Screening for depression disorders in patients with chronic somatic illness

Depression is one of the most common complications in patients with chronic somatic illnesses. Comorbidity of depression with physical illness often remains unrecognized and untreated, additionally aggravating the somatic illness itself, its treatment and prognosis. The aim of this study was to investigate the prevalence of depression in chronic somatic patients suffering from diabetes, epilepsy, asthma, chronic obstructive pulmonary disease (COPD) and hypothyroidism. Patients, who were regularly attending control examinations in neurological and internal medicine out-patient departments, were tested for the presence of depression with Beck Depression Inventory. The sample comprised 2153 chronic somatic patients aged between 18 and 80 years. Out of this total, 228 patients (10.6%) did not complete the study, (5.12%) refused to participate, and (5.5%) of the patients were technical failures. 1925 patients completed the study, and 1383 of them were not depressive. In 542 patients (28.5%) depression was confirmed, being almost twice more frequent in women, 346 (64%) vs. 196 (36%) male. Among these depressed examinees, mild depression was found in 284 (52.4%), major in 186 (34.3%) and severe in 72 (13.3%) chronic somatic patients. The majority of patients were aged over 55 yrs (49%). This population contained the largest number of depressed examinees (49.9%). The prevalence of depression with regard to subgroups shows that (25.6%) of asthma patients were depressed, as well as (26.6%) of those with COPD. These two groups did not present statistically significant differences regarding gender. The depression level of (32.2%) was found in patients with diabetes, of (29.6%) in patients with epilepsy and of (24.2%) among those with hypothyroidism. As for gender, statistically significant difference was found in the last three groups of patients (p < 0.001).     

Establishing a minor illness nurse in a busy general practice.

OBJECTIVE--To study the feasibility of a practice nurse caring for patients with minor illnesses. DESIGN--Nurse given training in dealing with patients with minor illnesses. Patients requesting a same day appointment were offered a nurse consultation. SETTING--Group practice in Stockton on Tees. MAIN OUTCOME MEASURES--Number of consultations which required a doctor contact, treatment, and rate of reconsultation. RESULTS--Of 696 consultations in six months, 602 (86%) required no doctor contact. 549 (79%) patients did not reconsult about the episode of illness, and 343 (50%) patients were given advice on self care only. CONCLUSION--Trained nurses could diagnose and treat a large proportion of patients currently consulting general practitioners about minor illness provided that the nurse has immediate access to a doctor.     

Depression in the elderly.

Depression in the elderly is very common and may be difficult to diagnose. Because of its varied presentation and its frequent association with physical illness it will be encountered increasingly by all physicians as the elderly population expands. Depression, though treatable, is often not treated, and suicide rates are high among depressed elderly persons. Diagnostic difficulties lie in distinguishing depression from organic brain syndromes, from so-called masked depressions and from normal grief reactions. Pharmacologic treatment is effective, but care must be taken to recognize side effects and to use adequate doses. Psychologic approaches should focus on reducing feelings of helplessness and failing self-esteem. The importance of the losses borne by elderly persons in the pathogenesis of depression continues to be of theoretical and practical interest.     

Special considerations in the treatment of patients with bipolar disorder and medical co-morbidities

BACKGROUND: The pharmacological treatment of bipolar disorder has dramatically improved with multiple classes of agents being used as mood-stabilizers, including lithium, anticonvulsants, and atypical antipsychotics. However, the use of these medications is not without risk, particularly when a patient with bipolar disorder also has comorbid medical illness. As the physician who likely has the most contact with patients with bipolar disorder, psychiatrists must have a high index of suspicion for medical illness, as well as a basic knowledge of the risks associated with the use of medications in this patient population. METHODS: A review of the literature was conducted and papers addressing this topic were selected by the authors. RESULTS AND DISCUSSION: Common medical comorbidities and treatment-emergent illnesses, including obesity, diabetes mellitus, dyslipidemia, cardiac disease, hepatic disease, renal disease, pulmonary disease and cancer are reviewed with respect to concomitant use of mood stabilizers. Guidance to clinicians regarding effective monitoring and treatment is offered. CONCLUSIONS: Mood-stabilizing medications are necessary in treating patients with bipolar disorder and often must be used in the face of medical illness. Their safe use is possible, but requires increased vigilance in monitoring for treatment-emergent illnesses and effects on comorbid medical illness.     

Palliatieve zorg op een chronische psychiatrische afdeling voor ouderen

Elderly, psychiatric patients admitted to a long-stay ward become physically ill and die. Which care can be offered on the ward and which cases require transferring a patient to specialized psychiatric-medical wards or a hospice? We studied 40 cases of death by malignancy in a clinic for elderly, long-term admitted psychiatric patients. Transferring the patient to such a ward was never indicated. Our population appeared to have a lack of awareness of their illness and expressed very few physical complaints. The possibilities of curative treatment of the malignancy were limited; the emphasis of the treatment was on palliative care. Because of the intensive support given on the patients ward the patients were able to die in peace. Deep sedation was never required.     

Depression and bipolar disorder: relationships to impaired fatty acid and phospholipid metabolism and to diabetes, cardiovascular disease, immunological abnormalities, cancer, ageing and osteoporosis. Possible candidate genes.

Depression and bipolar disorder are two of the commonest illnesses in the developed world. While some patients can be treated effectively with available drugs, many do not respond, especially in the depression related to bipolar disorder. Depression is associated with diabetes, cardiovascular disease, immunological abnormalities, multiple sclerosis, cancer, osteoporosis and ageing: in each case depressed individuals have a worse outcome than non-depressed individuals. In all of these conditions there is now evidence of impaired phospholipid metabolism and impaired fatty acid-related signal transduction processes. Impaired fatty acid and phospholipid metabolism may be a primary cause of depression in many patients and may explain the interactions with other diseases. Several novel gene candidates for involvement in depression and bipolar disorder are proposed.     

The prevalence of depression and anxiety in seafarers type 2 diabetic patients

Depression and anxiety are co-morbid condition in diabetes as disease-related psychological reactions on this chronic metabolic illness. This study was aimed to determine the occurrence of depression and anxiety in seafarer's type 2 diabetic patients. A random sample of 52 diabetic seafarers treated with diet and oral glucose lowering agents, and 56 healthy seafarers were screened for depression with The Beck Depression Inventory (BDI) and for anxiety with State-Trait Anxiety Inventory (STAI 1, STAI 2). Depression (BDI > 18.5) and anxiety (STAI < 28.5) was significantly higher in the group of diabetic seafarers than in control group (more than 30%). Significant correlation was noted between depression and duration of diabetes mellitus, degree of obesity and poor glycaemic control (HbA1C > 8%) and longer duration of shipping routes (over 6 months). The proportion of depression and anxiety was found higher in seafarer's type 2 diabetic patients than in the healthy seafarers.     

Linoleate and Fatty-acid Patterns of Serum Lipids in Multiple Sclerosis and Other Diseases

The linoleic acid content of serum lipids was measured in 47 patients with multiple sclerosis, 29 patients with other neurological diseases, 35 patients with acute non-neurological illnesses, and 49 healthy control subjects. Reduced linoleic acid content of serum lipids was not specific to multiple sclerosis and occurred in all ill patients with acute non-neurological illness. The fatty-acid pattern of serum lipids in illness resembles that of essential fatty-acid deficiency. It seems that this pattern of reduced linoleic acid content with increased oleic, palmitic, and palmitoleic acid content may be a general phenomenon in ill patients.     

Obesity and Physical and Emotional Well‐Being: Associations between Body Mass Index,Chronic Illness,and the Physical and Mental Components of the SF‐36 Questionnaire

Objective: To clarify the associations between obesity and health‐related quality of life by exploring the associations between physical and emotional well‐being in relation to obesity and the presence of other chronic illness. Research Methods and Procedures: The study data were collected as part of a postal‐survey within the old Oxford Regional Health Authority of England in 1997. Completed questionnaires were returned by 8889 of 13,800 randomly selected adults aged 18 to 64 years. The main outcome measures were body mass index in five categories (underweight, normal weight, overweight, moderately obese, morbidly obese); chronic illness status (any vs. none and number of such illnesses 0, 1 to 2, 3+); and mean SF‐36 questionnaire score in two summary component measures reflecting physical and emotional well‐being. Results: Of the subjects, 31% were overweight and an additional 11% were obese. Body mass index was significantly associated with health status, but the pattern varied according to whether the measure reflected physical or emotional well‐being. Physical, but not emotional, well‐being deteriorated markedly with increasing degree of overweight and was limited in subjects who were obese but had no other chronic condition; subjects with chronic illnesses other than obesity were compromised in both dimensions. In terms of the number of chronic illnesses reported, the additional presence of obesity was associated with a significant deterioration in physical but not emotional well‐being. Discussion: Overweight and obesity are associated with poor levels of subjective health status, particularly in terms of physical well‐being. The limitations in emotional well‐being that are reported here and in other studies may be a result of confounding by the presence of accompanying chronic illness.     

职业倦怠与抑郁症的相关性及其生物学基础研究*

职业倦怠和抑郁症是当今社会人群中普遍存在的影响心理健康的重要因素和疾病,这两者之间有一定的相关性.职业倦怠主要表现在三个方面:情感枯竭,去个性化,个人成就感缺乏.抑郁症主要表现在心境障碍或情感性障碍,缺乏激情.职业倦怠和抑郁症在表现行为方面存在一定关联,患有职业倦怠和抑郁症的人通常态度消极,缺乏对生活和工作的热情,自我评价低,影响工作和生活质量.抑郁情绪易引发职业倦怠,职业倦怠也可以导致抑郁症,二者相互影响.本文就职业倦怠与抑郁症的概念,两者之间的联系及相关的生物学基础进行了综述.     

Die „Pathologische Realangst“ am Beispiel kardiovaskulärer Erkrankungen

Fears of patients suffering from chronic or life threatening diseases are frequently observed as adjustment reactions. Left untreated they may lead to an unfavorable course of the disease and a generally poor outcome. Difficulties in diagnostic standard procedures arise from the question whether the anxiety symptoms are an expression of physical illness, or an independent anxiety disorder of clinical significance. The concept of Pathological Realistic Fear derives from these considerations, and describes the fear of a real threat, particularly in patients with chronic disease, especially those suffering from life threatening illnesses. Distorted perceptions of the primary disease, caused by subjective ideas about disease mechanisms often lead to misguided assumptions and frequently result in a distorted interpretation of the physical symptoms of illness. As a result a fearful attention focus evolves, which triggers the ultimate development of a Pathological Realistic Fear as. The following article is a first attempt to elaborate on the concept of Pathological Realistic Fear as a pathology and to describe its clinical relevance. The concept contributes to a more precise diagnosis of anxiety and could stimulate an interdisciplinary patient care.     

慢性心力衰竭患者自我管理的现状及影响因素分析

目的：了解慢性心力衰竭患者自我管理的现状及影响因素。方法：采用自行设计的心力衰竭自我管理量表、心力衰竭知识测评量表、患者信息调查表和社会支持评定量表、抑郁自评量表调查160 例慢性心力衰竭患者的现状。结果：心衰患者自我管理状况呈中等水平,自我管理水平与教育程度、心衰相关知识水平以及社会支持程度呈中度正相关关系,与抑郁情绪和年龄呈中度负相关关系。结论：慢性心衰患者自我管理水平受其生理、心理及社会等多因素的影响。     

A proposal for the use of advance directives in the treatment of incompetent mentally ill persons

[M]y question is how these patients while competent might be able to give their own informed consent to treatment, despite being both unwilling and incompetent to do so when treatment is to be begun, thereby reducing the need to relax the dangerousness criteria for involuntary commitment. It is uncontroversial that the dangerousness requirement would be too restrictive for all treatment of mental illness. When competent patients voluntarily seek and/or accept treatment for their mental illness, neither public policy nor medical practice restricts treatment to those patients judged to be dangerous. Instead, criteria should be and generally are comparable to those for the treatment of physical illness -- whether the patient is ill, in this case mentally ill, and likely to benefit from treatment. Through use of advance directives, it would be possible for mentally ill persons who are currently refusing treatment to give prior consent, while competent and with their disease in remission, to treatment at a later time when they are incompetent, have become noncompliant, and are refusing treatment. My proposal is certainly not entirely novel, since others have made similar proposals under the heading of Ulysses contracts and voluntary commitment contracts. Addressing briefly some of the criticisms of these earlier proposals will bring out one fundamental difference between them and my proposal here for a new use of advance directives -- whether the patient must then be incompetent when the contract or directive made earlier is later invoked -- a difference I shall argue strongly favors my proposal.     

Behandlung depressiver Störungen bei Diabetes mellitus

Approximately 25% of all diabetes patients suffer from symptoms of clinical depression. This comorbidity of depression and diabetes is associated with hypoglycaemia, microvascular and microvascular complications and a clearly increased mortality. With regard to psychosocial outcome depression is related to impaired generic and diabetes-specific quality of life and poor treatment adherence. Despite this life endangering interaction depression is under-diagnosed and under-treated in diabetes patients. Therefore a screening for depression should be an integral part of routine care. Treatment for depression is aimed not only towards improvement of depression but should focus on physical aspects of diabetes as well. Depression can be treated with antidepressant medication, psychotherapy or a flexible combination of both. These approaches demonstrate relatively good results that are comparable to those patients with depression without diabetes. Up to now no single treatment that consistently leads to better medical outcome in patients with depression and diabetes could be identified. The management of diagnosis and treatment of comorbid depression in diabetes can be enhanced by following algorithms that are grounded on evidence-based treatment guidelines.     

Depression and other psychiatric morbidity in carers of elderly people living at home.

OBJECTIVE--To describe the mental health of a community sample of carers of elderly people with dementia, depression, or physical disability and to compare that with the mental health of other adults living in the household and of those living alone. DESIGN--Assessment of psychiatric morbidity and physical disability with standardised questionnaire in randomly selected enumeration districts; subjects were interviewed at home. SETTING--London Borough of Islington. SUBJECTS--700 people aged > or = 65 and other coresidents. MAIN OUTCOME MEASURE--Depression measured with standardised interview. RESULTS--The prevalence of depression was not significantly higher in carers overall (15%) than in coresidents (11%). Being a woman carer was a significant predictor of psychiatric illness. Depression was more common in the carers of people with a psychiatric disorder than in coresidents (24% v 11%, P < 0.05) and in those living alone (19%). Depression was most common (47%) in women carers of people with dementia. CONCLUSION--The increase in psychiatric morbidity reported in carers of people with psychiatric disorders may reflect the lack of a confiding relationship.     

An epidemic of depression or the medicalization of distress?

The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model.     

Psychiatric Morbidity and Referral on Two General Medical Wards

Psychiatric morbidity among 230 medical inpatients was determined by a two-stage screening procedure, using the General Health Questionnaire and Standardized Psychiatric Interview. Of these patients, 23% were considered psychiatrically ill, affective disorders being the commonest illnesses encountered; and 27 (12%) were psychiatrically referred. While referral was related to severity of psychiatric illness and previous psychiatric illness, the degree to which the psychiatric illness obtruded or created problems in management appeared more crucial in determining referral. In half of those with psychiatric illness the problems did not appear to have been detected or dealt with. It is suggested that medical clerking should routinely include questions about mood and psychological responses to illness.     

Early detection of depression by primary care physicians.

The overall prevalence of depression is from 3.5% to 27%. The burden of suffering is high and includes death through suicide. In most cases treatment is effective, but important episodes of depression are being missed. To determine whether a brief, systematic assessment for the early detection of depression should be part of the periodic health examination we searched MEDLINE and the Science Citation Index for randomized controlled trials that evaluated the effectiveness of early detection of depression with a questionnaire. Seven instruments met our quality criteria; the Beck Depression Inventory, the Center for Epidemiologic Studies Depression Scale, the Zung Self-Assessment Depression Scale, the General Health Questionnaire, the Hopkins Symptom Checklist, the Mental Health Inventory and the Hospital Anxiety and Depression Scale. The four randomized controlled trials failed to provide adequate evidence of the benefit of routine screening. Early detection is difficult because of depression''s natural history, the role of symptoms, the cultural diversity of Canada and how detection instruments have been developed. Depression deserves careful attention from primary care physicians; however, further research and development is required before the widespread routine use of any detection test can be recommended.     

UK patients with primary Sjögren's syndrome are at increased risk from clinical depression

Objective: This study was undertaken to assess the presence and degree of anxiety and depression in a group of UK patients with primary Sjögren's syndrome (1°SS). Design: Cross‐sectional. Setting: Department of Oral Medicine, Liverpool University Dental Hospital. Subjects: Eighty adult patients; 40 diagnosed with 1°SS according to the revised European Criteria and 40 age/gender‐matched controls with no history of chronic illness. Intervention: Hospital Anxiety and Depression Scale (HADS), a self‐administered questionnaire designed to evaluate the presence and degree of anxiety and depression in a clinical setting. Main outcome measures: Age, gender, Hospital Anxiety and Depression Scale (HADS). Results: Forty patients with 1°SS and 40/age/gender‐matched controls completed the HADS. Scores for anxiety in both the 1°SS and control groups showed no statistically significant difference. Patients with 1°SS had statistically significant higher, mean HADS scores for depression than the controls. There was an increased prevalence of ‘definite’ clinical depression in the 1°SS group. Conclusion: Patients with 1°SS appear to be at increased risk from clinical depression. Early recognition and appropriate intervention is therefore essential to reduce the negative impact of depression on the patient's quality of life and outcome of their disease.