Marital distress and DSM-IV psychiatric disorders in a population-based national survey.

The associations between marital distress and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) Axis I psychiatric disorders were evaluated in a United States population-based survey of married individuals in which there was no upper age exclusionary criterion (N = 2,213). Marital distress was associated with (a) broad-band classifications of anxiety, mood, and substance use disorders and (b) all narrow-band classifications of specific disorders except for panic disorder, with the strongest associations obtained between marital distress and bipolar disorder, alcohol use disorders, and generalized anxiety disorder. The association between marital distress and major depressive disorder increased in magnitude with increasing age; there was no evidence that the association between marital distress and other psychiatric disorders was moderated by gender or age. Results support continued research on the association between couple functioning and mental health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pellucid marginal corneal degeneration 12 years after penetrating keratoplasty for keratoconus

Historically the divisions between the mental health and substance abuse fields have been so deep that attempts to provide coordinated treatment across service sectors for people with dual diagnoses of psychiatric disorder and substance use disorder have failed. The authors describe a program in Maine designed to develop collaboratives, or communities of providers, who work together to offer coordinated mental health and substance abuse treatment and support. Surveys of provider agencies in one collaborative conducted one year and two years after the collaborative was established showed an increase in interagency referrals, joint assessments of clients, and jointly sponsored training and client services.     

Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults.

The clinical importance of relationship discord was examined through evaluating the association between relationship discord and multiple measures of impairment and psychological distress in a population-based sample of married and cohabiting adults (N = 2,677). In comparison to people that were not in discordant relationships, individuals in discordant relationships reported greater social role impairment with relatives and friends and greater work role impairment. They also reported higher levels of general distress and poorer perceived health and were more likely to report suicide ideation. With the exception of suicide ideation, the associations between relationship discord and impairment and psychological distress remained significant when controlling for current mood, anxiety, and substance use disorders, suggesting that relationship discord is incrementally related to impairment and psychological distress over and above the effects of psychiatric disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Understanding general and specific connections between psychopathology and marital distress: A model based approach.

Marital distress is linked to many types of mental disorders; however, no study to date has examined this link in the context of empirically based hierarchical models of psychopathology. There may be general associations between low levels of marital quality and broad groups of comorbid psychiatric disorders as well as links between marital adjustment and specific types of mental disorders. The authors examined this issue in a sample (N = 929 couples) of currently married couples from the Minnesota Twin Family Study who completed self-report measures of relationship adjustment and were also assessed for common mental disorders. Structural equation modeling indicated that (a) higher standing on latent factors of internalizing (INT) and externalizing (EXT) psychopathology was associated with lower standing on latent factors of general marital adjustment for both husbands and wives, (b) the magnitude of these effects was similar across husbands and wives, and (c) there were no residual associations between any specific mental disorder and overall relationship adjustment after controlling for the INT and EXT factors. These findings point to the utility of hierarchical models in understanding psychopathology and its correlates. Much of the link between mental disorder and marital distress operated at the level of broad spectrums of psychopathological variation (i.e., higher levels of marital distress were associated with disorder comorbidity), suggesting that the temperamental core of these spectrums contributes not only to symptoms of mental illness but to the behaviors that lead to impaired marital quality in adulthood. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Use of formal and informal sources of mental health care among older African-American public-housing residents

BACKGROUND: Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents. METHOD: Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N = 818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care. RESULTS: Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38.5%) than informal sources (18.6%) for care. The strongest correlates of using formal providers were substance use disorder (OR = 15.62), Medicare insurance (OR = 10.31) and psychological distress (OR = 10.27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR = 21.65), cognitive disorder (OR = 19.71) and having a confidant (OR = 15.07). CONCLUSIONS: Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.     

Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study

BACKGROUND: Recently there has been increased interest in the special mental health needs of women. We used data from the PRIME-MD 1000 study to assess gender differences in the frequency of mental disorders in primary care settings, and to explore the potential impact of these differences on health-related quality of life (HRQL). SUBJECTS AND METHODS: One thousand primary care patients (559 women) were interviewed during the PRIME-MD study, which was conducted at four primary care clinics affiliated with university hospitals throughout the eastern United States. Patients completed a one-page questionnaire in the waiting room prior to being seen by the physician; patients and physicians then completed together a clinician evaluation guide that used DSM-III-R algorithms to diagnose mood, anxiety, somatoform, eating, and alcohol related disorders. Health-related quality of life was assessed with the Medical Outcomes Study SF-20 General Health Survey. RESULTS: Women were more likely than men to have at least one mental disorder (43% versus 33%, P < 0.05). Higher rates were particularly prominent for mood disorders (31% of women versus 19% of men, odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.4 to 2.6), anxiety disorders (22% versus 13%, OR = 1.9, CI = 1.3 to 2.8), and somatoform disorders (18% versus 9%, OR = 2.2, CI = 1.5 to 3.4). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, P < 0.05). Unadjusted HRQL scores, ranging from 0 to 100, with 100 = best health, were all significantly lower in women than in men (eg, physical function = 67 in women versus 76 in men, P < 0.0001; mental health = 69 in women versus 76 in men, P < 0.0001). Many HRQL differences persisted after controlling for age, education, ethnicity, marital status, and number of physical disorders; however, differences in HRQL were eliminated in 5 of 6 domains after controlling for number of mental disorders. When compared with female patients of male physicians, female patients of female physicians demonstrated similar satisfaction with care, health care utilization, HRQL, and recognition rate of mental disorders. CONCLUSIONS: In the 1,000 patients of the PRIME-MD study, mood, anxiety, and somatoform disorders and psychiatric comorbidity were all significantly more common in women than men. The HRQL scores were poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. These data suggest that one of the most important aspects of a primary care physician's care of female patients is to screen for and treat common mental disorders.     

The long-term outcomes of mental health treatment in a population-based study.

This study examined the long-term outcomes of mental health treatment, specifically individual therapy, group therapy, and pharmacotherapy, in a population-based study. Using a prospective cohort design. the effectiveness of mental health treatment was analyzed on the basis of data from an epidemiological catchment area follow-up study, which assessed health care use and mental health status at 2 times, 15 years apart, in a random sample of Baltimore residents. A cohort of 771 men and women with at least 1 diagnosable Diagnostic and Statistical Manual of Mental Disorders disorder was selected from the 1,920 individuals randomly sampled in 1980 who were followed in 1994–1996. The results are consistent with clinical trials on the efficacy of pharmacotherapy and psychotherapy. After controlling for baseline psychopathology, sociodemographic characteristics, and service providers, participants who received group and individual therapy had lower distress at follow-up than those who either received medication or did not seek or receive any treatment. No concomitant reductions in the number of disorders were found, except for a dose–response association between the number of therapy sessions and the number of disorders at follow-up, as well as distress at follow-up. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical implications of the co-occurrence of substance use and other psychiatric disorders.

The co-occurrence of substance use and psychiatric disorders is the rule rather than the exception in mental health and substance use treatment settings across the United States. Such co-occurrence may call for special assessment and evaluation procedures, modified treatment plans, and specialized follow-up. Treatment of co-occurrence of substance abuse and psychiatric disorders requires more cross-disciplinary collaboration; greater integration of substance use, mental health, and social services treatment approaches; and modifications in the training of care providers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I psychopathology in individuals with traumatic brain injury

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.     

Spectral properties of human cognition and skill

PURPOSE: To identify the predictors of depressive and anxiety disorders in general medical patients presenting with physical complaints and to determine the effect of these mental disorders on patient outcome. PATIENTS AND METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed with PRIME-MD to diagnose DSM-IV depressive and anxiety disorders. Clinical predictors were identified by logistic regression analysis. Outcomes were assessed immediately postvisit and at 2 weeks and 3 months. These included symptomatic improvement, functional status, unmet expectations, satisfaction with care, clinician-perceived patient difficulty, and health care utilization and costs. RESULTS: A depressive or anxiety disorder was present in 146 (29%) of the patients. Independent predictors of a mental disorder included recent stress, multiple physical symptoms (ie, 6 or more), higher patient ratings of symptom severity, lower patient ratings of their overall health, physician perception of the encounter as difficult, and patient age less than 50. Patients with depressive or anxiety disorders were more likely to have unmet expectations postvisit (20% versus 8%, P < 0.001), be considered difficult (26% versus 11%, P < 0.0001), and report persistent psychiatric symptoms and ongoing stress even 3 months following the initial visit. Psychiatric status was not associated with symptomatic improvement, health care utilization, or costs. CONCLUSION: Simple clinical clues in patients with physical complaints identify a subgroup who may warrant further evaluation for a depressive or anxiety disorder. Such disorders are associated with unmet patient expectations and increased provider frustration.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

Anxious children in adulthood: a prospective study of adjustment

OBJECTIVE: To prospectively examine psychosocial functioning in young adulthood for children and adolescents with anxiety disorders. METHOD: This 8-year prospective study compared psychosocial functioning in young adults (mean age 22 years) who had histories of early-onset anxiety disorders, comorbid anxiety and depressive disorders, or no history of psychiatric illness (NPI). Follow-up interviews assessed subjects' residential, educational, occupational, and marital status; utilization of mental health services; and psychological status RESULTS: Anxious subjects without histories of depression were less likely than NPI controls to be living independently. Anxious-depressed subjects were less likely than controls to be working or in school; more likely than purely anxious subjects to utilize mental health services; and more likely than both anxious and control subjects to report psychological problems, most frequently depression. CONCLUSIONS: Overall, results suggest that children with anxiety disorders are relatively well adjusted in young adulthood. However, a history of comorbid depression is prognostic of a more negative outcome.     

Paying for mental health and substance abuse care

Fifty-four billion dollars was spent on alcohol/drug abuse and mental health treatment in 1990. These expenditures were concentrated in the area of inpatient psychiatric care and on persons with severe mental health and substance abuse problems. The data on expenditure patterns for mental health and substance abuse care suggest that successful health care reform in this area must implement mechanisms for controlling inpatient utilization and managing the care of persons with the most severe disorders.     

Female veterans' use of Department of Veterans Affairs health care services

OBJECTIVES: As access of women to mental health services has become increasingly important, empirical research has begun to examine the determinants of mental health care utilization across gender. This article examines the effect of being an extreme minority on utilization of Department of Veterans Affairs (VA) health services by female veterans. METHODS: Data were collected on a representative national sample of veterans in 1992 as part of the National Survey of Veterans. These data included information on sociodemographic variables, military service variables, physical health and disability, and health services utilization. The authors examined whether women who used health services in 1992, and who were eligible for VA care, differed from men on the likelihood of using any VA health services and on the likelihood of use of VA outpatient and inpatient health services. In addition, we compared VA health care utilization among subgroups of veterans with physical and mental disorders, and compared self-reported reasons for choice of health care provider, across gender. RESULTS: Results indicated that female veterans were less likely than male veterans to use VA health services. This difference was explained by lower utilization by women of VA outpatient services, since inpatient admission rates were the same across gender. The lower outpatient utilization was specific to women with self-reported mental disorders. Women with physical conditions did not differ from men with similar conditions in their VA outpatient utilization. Finally, men and women did not differ on their reasons for choosing VA or non-VA care. CONCLUSIONS: The authors conclude that extreme gender minority status appears to affect outpatient utilization rates at the VA among women with mental disorders, perhaps because of the more personal or sensitive nature of the services involved. Further research is needed to understand why certain women may be underutilizing VA outpatient services and on the consequences of minority gender status for health service utilization, more generally.     

Variations in ADHD treatment among special education students

OBJECTIVE: To examine variation in patient characteristics (case-mix) and treatment patterns for attention-deficit/hyperactivity disorder (ADHD) by provider type. METHOD: By means of a two-stage study design, 102 children were identified as receiving treatment for ADHD in the past year, among a school district-wide sample of second-through fourth-grade special education students. Parent and child interviews were conducted using standardized measures of need for treatment, service use, and process of care. RESULTS: Nearly three fourths of the children received treatment for ADHD by a primary care provider, and of these, 68% did not have any contact with a mental health specialist. Children treated only by a primary care provider had fewer comorbid conditions, less impairment, and lower levels of family burden than children treated only by a mental health specialist. Treatment of ADHD solely by primary care providers was characterized by fewer sessions, less time with the patient, and less use of multimodal therapies. CONCLUSION: Future studies examining clinical outcomes for ADHD treatment should take into account variation in case-mix and treatment patterns by provider type.     

Attitudes toward adoption of evidence-based practices: A comparison of autism early intervention providers and children’s mental health providers.

Across the country, states are reporting increases in the number of children with autistic spectrum disorders (ASDs) served each year in the early intervention system. Research examining factors impacting the successful dissemination and implementation of evidence-based practices (EBPs) into service systems for these children is limited. Preliminary information indicates that adoption of EBPs is variable. Provider attitudes toward the adoption of EBPs may be one factor that limits or facilitates implementation of efficacious treatments and these attitudes vary by organizational context and provider individual differences. The current study examines cross-context differences in provider attitudes toward EBPs by comparing the attitudes of 71 education-based early intervention providers working with children with ASD to the attitudes of 238 mental health providers in the public mental health system. This provides the first examination of ASD early intervention provider attitudes toward EBP. Results indicated that early intervention providers reported significantly more favorable attitudes toward adopting EBPs than did mental health providers. Early intervention providers with extended experience in the field perceived less divergence between their current practice and EBPs. Implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An overview of mental health services for the elderly

Psychiatric distress is substantially prevalent among elderly individuals, particularly in the primary care and institutional settings, where most older persons receive mental health care. Barriers to care from providers include negative attitudes and stigmatization and poor recognition by general health care professionals. When psychiatric disorders are recognized, the intensity and duration of treatment provided is generally below standards for adequacy. Further research can determine the impact of patient, caregiver, and provider factors on treatment provision and on patient adherence to treatment. Assessment of factors influencing the treatment process are needed to ensure that treatments provided in the real world approximate the efficacy established in controlled clinical trials.     

The role of physical health functioning, mental health, and sociodemographic factors in determining the intensity of mental health care use among primary care medical patients.

The present study examined sociodemographic and attitudinal predisposing factors (gender, age, marital status, health insurance, household income, attitudes about mental health care), and need/illness variables (depression severity, physical and mental health functional status) as predictors of past-year mental health care use intensity (i.e., visit counts) and use/nonuse. The sample included 283 adult primary care patients from the Midwestern United States in a cross-sectional study. Nonlinear regression models demonstrated that past-year treatment use intensity was significantly associated with both married status and poorer physical health functioning, while the use (vs. nonuse) of treatment was associated with depression severity. A sociodemographic and attitudinal multivariate predictor model only explained 5% of the variance in treatment use intensity, but a need/illness model significantly contributed an additional 23% variance. Poorer physical health functioning was significant in predicting treatment use intensity, while depression severity was significant in predicting the use (vs. nonuse) of treatment. Results demonstrate the particular importance of physical health problems in determining the intensity of mental health care use, and depression severity in determining the use/nonuse of treatment, notwithstanding the restricted sociodemographic contour of the sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Marital distress and the metabolic syndrome: Linking social functioning with physical health.

Mechanisms by which poor relationship functioning contributes to poor health are not fully understood. We conducted a study to evaluate the association between marital distress and the metabolic syndrome (MetS), which refers to a clustering of characteristics that have individually been shown to be associated with elevated risk of cardiovascular disease and diabetes and which collectively have been shown to increase risk for cardiovascular disease, diabetes, stroke, and mortality. A population-based English sample of couples (N = 671 couples) in which both partners were between the ages of 52 and 79 years old completed a self-report measure of marital distress and a nurse visit that included collection of blood pressure, blood samples, and anthropometric measures. Results indicated that for women, after controlling for demographic variables, greater marital distress was significantly associated with increasing likelihood of meeting criteria for the MetS and with the individual MetS criteria of elevated blood pressure and elevated fasting glucose. The association between marital distress and the MetS remained significant for women when additionally controlling for depressive symptoms and health habits (smoking status, physical activity). Marital distress was not significantly associated with the MetS or any of the individual MetS criteria for men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The utility of motivational interviewing as an adjunct to exposure therapy in the treatment of anxiety disorders.

Motivational interviewing (MI; W. R. Miller & S. Rollnick, 2002) was designed as a prelude to standard substance use treatment. Because of its purported capacity to resolve ambivalence about change, MI has been applied to many other behavioral and mental health problems. Ambivalence about engaging in exposure-based therapies is common among those with anxiety disorders, and systematic efforts (e.g., MI) to ameliorate such ambivalence may yield superior clinical outcomes. The use of MI as an adjunct intervention to standard exposure therapy in anxiety disorders is explored with a focus on treatment retention and adherence. Shared and disparate treatment difficulties among substance use and anxiety disorder populations suggest that MI may be especially effective with anxiety disorders. Empirical evidence supporting the use of MI with substance abuse and anxiety disorder populations is presented. Practical aspects of MI's clinical application as an adjunct intervention to standard exposure therapies for anxiety disorders are discussed. Last, a future research agenda is delineated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)