Search

BackgroundThe clinical value of the identification of mood disorders in patients with acute coronary syndrome (ACS) is well established. However, assessment based on DSM criteria presents some limitations. This study aimed to provide an innovative strategy for evaluating the spectrum of mood disturbances in ACS.MethodsA total of 288 patients with a first episode of ACS underwent interviews based on DSM-IV-TR criteria (major depressive disorder, minor depression, and dysthymia), Diagnostic Criteria for Psychosomatic Research-DCPR (demoralization and type A behavior), and the Clinical Interview for Depression-CID. Additional self-report inventories (psychological well-being and distress) were administered. A total of 100 consecutive patients who satisfied criteria for DSM-IV-TR depression or DCPR demoralization were enrolled in a randomized controlled trial on a sequential combination of cognitive-behavioral and well-being therapy (CBT/WBT) vs clinical management (CM) and reassessed up to 30-month post-intervention.ResultsA total of 29.9% of patients showed a DSM-IV-TR depressive syndrome. Inclusion of demoralization and type A identified psychological distress in 58% of the sample. According to CID, reactivity to social environment, fatigue, depressed mood, and somatic anxiety were the most common symptoms. Somatic symptoms were significantly associated with DSM-IV-TR depression (fatigue and changes of appetite), whereas environmental reactivity with demoralization. Both depression and demoralization were associated with higher distress and lower well-being. Unlike CM, CBT/WBT was significantly associated with decrease of guilt, pessimism, fatigue, and early insomnia (CID).ConclusionsThe findings indicate that standard psychiatric approach identifies only a narrow part of mood disturbances affecting ACS patients. A more articulated assessment unravels specific clinical configurations that may entail prognostic and therapeutic implications.

Introduction. Among patients affected by masked hypertension (MH), psychological variables have been poorly investigated. This research aimed to fill the gap in the literature and to investigate ill-being and well-being in patients with MH, compared with patients with essential hypertension (EH) and normotensive subjects (NS). Methods. 10 patients with MH, enrolled at the Division of Internal Medicine, Sant’Orsola Hospital (Bologna, Italy), were compared with 10 EH patients recruited at Bellaria Hospital (Bologna, Italy), and 10 NS, matched for age and sex. They were administered both observer- and self-rated measures. Results. 70% of MH patients showed ill-being (40% depression, 40% anxiety, 60% at least one psychosomatic syndrome). The most frequent causes of stress were loneliness (70%), work (60%), illness/bereavement (50%) and significant changes in life (50%). 40% of the patients developed allostatic overload (AO) as a consequence of stress. Compared with EH patients and NS, patients with MH reported a higher frequency of psychiatric diagnoses (p

Benzodiazepines (BZs) have been used broadly in gastroenterology, for instance in treating anxiety symptomatology associated with gastrointestinal (GI) illness, or in treating some underlying conditions (e.g., addressing alcohol dependence in liver disease), or in various diagnostic endoscopy procedures, and in preparation for surgery. It is known that anxiety and GI symptomatology/disorders frequently co-exist, with anxiety exacerbating GI disorders, and some GI symptoms provoking anxiety.

Prospective memory (PM) is essential in everyday life because it concerns the ability to remember to perform an intended action in the future. This ability could be influenced by poor sleep quality, the role of which, however, is still being debated. To examine the role of sleep quality in PM in depth, we decided to perform a retrospective naturalistic study examining different clinical populations with a primary sleep disorder or comorbid low sleep quality. If sleep is important for PM function, we could expect poor sleep to affect PM performance tasks both directly and indirectly. We examined a total of 3600 nights, recorded using actigraphy in participants belonging to the following groups: primary insomnia (731 nights), narcolepsy type 1 (1069 nights), attention deficit hyperactivity disorder (152 nights in children and 239 in adults), severe obesity (232 nights), essential hypertension (226 nights), menopause (143 nights), healthy controls (808 nights). In a naturalistic activity-based PM task, each participant originally wore an actigraph around the non-dominant wrist and was requested to push the event-marker button at two specific times of day: bedtime (activity 1) and get-up time (activity 2). Each clinical group showed significantly lower sleep quality in comparison to the control group. However, only narcolepsy type 1 patients presented a significantly impaired PM performance at get-up time, remembering to push the event-marker button around half the time compared not only to healthy controls but also to the other clinical groups. Overall, the present results seem to point to sleep quality having no effect on the efficiency of a naturalistic activity-based PM task. Moreover, the data indicated that narcolepsy type 1 patients may show a disease-specific cognitive deficit of PM.

Background The literature has outlined positive effects of cardiac rehabilitation (CR) on clinical psychological distress (DSM depression and anxiety) and quality of life (QoL). In cardiac settings, subclinical distress (subthreshold depressive and anxious symptomatology) and psychological well-being also showed relevant clinical implications. This research explored these psychological variables, their changes over time and cardiac course of CR patients. Methods Clinical and subclinical distress, QoL, and psychological well-being were assessed in 108 consecutive patients undergoing CR, at baseline and up to 12 months after the program's completion. Results Of all patients, 25.9 per cent showed high distress with a DSM diagnosis, 31.5 per cent high distress without a DSM diagnosis, and 42.6 per cent low distress. Comparing these subgroups, worse QoL and psychological well-being were significantly linked not only to clinical but also to subclinical distress. After CR completion, a significant reduction in DSM diagnoses was observed, whereas there were no positive effects on subclinical distress, QoL, and well-being, or when they initially occurred, they were not long lasting. Moreover, only the subgroup with high distress without a DSM diagnosis was at greater risk for adverse cardiac outcomes, showing worse scores on items of contentment. Conclusions These findings confirm data on clinical distress reduction after CR completion. However, a large amount of relevant subclinical distress remains and predicts adverse cardiac events.

The side effects and risks associated with the medical intervention are defined as iatrogenesis. Adverse drug reactions, malpractice, medical error, and negligence constitute common iatrogenic complications. Examples of important syndromes induced by medications are asthma caused by beta-adrenoceptor antagonists, pulmonary fibrosis associated with cytotoxic agents, gastric bleeding and complications with anti-inflammatory agents, torsade de pointes tachycardia with various drugs, abnormal glucose homeostasis with thiazide and corticosteroids, and osteonecrosis of the jaw with bisphosphonates. In psychiatry, iatrogenesis has traditionally been concerned with medical complications of psychotropic drug treatment, such as tardive dyskinesia and insulin resistance with antipsychotic drugs, and cardiac and metabolic disturbances with antidepressant medications. The complications may occur due to direct toxicity, drug-drug interactions, intoxication, or withdrawal from psychotropic medications. In more recent years, attention has also been dedicated to the patient experience of negative effects of psychotherapy, including the interactions between pharmacotherapy and psychotherapy. As it happened with medical therapy, psychiatric treatment has mainly been assessed and evaluated as to its capacity to improve psychiatric symptomatology. Side effects have been conceptualized as the unavoidable drawbacks of any form of medical therapy. Little attention has been paid to the adverse psychological and behavioral effects of psychiatric treatment on psychopathology and illness course. In view of the insufficient body of knowledge on the iatrogenic effects of psychological therapies, we will only concentrate on the effects of psychotropic drug treatment. Many of the insights that have been gained in the past 25 years have originated in this journal.

OBJECTIVE: The role of depression and quality of life on clinical outcomes of congestive heart failure (CHF) is well recognised. However, there are fewer studies investigating the prognostic role of subclinical psychological distress and well-being impairments. The aims of this study were to evaluate clinical/subclinical psychological distress and well-being in CHF outpatients, and the influence of these psychological factors on adverse cardiac events (re-hospitalisation, cardiac death), at 4-year follow-up. DESIGN: Sixty-eight CHF outpatients underwent psychological assessment at baseline and, after 4 years, information about cardiac events was collected in 60 patients by means of clinical records. MAIN OUTCOME MEASURES: Psychological assessment included structured clinical interview for DSM (major/minor depression), Interview for diagnostic criteria for psychosomatic research (demoralisation), symptom questionnaire, psychological well-being scales. RESULTS: At follow-up, 39.7% of the baseline sample reported cardiovascular events (14 CHF-related re-hospitalisations and 13 cardiac deaths) and 5.9% other causes for death. Among the variables examined as potential risk factors for adverse cardiovascular outcomes, only hostility was significant, even after controlling for disease severity (hazard ratio = 2.38, 95%confidence interval: 1.04-5.45, p = .040). CONCLUSION: In outpatients with CHF, psychological assessment should include both clinical and subclinical distress such as hostility, in order to better address psychological risk factors for cardiac outcomes.

Objective Cardiac rehabilitation (CR) is considered the recommended secondary prevention treatment for cardiovascular diseases (CVD), in terms of health behaviours and, secondarily, better cardiac outcomes promotion. However, the role of psychiatric and psychosomatic distress on the efficacy of CR is unclear. This research aimed to evaluate the impact of CR on unhealthy behaviour modification and cardiac course, considering the moderating role of depression, anxiety, and psychosomatic syndromes. Design A longitudinal design between and within groups was employed. The assessment was repeated four times: at admission to CR (T1), at discharge (T2), 6 (T3) and 12 months following CR completion (T4). Method One hundred and eight patients undergoing CR versus 85 patients with CVD not referred to CR, underwent psychiatric, psychosomatic, and health behaviour assessment. The assessment included the Structured Clinical Interview for DSM-IV (depression and anxiety), the interview based on Diagnostic Criteria for Psychosomatic Research, GOSPEL Study questionnaire (health behaviours), Pittsburgh Sleep Quality Index, and 8-item Morisky Medication Adherence Scale. Results Cardiac rehabilitation was associated with maintenance of physical activity, improvement of behavioural aspects related to food consumption, stress management, and sleep quality. On the contrary, CR was not associated with weight loss, healthy diet, and medication adherence. Depression and psychosomatic syndromes seem to moderate the modification of specific health-related behaviours (physical activity, behavioural aspects of food consumption, stress management, and pharmacological adherence). Conclusion In CR settings, an integrated assessment including both psychiatric and psychosomatic syndromes is needed to address psychological factors associated with unhealthy behaviour modification. Statement of contribution What is already known on this subject? Cardiac rehabilitation (CR) is considered a class 1A treatment recommendation and the most cost-effective model of secondary prevention to reduce cardiovascular events. There is evidence about the association between psychological distress and both unhealthy behaviour and cardiac course. Depression and psychosomatic distress, such as type A behaviour and demoralization, are frequently associated with CVD course. However, the role of psychiatric and psychosomatic distress in CR is not well known. What does this study add? CR exerted a protective effect on physical activity and a positive effect on eating behaviour, stress management, and quality of sleep. CR did not show any particular effect on smoking, overweight/obesity, dietary habits, medication adherence, and patients’ 1-year survival. Findings from this study suggest the importance to consider specific psychological and psychosomatic aspects in affecting lifestyle.

The role of psychosocial stress in the development of essential hypertension has attracted increasing attention in the last decades, even though research findings have been often inconclusive. We specifically investigated allostatic overload (AO) in hypertensive patients using a clinimetric approach. Allostatic overload was assessed by a semi-structured research interview based on clinimetric criteria in 80 consecutive outpatients with essential hypertension (46.3 % females; mean age 62.18 ± 8.59 years; age range 47–74 years) and 80 normotensive matched controls. Three clinical interviews and two self-rating questionnaires for assessing psychological distress and well-being were also administered. Cardiac variables were collected. AO was present in 26 (32.5 %) of the hypertensive patients based on clinical interviewing, and in only 6 normotensive controls (p < .001). Hypertensive patients with AO had significantly higher levels of psychological distress than those without. Further, patients with AO displayed significantly lower levels of well-being and quality of life (p < .001). A significantly greater prevalence of psychosomatic syndromes was found to be associated with the presence of AO (p < .05), whereas no significant association was detected as to psychiatric diagnoses. Significantly greater cardiovascular risk was found among hypertensive patients reporting AO compared to those without (p < .05). The results of this study support the clinical relevance of a psychological assessment of hypertensive patients, with important implications for the non-pharmacological management of hypertension.

Purpose: There are several clinical areas where psychological well-being may play an important role: the assessment of the dynamic balance between ill-being and well-being; reduction of incidence, prevention of recurrence and achievement of full recovery in psychiatric disorders such as depression; patient’s satisfaction and perceived change after treatment. The aim of this article is to discuss the clinical role of Well-Being Therapy (WBT). Materials and methods: A critical review of the literature concerned with psychological well-being and its treatment was performed. WBT is a short-term psychotherapeutic strategy that emphasizes self-observation of psychological well-being, with the use of a structured diary, cognitive restructuring of interfering thoughts and/or behaviors through cognitive behavioral techniques, and homework assignments (i.e. pursuing optimal experiences). WBT is based on a multidimensional model of psychological well-being that was originally developed by Marie Jahoda and it is aimed at achieving a state of euthymia. Results: WBT has been validated in a number of randomized controlled trials. The sequential combination of cognitive behavior therapy (CBT) and WBT has mainly characterized its use so far. Illustration of a clinical case exemplifies its application and the potential role of psychological well-being in the clinical process. Conclusions: Even though more randomized controlled trials concerned with WBT are needed, consideration of psychological well-being may unravel innovative approaches to the prevention, assessment and treatment of mood and anxiety disorders.

Objective Psychiatric morbidity is quite common in vasovagal syncope (VVS), but findings are sometimes contradictory. Among patients with suspected VVS, up to 40% has a negative response to Head-Up Tilt test (HUT), the cause of syncope remaining unexplained (US). The authors evaluated and compared the psychological and psychosomatic profile in patients with positive (VVS) and negative HUT (US). Method A consecutive series of 67 patients with suspected VVS underwent HUT: 45 patients had a positive HUT, 22 negative. They were evaluated by means of observer- and self-rated measures. Results Of the total sample, 95.5% had at least one Diagnostic and Statistical Manual of Mental Disorders diagnosis or one psychosomatic syndrome, such as specific and social phobias, illness denial and demoralization. Comparing VVS and US patients, no statistical differences on diagnoses' frequencies were found. However, the US group had significantly poorer health habits, lower levels of well-being and higher psychological distress. They also reported to be more anxious, depressed and hostile. VVS patients were significantly more blood and social phobic than US patients. Conclusion Despite similar and remarkable observer-rated psychopathology, US patients reported higher self-perceived psychological distress than VVS patients. Psychological evaluation of patients undergoing HUT should incorporate both clinical and subclinical methods to better address syncope management.

Aiming to verify which is the most effective screening approach for sleep disorders between the serial (first step: sleep self-report measure; second step only in case of positive outcome at the first: objective tool) and parallel (unique step, with the concurrent use of sleep self-report measure and objective tool), a first secondary analysis of previously collected data (study 1) was carried out examining primary insomniacs (PI) and healthy controls (HC). Aiming to verify the implementation of such approaches in clinical populations presenting high comorbidity with sleep disorder, an additional secondary analysis (study 2) was carried out, investigating hypertensive patients (HP) and severe obese patients (SOP). 84 HC and 47 PI were examined in study 1, while 36 SOP, and 30 HP in study 2. All participants originally underwent actigraphic recordings for seven consecutive days, using the Actiwatch device (objective tool). At the end of the recording week, participants filled the Mini Sleep Questionnaire (sleep self-report measure). As regards the study 1, the parallel and serial approaches allowed to correctly identify the 97.87% and 55.32% of PI, respectively. With reference to the study 2, the 36.11% and 80.56% of SOP were identified as positive at the serial and parallel approaches, respectively, while the corresponding percentages of HP were 30% and 70%. Study 1 showed that parallel screening approach is the most effective in PI, allowing to correctly identifying almost the entirety of these patients. Study 2 highlighted that serial screening approach is more useful in SOP and HP, identifying a percentage of positive patients overall in line with the documented comorbidity with sleep disorder in these clinical populations.

The precipitating role of emotional stress in the development of congestive heart failure (CHF) is a long-standing clinical observation. We employed new clinimetric criteria for the assessment of allostatic overload (AO) in a sample of CHF patients, with regard to its associations with psychological distress and health status. Allostatic overload was assessed by a semi-structured interview based on clinimetric criteria in 70 consecutive outpatients with CHF. One observer-rated scale and two self-rating questionnaires for psychological distress were administered. Cardiac variables were also collected at intake. Twenty-three patients (32.9%) were classified as having AO according to clinimetric criteria. Significant differences were found with regard to gender, with women being more likely to report AO than men (23.5% versus 57.9%). Patients with AO presented significantly higher levels of psychological distress (based on scales administered) compared with those who did not. Among cardiac risk factors, hyperglycaemia was found to be significantly associated with the presence of AO. The use of the clinimetric criteria provides a global index for identifying distress that might adversely influence the course and progression of CHF. It may be of use in clinical practice, leading to therapeutic suggestions such as lifestyle modifications and psychotherapy to help patients deal with their difficulties.

HART) [7] , on depressed patients after CAD, found that the effect of sertraline was greater in patients with severe and recurrent depression. It is also true that, in cardiac settings, mild depressive symptoms are sufficient to enhance cardiovascular risk even in the absence of major depressive disorder [8–11] . Antidepressant treatment could thus be successful in terms of cardiac prognosis only in the subgroup of cardiac patients with more severe depression, but not in those with milder depression at equally elevated cardiac risk. It has been suggested that selective serotonin reuptake inhibitors (SSRIs) might ameliorate the adverse effect of depression on cardiovascular disease through the inhibition of platelet aggregation, even independently of changes in depression [12] . This potential benefit, however, is counteracted by recognized adverse cardiovascular side effects [13–15] . In particular, the use of SSRIs such as citalopram and escitalopram is associated with cases of arrhythmias and prolonged QTc interval on electrocardiogram in patients lacking cardiovascular disorders [16] . Licht et al. [17] found that all antidepressants, including SSRIs, have a lowering effect on cardiac vagal control that has been found to be associated with increased blood pressure and other metabolic abnormalities, such as unfavorable lipid profiles and high glucose levels [18] . A significant relationship between depression and cardiac morbidity has been documented [1] . The identification of depression as an unfavorable marker of the clinical course in coronary artery disease (CAD) in the 1990s [2– 4] generated the hope of improving the prognosis of cardiovascular disease with treatment of depression. This hope, however, has not survived the test of time. In a Cochrane review on randomized controlled clinical trials (RCTs) of any length of treatment and any length of follow-up [5] , psychological and pharmacological interventions have shown a small yet clinically meaningful effect on depression outcomes in CAD patients. However, no beneficial effects on the reduction of mortality rates and cardiac events have been found. Indeed, in some cases, treatment of depression was found to entail negative physical consequences. There are several potential explanations, involving drugs and psychotherapy, which account for this phenomenon.

Background Implantable cardioverter defibrillator (ICD) is a key treatment option for both primary and secondary prevention of sudden cardiac death. Despite this, there is a growing number of studies showing that ICD is often associated with post-implantation deleterious psychosocial effects, even in the absence of medical complications. Knowledge about the predictive role of pre-ICD psychological profile is scant. The present research aims to describe patients' pre-ICD psychological profile, focusing on acute and chronic distress, such as anxiety, depression, type D personality, psychosomatic syndromes and allostatic overload (AO), and to evaluate if these psychological variables could affect ICD outcomes and survival. Methods 117 consecutive patients (74.4% males; mean age=63.1±13.7years) underwent psychological assessment prior to ICD implantation. Data on ICD-related complications and death were collected up to 26months after the intervention. Results At baseline, 36.8% of the sample had anxiety and 17.9% depression. Among psychosomatic syndromes, psychological factors affecting medical conditions were the most frequent (37.6%). 12.8% presented with type D personality, whereas 16.2% showed moderate AO and 4.3% severe AO. 25.6% of the patients had post-ICD complications and 6% died. Severe AO was the only predictor of survival. Conclusion Our findings show that a reliable evaluation of stress and the inability to cope with it (allostatic overload) may help to identify patients at higher risk of post-ICD complications and death. Such sensitive index, more than traditional psychiatric diagnostic criteria, may help the physician to identify easily manifestations of distress and clinically relevant information, which could affect medical illness outcomes.

Heavy episodic alcohol consumption or binge drinking (BD) is highly prevalent among adolescents in Europe. Young BD is associated with a range of negative health and social outcomes and its causes could be referred to greater positive alcohol expectancies or low self-efficacy and personality characteristics. Moreover, it is likely that some adolescents drink because they want to reduce negative emotions or deal with stress. Little is known on the relationship between BD and specific well-being impairments, whereas it seems that meaning in life, a concept similar to psychological well-being, do not characterize such population. We recruited 679 consecutive students who completed the Psychosocial Index and the Alcohol Use Disorder Identification Test (AUDIT). Among the recruited students, 337 consume alcohol and 161 report BD. Significant differences have been highlighted among three groups (no drinkers, drinkers and bingers) concerning stress and environmental mastery. Both higher scores of stress and lower levels of environmental mastery are associated with BD. These preliminary data show that BD is highly represented and the novelty of this study refers to the evaluation of binge drinking phenomenon in adolescents, through validated and reliable methods in the field of clinimetrics.

Summary Aims: The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description. Methods: A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour. Results: A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness. Conclusions: Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.

BackgroundThe classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill.MethodA cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate.ResultsThree clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization.ConclusionsTwo-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Background Somatization is a widespread clinical phenomenon that cuts across diagnostic categories, both psychiatric and medical. Objective This study investigates whether somatization can be assessed with a comprehensive diagnostic system, the Diagnostic Criteria for Psychosomatic Research (DCPR) in gastroenterology and cardiology (myocardial infarction) patients. Method Authors assessed a group of 343 outpatients, 190 gastroenterology and 153 cardiology outpatients, with functional gastrointestinal disorders and recent first myocardial infarction. Results A total of 146 patients were diagnosed by the DCPR Somatization cluster and 106 by the DCPR Abnormal Illness Behavior cluster; 27 patients who met DSM–IV criteria for somatoform disorders were not classified with any DCPR somatization syndromes, whereas 120 with DCPR Somatization cluster did not satisfy the criteria for DSM–IV somatoform disorders. Conclusion Findings suggest that the DCPR is able to identify clinical and subthreshold psychosomatic syndromes and that it can used jointly with the DSM–IV.

Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase. Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004. Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p

Summary Background: In the past decade, in clinical psychiatry several investigations suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aim of this paper was to illustrate the practical implications of sequential treatment strategy for depression in primary care, with particular reference to the increasingly common problem of recurrent depression. Methods: The Authors tried to integrate the evidence which derives from meta-analyses and comprehensive general reviews with the insights which derive from controlled studies concerned with specific populations. Conclusions: The sequential treatment of mood disorders is an intensive, two-stage approach, which derives from the awareness that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the affective disturbances of patients, both in research and in clinical practice settings. The aim of the sequential approach is to add therapeutic ingredients as long as they are needed. In this sense, it introduces a conceptual shift in clinical practice.

Objective. The aim of this study was to compare patientswith symptomatic and asymptomatic atrial fibrillation, in terms of medical variables, self-rated psychological distress and well being, and to evaluate possible correlations among these variables. Methods. Sixty-two outpatients with documented atrial fibrillation (34 with symptomatic atrial fibrillation and 28 without) were evaluated by self-report instruments: the Psychological Well being Scale (PWB) and the Symptom Questionnaire to detect psychological distress. The two groups were compared by means of the t-test and x2-test. Linear regression was performed to evaluate correlations between psychological well being and distress in patients with symptomatic and asymptomatic atrial fibrillation. Results. Patients with symptomatic atrial fibrillation showed lower levels of psychological well being and higher scores of distress than asymptomatic participants. Only among patients with symptomatic atrial fibrillation, all the dimensions of PWB were significantly and negatively associated with the Symptom Questionnaire scores. Conclusion. These results suggest peculiar psychological correlates in the population of patients with symptomatic atrial fibrillation, which should be taken into account for their psychological and clinical management.

Objective We compared the provisional Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for Somatic Symptom Disorders (SSD) and an alternative classification based on the Diagnostic Criteria for Psychosomatic Research (DCPR) as to prevalence and associations with dimensional measures of psychological distress and functioning in a population of medical patients. Method Seventy consecutive outpatients with congestive heart failure were administered an ad hoc structured clinical interview for the identification of DSM-5 SSD, the section concerning hypochondriasis of the Structured Clinical Interview for DSM-IV, the Structured Interview for DCPR and Paykel's Clinical Interview for Depression. Subjects also completed the Symptom Questionnaire and the Psychosocial Index. Global assessment of functioning was performed with the DSM-IV Axis V. Results A diagnosis within DSM-5 SSD was found in 13 patients (18.5%): 61.5% of them were diagnosed with the Psychological Factors Affecting Medical Condition category. Twenty-nine patients (41.4%) were classified according to the DCPR-based proposal: illness denial, demoralization and irritable mood were the most frequent specifiers. The DCPR-based classification showed a greater number of significant associations with dimensional measures of psychological distress, global functioning and stress. Conclusion Compared to DSM-5 SSD, the DCPR-based proposal was more sensitive in detecting psychological factors relevant to illness course and provided a better characterization of such factors. The DCPR-based proposal was also superior in identifying patients with increased psychological distress and poor psychosocial functioning.

Atrial fibrillation (AF) is a chronic illness complicating both mental health and quality of life. Individuals with AF have been reported to experience greater psychological distress than the general population. Nevertheless, assessment strategies did not allow to evaluate fundamental information, such as type, extent and consequences of stress. Recently, according to the clinimetric approach, Fava and colleagues have introduced specific criteria for evaluating the allostatic overload (AO) in clinical setting. It refers to a state due to the cumulative interactions of life events and chronic life stressors that, by exceeding the individual resources, may constitute a danger to health. Our study aimed to evaluate the feasibility of this new definition of AO in a sample of 62 patients suffering from AF. Specifically, our goal was to verify if such definition of AO may discriminate AF patients at high risk for clinical psychological distress. Results showed no differences between AF participants with and without AO in socio-demographic and health variables. Concerning psychiatric variables, patients with AO were more likely to be diagnosed with minor depression, GAD and panic disorders than subjects without AO. Also, they were more likely to suffer from DCPR syndromes of health anxiety and demoralization than AF individuals without AO. Our findings support the hypothesis that clinimetric indexes may help physicians to identify distress manifestations and clinically relevant information more easily than diagnostic criteria do.

Background and Objectives: There is increasing interest in the issue of demoralization, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) in order to characterize demoralization in the medically ill. Methods: 1700 patients were recruited from 8 medical centers in the Italian Health System and 1560 agreed to participate. They all underwent a cross-sectional assessment with DSM-IV and DCPR structured interviews. 373 patients (23.9%) received a diagnosis of demoralization. Data were submitted to cluster analysis. Results: Four clusters were identified: demoralization and comorbid depression; demoralization and comorbid somatoform/adjustment disorders; demoralization and comorbid anxiety; demoralization without any comorbid DSM disorder. The first cluster included 27.6% of the total sample and was characterized by the presence of DSM-IV mood disorders (mainly major depressive disorder). The second cluster had 18.2% of the cases and contained both DSM-IV somatoform (particularly, undifferentiated somatoform disorder and hypochondriasis) and adjustment disorders. In the third cluster (24.7%), DSM-IV anxiety disorders in comorbidity with demoralization were predominant (particularly, generalized anxiety disorder, agoraphobia, panic disorder and obsessive-compulsive disorder). The fourth cluster had 29.5% of the patients and was characterized by the absence of any DSM-IV comorbid disorder. Conclusions: The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of demoralization as encompassed by the DCPR. Subtyping demoralization may yield improved targets for psychosomatic research and treatment trials.

PURPOSE: No previous study has reported upon comorbid depression and anxiety disorders and their treatment in heart failure (HF), which the current study has sought to document. MATERIALS AND METHODS: Total 29 HF patients under psychiatric management underwent primary depression cognitive behavioral therapy (CBT; n = 15) or primary generalized anxiety disorder (GAD) CBT (n = 14), and participated in a community exercise program and standard physician care. Repeated measures analysis of variance assessed Patient Health Questionnaire (PHQ-9) and GAD-7 symptom change pre- and post-CBT treatment, and assessed the interaction effects of treatment type, exercise, anti-depressant and anxiolytic. RESULTS: There was a significant time and treatment interaction effect that favored the primary GAD CBT group for reduction in PHQ symptoms (F(1, 24) = 4.52, p = 0.04). Analysis of PHQ-somatic symptoms also showed a significant main effect for participation in the exercise program (F(1, 24) = 4.21, p = 0.05) and a significant time and anxiolytic interaction (F(1, 24) = 3.98, p = 0.05). The average number of cardiac hospital readmissions favored the primary GAD CBT group (p = 0.05). CONCLUSION: The findings support the use of multifaceted interventions in the rehabilitation of HF patients with comorbid psychiatric needs. Implications for Rehabilitation Comorbid depression and anxiety disorders are a clinical and research focus that deserves more attention in the treatment of heart failure patients. Cognitive behavioral therapy, exercise, and anxiolytic use was associated with significant changes in depression and anxiety though discrete effects were evident. Multifaceted interventions are most likely to be successful in the rehabilitation of HF patients with psychiatric needs.

A few studies have investigated the role of psychosocial variables on clinical outcomes in coronary artery bypass grafting patients. The aims of this prospective study were 1) to assess clinical and subclinical distress in a consecutive sample of patients who underwent coronary artery bypass grafting surgery at both a 1-month assessment and a 6- to 8-year follow-up visit; and 2) to investigate the relationship between psychological variables and coronary events. A consecutive series of 47 patients with recent coronary artery bypass grafting surgery was evaluated by means of observer-rated categories (both the Diagnostic and Statistical Manual [DSM] and the new Diagnostic Criteria for Psychosomatic Research [DCPR]), and self-rated scales such as the Psychosocial Index. Survival analysis was used to characterize the clinical course of patients at the 6- to 8-year follow-up. One month after surgery, at the first psychological assessment, 36% of patients received a psychiatric diagnosis, and almost half of the sample met the criteria for a DCPR cluster. At follow-up, only abnormal illness behavior scores varied significantly from those at the first evaluation. Among the variables examined as potential risk factors for coronary events, only minor depression attained statistical significance. Psychological evaluation of patients who underwent coronary artery bypass grafting surgery needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Furthermore, the data suggest minor depression as a potential cardiac risk factor in coronary artery bypass grafting patients. The clinical approach to coronary artery bypass grafting patients should thus include not only major depressive symptoms but also minor depression.

Objective: Administration of treatments in a sequential order is a common practice in clinical medicine, but has received insufficient attention in psychiatry. The aim of this review was to survey the literature concerned with a sequential use of pharmacotherapy and psychotherapy in mood and anxiety disturbances. Data sources and study selection: A review of the clinical trials in which treatment components were used in a sequential order (i.e., pharmacotherapy followed by psychotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, or one psychotherapeutic technique following another) was performed. Studies were identified by using MEDLINE (English language articles published from 1967 to March 2005; keywords: sequential treatment, drugs and psychotherapy, combined treatment related to depressive disorder, bipolar disorder, depression, mania, anxiety disorders, panic disorder, social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder) and a manual search of the literature and Index Medicus for the years 1960 to 2005. Data synthesis: In unipolar recurrent depression, the sequential use of pharmacotherapy was found to reduce relapse rate. In bipolar disorder, the use of psychotherapeutic strategies in patients who were already undergoing treatment with mood stabilizers was also found to yield clinical benefits. In anxiety disorders, the sequential use of pharmacotherapy and psychotherapy was not found to improve long-term outcome. Conclusion: The sequential treatment of mood and anxiety disorders does not fall within the realm of maintenance strategies. It is an intensive, 2-stage approach, which is based on the fact that one course of treatment with a specific treatment (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the complex array of symptoms of patients with mood and anxiety disorders. The sequential model introduces a conceptual shift in current assessment methods.

Objective The aim of this study was to assess the presence of demoralization and major depression in the setting of medical disease. Method 807 consecutive outpatients recruited from different medical settings (gastroenterology, cardiology, endocrinology, and oncology) were assessed according to DSM-IV criteria and Diagnostic Criteria for Psychosomatic Research, using semistructured research interviews. Results Demoralization was identified in 245 patients (30.4%), while major depression was present in 135 patients (16.7%). Even though there was a considerable overlap between the 2 diagnoses, 59 patients (43.7%) with major depression were not classified as demoralized, and 169 patients (69.0%) with demoralization did not satisfy the criteria for major depression. Conclusions The findings suggest a high prevalence of demoralization in the medically ill and the feasibility of a differentiation between demoralization and depression. Further research may determine whether demoralization, alone or in association with major depression, entails prognostic and clinical implications.

The aim of this study was to explore the prevalence and characteristics of anniversary reactions (somatic symptoms occurring at the anniversary of specific events) in a large sample of 1498 medical patients from different medical settings who underwent the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR), which provide definition of anniversary reactions. In 54 (3.6%) of the 1498 patients for whom anniversary reaction was identified, 61.1% had a concurrent DSM-IV diagnosis. Other syndromes related to somatization, abnormal illness behavior, irritable mood, demoralization, and alexithymia were present in 9 of 10 cases. Symptoms of the conversion syndrome were found in 6 (0.4%) patients with the SCID and in 67 (4.5%) patients with the DCPR, 20% of whom also had anniversary reaction. The results should alert physicians to enquire about the timing of symptoms in relation to meaningful personal events.

The evidence linking essential systemic arterial hypertension (SAH) with psychological characteristics remains equivocal. The aims of this study were to assess clinical and subclinical distress, psychosocial aspects and psychological well-being in treated hypertensive patients and to evaluate the psychosocial variables associated with higher levels of blood pressure according to guidelines for hypertension management. A consecutive series of 125 hypertensive patients were evaluated using both self- and observer-rated reliable measures. Generalized anxiety disorder, minor depression, demoralization and alexithymia were the most frequent diagnoses. Cluster analysis revealed an association of three distinct symptomatological groups such as the Anxiety-Depression, the Alexithymia and the Somatization groups, with different levels of hypertension. In particular, patients with moderate to severe hypertension were more frequently in the Anxiety-Depression and the Alexithymia groups, whereas the Somatization cluster has been shown to be associated with isolated systolic hypertension. The results provide new insight into the psychosocial characteristics among patients with different levels of SAH according to recent guidelines of the management of hypertension. They also outline the need to monitor the clinical course of hypertensive patients characterized by these specific clinical and subclinical psychological conditions.

Background Although a number of risk factors are known to predict mortality within the first years after myocardial infarction, little is known about interactions between risk factors, whereas these could contribute to accurate differentiation of patients with higher and lower risk for mortality. This study explored the effect of interactions of risk factors on all-cause mortality in patients with myocardial infarction based on individual patient data meta-analysis. Methods Prospective data for 10,512 patients hospitalized for myocardial infarction were derived from 16 observational studies (MINDMAPS). Baseline measures included a broad set of risk factors for mortality such as age, sex, heart failure, diabetes, depression, and smoking. All two-way and three-way interactions of these risk factors were included in Lasso regression analyses to predict time-to-event related all-cause mortality. The effect of selected interactions was investigated with multilevel Cox regression models. Results Lasso regression selected five two-way interactions, of which four included sex. The addition of these interactions to multilevel Cox models suggested differential risk patterns for males and females. Younger women (age

Background: The application of cognitive-behavioral treatment (CBT) to patients with bipolar disorder who had an affective episode while on lithium prophylaxis has received little research attention. The aim of this preliminary study was to test whether reduction of residual symptomatology by cognitive-behavioral methods could yield long-term beneficial effects in patients with bipolar disorder, as was found to be the case in recurrent unipolar depression. Method: Fifteen patients with RDC bipolar disorder, type I, who relapsed while on lithium prophylaxis despite initial response and adequate compliance were treated by cognitive-behavioral methods in an open trial. A 2- to 9-year follow-up was performed. Results: Five of the 15 patients had a new affective episode during follow-up. CBT was associated with a significant reduction of residual symptomatology. Conclusion: These preliminary results suggest that a trial of CBT may enhance lithium prophylaxis and improve long-term outcome of bipolar disorder.

Background: Little is known about psychological well-being in remitted patients with panic disorder and agoraphobia and its interactions with residual symptoms. Methods: Thirty patients with panic disorder and agoraphobia who displayed a successful response to exposure therapy, and 30 control subject matched for sociodemographic variables, were administered both observer-rated and self-rated scales for assessing residual symptoms and well-being. Results: Patients had significantly more residual symptoms — as assessed by the Clinical Interview for Depression (CID) and the Symptom Questionnaire (SQ) — than controls. They also had significantly less environmental mastery, personal growth, purpose in life and self-acceptance — as measured by the Psychological Well-being Scales (PWB) — and less SQ physical well-being than controls. Limitation: The findings apply to patients with panic disorders who had been treated by behavioral methods and may be different in drug-treated subjects. Conclusions: The results indicate that successful reduction of symptomatology in panic disorder cannot be equated to a pervasive recovery (encompassing psychological well-being) and may pave the way for sequential therapeutic strategies of more enduring quality.

Background. There is very little information on long-term follow-up of social phobia.Methods. A consecutive series of 70 patients satisfying the DSM-IV criteria for social phobia was treated in an out-patient clinic with behavioural methods based on exposure homework. Forty-five patients were judged to be remitted after eight individual sessions of psychotherapy. A 2 to 12 year (median = 6 years) follow-up was performed. Survival analysis was selected to characterize the clinical course of patients. Assessments were performed before treatment, at the end of therapy, after 1 year, and subsequently on a yearly basis, and utilized selected items of Paykel's Clinical Interview for Depression.Results. Six of the 45 patients (13%) had a relapse of social phobia at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 98 after 2 years, 85 after 5 years and 85 after 10 years. Such probabilities increased in the absence of a personality disorder, of residual social phobic avoidance after exposure, and of concurrent use of benzodiazepines.Conclusions. The findings suggest that, even though one patient out of three is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting effects to the majority of patients with social phobia. Disappearance of residual, subclinical social phobic avoidance appears to be the target of treatment.

There is insufficient research on rating psychological well-being and distress in clinical populations. The aim of this study was to evaluate the differential characteristics of instruments assessing well-being and distress in 20 remitted patients with affective (mood and anxiety) disorders and 20 healthy control subjects matched for sociodemographic variables. Remitted patients displayed significantly higher levels of psychological distress—as measured by Paykel's Clinical Interview for Depression (CID), Van Praag's Scale for Personality Disturbances and Kellner's Symptom Questionnaire (SQ)—and significantly less well-being—as measured by Ryff's Scales of Psychological Well-Being (PWB) and the SQ—than control subjects. The correlations between scales of psychological distress and well-being were found to be complex in both patients and controls. Psychotherapeutic treatment of residual symptomatology in patients disclosed a differential sensitivity of the scales to changes. The results thus suggest that well-being cannot be equated to lack of distress (as implicitly endorsed by current psychiatric paradigms), and the need for a multidimensional assessment in stress medicine. Copyright © 2000 John Wiley & Sons, Ltd.

Relapse and recurrence are vexing problems of unipolar depression. Awareness of their frequent occurrence has led to the development of pharmacological long-term strategies. A substantial proportion of patients with mood disorders still display residual symptoms upon successful treatment of their illness. Such symptoms were found to entail prognostic value in the prediction of relapse in the entire range of affective disorders. Specific psychotherapeutic strategies for this stage of illness have been developed. One involves cognitive-behavioral treatment of residual symptoms after successful pharmacological therapy of acute depression. This strategy has resulted in a lower relapse rate at a four-year follow-up compared to a clinical management group. The other strategy, based on Ryff's conceptual model, was developed to enhance well-being (well-being therapy). Results from recent pilot studies indicate that well-being therapy may be a promising strategy for decreasing residual symptomatology in affective disorders and thus as a relapse-preventive strategy. Copyright © 1999 John Wiley & Sons, Ltd.

Objective To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and other DCPR criteria. Method Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of 188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to cluster analysis. Results Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%). Conclusions The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety disorder in about one third of cases; it is related to various forms of somatization and abnormal illness behavior in another third and may occur without psychiatric comorbidity in another subgroup. Identification of alexithymic features may entail major prognostic and therapeutic differences among medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or medical diagnosis.

BackgroundThe association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity.AimsTo combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity.MethodAn individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses.ResultsSixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26–1.38,PPConclusionsThe association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depressionz-score.

Prodromal symptoms were investigated in 30 patients with obsessive-compulsive disorder. The large majority of patients (93%) reported at least one prodromal symptom before disease onset. Generalized anxiety, irritability, indecision, phobic and somatic anxiety occurred in about half of patients. Also common were depressive symptoms such as fatigue, lowered self-esteem, depressed mood, pessimism, impaired work, and guilt. The results suggest a close association of obsessions and compulsions with affective symptoms.

Objective The aim of this review was to examine the clinical process in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy. Data sources A MEDLINE search from inception to August 2010 was performed for English-language articles using the keywords clinical judgment, clinimetric, staging, comorbidity, sequential treatment, and subclinical symptoms in relation to psychiatric illness. It was supplemented by a manual search of the literature. Study selection Choice of assessment strategies was based on their established or potential incremental increase in clinical information compared to use of diagnostic criteria. Data extraction Contributions were evaluated according to the principles of clinimetrics. Results Several innovative assessment strategies were identified: the use of diagnostic transfer stations with repeated assessments instead of diagnostic endpoints, subtyping versus integration of different diagnostic categories, staging methods, and broadening of clinical information through macroanalysis and microanalysis. The most representative examples were selected. Conclusions Current assessment strategies in psychiatric research do not reflect the sophisticated thinking that underlies clinical decisions in practice. The clinimetric perspective provides an intellectual home for the reproduction and standardization of these clinical intuitions.

The measures of disease status alone are insufficient to describe the burden of illness or one’s attitudes toward illness and life. The subjective health status including psychological resources and well-being, is as valid as that of the clinician when it comes to evaluating outcomes. The aim of this chapter is to provide a theoretical framework for the assessment of psychological well-being and positive functioning and to review the literature supporting the influence of these positive dimensions on illness development and health protection. We selected the assessment tools, such as Kellner’s Symptom Questionnaire, Antonovsky’s Sense of Coherence, Ryff’s Psychological Well-being Scales and Psychosocial Index, that we found most helpful in clinical and psychosomatic practice and that displayed clinimetric properties of sensitivity in research.

Background There is increasing awareness of the need of subtyping major depressive disorder, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing depression in the medically ill. Methods 1700 patients were recruited from 8 medical centers in the Italian Health System and 1560 agreed to participate. They all underwent a cross-sectional assessment with DSM-IV and DCPR structured interviews. 198 patients (12.7%) received a diagnosis of major depressive disorder. Data were submitted to cluster analysis. Results Two clusters were identified: depressed somatizers and irritable/anxious depression. The somatizer cluster included 58.6% of the cases and was characterized by DCPR somatization syndromes (persistent somatization, functional somatic symptoms secondary to a psychiatric disorder, conversion symptoms, and anniversary reactions) and DCPR alexithymia. The anxious/irritable cluster had 41.4% of the total sample and included DCPR irritable mood and type A behavior and DSM-IV anxiety disorders. Limitations The study has limitations due to its cross-sectional nature. Further, these findings require additional validation in another sample. Conclusions The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, irritable mood, type A behavior and alexithymia, as encompassed by the DCPR. Subtyping major depressive disorder may yield improved targets for psychosomatic research and treatment trials.

Background Despite its implications for treatment strategies, the potential role of previous depression on the medical course after coronary heart disease (CHD) has not yet been thoroughly studied. Objective The aim of this study was to determine whether the presence of major and minor depression, dysthymia, and demoralization in the years preceding the first myocardial infarction (MI) or angina, was associated with poor cardiac outcome at 2.5-year follow-up. Method A group of 97 consecutive patients with acute CHD, admitted to a coronary-care unit, were studied while in remission from the acute phase of CHD. Various clinical depression measures were used to assess the occurrence or recurrence of mood disorders preceding the first episode of CHD (baseline visit) and at 2.5 years after the first interview. Results Among the variables examined as potential cardiac risk factors, only dysthymia attained statistical significance. Discussion Further research is needed to identify an effective treatment for dysthymic patients.

Objective The purpose of this cross-sectional study was to assess the prevalence and characteristics of anxiety disorders in the medically ill. Method A sample of 1,660 medical patients was recruited from different medical settings in different periods from 1996 to 2007. All patients underwent detailed semistructured interviews with the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR). Results Generalized anxiety disorder was the most frequent anxiety disturbance (10.3%) and was associated with DCPR somatization syndromes, Type A behavior, and irritable mood. Panic disorder with agoraphobia and agoraphobia without history of panic disorder had almost identical prevalence (about 4.5%), but differed in some patterns of somatization. Agoraphobia without panic attacks was related to illness denial, persistent somatization, anniversary reactions, and demoralization. Much lower prevalence rates were reported for social phobia and obsessive-compulsive disorder. Conclusions The findings indicate that anxiety disorders are common in the setting of medical disease and are associated with several types of psychosomatic presentations. The links between agoraphobia without history of panic disorder and illness denial may provide an explanation for some discrepancies that have occurred in the literature as to the prevalence of agoraphobia in clinical samples compared to epidemiologic studies.

The Diagnostic Criteria for Psychosomatic Research (DCPR) represent a diagnostic and conceptual framework that aims to translate psychosocial variables derived from psychosomatic research into operational tools whereby individual patients can be identified. A set of 12 syndromes was developed: disease phobia, thanatophobia, health anxiety, illness denial, persistent somatization, functional somatic symptoms secondary to a psychiatric disorder, conversion symptoms, anniversary reaction, irritable mood, type A behavior, demoralization, and alexithymia. The aim of this article is to survey the research evidence that has accumulated on the DCPR in several clinical settings (cardiology, oncology, gastroenterology, endocrinology, primary care, consultation psychiatry, nutrition, and community), to examine prevalence and specific diagnostic clusters of the more prevalent DCPR syndromes, and to review their clinical utility in terms of clinical decision, prediction of psychosocial functioning, and treatment outcomes. The implications for classification purposes (DSM-V) are also discussed.

Background In the past decade, there has been an increasing awareness of both quality-of-life impairment and the negative prognostic role of depression in congestive heart failure (CHF) patients. Objective The aims of this study were to evaluate distress, psychological well-being, and clinical and subclinical depression in 68 CHF outpatients at Bellaria Hospital in Bologna, Italy, at an initial assessment and at a 2-month routine follow-up visit. Results Patients reported a high prevalence of somatic complaints, depression, and demoralization, and low scores on psychological well-being. Among the variables examined as potential risk factors for cardiovascular outcome events, based on rehospitalization and cardiac death, only minor depression attained statistical significance. Conclusion Clinicians should thus assess minor depression among other psychological variables in these patients.

The evidence which has accumulated on the course of agoraphobia challenges the DSM view that phobic avoidance is secondary to panic attacks. In particular, a longitudinal study by Wittchen et al. indicates that agoraphobia, as a diagnostic category, is frequently independent of panic disorder and panic attacks, is unlikely to remit spontaneously and entails compromised quality of life. A staging system of agoraphobia is presented. Panic may ensue in the longitudinal development of agoraphobia, as well as of other anxiety disorders, and be conceptualized as a potential outcome in the course of anxiety, phobias and hypochondriasis as more than a specific disease entity. These recent research findings confirm the clinical observations and phenomenological research of Sir Martin Roth (1917–2006) and call for a reassessment of the concept of neurosis.

The aim of this investigation was to explore the prevalence and features of discontinuation syndromes ensuing with gradual tapering of selective serotonin reuptake inhibitors (SSRIs), in optimal clinical conditions in patients with panic disorder and agoraphobia. Twenty-six consecutive outpatients met the DSM-IV criteria for panic disorder and agoraphobia while taking SSRIs. Twenty remitted upon behavioural treatment. Antidepressant drugs were then tapered at the slowest possible pace and with appropriate patient education. Patients were assessed with the Discontinuation-Emergent Signs and Symptoms (DESS) checklist 2 wk, 1 month and 1 yr after discontinuation. Nine of the 20 patients (45%) experienced a discontinuation syndrome, which subsided within a month in all but three patients who had been taking paroxetine for a long time. Discontinuation syndromes appeared to be fairly common even when performed with slow tapering and during clinical remission. In some cases disturbances persisted for months after discontinuation.