Persons with moderate-improved depression experienced a 72% reduction in disability days (62 days per year to 18 days per year) and a 40% reduction in disability score. In contrast, persons with severe-unimproved depression reported 134 disability days per year at baseline, while persons with moderate-unimproved depression reported 77 disability days per year at baseline. Neither group with unimproved depression showed improvement in either disability days or disability score during the 1-year follow-up period. High utilizers of health care with severe-unimproved depression were more likely to have current major depression and to be unemployed. Improved (relative to unimproved) depression was associated with borderline differences in the severity of physical disease and in the percent married. We conclude that depression and disability showed synchrony in change over time. However, depression and disability may show synchrony in change with disability because both depression and disability are controlled by some other factor that influences the chronicity of depression (eg, chronic disease or personality disorder). The finding of synchronous change of depression and disability provides a rationale for randomized controlled trials of depression treatments among depressed and disabled medical patients to determine whether psychiatric intervention might improve functional status in such patients. Such research is needed to determine whether there is a causal relationship between depression offset and reductions in functional disability.

Activities of Daily Living↗

PubMed1992

A randomized trial of psychiatric consultation with distressed high utilizers.

This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care).

Ambulatory Care↗

PubMed1992

Epidemiology of depression in primary care.

Major depressive disorder has been recently found to be associated with high medical utilization and more functional impairment than most chronic medical illnesses. Major depression is a common illness among persons in the community, in ambulatory medical clinics, and in inpatient medical care. Studies have estimated that major depression occurs in 2%-4% of persons in the community, in 5%-10% of primary care patients, and 10%-14% of medical inpatients. In each setting there are two to three times as many persons with depressive symptoms that fall short of major depression criteria. Recent studies have found that in one-third to one-half of patients with major depression, the symptoms persist over a 6-month to one-year period. The majority of longitudinal studies have determined that severity of initial depressive symptoms and the presence of a comorbid medical illness were predictors of persistence of depression.

Cross-Sectional Studies↗

PubMed1992

Adequacy and duration of antidepressant treatment in primary care.

Among a sample of 119 distressed high-utilizers of primary care, 45% of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination. However, only 11% of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy. In the year following the intervention, study patients whose physicians were advised regarding treatment during a psychiatric consultation were more likely to receive antidepressant medications (52.7%) relative to a randomized control group (36.1%). However, the intervention did not significantly increase the provision of adequate antidepressant therapy (37.1% vs 27.9%). Among study patients using antidepressants, patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not. Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20% of patients who had been given prescriptions for first-generation antidepressants (amitriptyline, imipramine, or doxepin) filled four or more prescriptions in the following six months, compared to 34% of patients who had prescriptions for newer antidepressants (nortriptyline, desipramine, trazodone and fluoxetine). Experimental research evaluating whether these newer medications (with more favorable side effect profiles) improve adherence, and thereby patient outcome, is needed.

Adult↗

PubMed1991

Mixed anxiety and depression.

We review evidence from community, primary care, and psychiatric samples to determine whether there are a group of patients who have mixed symptoms of anxiety and depression that are below diagnostic thresholds for either group of disorders. A review of the data strongly suggests that such a group of patients exists and that, despite lacking sufficient symptoms to meet diagnostic thresholds from the revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), they often have significant impairment in social and vocational functioning. Because many of these patients also suffer from medically unexplained somatic symptoms, they may be more likely to frequently use nonpsychiatric medical care. Longitudinal studies suggest that persons with mixed anxiety-depression symptoms may represent a population who are at increased risk for more severe mood and anxiety disorders.

Anxiety Disorders↗

PubMed1991

Somatization: a spectrum of severity.

OBJECTIVE: The DSM-III-R diagnosis of somatization disorder requires that a patient have a specific number of medically unexplained somatic symptoms. This number of symptoms was developed by committee consensus, and it is not clear whether patients with this specific number of symptoms can be differentiated from patients with lower but still substantial numbers of somatic symptoms. METHOD: Fifty-one percent of 767 high utilizers of two primary care clinics were identified as distressed by an elevated SCL anxiety, depression, or somatization scale score or by their primary care physician. The Diagnostic Interview Schedule (DIS) was completed on 119 distressed high utilizers who were randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The 119 distressed high utilizers were separated into four categories according to the number of unexplained somatic symptoms found on the DIS and were compared on demographic, psychiatric distress, disability, medical, and health utilization variables. RESULTS: The data suggest that many clinical and behavioral features of somatization are significantly more common in patients with four to 12 medically unexplained somatic symptoms rather than changing dramatically at the diagnostic threshold for somatization disorder. The data also showed that patients who meet the DSM-III-R criteria for somatization disorder are severely ill and have a high burden of psychiatric illness and disability. CONCLUSIONS: The results suggest that the DSM-IV somatoform disorders section should include somatization disorder, an abridged definition of somatization disorder often associated with anxiety and depression, as well as a type of somatization associated with an adjustment disorder.

Activities of Daily Living↗