Peter H Silverstone, MB, BS, Tania Lemay, BSc, Jasen Elliott, BSc, Vicky Hsu, BSc, and Rachel Starko, BSc
Objective:
To determine the prevalence of major depressive disorder in acutely ill medical inpatients, and the relationship of this to low self-esteem.
Method:
A total of 186 patients were interviewed 6 or 7 days following admission to detect the presence of DSM-IV major depressive disorder (MDD). Patients were assessed using a new brief psychiatric interview, the Silverstone Concise Assessment for Depression (SCAD), which has previously been validated for use in the physically ill. The cognitive function of the patients was measured, using the Mini-Mental State Examination (MMSE), with patients scoring less than 22 on the MMSE being excluded from the study. The patients' self-esteem was also assessed, using the Rosenberg self-esteem rating scale. The severity and type of the patients' medical illness, and the recognition of psychiatric illness by both nurses and physicians were also noted.
Results:
The results showed that 18 patients (9.7%) were depressed. The depressed patients were significantly younger than the nondepressed patients (mean age 46.3 3.9 years versus 57.1 1.5 years, respectively) and were significantly more likely to be female (61% versus 44%, respectively). The depressed patients had a significantly lower self-esteem than the nondepressed patients, whose self-esteem was no different from the general population. However, the depressed patients were not more severely ill than the nondepressed patients. The results also demonstrated that both nurses and physicians were poor at recognizing the presence of major depression, with nurses recognizing 33% of cases compared to 22% for medical staff.
Conclusions:
The results from this study demonstrate that while there is an increase in the incidence of depression in medically ill patients, this is not as great as has been previously reported, and is not related to severity of illness. The results from this study, therefore, are in keeping with other recent findings which show that the prevalence rates for MDD in medical patients is between 5% to 10%, rather than the previously accepted range of 20% to 40%.
(Can J Psychiatry 1996;41:67-74)
Joel Paris, MD
Objective:
To propose an etiological model of antisocial personality disorder that is grounded in empirical data.
Method:
Recent research findings are reviewed that clarify our understanding of the etiology and course of antisocial pathology.
Results:
Neither biological nor psychological factors fully account for the development of this disorder. Epidemiological studies show that there are strong cross-cultural differences in its prevalence, pointing to the importance of social factors in its etiology. Outcome research shows that antisocial personality only partially remits with time, and that most patients continue to be dysfunctional in later life. No treatment modality has been shown to be effective.
Conclusions:
All these empirical findings can be accounted for by a biopsychosocial model of antisocial personality disorder.
(Can J Psychiatry 1996;41:75-80)
Robert van Reekum, MD, Paul S Links, MD, M Janice E Mitton, RN, BA, MHSc, Cecilia Fedorov, RN, and Jayne Patrick, PhD, C Psych
Objective:
To replicate previous research suggesting that impulsivity highly predicts current DIB(R) score and social functioning, with the additional inclusion of other measures, including defensive functioning.
Method:
Correlational analyses between impulsivity and other measures, and regression analyses with DIB(R) and SAS-SR as outcome measures, and impulsivity and other measures as predictor variables, were performed on data derived from n = 57 initially borderline personality disorder (BPD) subjects recruited as part of a 7-year follow-up study of BPD.
Results:
Data showed strong correlations between the elements of impulsivity described previously and defensive functioning. The initial study results were repeated, and only a minor contribution from defensive functioning additionally contributed to the regression models. No other variables entered the model, unless anger was dropped from the variables entered into the analysis.
Conclusions:
The results may contribute to a better definition of the term "impulsivity" as related to BPD, and may lead to further, improved research into the cause, treatment, and prognosis of BPD.
(Can J Psychiatry 1996;41:81-84)
Graham Bean, PhD, Shizuhiko Nishisato, PhD, Neil A Rector, DPhil, and Graham Glancy, MB
Objective:
To compare physicians' judgements of competency in routine clinical practice with the findings obtained from a structured clinical interview.
Methods:
Ninety-six patients referred for electroconvulsive therapy were administered the Competency Interview Schedule (CIS) prior to their first treatment. Cluster analysis was employed to categorize patients to 1 of 5 cluster centres represented by case studies previously judged competent or incompetent by lawyers and health professionals.
Results:
A match-mismatch table revealed 88% (N = 66) of the 75 patients found competent by the attending physician and 90.5% (N = 19) of the 21 patients found incompetent by the attending physician were classified in agreement with the CIS. The 9 misclassified patients found competent by the attending physician but classified incompetent by the CIS had consented to treatment. The 2 misclassified patients found incompetent by the attending physician but classified competent by the CIS had refused treatment. Examination of individual item scores from the CIS indicated that, in some cases, a different standard of competency was applied in routine clinical practice depending upon the patient's treatment decision.
Conclusions:
The CIS is presented as a useful guide for clinicians with an interest in competency evaluations but caution is advised in using the instrument to make formal evaluations of competency owing to the imprecise definition of competency in various jurisdictions.
(Can J Psychiatry 1996;41:85-92)
Cameron A Mustard, ScD, Shelley Derksen MSc, and Douglas Tataryn PhD
Objective:
To describe the profile of the intensive use of mental health services over a 4-year period in a population of 1.1 million people.
Methods:
Data obtained from computerized hospital separation records and physician reimbursement claims were combined to form patient-based histories of mental health care utilization. Users of mental health services in a 24-month period were hierarchically classified as having a psychotic disorder (ICD-9-CM 295-299) or a nonpsychotic disorder (ICD-9-CM 300-301, 306-309, 311). Intensive use was defined as 12 or more contact months or a minimum of 2 episodes of therapy in the 24-month period. The cohort of intensive users were followed over the subsequent 24-month interval to describe the persistence of intensive use.
Results:
In the initial observation period, intensive users constituted 27.4% of individuals in treatment for psychotic disorder and 4.4% of persons in treatment for nonpsychotic disorder. These 2 groups, which represent 7.4% of all users of mental health care, were responsible for 53% of physician services, 72.7% of contacts with psychiatrists, and 64.4% of acute psychiatric bed days in the initial period. In the follow-up period, intensive use status was replicated by 44.6% of the cohort.
Conclusions:
The diagnostic and therapeutic characteristics of intensive users of mental health services are heterogeneous. There is substantial persistence of intensive mental health service use over time.
(Can J Psychiatry 1996;41:93-101)
Amanda Johnson, MD, R Michael Giuffre, MD, and Keiran O'Malley, MD
Objective:
To determine if there is an altered pattern of cardiac electrical activity in children treated with tricyclic antidepressants, desipramine, or imipramine, which may predispose these patients to sudden death.
Methods:
All patients in a child psychiatry practice from 1989 to 1993 in Calgary, Alberta, treated with desipramine or imipramine with both pre- and post-treatment electrocardiograms (ECGs) were included in the study (n = 21; ages 8 to 17years). Thirty-six blinded post-treatment ECGs were analysed for interval measurement and compared to the pre-treatment ECGs.
Results:
Drug dosages ranged from 25mg to 125 mg per day and treatment duration ranged from 1to 49 months. Seven of 21 patients were concurrently receiving an antipsychotic medication (pericyazine). The maximal increase in PR, and QRS, and QT interval changes were 40 msec and 70 msec, respectively, with most patients demonstrating no significant changes in the ECG intervals. The QT interval was corrected for heart rate (QTc). No significant arrhythmias or tachycardias were observed. ECG interval changes were not related to drug dosage, age, treatment duration or plasma levels.
Conclusions:
No consistent pattern of ECG interval changes including the QTc interval was observed in children on desipramine and imipramine.
(Can J Psychiatry 1996;41:102-106)
James D Mendonca, PhD, Varadaraj R Velamoor, MB, and Danielle Sauve, MA
Objective:
To identify contributory factors of elder abuse by caregivers in home settings.
Method:
Using a reliable instrument, visiting nurses rated observations symptomatic of abuse and neglect found in their current caseload of elderly patients. Their observations were also classified as related or unrelated to wilful maltreatment.
Results:
Regression analysis produced the following significant findings: 1. signs of poor physical care were found to be predictors of physical abuse; 2. signs of psychosocial distress and exploitation were identified as predictors of emotional abuse; 3. defensiveness and irritability shown by caregivers and strained family relationships, in general, were also associated with abuse.
Conclusion:
It appears that emotional abuse is more prevalent than, and not a necessary precursor of, physical abuse; however, reliable signs of impending or actual abuse of the elderly can be found in a home during visitation.
(Can J Psychiatry 1996;41:107-113)
Philippe Cappeliez, PhD, Marie Quintal, MD, Mariette Blouin, BA, Serge Gagné, MD, Anne Bourgeois, Michel Finlay, MD, et Andrée Robillard, MD
Objective:
This research evaluates the psychometric properties of the French version of the Modified Mini-Mental State (3MS), an instrument for the screening of dementia, in a sample of patients seen in geriatric psychiatry.
Methods:
Subjects (N = 94, 63 to 93 years of age) were outpatients of a service in geriatric psychiatry. In addition to the 3MS, a battery of tests evaluating the cognitive functioning and depressive symptomatology was administered.
Results:
Test-retest reliability coefficient was 0.87 for a subsample of 35subjects. An exploratory factor analysis revealed 4 factors accounting for 63.2% of the variance. Cut-off scores of 79 to 80 (with years of education 8) and 71 to 72 (with years of education 7) presented the best combination sensitivity/ specificity, respectively 0.80 and 0.96.
Conclusions:
This study documents the psychometric properties of the French version of the 3MS for use in patients seen in geriatric psychiatry, in suggesting cut-off scores which take into account the level of education. This study underlines the influence of sociodemographic variables on test performance.
(Can J Psychiatry 1996;41:114-121)