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In the United States alone, about 10 million persons are newly bereaved each year. Most do not require professional intervention or treatment, but many can benefit from targeted support. However, a significant minority of bereaved persons experience intense, prolonged and disabling grief symptoms associated with considerable morbidity and mortality (aka, "Complicated Grief"). Individuals with Complicated Grief require more formal interventions. In this article, we describe a compassionate and evidence-based approach to bereavement-care that can be provided in varied mental health settings. For individuals struggling with acute grief, clinicians can help by providing recognition and acceptance of the grief, eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly "checking in" regarding their grief experiences. For bereaved persons who are experiencing Complicated Grief, we recommend an evidence-based approach to bereavement-care, complicated grief therapy (CGT), that involves helping the individual accept and cope with the loss while simultaneously assisting them with adaptation to life without the deceased. We describe ways of implementing CGT's seven core themes: (1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died. This work can be done in a variety of settings, taking into consideration the needs of the patient, the limitations of the setting, and the skills and experiences of each clinician., (© 2019 Wiley Periodicals, Inc.)

Background: Complicated grief (CG) is characterized by persistent, impairing grief after losing a loved one. Little is known about sleep disturbance in CG. Baseline prevalence of subjective sleep disturbance, impact of treatment on sleep, and impact of mid-treatment sleep on CG and quality of life outcomes were examined in adults with CG in secondary analyses of a clinical trial., Methods: Patients with CG (n = 395, mean age =53.0; 78% female) were randomized to CGT+placebo, CGT+citalopram (CIT), CIT, or placebo. Subjective sleep disturbance was assessed by a grief-anchored sleep item (Pittsburgh Sleep Quality Index: PSQI-1) and a four-item sleep subscale of the Quick Inventory of Depressive Symptomatology (QIDS-4). Sleep disturbance was quantified as at least one QIDS-4 item with severity ≥2 or grief-related sleep disturbance ≥3 days a week for PSQI-1. Outcomes included the Inventory of Complicated Grief (ICG), Work and Social Adjustment Scale (WSAS), and Clinical Global Impressions Scale., Results: Baseline sleep disturbance prevalence was 91% on the QIDS-4 and 46% for the grief-anchored PSQI-1. Baseline CG severity was significantly associated with sleep disturbance (QIDS-4: p = .015; PSQI-1: p = .001) after controlling for comorbid depression and PTSD. Sleep improved with treatment; those receiving CGT+CIT versus CIT evidenced better endpoint sleep (p = .027). Mid-treatment QIDS-4 significantly predicted improvement on outcome measures (all p < .01), though only WSAS remained significant after adjustment for mid-treatment ICG (p = .02)., Conclusions: Greater CG severity is associated with poorer sleep beyond PTSD and depression comorbidity. Additional research including objective sleep measurement is needed to optimally elucidate and address sleep impairment associated with CG., (© 2020 Wiley Periodicals, Inc.)

Background: Prolonged grief disorder (PGD) is a new diagnosis in the 11th edition of the International Classification of Diseases, estimated to affect 1 in 10 bereaved people and causing significant distress and impairment. Maladaptive thoughts play an important role in PGD. We have previously validated the typical beliefs questionnaire (TBQ), which contains five kinds of thinking commonly seen in PGD: protesting the death, negative thoughts about the world, needing the person, less grief is wrong, and grieving too much. The current paper examines the role of maladaptive cognition as measured by the TBQ in PGD and its change with treatment., Methods: Among participants in a multisite clinical trial including 394 adults, we examined (a) the relationship between maladaptive thoughts at baseline and treatment outcomes, (b) the relationship between maladaptive thoughts and suicidality at baseline and posttreatment, and (c) the effect of treatment with and without complicated grief therapy (CGT) on maladaptive thinking., Results: TBQ scores were associated with treatment outcomes and were strongly related to suicidal thinking before and after treatment. TBQ scores showed significantly greater reduction in participants who received CGT with citalopram versus citalopram alone (adjusted mean standard error [SE] difference, -2.45 [0.85]; p = .004) and those who received CGT with placebo versus placebo alone (adjusted mean [SE] difference, -3.44 [0.90]; p < .001)., Conclusions: Maladaptive thoughts, as measured by the TBQ, have clinical and research significance for PGD and its treatment., (© 2019 Wiley Periodicals, Inc.)

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis., (© 2020 Wiley Periodicals, Inc.)

Background/objectives: Bereavement is associated with increases in prevalence of mental health conditions and in healthcare utilization. Due to younger age and bereavement by sudden and violent deaths, military widows may be vulnerable to poor outcomes. No systematic research has examined these effects., Method: Using outpatient medical records from wives of active-duty military service members (SMs), we compared the prevalence of mental health conditions and mental healthcare visits among case widows (n = 1,375) to matched (on age, baseline healthcare utilization, SM deployment, and rank) nonbereaved control military wives (n = 1,375), from 1 year prior (Yr-1) to 2 years following (Yr+1 and Yr+2) SM death. Prevalence risk ratios and confidence intervals were compared to determine prevalence rates of mental health conditions and outpatient mental healthcare visits over time., Results: The prevalence of any mental health condition, as well as a distinct loss- and stress-related mental health conditions, significantly increased from Yr-1 to Yr+1 and Yr+2 for cases as did mental healthcare utilization. Widows with persistent disorders (from Yr+1 to Yr+2) exhibited more mental conditions and mental healthcare utilization than widows whose conditions remitted., Conclusion: Bereavement among military widows was associated with a two- to fivefold increase in the prevalence of depression, posttraumatic stress disorder, and adjustment disorder postdeath, as well as an increase in mental healthcare utilization. An increase in the prevalence of loss- and stress-related conditions beyond 1 year after death indicates persistent loss-related morbidity. Findings indicate the need for access to healthcare services that can properly identify and treat these loss-related conditions., (Published 2019. This article is a U.S. Government work and is in the public domain in the USA.)

In psychiatry, clinicians use criteria sets from the Diagnostic and Statistical Manual of Mental Disorders to diagnose mental disorders. Most criteria sets have several symptom domains, and in order to be diagnosed, an individual must meet the minimum number of symptoms required by each domain. Some efforts are now focused on adding biomarkers to these symptom domains to facilitate the detection of and highlight the neurobiological basis of psychiatric disorders. Thus, a new criteria set may consist of both clinical symptom counts in several domains and continuous biomarkers. In this paper, we propose a method to integrate classification rules from multiple data sources to estimate an optimal criteria set. Each domain-specific rule can be counts of symptoms, a linear function of symptoms, or even nonparametric. The overall classification rule is the intersection of these domain-specific rules. Based on examining the expected population loss function, we propose two iterative algorithms using either support vector machines or logistic regression to fit intersection rules consistent with the Diagnostic and Statistical Manual of Mental Disorders. In simulation studies, these proposed methods are comparable with the true decision rule. The methods are applied to the motivating study to construct a criteria set for complicated grief. The developed criteria set shows a substantial improvement in sensitivity and specificity compared to the current standards on an independent validation study., (© 2019 John Wiley & Sons, Ltd.)

Objective: In this study, we examined the mechanisms of action of complicated grief treatment (CGT), an efficacious psychotherapy for complicated grief., Method: We explored 3 putative mediators (guilt/self-blame related to the deceased, negative thoughts about the future, and avoidance) among treatment completers assigned to either CGT (n = 35) or interpersonal psychotherapy (n = 34) in a previously reported randomized controlled trial. Antidepressant use was examined as a moderator of mediation effects., Results: A reduction in guilt/self-blame, negative thoughts about the future, and avoidance behavior each mediated the relationship between treatment group and complicated grief outcomes. Reduction in avoidance emerged as an independent mediator after controlling for all mediators., Conclusion: Reducing avoidance of situations and emotions connected to the loss seems to be a key mechanism of change in CGT. Revising counterfactual thinking around troubling aspects of the death may also play a role in facilitating effective adaptation to loss., (© 2016 Wiley Periodicals, Inc.)

Background: Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT., Method: The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively., Results: Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms., Conclusions: These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368., (© 2015 Wiley Periodicals, Inc.)

Background: Complicated grief (CG) has been recently included in the DSM-5, under the term "persistent complex bereavement disorder," as a condition requiring further study. To our knowledge, no psychometric data on any structured clinical interview for CG (SCI-CG) is available to date. In this manuscript, we introduce the SCI-CG, a 31-item "SCID-like" clinician-administered instrument to assess the presence of CG symptoms., Methods: Participants were 281 treatment-seeking adults with CG (77.9% [n = 219] women, mean age = 52.4, standard deviation [SD] = 17.8) who were assessed with the SCI-CG and measures of depression, posttraumatic stress, anxiety, functional impairment., Results: The SCI-CG exhibited satisfactory internal consistency (α = .78), good test-retest reliability (interclass correlation [ICC] 0.68, 95% CI [0.60-0.75]), and excellent interrater reliability (ICC = 0.95, 95% CI [0.89-0.98]). Exploratory factor analyses revealed that a five-factor structure, explaining 50.3% of the total variance, was the best fit for the data., Conclusions: The clinician-rated SCI-CG demonstrates good internal consistency, reliability, and convergent validity in treatment-seeking individuals with CG and therefore can be a useful tool to assess CG. Although diagnostic criteria for CG have yet to be adequately validated, the SCI-CG may facilitate this process. The SCI-CG can now be used as a validated instrument in research and clinical practice., (© 2015 Wiley Periodicals, Inc.)

Background: Complicated grief (CG) is a bereavement-specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e., periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD-adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop-out rate., Methods: PLD data collected as part of a randomized controlled trial of two loss-focused psychotherapy approaches for CG were examined. Treatment-seeking individuals with primary CG (n = 193) were assessed for PLD at the initial visit, 95 of whom were randomized and completed at least one treatment session., Results: The PLD-adapted Peritraumatic Dissociative Experiences Questionnaire was found to be internally consistent (α = 0.91) with good convergent and divergent validity. After controlling for age, gender, time since loss, and current comorbid psychiatric diagnosis, self-reported PLD was associated with greater CG symptom severity (P < .01). However, contrary to our hypotheses, after controlling for age, baseline symptoms severity, psychiatric comorbidity, and treatment arm, PLD was predictive of better treatment response (P < .05) and lower study discontinuation (P < .01)., Conclusions: PLD may be useful in identifying individuals at risk for CG and those who might respond to psychotherapy. Additional research should investigate the relationship of PLD with treatment outcome for different treatment approaches, and whether PLD prospectively predicts the development of CG., (© 2012 Wiley Periodicals, Inc.)

Acute grief is emotionally intense, cognitively preoccupying, and disruptive, but grief is not an illness; major depression and anxiety disorders are. Grief and mourning have a purpose. They provide an intense, focused opportunity to reregulate emotion and to engage in a learning process that is aimed at reconfiguring life without the deceased—both the internal life of the mind, and ongoing life in the world. A bereaved person needs to figure out how to find meaning, purpose, joy, and satisfaction in life without someone who has previously been central to these feelings. This reconfiguration is a very natural process that tends to occur in fits and starts as bereaved people move forward and deal with everyday life. Nevertheless, a knowledgeable, empathic and supportive clinician can foster good adjustment. Successful mourning is, however, not a given. For some people, the mourning process is derailed and acute grief is inordinately painful and prolonged. For others, the stress of bereavement triggers the onset or worsening of symptoms of MDD, an anxiety disorder or another psychiatric or medical condition, suicidality or negative health behaviors. Clinicians need to be alert to all of these problematic responses to loss. In the wake of bereavement, we need to both facilitate effective mourning and diagnose and treat co-occurring conditions.

Background: Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one., Methods: Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related adjustment disorder., Results: Fifty-eight and half percent of respondents reported a significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty-six point one percent respondents with significant loss had possible CG and 7.0% moderate-to-severe CG. Death of loved one was associated with the highest conditional probability of moderate-to-severe CG (18.5%, compared to 1.1-10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate-to-severe CG due to its comparatively low prevalence. Most moderate-to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial-ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.)., Conclusions: Nonbereavement losses accounted for the vast majority of hurricane-related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses., (© 2011 Wiley-Liss, Inc.)

Background: Complicated Grief (CG) is under consideration as a new diagnosis in DSM5. We sought to add empirical support to the current dialogue by examining the commonly used Inventory of Complicated Grief (ICG) scale completed by 782 bereaved individuals., Methods: We employed IRT analyses, factor analyses, and sensitivity and specificity analyses utilizing our full sample (n = 782), and also compared confirmed CG cases (n = 288) to noncases (n = 377). Confirmed CG cases were defined as individuals bereaved at least 6 months who were seeking care for CG, had an ICG ≥ 30, and received a structured clinical interview for CG by a certified clinician confirming CG as their primary illness. Noncases were bereaved individuals who did not present with CG as a primary complaint (including those with depression, bipolar disorder, anxiety disorders, and controls) and had an ICG<25., Results: IRT analyses provided guidance about the most informative individual items and their association with CG severity. Factor analyses demonstrated a single factor solution when the full sample was considered, but within CG cases, six symptom clusters emerged: (1) yearning and preoccupation with the deceased, (2) anger and bitterness, (3) shock and disbelief, (4) estrangement from others, (5) hallucinations of the deceased, and (6) behavior change, including avoidance and proximity seeking. The presence of at least one symptom from three different symptom clusters optimized sensitivity (94.8%) and specificity (98.1%)., Conclusions: These data, derived from a diverse and predominantly clinical help seeking population, add an important perspective to existing suggestions for DSM5 criteria for CG., (© 2010 Wiley-Liss, Inc.)

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders., (© 2011 Wiley-Liss, Inc.)

Major depression affects one out of five women during her lifetime. Depressed mothers with psychiatrically ill children represent an especially vulnerable population. Challenged by the demands of caring for ill children, these mothers often put their own needs last; consequently, their depressions remain untreated. This population is especially difficult to engage in treatment. We have developed a nine-session intervention, an engagement session followed by eight sessions of brief interpersonal psychotherapy designed to increase maternal participation in their own psychotherapy, resolve symptoms of maternal depression, and enhance relationships (IPT-MOMS). This open-label trial assesses the feasibility and acceptability of providing this treatment to depressed mothers. Thirteen mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment. Subjects (mothers) were treated openly with IPT-MOMS. Eighty-five percent (11/13) completed the study. Subjects were evaluated with the Hamilton Rating Scale for Depression, and completed self-report measures of quality of life and functioning at three time points: baseline, after treatment completion, and 6-months posttreatment. A signed rank test was used to compare measurement changes between assessment time points. Subjects showed significant improvement from baseline to posttreatment on measures of maternal symptoms and functioning. These gains were maintained at 6-month follow-up. Therapy was well tolerated and accepted by depressed mothers, who are typically difficult to engage in treatment. A high proportion of subjects completed treatment and experienced improvements in functioning. Future randomized clinical trials are needed to establish the efficacy of this approach.

The aim of the present study was to evaluate severity of sleep disturbances in a group of 105 individuals presenting with complicated grief (CG) accompanied or not by comorbid depression and/or posttraumatic stress disorder (PTSD). A sample of 105 adults meeting criteria for CG was included in this study. All completed the Pittsburgh Sleep Quality Index (PSQI). The total sample presented a mean global PSQI score of 9.44, indicating overall poor sleep quality. Comorbid depression, but not PTSD, further worsened sleep quality. Further studies are required to investigate the potential role of poor sleep quality as a modifiable risk factor of complicated grief response.

Patients whose depression is complicated by a lifetime history of panic symptoms display a poorer treatment response to both psychotherapeutic and pharmacologic interventions. A newly adapted psychosocial treatment for depression with lifetime panic spectrum symptoms was evaluated in an open pilot study., (Copyright (c) 2005 Wiley-Liss, Inc.)

Sleep disturbances (SD) are a core clinical feature of PTSD. The goal of the study was to determine the influence of patient-related characteristics, disorder-related characteristics, and psychiatric comorbidity on the severity of SD in PTSD outpatients (n = 367) who were not recruited for a sleep study. Increased severity of SD paralleled increasing overall PTSD severity. The severity of SD did not differ according to gender, age groups, types of trauma, PTSD chronicity, or psychiatric comorbidity. Results suggest that age, gender, and psychiatric comorbidity have minimal impact on sleep quality in this PTSD sample. The inclusion of PTSD patients who were not specifically seeking treatment for SD reinforces the study findings.

We assessed the reliability and validity of the Turkish version of the seven-item Panic Disorder Severity Scale (PDSS). We recruited 174 subjects, including 104 with current DSM-IV panic disorder with (n=76) or without(n=28)agoraphobia, 14 with a major depressive episode, 24 with a non-panic anxiety disorder, and 32 healthy controls. Assessment instruments were Panic Disorder Severity Scale, Panic and Agoraphobia Scale, both the observer-rated (P&Ao) and self-rating (P& Asr); Clinical Global Impression Scale (CGI); Hamilton Anxiety Scale, and Beck Depression Inventory. We repeated the measures for a group of panic disorder patients (n = 51) after 4 weeks to assess test-retest reliability. The internal consistency (Cronbach's alpha) of the PDSS was .92-94. The inter-rater correlation coefficient was .79. The test-retest correlation coefficient after 4 weeks was .63. In discriminant validity analyses, the highest correlation for PDSS was with P&Ao, P&Asr (r=.87 and.87, respectively) and CGI (r=.76) and the lowest with Beck Depression Inventory (r=.29). The cut-off point was six/seven, associated with high sensitivity (99%) and specificity (98%). This study confirmed the objectivity, reliability and validity of the Turkish version of the PDSS.

The Collaborative Spectrum Project has developed structured interviews and self-report instruments to assess the spectrum of symptomatology related to panic-agoraphobia, mood, social phobia, and obsessive-compulsive and eating disorders. In order to obtain a rapid pre-test on all five of these spectrum conditions, the authors sought to develop a brief instrument that would tap these conditions. This paper reports on 1) the procedures to derive this composite instrument, the General 5-Spectrum Measure (GSM-V), by selecting items from five existing spectrum instruments, and 2) preliminary testing of the internal consistency and test-retest reliability of the GSM-V. The GSM-V consists of 54 items grouped into scales that explore the five spectra described above. It was derived from existing data on five Structured Clinical Interviews that were designed to assess spectrum features by using multiple regression models. The GSM-V was administered as a stand-alone instrument along with the self-report versions of the spectrum interviews to a sample of 56 psychiatric patients in order to determine the internal consistency of its scales and the correlation with the parent spectrum measures. Moreover, to determine whether subjects would respond consistently to the same items on two different occasions (test-retest reliability), the GSM-V was re-administered within 1 month from the baseline. From each of the five spectrum interviews, items were selected that accounted for a significant proportion of variance of the total score of the parent instrument. The five sets of items so selected constitute separate scales. The scales of the GSM-V had a good to excellent internal consistency, excellent test-retest reliability, and proved to reproduce adequately the long-form measures. The GSM-V appears to provide a reliable alternative to the five longer spectrum interviews. It is envisaged that the instrument will be most useful as a pre-test to identify subjects with spectrum features that should be explored in greater detail. Additionally, it could provide a better characterization of patients with a syndromal level Axis-I disorder, who might require specific treatment strategies targeted to co-occurring subsyndromal conditions., (Copyright 2003 Wiley-Liss, Inc.)

A large number of studies suggest that individual characteristics of psychotherapists affect the outcome of psychosocial treatments for psychiatric illness, but little work has been done to see if this is also the case for pharmacotherapy. In the context of a multicenter study that compared psychosocial and medication treatments for panic disorder, we assessed whether such characteristics as age of the psychiatrist, number of years of experience, and gender influence the outcome of treatment with the antipanic drug imipramine. Data were examined by multiple and logistic regression analyses for eight psychiatrists who treated a total of 57 patients with panic disorder. More physician experience, measured as years since completing residency, was associated with better response to imipramine on one of two main dichotomous measures (the Clinical Global Impression-Improvement Scale) and on six of nine continuous measure rating scales. Associations between psychiatrist age and outcome and between psychiatrist gender and outcome were also present but on fewer measures. Although these are post-hoc analyses that were not planned when the multicenter study was originally designed and therefore there are limitations in the information available about the psychiatrists' characteristics, the findings suggest that even in the context of a clinical trial that employs a specific protocol and single medication, physician experience may influence patient outcome. Depression and Anxiety 17:88-93, 2003., (Copyright 2003 Wiley-Liss, Inc.)

The interview-administered Panic Disorder Severity Scale (PDSS) has been demonstrated to be a reliable and valid measurement of panic disorder severity. The purpose of this paper is to report on the reliability and usefulness of the self-report form (PDSS-SR). The PDSS and PDSS-SR were administered to 108 psychiatric outpatients with and without panic disorder. The internal consistency of the instruments was analyzed with Cronbach's alpha. Test-retest reliability was assessed on 25 of these subjects by using intraclass correlation coefficient (ICC). In addition, decrease in panic symptoms was measured after cognitive-behavioral treatment (CBT) treatment on 27 subjects. Cronbach's alpha was.917 for PDSS-SR and.923 for the PDSS. The PDSS-SR had good test-retest reliability (ICC=0.81) and was sensitive to change with treatment, with a mean decrease of 7.3 (S.D.=5.1). The self-report version of the PDSS is a reliable format, which could be useful in clinical and research settings., (Copyright 2002 Wiley-Liss, Inc.)

The Hamilton Anxiety Rating Scale, a widely used clinical interview assessment tool, lacks instructions for administration and clear anchor points for the assignment of severity ratings. We developed a Structured Interview Guide for the Hamilton Anxiety Scale (SIGH-A) and report on a study comparing this version to the traditional form of this scale. Experienced interviewers from three Anxiety Disorders research sites conducted videotaped interviews using both traditional and structured instruments in 89 participants. A subset of the tapes was co-rated by all raters. Participants completed self-report symptom questionnaires. We observed high inter-rater and test-retest reliability using both formats. The structured format produced similar but consistently higher (+ 4.2) scores. Correlation with a self-report measure of overall anxiety was also high and virtually identical for the two versions. We conclude that in settings where extensive training is not practical, the structured scale is an acceptable alternative to the traditional Hamilton Anxiety instrument., (Copyright 2001 Wiley-Liss, Inc.)

Given the high rates of maladjustment among children of depressed mothers, parenting is likely to cause significant life stress in this population, potentially worsening the course of mothers' depression. The present study is a comparison of severe life stress in 38 mothers and 62 non-mothers receiving treatment for recurrent major depression. Life stress was assessed using the Life Events and Difficulties Schedule [Brown and Harris, 1978a]. We hypothesized that mothers would evidence a greater number of severe life events and marked difficulties both in the year prior to the onset of their depressive index episode and in the time period following the onset of their current depressive episode. Prior to depression onset, mothers reported a significantly greater number of entrapping difficulties, but not marked difficulties, severe events, entrapping events, or humiliating events. However, following the onset of depression, mothers experienced a significantly greater number of severe events, entrapping events, marked difficulties, and entrapping difficulties, but not humiliating events. Mothers' elevated levels of stress were attributable to child-related stress, predominantly related to children's psychological and behavioral problems. Our findings suggest that comprehensive treatment for mothers with major depression needs to address their parenting style and any psychological problems experienced by their children.

Since psychiatric disorders differ throughout the lifespan in phenomenology, course, and treatment, there is need for study of comorbidity of such disorders in geriatric populations. Prior findings of low prevalence of comorbid late-life anxiety disorders in depressed elderly are now disputed by recent studies. Risk factors for comorbid late-life depression and anxiety may be different from those for depression without anxiety. Similar to adults, elderly depressives with comorbid anxiety symptoms present with more severe pathology and have a more difficult course of illness, including decreased or delayed treatment response. In this paper, we review the literature on anxiety and depression comorbidity in late life, and we make recommendations for the assessment and treatment of comorbid late-life anxiety and depression. We also recommend directions for future research in the area of psychiatric comorbidity in late life., (Copyright 2001 Wiley-Liss, Inc.)

This study seeks to determine how panic disorder patients with anxiety and depression comorbidity differ from panic disorder patients without comorbidity at the time of presentation for treatment. One-hundred seventy-one panic disorder patients presenting for their initial assessment and treatment at the Payne Whitney Anxiety Disorders Clinic agreed to participate and completed self-report and diagnostic assessments. Sixty-seven percent of panic disorder subjects were found to have at least one comorbid anxiety or depression diagnosis. Age and gender ratio were not affected by the presence of comorbid diagnoses. Comorbidity significantly contributed to psychological distress and symptom load, overall impairment, and interpersonal impairment.

In this second review on research examining psychosocial cognitive-behavioral, and basic behavioral research, we focus on recent findings pertaining to: (a) relevant psychological constructs in anxiety, and (b) the treatment of anxiety. We first present several studies in which researchers investigated psychological models or constructs with the aim of enhancing the current understanding of the development and persistence of anxiety. Most of these studies also have implications for the treatment of anxiety disorders. We go on to review studies exploring novel approaches to the treatment of persons with anxiety.

Ninety-three patients with panic disorder and mild or no agoraphobia were treated for their panic disorder by using either 11 sessions of individual cognitive-behavior therapy or imipramine. Before and after treatment, their panic disorder symptomatology was assessed, and a self-report measure was administered to measure personality disorder characteristics [Klein et al., 1990: Wisconsin Personality Disorders Inventory]. In addition, some patients received this personality assessment again after six monthly maintenance sessions. Both treatments were equally effective in reducing panic disorder symptomatology, and both treatments had a positive influence on personality disorder characteristics. Personality disorder characteristics did not predict treatment outcome in either group. The implications of the findings for the assessment of personality and the treatment of panic disorder are discussed.

Major depression and anxiety frequently co-occur, but the implications for psychological treatments have rarely been studied. We examined predictors of acute response to interpersonal psychotherapy in 134 consecutively treated female outpatients with recurrent unipolar depression. Women who failed to remit with interpersonal psychotherapy alone experienced higher levels of somatic anxiety, were more likely to meet criteria for lifetime panic disorder, were more likely to meet criteria for nonendogenous or nonmelancholic depression, and reported greater vocational impairment, higher levels of global severity, a longer duration of the index episode, and, somewhat surprisingly, lower levels of social impairment at pretreatment evaluation. A series of backwards stepping logistic regression analyses showed higher levels of baseline somatic anxiety and social functioning to be the most consistent predictors of nonresponse. Our findings strengthen existing evidence that concomitant anxiety can adversely affect the outcome of interpersonal therapy for depression.

The purpose of this review is to propose a systematic approach to the assessment of social phobia for monitoring treatment outcome in clinical settings. A selection of measures is available, including questionnaires and structured interviews varying in length, complexity, and content. To design an assessment protocol for a particular patient or patient population, the clinician needs to be familiar with the characteristics of these available measures. The measures selected for detailed description and discussion here: (a) are specifically designed to assess social anxiety and social phobia, (b) have been demonstrated to have acceptable psychometric characteristics, and (c) have been utilized in treatment outcome research. Five questionnaire measures will be reviewed: (1) the Social Phobia and Anxiety Inventory (SPAI) (Turner et al., 1989a: Psychol Assessment 1:35-40), (2) the Social Interaction and Anxiety Scale (SIAS) (Mattick and Clarke, 1989 in Heimberg et al., 1992), (3) the Social Phobia Scale (SPS) (Mattick and Clarke, 1989 in Heimberg et al., 1992: Behav Therapy 23:53-73), (4) the Fear of Negative Evaluation Scale (FNES) (Watson and Friend, 1969: J Consult Clin Psychol 33:448-457), and (5) The Social Anxiety and Distress Scale (SADS) (Watson and Friend, 1969: J Consult Clin Psychol 33:448-457). Two interview measures will be reviewed, the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987: Modern Problems Pharmacopsych 22:141-173) and Brief Social Phobia Scale (BSPS) (Davidson et al., 1991: J Clin Psychiatry 52:48-51). Measures developed for specific subgroups, including patients with speech anxiety and musical performance anxiety, as well as the application of other evaluation methods, such as the Behavioral Assessment Test, will also be discussed. Guidelines for selecting appropriate social phobia measures for varying clinical and research situations will be proposed that take into consideration the strengths and weaknesses of these methods.

Unlabelled: The objectives of this report were (1) to describe residual depressive symptoms in elderly patients during continuation therapy with combined nortriptyline and interpersonal psychotherapy; (2) to determine which symptoms were persistent; (3) to determine the clinical correlates of residual depressive symptoms; and (4) to document distinct response pattern clusters during combined continuation therapy., Method: Box plot analyses of Hamilton depression scores and Global Assessment Scale scores, repeated twice monthly over 4 months, were conducted using data from 105 elderly depressives. Temporal trends in the data were examined via random regression analysis. Individual trajectories for each of the 105 patients were examined for patterns of response during continuation therapy., Results: We observed a low mean Hamilton rating of 7 (SD = 2.3) at the start of continuation therapy and 5 (SD = 3.0) at the end. Both Hamilton and GAS scores showed modest but significant improvement over time. Hamilton variability was most apparent in symptoms of mood lowering, apathy, anxiety (psychological and somatic), feelings of guilt, anergia, insomnia, and loss of libido; other symptoms (retardation, agitation, hypochondriasis, loss of appetite, loss of weight, suicidal ideation, and loss of insight) showed clear resolution. A diagnosis of RDC situational depression was associated with higher levels of residual symptoms, while level of chronic medical burden, personality dysfunction, and social support were not. Examination of response patterns showed that a quarter of patients experienced one or more brief symptomatic exacerbations., Conclusion: On average, an excellent level of symptom resolution was achieved for most patients with Hamilton scores comparable to those seen in healthy elderly controls. These data support a position of therapeutic optimism in late-life depression and underscore full remission as an achievable therapeutic goal.