Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial

This study examined patient-level factors associated with engagement in mental health treatment in a sample of medically ill patients with clinically significant symptoms of depression and/or anxiety. A total of 248 patients was enlisted from a randomized controlled trial of cognitive-behavioral therapy for depression and anxiety in patients with chronic obstructive pulmonary disease (COPD). Logistic regression analysis was used to predict mental health engagement, defined as attending at least one intervention session. Results indicated that patient-perceived mastery over COPD was negatively related to mental health engagement. Further, mastery was the only significant predictor of mental health engagement after controlling for patient demographic characteristics, severity of COPD, depression, and anxiety. To improve engagement for medically ill patients with comorbid mental health difficulties, clinicians should explore patients’ attitudes about their mental health within the context of their perceived ability to cope with their medical disease.     

Cognitive-Behavioral Therapy: Innovations for Cardiopulmonary Patients With Depression and Anxiety

Medically ill patients face unique physical and emotional challenges that place them at increased risk for symptoms of depression and anxiety. Despite high prevalence and significant impact, depression and anxiety are infrequently treated in the medically ill because of a variety of patient, provider, and system factors. The current article describes the development of an innovative, modular-based cognitive-behavioral intervention (Adjusting to Chronic Conditions Using Education Support and Skills [ACCESS]) that integrates treatment for symptoms of anxiety and depression with medical disease self-management in patients with heart failure and chronic obstructive pulmonary disease. Data from 3 patients who participated in an ongoing open clinical trial are reviewed to illustrate the feasibility, acceptability, and potential strengths and limitations of this intervention.     

Telephone-Administered Cognitive Behavioral Therapy: A Case Study of Anxiety and Depression in Parkinson’s Disease

Parkinson’s disease (PD) is a chronic medical illness with a high incidence of psychiatric comorbidity, specifically depression and anxiety. Research on treatment of such psychiatric complications is scarce. Non-pharmaceutical treatment options are especially attractive. Cognitive behavioral therapy (CBT) is a psychotherapeutic treatment option that has been successful in other chronically medically ill populations with comorbid depression and anxiety. The current research had two aims. The first was to pilot the feasibility of screening and identifying PD patients with symptoms of anxiety and depression in a specialized outpatient clinic. The second aim was to pilot the feasibility of telephone-administered CBT for the treatment of depression and anxiety in persons with PD, which was done through a case series comparing telephone-administered CBT to a Support strategy. A fairly large portion (67.5%) of patients screened in the outpatient clinic were identified as having symptoms of anxiety and/or depression. Results also indicated that CBT delivered via the telephone is a useful approach for targeting psychiatric symptoms in this population. A case example is given to illustrate the clinical considerations associated with delivering therapy via telephone to persons with PD. This study was conducted at the Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The first author was previously affiliated with the Houston Center for Quality of Care and Utilization Studies.     

Depression Screening in Medically Ill Homecare Elderly

PURPOSE: This article provides data on a depression screening model (HOME) in acute home health care designed to detect clinical depression among medically ill homebound older patients. The model was developed to address the lack of mental health services in home health care settings and to specifically improve geriatric depression screening as part of routine care. Authors report on the concordance of homecare and research interview ratings of depression in older homecare patients. DESIGN AND METHODS: Using a prospective cohort design, data were collected from 289 elderly patients, aged 65 and older, from a large home health care agency to examine depression, cognitive functioning, medical comorbidity, functional status, and social isolation. Research interviews used the depression module of the structured clinical interview for DSM (SCID). RESULTS: The overall prevalence of major depression was 5.7 percent according to both homecare and research raters. The prevalence of subthreshold depressive disorder was 16.4 percent as reported by research raters. Observed agreement was 73 percent and kappa agreement was 0.42, indicating a fair to moderate agreement. We identified patient characteristics that may influence the accuracy of homecare worker estimates of depressive symptoms. IMPLICATIONS: Findings suggest that depression continues to be underdetected in medically ill homebound elderly patients. Ongoing training in depression screening methods, patient follow-up interviews, and appropriate referral would improve care of depressed elderly homecare patients.     

Lack of a close confidant: prevalence and correlates in a medically underserved primary care sample

The present study examined prevalence of lack of a close confidant in a medically underserved primary care sample, and evaluated demographic, medical, and psychological correlates of patients' deficits in close, personal contact. Adult patients (n = 413) reported on confidant status and symptoms of depression and anxiety. Sociodemographic and medical information were obtained through chart review. One-quarter of patients endorsed lack of a close confidant. Past month anxiety and depression symptoms, but not medical status, were associated with unmet socioemotional needs. Implications for primary healthcare interventions are discussed.     

The Role of Cardioprotective Avoidance Beliefs in Noncardiac Chest Pain and Associated Emergency Department Utilization

This study examined cardioprotective avoidance beliefs and general panic/agoraphobia variables among 45 Emergency Department patients with a primary complaint of noncardiac chest pain (NCCP) in the absence of coronary artery disease or other medical explanation. Cardioprotective beliefs about the dangerousness of work and physical activity were assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). Additional measures assessed complaints of cardiac distress and panic, anxiety sensitivity, panic-related beliefs, agoraphobic avoidance, and depressive symptoms. Hierarchical regression analysis indicated that cardiac distress symptoms are a function of panic symptoms and cardioprotective beliefs concerning both physical activity and work, with 62% of the total variance explained. The predictors also explained 57% of the variance in Emergency Department utilization, which was significantly related to cardiac distress symptoms, number of illnesses, and work-avoidance beliefs. Neither outcome was related to demographics, depression symptoms, general anxiety sensitivity, general panic cognitions, or agoraphobic avoidance. Results suggest that current behavioral understandings of NCCP might be advanced by further examination of cardiac-specific avoidance beliefs and behavior and the potential role these factors play in both symptom experience and medical utilization.     

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.     

Psychosomatik der koronaren Herzkrankheit

Coronary heart disease is one of the leading causes of death in industrialized countries. In its multifactorial pathogenesis psychosocial factors are considered cofactors influencing health behaviors and physiological processes. They are also potent triggers of acute myocardial infarctions. The heart disease itself can, in turn, lead to anxiety, denial, and depression. Psychological maladjustment, especially depression, can impair subjective well-being and clinical disease outcomes. It should therefore be identified systematically. Besides the somatic treatment, behavioral interventions can help patients to cope with stressors and control coronary risk factors. Psychotherapy and antidepressant medications are available for treating comorbid mental illnesses, especially depression. However, psychotherapy with cardiac patients has to take into account the particular characteristics and needs of these patients.     

Posttraumatic stress disorder in medically ill patients: what is known, what needs to be determined, and why is it important?

Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.     

Reply to lokhandwala and westefeld

Abstract

Lokhandwala and Westefeld's article highlighting the ethical dilemma in rational suicide raises the pragmatic question of how one would actually assess a client's situation. A particularly relevant diagnosis that should be ruled out is clinical depression. The DSM-IV lists nine symptoms of major depressive disorder, eight of which could easily be masked as symptoms of the physical illness or side effects of treatment. These symptoms can be grouped into three categories: central features of depression, physical signs of depression, and cognitive signs of depression. All three of these categories, particularly physical signs, could easily be mistaken for medical problems. Reviewing the nine criteria for a diagnosis of clinical depression might be a good way to explore the possibility of clinical depression in a terminally ill person who is supposedly making a “rational” decision to commit suicide.     

Suicidal Ideation in Elderly Bereaved: The Role of Complicated Grief

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.     

Pharmacotherapeutic options in the treatment of comorbid depression and anxiety

Although anxiety and mood disorders are listed as separate disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, they frequently coexist. They may be expressed phenotypically as comorbidities or as the provisional entity mixed anxiety-depressive disorder. Patients with both anxiety and depression are more symptomatic, use more health care resources, and have a worse prognosis than those with a single disorder. Recognizing and treating these patients are challenges for physicians because the symptoms of the two disorders often overlap. Administration of effective treatment, comprising both anxiolytic and antidepressant effects, can reduce patient distress and disability, as well as inappropriate utilization of medical services. Medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors, nefazodone, venlafaxine XR (extended release) and mirtazapine, are highly effective in treating comorbid depression and anxiety. These newer agents now represent the pharmacotherapeutic treatments of choice for the comorbid conditions.     

PCI术前术后的心理障碍识别与处理

概述冠心病经皮冠状动脉介入治疗（PCI）术前术后患者合并心理障碍的较高发生率以及心理障碍对冠心病发生、发展及预后的影响,分析 PCI 术前术后患者出现焦虑抑郁等心理障碍的原因、产生机制及影响因素,强调心内科医生应及时识别 PCI 术前术后患者出现的心理障碍,并以“双心医学”方式对其进行心理精神医学及心血管专科医学治疗,同时对心血管专科医学治疗效果不明显的冠心病 PCI 患者,进行相关的鉴别诊断后也要进行心理精神医学的诊断和治疗,以便有利于 PCI 术患者的康复和预后,减少不必要的检查和治疗。     

Factor Structure of the Illness Intrusiveness Rating Scale in Patients Diagnosed with Anxiety Disorders

The Illness Intrusiveness Rating Scale (IIRS) is a measure designed to assess the impact of illness on various domains of functioning (G. M. Devins, 1994). In anxiety disordered patients, illness intrusiveness ratings are higher than those of chronically ill medical patients, suggesting that the IIRS may have a different underlying structure in a sample of individuals with anxiety disorders. To examine this possibility, IIRS items were submitted to an exploratory and confirmatory factor analysis in 2 samples (total N = 294). These solutions were compared to solutions in chronically ill populations from a previous study. In the exploratory analysis, both a one-factor and a three-factor solution were identified, accounting for 42 and 61% of the variance, respectively. Confirmatory analyses showed adequate similarity between the three-factor structure of the IIRS from a medically ill population and the current three-factor structure, suggesting that elevated IIRS scores in anxiety disordered samples cannot be explained simply by a different structure of the instrument.     

Holocaust survivors in a primary care setting: fifty years later

Past studies have not assessed the prevalence of emotional disturbances in Holocaust survivors seeking medical treatment in a family practice environment. The present study examined the prevalence of lifetime (the presence of symptomatology at any time) and current posttraumatic stress disorder (PTSD) symptoms, general anxiety, and depression in Holocaust survivors seeking medical treatment in a primary care setting. 20 of the 27 Holocaust survivors in our sample received a current diagnosis of PTSD and reported significant symptoms of depression and general anxiety. Although 74% of the survivors were currently diagnosed with PTSD, participants in this study had reported an overall decline in reexperiencing, hyperarousal, and overall PTSD symptoms but exhibited increased avoidance and numbing symptoms throughout the lifespan. These preliminary results suggest that removing avoidance as a defense mechanism during the course of psychotherapy may leave these survivors without an adequate way for coping with their trauma, subsequently increasing their vulnerability to psychopathology. Implications for psychological interventions are provided.     

CBT for Anxiety and Associated Somatic Complaints in Pediatric Medical Settings: An Open Pilot Study

Objective To examine the initial feasibility and potential efficacy of a cognitive-behavioral intervention for youth with anxiety disorders and non-medical somatic symptoms. Background Based on a strong relationship between somatic complaints and anxiety disorders, screening youngsters seeking medical care due to physical symptoms with no organic basis may enhance the recognition of anxiety disorders and facilitate access to appropriate services. Method Seven boys and girls, ages 8 through 15, with medically unexplained gastrointestinal complaints and anxiety disorders received a 12-session cognitive-behavioral intervention targeting anxiety and physical symptoms. Assessments were conducted at baseline and following treatment. Results All participants were classified as treatment responders. Three of the seven participants no longer met diagnostic criteria for their principal anxiety disorder. Children’s physical discomfort decreased from a moderate to minimal level based on self- and parent-reports. Conclusions Our modified cognitive-behavioral approach has promise for reducing anxiety and somatic symptoms in children seeking medical care.     

Factors that influence emotional disturbance in adults living in extreme poverty

Living in poverty conditions implies exposure to severe circumstances of social disadvantage, associated with greater propensity to contract illnesses. A negative correlation has consistently been observed between health and poverty. The chronic exposure to stress affects people's well-being through the development of symptoms of anxiety and depression. The suffering of these symptoms for a long time period may be considered as part of a more general syndrome of emotional disturbance, in detriment to a person's mental health. The objective of this study is to identify psychological factors that influence emotional disturbance, measured as symptoms of anxiety and depression, in adults living in poverty conditions in Mexico's central region. A total of 913 adults, 65.2% female, were surveyed. The mean age of the participants was 43.71 (±12.58) years and the mean number of years of schooling was 4.04 (±3.36). Variables corresponding to personal characteristics were measured. The results indicate that the most important risk factor for depression is anxiety and vice versa. Additionally, gender, negative self-esteem, lack of adequate strategies for confronting and resolving difficulties, and lack of self-regulation predicted depression, whereas stress, lack of self-regulation, and coping style predicted anxiety. These variables were better predictors than optimism, locus of control, sense of humor or religiosity.     

An Innovative Treatment Approach for Children With Anxiety Disorders and Medically Unexplained Somatic Complaints

Anxiety disorders in children and adolescents are largely undetected and the majority of youth do not receive services. Given the deleterious consequences of anxiety disorders, early identification and intervention have public health implications. In order to increase identification and treatment of anxious youth, expansion to nonpsychiatric settings (i.e., pediatric medical settings, schools) is necessary. Pediatric medical offices represent ideal settings for detection and intervention for several reasons: (1) access to large numbers of children, (2) high prevalence of unrecognized anxiety disorders in medical settings, and (3) an association between anxiety disorders and medically unexplained somatic symptoms. This paper describes a cognitive-behavioral intervention for youth who present to pediatric medical settings with nonmedical somatic symptoms and undiagnosed anxiety disorders. We explain the rationale for and focus of our treatment approach, present two case studies illustrating the treatment process, and conclude with a discussion of implementation considerations.     

Psychological frailness and strength in an AIDS-affected community: A study of seropositive gay men and voluntary caregivers

Addressed both the psychological frailness and strength in an AIDS-affected community. The gay community in Sydney, Australia, was represented by men who were seropositive (n = 60) and voluntary caregivers (n = 60). They were compared with two samples of men outside the gay community, who were ill with non-AIDS-related medical conditions (n = 30), and well (n = 30). Their psychological frailness and strength were measured by content analysis scales. Both the seropositive men and the caregivers showed the frailness of anxiety, indirectly expressed anger and helplessness, but also the compensating strength of greater personal competence and good feeling relative to the other men. The men who were seropositive or had other illnesses showed the predicted frailness of anxiety and depression but neither indirectly expressed anger nor helplessness. The seropositive men and caregivers of the gay community differed from each other only in the high levels of depression of the former.