Do family physicians treat older patients with mental disorders differently from younger patients?
OBJECTIVE: To determine whether there are differences between family physicians' beliefs and treatment intentions regarding older patients with mental disorders and younger patients with similar disorders. Such differences might contribute to older adults' lower rates of mental health service use. DESIGN: Mailed survey. SETTING: Primary care practices in and around Kingston, Ont. PARTICIPANTS: Questionnaires were mailed to 294 general practitioners listed in the 42nd Annual Canadian Medical Directory. Of the 285 eligible physicians, 115 (40%) completed and returned questionnaires. MAIN OUTCOME MEASURES: Physicians' ratings of preparedness to identify and treat, likelihood of treating, likelihood of using each of five different treatment methods, likelihood of referral, preferences for six referral options, and treatment effectiveness with respect to hypothetical older and younger patients with panic disorder or dysthymia. RESULTS: Physicians reported being less prepared to identify and treat older patients than younger patients. In addition, physicians reported being significantly less likely to treat and to refer older patients than younger patients. Finally, physicians reported that both psychotherapy alone, and in combination with pharmacotherapy, were less effective for older patients than for younger patients. CONCLUSIONS: In addition to other possible reasons for older adults' low rates of mental health service use, this study suggests that family physicians' beliefs and treatment intentions could be contributing factors. Changes in medical education aimed at replacing inaccurate beliefs with accurate information regarding older patients might be one way to increase rates of use in this underserved age group, because family physicians play a key role in the mental health care of older adults. (+info)
Rater agreement on interpersonal psychotherapy problem areas.
There has been much outcome research on interpersonal psychotherapy (IPT) but little investigation of its components. This study assessed interrater reliability of IPT therapists in identifying interpersonal problem areas and treatment foci from audiotapes of initial treatment sessions. Three IPT research psychotherapists assessed up to 18 audiotapes of dysthymic patients, using the Interpersonal Problem Area Rating Scale. Cohen's kappa was used to examine concordance between raters. Kappas for presence or absence of each of the four IPT problem areas were 0.87 (grief), 0.58 (role dispute), 1.0 (role transition), and 0.48 (interpersonal deficits). Kappa for agreement on a clinical focus was 0.82. IPT therapists agreed closely in rating problem areas and potential treatment foci, providing empirical support for potential therapist consistency in this treatment approach. (+info)
Adding group psychotherapy to medication treatment in dysthymia: a randomized prospective pilot study.
Patients with dysthymia have been shown to respond to treatment with antidepressant medications, and to some degree to psychotherapy. Even patients successfully treated with medication often have residual symptoms and impaired psychosocial functioning. The authors describe a prospective randomized 36-week study of dysthymic patients, comparing continued treatment with antidepressant medication (fluoxetine) alone and medication with the addition of group therapy treatment. After an 8-week trial of fluoxetine, medication-responsive subjects were randomly assigned to receive either continued medication only or medication plus 16 sessions of manualized group psychotherapy. Results provide preliminary evidence that group therapy may provide additional benefit to medication-responding dysthymic patients, particularly in interpersonal and psychosocial functioning. (+info)
A randomized controlled trial comparing moclobemide and moclobemide plus interpersonal psychotherapy in the treatment of dysthymic disorder.
The authors compared the outcomes of 35 outpatients with dysthymic disorder randomized to receive either treatment with moclobemide and interpersonal therapy (IPT) or moclobemide and routine clinical management. Diagnosis was based on the ICD-10 symptom checklist. Patients were evaluated by trained raters using the 17-item Hamilton Rating Scale for Depression (Ham-D), Montgomery-Asberg Depression Rating Scale (MADRS), Global Assessment of Functioning, and Quality of Life and Satisfaction Questionnaire at baseline, 12, 24, and 48 weeks. Patients in both treatment groups showed statistically significant improvement in all measures across time. There was a nonsignificant trend toward lower scores on Ham-D and MADRS for patients in the moclobemide plus IPT group. Longer, better-powered trials should be carried out to study the efficacy of IPT plus antidepressant medication in the treatment of dysthymic disorder. (+info)
Proposed endophenotypes of dysthymia: evolutionary, clinical and pharmacogenomic considerations.
Dysthymia is highly prevalent--though underdiagnosed--occurring in at least 3% of the population. We conceptualize it as the clinical extension of adaptive traits that have developed during evolution to cope with stress and failure. A classification of dysthymias into anxious and anergic subtypes--and their putative association to bipolarity--is proposed. We further posit neurochemical and neurophysiological substrates for the two subtypes. A better recognition and understanding of dysthymic subtypes and their respective place in the affective spectrum will increase the proportion of people that may benefit from targeted treatments. It would also expand the pool of subjects that may be enrolled in genetic and pharmacogenomic research studies. (+info)
Depressive disorder, dysthymia, and risk of stroke: thirteen-year follow-up from the Baltimore epidemiologic catchment area study.
BACKGROUND AND PURPOSE: This study examined depressive disorder as a risk factor for incident stroke in a prospective, population-based design. METHODS: The Baltimore Epidemiologic Catchment Area Study is a prospective 13-year follow-up of a probability sample of household residents from Baltimore, Md. Depressive disorder was measured with the diagnostic interview schedule, and stroke was assessed by questions from the health interview survey or by documentation on a death certificate. RESULTS: During the 13-year follow-up of 1703 individuals, 66 strokes were reported and 29 strokes were identified by death certificate search. Individuals with a history of depressive disorder were 2.6 times more likely to report stroke than those without this disorder after controlling for heart disease, hypertension, diabetes, and current and previous use of tobacco. Medications used in the treatment of depressive disorder at baseline did not alter this finding. A history of dysthymia demonstrated a similar relationship to stroke, although the estimate was not statistically significant. CONCLUSIONS: Depressive disorder is a risk factor for stroke that appears to be independent of traditional cardiovascular risk factors. Further research on mechanisms for the association and the impact of treatment for depressive disorder on subsequent stroke is needed. (+info)
The substituted benzamides and their clinical potential on dysthymia and on the negative symptoms of schizophrenia.
In this paper the historical and scientific background that led to the use of substituted benzamides in two apparently unrelated clinical conditions namely dysthymic disorder and schizophrenia will be reviewed, in order to understand if a common mechanism of action may support this dual therapeutic indication. The dopaminergic antidepressant action of substituted benzamides such as sulpiride, has been proposed, since the late 1970s, by several authors and extensively explored in preclinical experiments by our group. In Italy the first marketing authorization obtained for the new substituted benzamide amisulpride, was with the sole indication of dysthymia and therefore a solid clinical experience exists in the use of substituted benzamides in mild forms of depression, with more than 1 000 000 patients being treated in the last 7 years. The proposed mechanism of action of substituted benzamides implies a selective modulation of the dopaminergic system in the mesocorticolimbic area, important for cognitive processing of internal and external cues, related to survival. The selective antagonism of dopamine D2-D3 receptors has been evoked to explain, in small to moderate doses (ie 50-100 mg day(-1)), the antidepressant effect and, in moderate to medium doses (100-400 mg day(-1)), the reported efficacy on negative symptoms of schizophrenia. Thus, substituted benzamides could represent the first class of atypical antipsychotics successfully employed for both depressive states and schizophrenia. Interestingly, recent evidence in the literature suggests that depressive episodes belonging to the bipolar spectrum are among "alternative indications" of other atypical antipsychotics such as olanzapine and risperidone. (+info)
Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents.
Food insufficiency has been shown to be associated with poor health, academic and psychosocial outcomes in American children, but the relationship between food insufficiency and depressive disorders in U.S. adolescents has not been studied. Further, there are no national estimates of the prevalence of depressive disorders for U.S. adolescents, nor investigation of associations with sociodemographic characteristics using national data. Therefore, we analyzed data for 15- and 16-y-old adolescents from the Third National Health and Nutrition Examination Survey (NHANES III). Depressive disorders and suicidal symptoms were assessed using the Diagnostic Interview Schedule. Adolescents were classified as "food insufficient" if a family respondent reported that the family sometimes or often did not have enough to eat. The prevalence of depression outcomes is reported by sociodemographic characteristics. Odds ratios for associations with food insufficiency are reported, adjusted for sociodemographic factors. Overall, lifetime prevalence of major depressive disorder was 6.3% and of dysthymia, 5.4%. Almost 5% of 15- to 16-y-old adolescents reported that they had ever attempted suicide and 38.8% reported at least one suicidal symptom. Female adolescents were significantly more likely than males to have had dysthymia, any depressive disorder and all symptoms of suicide. Low income adolescents were less likely to report suicide ideation than high income adolescents, but there were no other differences by family income. Food-insufficient adolescents were significantly more likely to have had dysthymia, thoughts of death, a desire to die and have attempted suicide. There is a strong association between food insufficiency and depressive disorder and suicidal symptoms in U.S. adolescents. (+info)