Generalizability of antidepressant efficacy trials.
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Antidepressive Agents↗
Biomedical subjects
Mark Zimmerman
Publications and source records attributed to Mark Zimmerman.
How accurate are patients in reporting their antidepressant treatment history?
BACKGROUND: A patient's report of their antidepressant treatment history is one of the most important pieces of information used in selecting an antidepressant regimen. It is currently unknown how accurate patients are in describing and characterizing their antidepressant treatment history. METHODS: Seventy-three patients receiving treatment for depression at our outpatient psychiatric practice were interviewed by an independent evaluator who was blind to each patient's treatment history. Information was obtained regarding which antidepressant and augmentation regimens patients had undergone, antidepressant doses, duration of trials, and the nature of response to each trial. The results of these interviews were then compared with patients' actual treatment history as elicited from an independent chart review. RESULTS: Patients recalled 85 of the 104 (81.7%) monotherapy trials they had undergone in the past 5 years, but only recalled 12 of 46 (26.1%) augmentation trials (P<0.001). Patients were found to be very reliable in distinguishing between those trials that were of adequate dose and duration and those that were not. Patients were also generally reliable in depicting the quality of response to past trials, though patient report of a past negative trial was significantly more reliable than a report of a past positive trial. The presence of current depressive symptomatology did not adversely affect patients' ability to recall past trials or accurately describe their responses to past regimens. LIMITATIONS: All patients were treated by a single psychiatrist, and all trials occurred within the last 5 years. CONCLUSION: Patients are able to recall the majority of monotherapy trials they have undergone, but have great difficulty remembering when two medications were taken concurrently, i.e. augmentation trials. Patient report appears to be a satisfactory method to obtain information regarding trial adequacy and response in most, but not all instances.
Adult↗
Pathological worry in depressed and anxious patients.
Anxious apprehension is present in all anxiety disorders and concerns have been raised that worry is not confined to Generalized Anxiety Disorder (GAD). The aims of the present project were three-fold. First, we reexamined whether the level of pathological worry is higher in patients with GAD than other anxiety disorders. Second, we compared worry scores of patients with "pure" GAD, "pure" MDD, and MDD with comorbid GAD. And third, to examine whether worry is specific to psychopathology in general rather than anxiety or depression, we included a control group (psychiatric outpatients without an affective or anxiety disorder). Twelve hundred outpatients were interviewed and completed the Penn State Worry Questionnaire (PSWQ) upon presentation for treatment. Patients with "pure" GAD had the highest scores. Depressed patients were similar to those with anxiety disorders other than GAD, and the control group showed worrying similar to that in general population and nonanxious samples.
Adolescent↗
The clinical relevance of a partial remission specifier for posttraumatic stress disorder.
The clinical relevance of a partial remission specifier for posttraumatic stress disorder (PTSD) was examined. Using a subgroup of outpatients from the Rhode Island Methods to Improve Diagnostic Assessment and Services project who met criteria for lifetime PTSD (N = 261), participants with current PTSD, PTSD in partial remission, and PTSD in full remission were compared on various indices of impairment. A substantial number (n = 75) of patients met criteria for PTSD in partial remission (28.7%). Outpatients in partial remission of PTSD displayed comparable levels of social and employment functioning as those with current PTSD, and over half of these patients requested treatment for their symptoms. Results support the clinical utility of a partial remission specifier for PTSD.
Adolescent↗
A taxometric study of borderline personality disorder.
Taxometric methodology was used to determine whether borderline personality disorder (BPD) represents a taxon that is categorically distinct from normal personality or whether it falls on a dimensional continuum with normality. Two taxometric procedures were used with a sample of 1,389 outpatients assessed for BPD symptoms by semistructured interview. The procedures indicated that BPD does not represent a latent category. Implications are drawn for the conceptualization and etiology of BPD, and for the categorical versus dimensional status of personality disorders in general.
Adult↗
Screening for principal versus comorbid conditions in psychiatric outpatients with the Psychiatric Diagnostic Screening Questionnaire.
In examining the performance of screening scales, a distinction should be made between principal and additional diagnoses. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong self-report scale designed to screen for the most common Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) Axis I disorders encountered in outpatient mental health settings. In the present report, the authors compared the performance of the PDSQ in identifying principal and comorbid disorders. Seven hundred ninety-nine psychiatric outpatients completed the PDSQ and were interviewed with the Structured Clinical Interview for DSM-IV. The sensitivity and negative predictive values of the PDSQ subscales were similar for principal and additional diagnoses.
Adolescent↗
What should the standard of care for psychiatric diagnostic evaluations be?
Recent research has raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice. Semistructured diagnostic interviews have been considered the diagnostic gold standard. Judged against this standard, studies comparing unstructured clinical evaluations with semistructured interviews have found that there is a high rate of missed diagnoses and misdiagnosis using the usual clinical assessment. Whether this is clinically significant is uncertain because there are no studies that have examined whether the use of standardized research interviews improves clinical outcome. Based on common sense, however, it seems reasonable that greater diagnostic precision will improve outcome. More complete and accurate diagnostic evaluations may impact on patients' satisfaction with the diagnostic assessment, alliance with the treating clinician, selection of medication, or recommendation for psychotherapy. Additionally, improved diagnostic practice may be a better predictor of course and outcome, another important function of diagnosis. In the meantime, until studies are conducted to determine whether standardized research-like evaluations improve outcome or the prediction of outcome, clinicians may want to consider whether one of the recently developed broad-based self-administered diagnostic screening questionnaires could be a useful adjunct to their unstructured diagnostic interview. The results of recent work on the Psychiatric Diagnostic Screening Questionnaire (PDSQ) are summarized.
Comorbidity↗
Generalized anxiety disorder in patients with major depression: is DSM-IV's hierarchy correct?
OBJECTIVE: DSM-III imposed a hierarchical relationship in the diagnosis of anxiety disorders in depressed patients, stipulating that anxiety disorders could not be diagnosed if their occurrence was limited to the course of a mood disorder. In the subsequent versions of the DSM this hierarchy was eliminated for all anxiety disorders except generalized anxiety disorder. The authors examined the validity of this remaining hierarchical relationship between mood and anxiety disorders. METHOD: Psychiatric outpatients with major depressive disorder (N=332) were evaluated with a semistructured diagnostic interview and completed paper-and-pencil questionnaires on presentation for treatment. To study the validity of the DSM-IV hierarchical relationship between generalized anxiety disorder and mood disorders, the authors made a diagnosis of modified generalized anxiety disorder for patients with major depressive disorder who met all the criteria for generalized anxiety disorder except for the exclusion criterion. The analyses compared the characteristics of three nonoverlapping groups of patients with DSM-IV major depressive disorder: 1) those with coexisting DSM-IV generalized anxiety disorder, 2) those with coexisting modified generalized anxiety disorder, and 3) those with neither DSM-IV nor modified generalized anxiety disorder. RESULTS: Compared to the depressed patients without generalized anxiety disorder, the depressed patients with DSM-IV and modified generalized anxiety disorder had higher levels of suicidal ideation; poorer social functioning; a greater frequency of other anxiety disorders, eating disorders, and somatoform disorders; higher scores on most subscales of a multidimensional self-report measure of DSM-IV axis I disorders; a greater level of pathological worry; and a higher morbid risk for generalized anxiety disorder in first-degree family members. The two generalized anxiety disorder groups did not differ from each other. CONCLUSIONS: The findings question the validity of the DSM-IV hierarchical relationship between major depressive disorder and generalized anxiety disorder and suggest that the exclusion criterion should be eliminated.
Adolescent↗
The construct validity of depressive personality disorder.
This study examined the construct validity of depressive personality disorder (DPD: American Psychiatric Association, 1994). Adult psychiatric outpatients (N = 900) underwent comprehensive Axis I and II evaluations and provided data on 4,768 of their 1st-degree relatives. Despite modest overlap, DPD was not redundant with any Axis I or II disorder. Participants with DPD exhibited more Axis I and Axis II comorbidity, and greater psychosocial dysfunction, than participants without DPD. Relatives of participants with DPD had higher rates of mood disorders, alcohol abuse, and antisocial personality. Results are consistent with findings of several other similar investigations. The authors argue that DPD is a valid construct and should be conceptualized as a personality disorder as opposed to a mood disorder.
Adult↗
Update on the diagnosis and treatment of depression.
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Depression↗
Lack of association between seasonality and psychopathology in psychiatric outpatients.
There exists an extensive literature documenting the impact of seasonality on rates of depression, atypical depression, bulimia, and suicide. In the present report drawn from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reviewed the results of 1500 diagnostic evaluations of patients who presented to our psychiatric outpatient practice between 1995 and 2001. We sought to determine whether seasonal fluctuations in psychopathology were discernible at the level of how patients present for psychiatric treatment. Contrary to our hypotheses, we did not find (1) higher rates of onset of major depressive disorder in the spring and fall, (2) higher rates of depressive symptoms or rates of atypical depression in the winter, (3) higher rates of bulimia in the winter, or (4) higher rates of suicidal ideation in the spring. We conclude from these results that the association between seasonality and psychopathology may not be discernible at the level of presentations to an outpatient psychiatric practice.
Adult↗
Case identification of depression with self-report questionnaires.
Many self-report measures that are used to identify cases of depression are symptom severity measures that are adopted for diagnostic purposes by use of cutoff scores. A troublesome problem with this approach is that optimal cutoff scores often vary across studies, which increases the difficulty of cross-study comparisons. This study evaluated the performance of a DSM-IV based depression screening scale, the Diagnostic Inventory for Depression. We compared the diagnostic performance of two different approaches to scoring the DID: a cutoff scoring approach and a standardized DSM-IV symptom-summation algorithm. Clinical diagnosis based on a semi-structured interview was the standard of comparison. Receiver operating characteristic (ROC) analysis indicated that a DID cutoff score performed comparably to the DID algorithmic approach in identifying cases. This finding is in contrast to prior research which suggested that algorithmic approaches might improve test performance over the cutoff score approach. The manner by which a user might choose the appropriate scale-scoring method for case identification is discussed.
Adolescent↗
Partial validation of the atypical features subtype of major depressive disorder.
BACKGROUND: Symptoms of the atypical features subtype of major depressive disorder include mood reactivity, hypersomnia, hyperphagia, leaden paralysis, and rejection sensitivity. This subtype was introduced into the mood disorders section of the DSM-IV following a series of antidepressant trials showing that such patients responded preferentially to monoamine oxidase inhibitors. Studies aimed at validating the atypical features subtype have yielded inconsistent results. Our study sought to reevaluate the validity of atypical depression by examining the demographic and clinical features of a large cohort of depressed patients who met DSM-IV criteria for atypical features. METHODS: We evaluated 579 psychiatric outpatients with a current diagnosis of major depressive disorder for the presence of atypical features. Detailed demographic and clinical information was obtained for each patient through semistructured interviews. Using the available literature, we made a series of a priori hypotheses regarding how depressed patients with atypical features (n = 130) would differ from those without atypical features (n = 449). In addition, we tested the strength of the associations between each of the 5 atypical symptoms. RESULTS: Although many of the predicted hypotheses were substantiated, an equal number were not. Correlation analyses revealed modest associations between several of the atypical symptoms, but mood reactivity was not associated with any of the other symptom criteria. CONCLUSION: Our results provide partial support for the validity of the atypical features subtype of major depressive disorder.
Adult↗
The effectiveness of switching antidepressants during remission: a case series of depressed patients who experienced intolerable side effects.
BACKGROUND: It is unknown whether depressed patients who have experienced intolerable side effects to one antidepressant can safely and effectively be switched to a second antidepressant while the depressive disorder is in remission. The present study sought to determine the viability of such a strategy. METHODS: All subjects were psychiatric outpatients who were treated in an open-label manner according to standard clinical practice. From an initial cohort of approximately 200 patients with major depressive disorder, 9 had their antidepressant switched while in remission because of intolerable side effects. Their subsequent course was prospectively assessed at each follow-up visit using Standardized Clinical Outcome Ratings and the Clinical Global Impression-Improvement scale. RESULTS: Patients were prospectively followed for 8 to 110 weeks (median, 30 weeks) subsequent to the initiation of the second antidepressant trial. Switching antidepressants effectively eliminated the problematic side effects in all 9 cases. No relapses occurred during the second antidepressant trial. CONCLUSION: The present study provides preliminary evidence that switching antidepressants while in remission may be a safe and effective strategy for managing antidepressant-induced side effects. LIMITATIONS: Our findings are limited by the small sample size, lack of control group, and short follow-up periods in some cases.
Adult↗
Rapid onset of pathological gambling in machine gamblers.
A particularly rapid onset of pathological gambling (PG-onset) through the use of gambling machines has been widely alluded to, but this is the first study to empirically examine the phenomenon. This study compared the latency of PG-onset in those who gambled primarily on machines, compared to those who gambled primarily on more "traditional" forms of gambling at PG-onset. Subjects were 44 adult pathological gamblers (PGs) seeking outpatient treatment in Rhode Island (17 females; mean age = 46.9). Subjects completed questionnaires and a diagnostic interview including a complete history of gambling activities and the course of PG. The "latency" of PG-onset was defined as the time (in years) elapsed between the age of regular involvement in the primary form of gambling and the age at which DSM-IV criteria were first met. "Machine" PGs (n = 25) had a significantly shorter latency of onset than did "traditional" PGs (1.08 years vs. 3.58 years). Females and machine PGs had a significantly older age of onset, but gender was not associated with latency of PG-onset. Lifetime comorbidity of either substance use disorders (SUDS) or depressive disorders (DDS) was also not associated with the latency of PG-onset. The results of the current study suggest that intrapersonal variables such as gender and comorbid disorders do not generally affect the speed with which people develop PG. Rather, the social, environmental, and stimulus features of mechanized gambling are implicated. Prospective longitudinal studies on the onset and course of PG are needed, as well as more basic research on the features of machine gambling that may contribute to rapid onset.
Adult↗
Screening for posttraumatic stress disorder in a general psychiatric outpatient setting.
Posttraumatic stress disorder (PTSD) may affect survivors of a number of accidents and illnesses, in addition to violence victims and combat veterans. Prior research suggests that PTSD may be underdiagnosed when trauma is not the presenting problem. Thus, a PTSD screening scale might have utility in routine clinical settings. The authors evaluated the screening performance of the Posttraumatic Diagnostic Scale (PDS) in a general psychiatric setting. Results indicated that the PDS performed as well in this setting as it did in the original trauma-focused validation studies, independent of PTSD status as a primary, versus secondary, reason for presenting. A simple cutoff score was adequate for case identification. There were no gender effects, and the scale performed equally well among patients with, versus without, a depressive diagnosis.
Adolescent↗
Screening for trauma histories, posttraumatic stress disorder (PTSD), and subthreshold PTSD in psychiatric outpatients.
The ability of the Structured Clinical Interview for DSM-IV (SCID) posttraumatic stress disorder (PTSD) module's screening question to identify individuals with PTSD or subthreshold PTSD was examined. First, the screen's sensitivity for detecting a trauma history was determined. Second, the incremental validity of a more thorough trauma assessment was examined by determining how many individuals responded negatively to the screen but then were diagnosed with PTSD or subthreshold PTSD. Last, the optimal SCID termination point for assessing subthreshold PTSD was determined. Using a trauma list increased the number of participants reporting a trauma; however, the SCID screen captured almost all individuals who had PTSD or subthreshold PTSD. When one screens for subthreshold PTSD, the SCID can be terminated on failure to meet Criterion B.
Adolescent↗
Symptom severity and exclusion from antidepressant efficacy trials.
It is the standard practice in antidepressant efficacy trials (AETs) to exclude potential participants with major depressive disorder (MDD) who score below a threshold on the Hamilton Rating Scale for Depression (HAM-D). It is unknown to what extent various cutoff scores impact on the generalizability of these trials. In the present report, we sought to determine how many patients with MDD presenting to an outpatient practice would fail to qualify for an AET because their symptoms were not sufficiently severe, and to what extent the variability in HAM-D cutoff scores impacts exclusion rates. Fifteen hundred individuals presenting for an intake at a psychiatric outpatient practice underwent an evaluation with semistructured diagnostic interviews. Five hundred and three patients received a principal diagnosis of nonbipolar, nonpsychotic MDD. Thirty-nine AETs published in five leading journals during the past 7 years were reviewed, 36 of which required a minimum score on the HAM-D for inclusion. We applied the HAM-D cutoffs used in these AETs to the 503 depressed patients to determine how many would qualify for each AET. Based on the least and most restrictive cutoff scores, between 11.3% and 71.0% of the depressed patients from our practice had an insufficient HAM-D score to qualify for an AET. The two most commonly used cutoff scores would lead to the exclusion of almost half of our sample. AETs tend to include the subset of depressed individuals with moderate to severe MDD and exclude a significant proportion of depressed patients who have mild MDD. The implications of these findings are discussed.
Adult↗