Telephone Survey Finds Portion of Depressed and Anxious Patients Remain Ill Years After Treatment is Initiated

Although effective treatments are available, a large portion of patients suffering from depressive and anxiety disorders can remain ill for many years after initial diagnosis. Alexander S. Young, MD, MSPH, and colleagues from the University of California, Los Angeles, conducted telephone surveys of adults suffering from dysthymia, generalized anxiety disorder, panic disorder, or probable major depressive disorder from 1997–1998 as part of the “Healthcare for Communities” (HCC) project. On average, these patients were followed up with within 32 months. The surveys collected information about demographics; health and daily activities; mental health; alcohol and drug use; use of prescription and nonprescription medications; health insurance and coverage for mental health and substance abuse care; access, utilization, and quality of behavioral health care; labor market status; income and wealth; participation in public assistance programs; and life difficulties.

“The survey was conducted with a national probability sample,” Dr. Young said. “These households were randomly selected so that they are representative of the United States community populations of interest. The first wave of the survey, conducted in 1997–1998, consisted of ~9,600 adults who participated in the Community Tracking Study (CTS) household survey, affording an over-sample of persons at risk for alcohol, drug abuse, and mental health problems [as well as] of the poor. The second wave survey, conducted in 2000–2001, consisted of ~12,000 respondents, including those who participated in the first wave of HCC and some participants in the second wave of the CTS."

 Young and colleagues found that 59% of the originally surveyed population no longer met the criteria for the disorder they were initially suffering from. However, of the 41% of patients still suffering, 87% had a chronic comorbid medical disorder. They also found that 88% had seen a primary care physician and 22% had seen a mental health specialist in the past year.

“We have known about the cross-sectional prevalence of psychiatric disorders, from the National Comorbidity Study and related efforts,” Dr. Young said. “However, there has been too little accurate information regarding the prevalence of chronic and recurrent disorders. We found that chronic depressive and anxiety disorders are relatively common, and should be a major policy focus. We know that psychiatric disorders in general are becoming the leading cause of disability in the US, and our healthcare system needs to do a better job of helping people with these disorders. Persistent disorders appear to be a particular problem.”

At baseline, 21% of patients were taking medication. At follow-up, this increased to 29%. At baseline, 235 of patients were getting the appropriate amount of counseling. This decreased to 19% at follow-up. Combined, only 12% of the patient population received the appropriate amount of both counseling and medication treatment. The researchers also found that fewer men and people with less education sought treatment.

Lastly, Young and colleagues found that over half of the population (51%) were still suffering from suicide ideation at follow-up.

“Serious depressive disorders are often accompanied by suicidal ideation,” Dr. Young said. “It is not surprising that this is common; however, this study shows that suicidal ideation is in fact very common. Efforts to help with suicidality will need to address the fact that many people with these chronic disorders are not receiving specialty mental health care, rates of psychotherapy are particularly low, and rates of appropriate treatment (combined psychotherapy and medication) are very low.”

Young and colleagues believe that more strategies aimed at increasing treatment usage are needed. In addition, patients with persistent depressive and anxiety disorders need a more intense treatment program. Further research and policy will be needed to ensure equity of provision of mental health services to vulnerable populations, especially those with chronic and recurrent psychiatric illness.

Funding for this research was provided by a grant from the Robert Wood Johnson Foundation; and by grant P50MH54623, from the National Institute of Mental Health, to the UCLA–RAND Research Center on Managed Care for Psychiatric Disorders. Infrastructure support was also provided by the Department of Veterans Affairs. (Psychiatr Serv. 2008;59(12):1391.1398.) –CDN

Sleep Pattern Disturbances May Exacerbate Symptoms of Postpartum Depression for New Mothers

According to the National Institute of Mental Health, 10% to 15% of women experience postpartum depression (PPD)—characterized by feelings of hopelessness, exhaustion, anhedonia, among other symptoms—in the first year following childbirth. Prior research has also shown that PPD can negatively affect sleep quality, which may lead to deficits in the care a mother provides for her infant. In addition, studies have shown that patients with PPD who have irregular sleep patterns or who are sleep deprived may also alter their infant’s sleep quality as infants often adopt the sleep rhythm of their mothers. Recently, researchers at the College of Nursing and Health Professions of Drexel University in Newtown, Pennsylvania, sought to understand the degree of difference in sleep quality between mothers with or without PPD.

Bobbie Posmontier, CNM, PhD, and colleagues studied 46 women who were 6–26 weeks postpartum to determine the relationship between PPD and effects on sleep quality. Although most women experience some sleep loss postpartum (studies have shown that postpartum women remain awake for 20% longer over a 24-hour period than non-postpartum women), the researchers sought to understand if PPD contributed to greater sleep loss or if typical postpartum sleep loss had a causal connection or exacerbated symptoms of PPD.

Posmontier and colleagues utilized actigraphy to evaluate sleep quality. All patients wore wrist-bound actigraph units at home for 7 consecutive days. A structured clinical interview was used to determine the presence of PPD and the Postpartum Depression Screening Scale was then used to measure the severity of PPD symptoms. Other psychosocial measures, such as the presence of comorbid conditions, were also assessed to identify potential confounding variables. The authors found that ~50% of postpartum women in the study had PPD; two patients were removed from the study analyses because their data were outliers.

They found that patients with PPD experienced worse sleep quality that those without the disorder, and that as PPD symptoms worsened, sleep quality became poorer for women with PPD. When evaluating all patients in the study, researchers found that longer latency to sleep, increased wakefulness after sleep onset, and poor overall sleep efficiency predicted the presence of PPD. These results persisted after researchers accounted for the presence of other psychosocial variables.

Posmontier and colleagues concluded that primary care physicians (PCPs) should discuss various methods to improve sleep quality in new mothers with PPD in order to decrease overall symptom severity, which can further impair sleep quality. The importance of maintaining adequate sleep should be a significant topic in discussions between PCPs and mothers with PPD. The authors added that potential methods for improving sleep efficiency for mothers with PPD include creating a schedule for other family members to care for the infant at night as well as maintaining good sleep hygiene by avoiding caffeine or strenuous activity 4 hours prior to sleep and beginning sleep at the same time each night. In addition, researchers should develop more treatment interventions to facilitate improved sleep quality for patients with PPD. (J Obstet Gynecol Neonatal Nurs. 2008;37(6):722-735.) –CP

Psychiatric dispatches is written by Christopher Naccari and Carlos Perkins, Jr.