Social phobia: still a neglected anxiety disorder?
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Adult↗
Biomedical subjects
Mark Zimmerman
Publications and source records attributed to Mark Zimmerman.
Psychiatric patients' vulnerability in the wake of the September 11th terrorist attacks.
The September 11, 2001 (9/11) terrorist attacks led to speculation about the vulnerability of psychiatric patients to psychological distress following such events. This study examined the impact of national terrorist attacks on psychiatric and medical outpatients living approximately 150 to 200 miles from the attack sites (N = 308). Two to 3 weeks following 9/11, patients were given questionnaires assessing background information, healthcare service utilization, and posttraumatic stress disorder (PTSD) symptoms. Psychiatric patients (33%) were significantly more likely than medical patients (13%) to report distressing symptoms meeting criteria for PTSD (except for the duration criterion) despite no differences in learning about the attacks or personal involvement with the victims. Patients meeting PTSD criteria were more likely to schedule an appointment to speak with their physician about their reactions. Psychiatric patients not directly impacted by the 9/11 terrorist attacks are at increased risk for experiencing distressing symptoms following national terrorist attacks.
Adult↗
Is comorbidity of posttraumatic stress disorder and borderline personality disorder related to greater pathology and impairment?
OBJECTIVE: The authors examined whether patients with comorbid borderline personality disorder and posttraumatic stress disorder (PTSD) have a more severe clinical profile than patients with either disorder without the other. METHOD: Outpatients with borderline personality disorder without PTSD (N=101), PTSD without borderline personality disorder (N=121), comorbid borderline personality disorder and PTSD (N=48), and major depression without PTSD or borderline personality disorder (N=469) were assessed with structured interviews for psychiatric disorders and for degree of impairment. RESULTS: Outpatients with diagnoses of comorbid borderline personality disorder and PTSD were not significantly different from outpatients with borderline personality disorder without PTSD, PTSD without borderline personality disorder, or major depression without PTSD or borderline personality disorder in severity of PTSD-related symptoms, borderline-related traits, or impairment. CONCLUSIONS: The additional diagnosis of PTSD or borderline personality disorder does little to augment the pathology or dysfunction of patients who have either disorder without the other.
Adult↗
A reevaluation of the exclusion criteria used in antidepressant efficacy trials.
OBJECTIVE: Antidepressant efficacy trials use multiple exclusion criteria that are intended primarily to maximize differences between the drug and placebo. These exclusion criteria were implemented prior to having undergone rigorous testing, however, and it is unclear whether they accomplish their intended goal. The authors review the current state of knowledge about treatment response rates in individuals who are typically excluded from antidepressant efficacy trials. METHOD: After reviewing 31 antidepressant efficacy trials published between 1994 and 1998, the authors identified 10 commonly used exclusion criteria. A computerized MEDLINE search and a manual search were used to identify studies evaluating the efficacy of antidepressant medications in populations of subjects typically excluded from antidepressant efficacy trials. RESULTS: Three exclusion criteria-short episode duration, mild severity of illness, and positive response during the placebo lead-in phase-are used primarily to reduce placebo response rates. Preliminary evidence suggests that, of those three criteria, only a short episode duration has been associated with less robust differences between drug and placebo response rates. The seven other exclusion criteria, including various psychiatric comorbidities, long duration of illness, medical comorbidity, and prior nonresponse to treatment, are used because individuals who meet those criteria are believed to have lower response rates to somatic therapy. Although such individuals are often found to have lower response rates to somatic therapy, they also appear to have lower response rates to placebo, and there is little evidence to suggest that drug-placebo differences are any less robust in these individuals. CONCLUSIONS: Many of the standard exclusion criteria currently used in antidepressant efficacy trials may not be achieving their intended goal of maximizing drug-placebo differences. The practice of excluding subjects with particular clinical profiles, which greatly reduces the generalizability of antidepressant efficacy trials, appears to lack empirical support.
Adult↗
Are subjects in pharmacological treatment trials of depression representative of patients in routine clinical practice?
OBJECTIVE: The methods used to evaluate the efficacy of antidepressants differ from treatment for depression in routine clinical practice. The rigorous inclusion/exclusion criteria used to select subjects for participation in efficacy studies potentially limit the generalizability of these trials' results. It is unknown how much impact these criteria have on the representativeness of subjects in efficacy trials. This study estimated the proportion of depressed patients treated in routine clinical practice who would meet standard inclusion/exclusion criteria for an efficacy trial. METHOD: A total of 803 individuals, aged 16--65 years, who were seen at intake at an outpatient practice underwent a thorough diagnostic evaluation, including the administration of semistructured diagnostic interviews; 346 patients had current major depression. Common inclusion/exclusion criteria used in efficacy studies of antidepressants were applied to the depressed patients to determine how many would have qualified for an efficacy trial. RESULTS: Approximately one-sixth of the 346 depressed patients would have been excluded from an efficacy trial because they had a bipolar or psychotic subtype of depression. The presence of a comorbid anxiety or substance use disorder, insufficient severity of depressive symptoms, or current suicidal ideation would have excluded 86.0% (N=252) of the remaining 293 outpatients with nonpsychotic unipolar major depressive disorder from an antidepressant efficacy trial. CONCLUSIONS: Subjects treated in antidepressant trials represent a minority of patients treated for major depression in routine clinical practice. These results show that antidepressant efficacy trials tend to evaluate a subset of depressed individuals with a specific clinical profile.
Adolescent↗
Integrating outcomes research into clinical practice.
A cohort of 102 psychiatric outpatients with major depressive disorder were followed up for about two years. Prospective ratings were obtained at each medication management visit with two instruments that measured changes in symptoms. The mean time to recovery was very similar to that reported in the National Institute of Mental Health's Collaborative Depression Study. This finding supports the validity of using brief instruments to measure outcomes in routine clinical practice.
Adult↗
Borderline personality disorder and age of onset in major depression.
In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we tested the hypothesis that borderline personality disorder (BPD) accounts for the observed differences between early and late onset major depressive disorder (MDD). A total of 440 depressed outpatients were evaluated with semistructured interviews. Patients were subdivided by age of onset and the presence or absence of comorbid BPD. The overall pattern of clinical and demographic variables differed and two separate, multiple, logistic regression analyses addressed the association between age of onset and BPD in MDD patients. Comorbid BPD was not significant in the multivariable age of onset equation and the results of the multivariable analyses support the idea of difference between subtypes. It is concluded that although early age of onset is predictive of BPD, BPD is not a universal feature of early-onset MDD.
Adult↗
The role of gender in the clinical presentation of patients with borderline personality disorder.
This study examined gender differences in the pattern of comorbid disorders and degree of impairment among outpatients with borderline personality disorder (BPD). A total of 130 outpatients with BPD were assessed for various lifetime impulse-related disorders and post-traumatic stress disorder and for indices of impairment. Compared with women with BPD, men with BPD reported significantly more lifetime substance abuse disorders, antisocial personality and met criteria of intermittent explosive disorder that did not overlap with a diagnosis of BPD. Women with BPD reported significantly more lifetime eating disorders than men with BPD. No gender differences were found in degree of overall impairment. These results suggest that male and female patients with BPD, although equally distressed, present with different lifetime patterns of impulse-related disorders.
Adult↗
Personality disorders and the duration of depressive episode: a retrospective study.
In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the relationship between chronicity of depression and personality disorders. Three hundred and eighty-five depressed outpatients were evaluated with semi-structured interviews. Duration of depression was analyzed as a continuous variable, and by subdividing patients by the DSM-IV (APA, 1994) chronic specifier (i.e., more or less than 2 years). Two separate regression analyses addressed the association between major depressive episode duration and each of the ten personality disorders found on Axis II. Although there was some difference between particular personality disorders associated with the two indicators of depressive duration, the results of the regression analyses indicate that the chronicity of depression is associated with personality disorders.
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An open-label study of citalopram in the treatment of pathological gambling.
BACKGROUND: This study evaluated the effectiveness of citalopram in the treatment of pathological gambling. METHOD: Fifteen adult pathological gamblers (DSM-IV criteria) were administered citalopram in an open-label fashion for up to 12 weeks. Subjects were rated at baseline and at 2-week intervals on measures of gambling severity and depression, and monthly on quality of life. RESULTS: Patients reported significant (p < .05) improvements on all gambling measures including the number of days gambled, the amount of money lost gambling, preoccupation with gambling, and urges to gamble. Thirteen (86.7%) of the patients were rated as "much improved" or "very much improved" on a clinician-rated Clinical Global Impressions scale for gambling. Patients reported improvement in depression and overall quality of life. Patients with major depressive disorder (MDD) (N = 8) improved to approximately the same degree as patients without MDD (N = 7). For most patients, clinical improvement occurred during the first 2 weeks of treatment; for the 9 patients who completed the entire 12-week trial, these gains were maintained. CONCLUSION: Citalopram appears to be an effective treatment for pathological gambling, and this benefit was independent of its antidepressant properties. Future studies employing a control group will be important to examine the extent of the response to nonspecific factors of treatment.
Adolescent↗
Major depressive disorder and axis I diagnostic comorbidity.
BACKGROUND: Recognition of comorbid conditions in patients presenting for the treatment of depression is clinically important because the presence of other disorders can influence treatment planning. In the present study, we examined the frequency of diagnostic comorbidity in psychiatric outpatients presenting for treatment of nonbipolar major depressive disorder (MDD) and patients' desire for treatment for the comorbid disorders. METHOD: Four hundred seventy-nine psychiatric outpatients with DSM-IV nonbipolar MDD were evaluated with a modified version of the Structured Clinical Interview for DSM-IV. RESULTS: Excluding nicotine dependence, at the time of the evaluation 64.1% (N = 307) of the patients met criteria for at least 1 of the 23 specific Axis I disorders, and more than one third (36.7%, N = 176) had 2 or more disorders. Anxiety disorders, as a group, were the most frequent current comorbid disorders (56.8%), and social phobia was the most frequent individual disorder. Including subthreshold conditions, the percentage of patients with at least 1 disorder increased to 73.5%. When the scope of assessment was expanded to include nicotine dependence, nicotine dependence was the most frequent lifetime individual disorder (38.2%) and the second most frequent current disorder (27.3%). There was considerable variability among the disorders regarding desire for treatment of the comorbid condition. CONCLUSION: The majority of nonbipolar depressed patients have a current comorbid disorder, especially an anxiety disorder, although the actual rate of comorbidity depends on the breadth of the assessment.
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Anger and aggression in psychiatric outpatients.
BACKGROUND: This study sought to evaluate the degree of anger and aggression experienced by psychiatric outpatients and to determine whether anger is as prominent an emotional state in these patients as are depression and anxiety. We also sought to determine which Axis I and Axis II disorders were associated with increased rates of subjective anger and aggressive behavior. METHOD: 1300 individuals presenting to a psychiatric outpatient practice underwent semistructured interviews to evaluate current DSM-IV Axis I (N = 1300) and Axis II disorders (N = 687). Levels of subjective anger and aggression during the preceding week were assessed in each patient, and the odds ratios were calculated for each disorder. A multiple regression analysis was performed to determine which psychiatric disorders independently contributed to the presence of subjective anger and aggressive behavior. RESULTS: Approximately one half of our sample reported currently experiencing moderate-to-severe levels of subjective anger, and about one quarter had demonstrated aggressive behavior in the preceding week. This level of anger was found to be comparable to the levels of depressed mood and psychic anxiety reported by our sample. Major depressive disorder, bipolar I disorder, intermittent explosive disorder, and cluster B personality disorders independently contributed to the presence of both anger and aggression. CONCLUSION: Anger and aggression are prominent in psychiatric outpatients to a degree that may rival that of depression and anxiety; it is therefore important that clinicians routinely screen for these symptoms.
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Outcome Following Electroconvulsive Therapy: A Comparison of Primary and Secondary Depression.
In a consecutive series of 117 depressed patients referred for electroconvulsive therapy, the 10 with secondary depression had significantly poorer outcomes according to three independently assessed measures-Hamilton rating scale score at discharge, global rating at discharge, and mean depressive symptom score during a 6-month follow-up.
Journal Article↗
Validity of a self-report depression symptom scale for identifying remission in depressed outpatients.
In treatment studies of depression, remission is usually defined by scoring less than a threshold value on an interview-based measure of depression severity such as the Hamilton Rating Scale for Depression (HRSD). Although it has been recommended that measures such as the HRSD be used by clinicians in clinical practice to evaluate remission status, the time demands of clinical practice limit the feasibility of this suggestion. Self-report questionnaires are a cost-effective option to thoroughly, systematically, reliably, and validly evaluate clinical status because they are inexpensive in terms of professional time needed for administration and do not require special training for administration. In a previous report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we derived a cutoff on a self-report depression questionnaire corresponding to the widely used definition of remission on the HRSD (ie, < or = 7). In the present report, we examined the validity of this questionnaire as an indicator of remission among patients who responded to antidepressant treatment. Specifically, we examined psychosocial functioning in treatment responders who were and were not in remission according to the self-report symptom scale. In a sample of 371 depressed outpatients who were judged by their treating psychiatrists as having responded to treatment, 250 scored in the remission range on the symptom scale. Compared with treatment responders whose depression was not in remission, the patients who were in remission reported significantly less psychosocial impairment and significantly better quality of life and were significantly more likely to assert that they are in remission from their depression. These findings support the validity of a self-report depression questionnaire as an index of remission status among treatment responders.
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Derivation of a definition of remission on the Montgomery-Asberg depression rating scale corresponding to the definition of remission on the Hamilton rating scale for depression.
During the past decade the Montgomery-Asberg Depression Rating Scale (MADRS) has been used with increasing frequency to measure outcome in antidepressant efficacy trials (AETs). In characterizing treatment outcome in AETs it is common to define treatment remission as a score below a predetermined cutoff score on the scale. Various cutoffs have been used to define remission on the MADRS. The goal of the present paper is to determine the cutoff on the MADRS that most closely corresponds to the cutoff most frequently used on the Hamilton Rating Scale for Depression to define remission. Three hundred and three psychiatric outpatients who were being treated for a DSM-IV major depressive episode were rated on the HRSD and the MADRS. A linear regression equation was computed to estimate MADRS scores from HRSD scores. After deriving the regression equation, we computed the MADRS score corresponding to an HRSD score of 7. We also examined the sensitivity, specificity and overall classification rate of the MADRS for identifying remission on the HRSD. Based on the equation from a linear regression analysis for the entire sample, a MADRS score of </=11 would correspond to a score of </=7 on the HRSD. We repeated the analysis after excluding the more severely depressed patients who currently met criteria for MDD, and based on the equation from this regression analysis a MADRS score of </=10 would correspond to a score of </=7 on the HRSD. In a complementary analysis, we examined the sensitivity, specificity and overall classification rate of the MADRS at different cutoff points for identifying remission, and found that a cutoff of </=10 maximized the level of agreement with the HRSD definition of remission. In conclusion, the regression equation relating HRSD and MADRS scores is dependent, in part, on the range and severity of scores in the sample. To facilitate comparisons of studies using the HRSD and MADRS our results suggest that a cutoff of 10 on the MADRS is equivalent to the HRSD cutoff of 7.
Adolescent↗
Clinician recognition of anxiety disorders in depressed outpatients.
The recognition of anxiety disorders in depressed patients has potential clinical significance because their presence predicts poorer outcome and may influence treatment selection. In routine clinical settings, an unstructured diagnostic interview is typically used to assess patients at the initiation of treatment. Unstructured interviews, however, may result in missed diagnoses, with potential negative clinical consequences. The goals of the present study were to examine whether anxiety disorders are less frequently identified using a routine unstructured clinical evaluation than a semi-structured diagnostic interview in patients with a principal diagnosis of major depressive disorder (MDD), and to determine patients' desire for treatment for comorbid anxiety disorders. Psychiatric outpatients with MDD were evaluated with either a semi-structured or an unstructured diagnostic interview. Current DSM-IV anxiety disorder diagnoses were compared in the two, nonoverlapping, groups of depressed psychiatric outpatients seen in the same practice setting. Patients with comorbid anxiety disorders who were interviewed with the semi-structured interview were asked if they wanted treatment to address their anxiety symptoms. Individuals interviewed with the semi-structured interview were diagnosed with significantly more current anxiety disorders than individuals who were assessed with an unstructured interview. There was variability in patients' desire for treatment of the different anxiety disorders, though for each disorder the majority of patients wanted treatment to address the anxiety symptoms. In psychiatric outpatients with a principal diagnosis of MDD psychiatrists underrecognize anxiety disorder comorbidity for which patients want treatment.
Adult↗
The prevalence of atypical features across mood, anxiety, and personality disorders.
This study examines and compares the prevalence rates of the atypical features subtype across each of the major mood, anxiety, and personality disorders (PDs). It also evaluates the impact that comorbid anxiety and PDs have on the likelihood that depressed patients will present with atypical symptoms. Eleven hundred thirty psychiatric outpatients were evaluated for the presence of atypical symptoms. All axis I diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID). PDs were assessed in a subset of 530 patients using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). From a sample of 579 patients diagnosed with a current major depressive disorder, 22.5% met criteria for the atypical subtype. Prevalence rates were similar in bipolar and unipolar patients, although the pattern of symptoms was distinct. Prevalence rates were lower in patients with dysthymic disorder (12.5%), adjustment disorder with depressed mood (9.4%), and depression not otherwise specified (NOS) (7.9%). When major depression existed in the presence of a comorbid anxiety disorder, the likelihood of presenting with atypical features doubled. Nine percent of the patients diagnosed with an anxiety disorder (without a comorbid depressive disorder) met criteria for atypical features. Two of the four atypical symptoms, leaden paralysis and rejection sensitivity, were found to be especially prominent in nondepressed anxiety disorder patients. Of the 10 PDs listed in DSM-IV, only avoidant PD was associated with the atypical features subtype. In large part, this was accounted for by the high rate of rejection sensitivity in these patients. In conclusion, as many as one quarter of depressed patients who present for outpatient psychiatric treatment meet criteria for the atypical features subtype. There appears to be a strong association between anxiety and atypical depression, but the exact nature of this relationship needs to be further elucidated. It is unclear whether personality pathology is independently associated with the atypical features subtype.
Adolescent↗
Does "subthreshold" posttraumatic stress disorder have any clinical relevance?
The present report examined the extent to which subthreshold posttraumatic stress disorder (PTSD) (without lifetime PTSD) and full PTSD are associated with impairment or distress, controlling for comorbidity (i.e., major depression and panic disorder) in a sample of treatment-seeking psychiatric patients. Patients were administered diagnostic interviews and assessed for psychosocial impairment and whether or not they desired treatment for their PTSD symptoms. No significant differences were found between patients with full PTSD (N = 156) and those with subthreshold PTSD (N = 56) in degree of impairment (i.e., social and work functioning, as well as number of suicide attempts). In contrast, those with full PTSD had significantly more psychiatric hospitalizations and worse global functioning and were more likely to want treatment for their PTSD symptoms compared to those with subthreshold PTSD, albeit the majority of patients with subthreshold PTSD wanted treatment for their PTSD symptoms. These findings, like past research, suggest that subthreshold PTSD is associated with levels of social and work morbidity comparable to full PTSD. However, the report also underscores the difficulties in identifying a set of clinical criteria that clearly delineates between full PTSD and subthreshold PTSD.
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