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Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyper-activity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.

Objectives To evaluate the epidemiology of and postintensive care unit (ICU) interventions for anxiety symptoms after critical illness. Methods We searched five databases (1970–2015) to identify studies assessing anxiety symptoms in adult ICU survivors. Data from studies using the most common assessment instrument were meta-analyzed. Results We identified 27 studies (2880 patients) among 27,334 citations. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale was the most common instrument (81% of studies). We pooled data at 2–3, 6 and 12–14month time-points, with anxiety symptom prevalences [HADS-A≥8, 95% confidence interval (CI)] of 32%(27–38%), 40%(33–46%) and 34%(25–42%), respectively. In a subset of studies with repeated assessments in the exact same patients, there was no significant change in anxiety score or prevalence over time. Age, gender, severity of illness, diagnosis and length of stay were not associated with anxiety symptoms. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were potential risk factors. Physical rehabilitation and ICU diaries had potential benefit. Conclusions One third of ICU survivors experience anxiety symptoms that are persistent during their first year of recovery. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were associated with post-ICU anxiety. Physical rehabilitation and ICU diaries merit further investigation as possible interventions.

To synthesize data on prevalence, natural history, risk factors, and post-ICU interventions for depressive symptoms in ICU survivors.PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and Cochrane Controlled Trials Registry (1970-2015).Studies measuring depression after hospital discharge using a validated instrument in more than 20 adults from non-specialty ICUs.Duplicate independent review and data abstraction.The search identified 27,334 titles, with 42 eligible articles on 38 unique studies (n = 4,113). The Hospital Anxiety and Depression Scale-Depression subscale was used most commonly (58%). The pooled Hospital Anxiety and Depression Scale-Depression subscale prevalence (95% CI) of depressive symptoms at a threshold score greater than or equal to 8 was 29% (22-36%) at 2-3 months (12 studies; n = 1,078), 34% (24-43%) at 6 months (seven studies; n = 760), and 29% (23-34%) at 12-14 months (six studies; n = 1,041). The prevalence of suprathreshold depressive symptoms (compatible with Hospital Anxiety and Depression Scale-Depression subscale, ≥ 8) across all studies, using all instruments, was between 29% and 30% at all three time points. The pooled change in prevalence (95% CI) from 2-3 to 6 months (four studies; n = 387) was 5% (-1% to +12%), and from 6 to 12 months (three studies; n = 412) was 1% (-6% to +7%). Risk factors included pre-ICU psychologic morbidity and presence of in-ICU psychologic distress symptoms. We did not identify any post-ICU intervention with strong evidence of improvement in depressive symptoms.Clinically important depressive symptoms occurred in approximately one-third of ICU survivors and were persistent through 12-month follow-up. Greater research into treatment is needed for this common and persistent post-ICU morbidity.

Survivors of acute respiratory failure commonly experience long-term psychological sequelae and impaired quality of life. For researchers interested in general mental health, using multiple condition-specific instruments may be unnecessary and inefficient when using the Medical Outcomes Study Short Form (SF)-36, a recommended outcome measure, may suffice. However, relationships between the SF-36 scores and commonly used measures of psychological symptoms in acute survivors of respiratory failure are unknown.Our objective is to examine the relationship of the SF-36 mental health domain (MH) and mental health component summary (MCS) scores with symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) evaluated using validated psychological instruments.We conducted a cross-sectional analysis of 1,229 participants at 6- and 12-month follow-up assessment using data from five studies from the United States, the United Kingdom, and Australia.Symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS), Depression Anxiety Stress Scales, the Davidson Trauma Scale, Impact of Event Scale (IES), and IES-Revised (IES-R). At 6-month assessment there were moderate to strong correlations of the SF-36 MH scores with HADS depression and anxiety symptoms (r = -0.74 and -0.79) and with IES-R PTSD symptoms (r = -0.60) in the pooled analyses. Using the normalized population mean of 50 on the SF-36 MH domain score as a cut-off, positive predictive values were 16 and 55% for substantial depression; 20 and 68% for substantial anxiety (Depression Anxiety Stress Scales and HADS, respectively); and 40, 44, and 67% for substantial PTSD symptoms (IES-R, IES, and Davidson Trauma Scale, respectively). Negative predictive values were high. The area under the receiver operating characteristics curve of the SF-36 MH score was high for depression, anxiety, and PTSD symptoms (0.88, 0.91, and 0.84, respectively). All results were consistent for the MCS, across the individual studies, and for the 12-month assessment.For researchers interested in general mental health status, the SF-36 MH or MCS offers a strong measure of psychological symptoms prevalent among survivors of acute respiratory failure. For researchers interested in specific conditions, validated psychological instruments should be considered.

To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome.Prospective longitudinal cohort study.Forty-one Acute Respiratory Distress Syndrome Network hospitals across the United States.Six hundred ninety-eight acute respiratory distress syndrome survivors.None.Psychiatric symptoms were evaluated by using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at 6 and 12 months. Adjusted prevalence ratios for substantial symptoms (binary outcome) and severity scores were calculated by using Poisson and linear regression, respectively. During 12 months, a total of 416 of 629 patients (66%) with at least one psychiatric outcome measure had substantial symptoms in at least one domain. There was a high and almost identical prevalence of substantial symptoms (36%, 42%, and 24% for depression, anxiety, and posttraumatic stress disorder) at 6 and 12 months. The most common pattern of co-occurrence was having symptoms of all three psychiatric domains simultaneously. Younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU were significantly associated with psychiatric symptoms, whereas greater severity of illness and ICU length of stay were not associated.Psychiatric symptoms occurred in two thirds of acute respiratory distress syndrome survivors with frequent co-occurrence. Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery. Given high co-occurrence, acute respiratory distress syndrome survivors should be simultaneously evaluated for a full spectrum of psychiatric sequelae to maximize recovery.

Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.

Background Prior randomised trials have evaluated statins in patients with sepsis and acute respiratory distress syndrome (ARDS), but there has been no comprehensive evaluation of long-term effects, despite potential neuromuscular and mental health adverse effects of these drugs. Aim To evaluate the effect of rosuvastatin versus placebo on survival, physical function and performance, and mental health outcomes in patients with sepsis-associated ARDS. Methods Prospective follow-up evaluation of the ARDS Clinical Trials Network Statins for Acutely Injured Lungs from Sepsis trial of rosuvastatin versus placebo in 568 mechanically ventilated patients with sepsis-associated ARDS, with blinded 6-month outcome assessment performed in the 272 eligible survivors for age-adjusted and sex-adjusted 36-Item Short Form Health Survey (SF-36) physical function and mental health domains, and in 84 eligible survivors for the 6 min walk test, along with secondary outcomes evaluations of survival, and additional patient-reported and performance-based measures at 6-month and 12-month follow-up. Results Over 1-year follow-up, there was no significant difference in cumulative survival in the rosuvastatin versus placebo groups (58% vs 61%; p=0.377), with survivors demonstrating substantial impairments in physical function and mental health. Rosuvastatin versus placebo had no effect (mean treatment effect (95% CI)) on SF-36 physical function (0 (−7 to 8), p=0.939) or mental health (−6 (−12 to 1) p=0.085) domains, 6 min walk distance (per cent predicted: 2 (−9 to 14), p=0.679) or the vast majority of secondary outcomes. Conclusions Over 1-year follow-up, patients with sepsis-associated ARDS had high cumulative mortality, with survivors commonly experiencing impairments in physical functioning and performance, and mental health. Randomisation to rosuvastatin had no effect on these outcomes. Trial registration number NCT00979121 and NCT00719446.

Because of pervasive poor general medical and mental health status among patients receiving Medicaid, there has been substantial debate about whether Medicaid, as currently financed and delivered, is better than no insurance. The study aimed to address whether insurance status is associated with the subsequent incidence and persistence of common mental disorders.Data came from a nationally representative U.S. population-based longitudinal survey that assessed mental disorders at two time points three years apart. Propensity score methods were used to adjust for potential confounding and to assess the association between three mutually exclusive insurance status groups (no insurance, private insurance only, and Medicaid only) and the subsequent incidence and persistence of mood, anxiety, and substance use disorders for persons ages 18-65 (N=26,410).Compared with private insurance, lack of insurance was associated with higher odds of both the incidence and persistence of substance use disorders and with higher odds of persistence of any mood or anxiety disorder. Compared with having private insurance, having Medicaid insurance was associated with increased odds of persistent mood and anxiety disorders during follow-up. Overall, findings did not significantly differ between the uninsured and Medicaid groups.The findings do not support prior reports that U.S. adults with Medicaid have worse mental health outcomes than uninsured adults. Lacking insurance may put individuals at higher risk of developing substance use disorders, and uninsured individuals with preexisting mental conditions were more likely to have mood, anxiety, and substance use problems that persist over time.

The category of non-cardiac thoracic surgery, or general thoracic surgery, includes procedures on the respiratory and gastrointestinal systems. In the perioperative period, difficulty breathing, swallowing, and communicating are common physically and psychologically distressing experiences. Most conditions for which thoracic surgeries are indicated are associated with elevated preoperative prevalences of depressive and anxiety phenomena. Postoperative psychiatric symptoms are associated with increased morbidity and mortality. Mechanical ventilation and related interventions can interfere with communication, including the traditional psychiatric interview. Awareness of the unique challenges and significance of psychiatric symptoms in the perioperative period is key in the care of non-cardiac thoracic surgery patients.

In-ICU conflicts are common and tend to be less apparent to physicians than to nurses, who spend more time with patients and family members. Timely and clear communication, involving multiple voices, is necessary to prevent or mitigate conflict regarding patients with poor prognoses. Ethics and palliative care consults can facilitate conflict resolution without increasing patient mortality.

BACKGROUND: To determine possible dimensions that underlie obsessive-compulsive personality disorder (OCPD) and to investigate their clinical correlates, familiality, and genetic linkage. METHODS: Participants were selected from 844 adults assessed with the Structured Instrument for the Diagnosis of DSM-IV Personality Disorders (SIDP) in the OCD Collaborative Genetics Study (OCGS) that targeted families with obsessive-compulsive disorder (OCD) affected sibling pairs. We conducted an exploratory factor analysis, which included the eight SIDP-derived DSM-IV OCPD traits and the indecision trait from the DSM-III, assessed clinical correlates, and estimated sib-sib correlations to evaluate familiality of the factors. Using MERLIN and MINX, we performed genome-wide quantitative trait locus (QTL) linkage analysis to test for allele sharing among individuals. RESULTS: Two factors were identified: Factor 1: order/control (perfectionism, excessive devotion to work, overconscientiousness, reluctance to delegate, and rigidity); and Factor 2: hoarding/indecision (inability to discard and indecisiveness). Factor 1 score was associated with poor insight, whereas Factor 2 score was associated with task incompletion. A significant sib-sib correlation was found for Factor 2 (rICC =.354, P CONCLUSIONS: The results indicate two factors of OCPD, order/control and hoarding/indecision. The hoarding/indecision factor is familial and shows modest linkage to a region on chromosome 10. Language: en

To evaluate the cooccurrence, and predictors of remission, of general anxiety, depression, and posttraumatic stress disorder symptoms during 2-year follow-up in survivors of acute lung injury treated in an ICU.Prospective cohort study, with follow-up at 3, 6, 12, and 24 months post-acute lung injury.Thirteen medical and surgical ICUs in four hospitals.Survivors among 520 patients with acute lung injury.The outcomes of interest were measured using the Hospital Anxiety and Depression Scale anxiety and depression subscales (scores ≥ 8 indicating substantial symptoms) and the Impact of Event Scale-Revised (scores ≥ 1.6 indicating substantial posttraumatic stress disorder symptoms). Of the 520 enrolled patients, 274 died before 3-month follow-up; 186 of 196 consenting survivors (95%) completed at least one Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised assessment during 2-year follow-up, and most completed multiple assessments. Across follow-up time points, the prevalence of suprathreshold general anxiety, depression, and posttraumatic stress disorder symptoms ranged from 38% to 44%, 26% to 33%, and 22% to 24%, respectively; more than half of the patients had suprathreshold symptoms in at least one domain during 2-year follow-up. The majority of survivors (59%) with any suprathreshold symptoms were above threshold for two or more types of symptoms (i.e., general anxiety, depression, and/or posttraumatic stress disorder). In fact, the most common pattern involved simultaneous general anxiety, depression, and posttraumatic stress disorder symptoms. Most patients with general anxiety, depression, or posttraumatic stress disorder symptoms during 2-year follow-up had suprathreshold symptoms at 24-month (last) follow-up. Higher Short-Form-36 physical functioning domain scores at the prior visit were associated with a greater likelihood of remission from general anxiety and posttraumatic stress disorder symptoms during follow-up.The majority of acute lung injury survivors had clinically significant general anxiety, depression, or posttraumatic stress disorder symptoms, and these symptoms tended to co-occur across domains. Better physical functioning during recovery predicted subsequent remission of general anxiety and posttraumatic stress disorder symptoms.

Disrupted sleep is a common and potentially modifiable risk factor for delirium in the ICU. As part of a quality improvement project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium.Secondary analysis of prospective observational study.Medical ICU over a 201-day period.Two hundred twenty-three patients with greater than or equal to one night in the medical ICU in between two consecutive days of delirium assessment.None.Daily perceived sleep quality ratings were measured using the Richards-Campbell Sleep Questionnaire. Delirium was measured twice daily using the Confusion Assessment Method for the ICU. Other covariates evaluated included age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day's delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [interquartile range] ratings, 58 [35-76] vs 57 [33-78], respectively; p = 0.71), and perceived sleep quality was unrelated to delirium transition (adjusted odds ratio, 1.00; 95% CI, 0.99-1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted odds ratio, 4.02; 95% CI, 2.19-7.38; p0.001), and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted odds ratio, 0.40; 95% CI, 0.20-0.80; p = 0.01).We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.

Anxiety disorders are among the most prevalent mental disorders, but the subcategory of specific phobias has not been well studied. Phobias involve both fear and avoidance. For people who have specific phobias, avoidance can reduce the constancy and severity of distress and impairment. However, these phobias are important because of their early onset and strong persistence over time. Studies indicate that the lifetime prevalence of specific phobias around the world ranges from 3% to 15%, with fears and phobias concerning heights and animals being the most common. The developmental course of phobias, which progress from fear to avoidance and then to diagnosis, suggests the possibility that interrupting the course of phobias could reduce their prevalence. Although specific phobias often begin in childhood, their incidence peaks during midlife and old age. Phobias persist for several years or even decades in 10–30% of cases, and are strongly predictive of onset of other anxiety, mood, and substance-use disorders. Their high comorbidity with other mental disorders, especially after onset of the phobia, suggests that early treatment of phobias could also alter the risk of other disorders. Exposure therapy remains the treatment of choice, although this approach might be less effective in the long term than previously believed. This Review discusses the literature regarding the prevalence, incidence, course, risk factors, and treatment of specific phobias, and presents epidemiological data from several population-based surveys.

Patients recovering from critical illness can be left with significant psychological problems that have a profound effect on their quality of life. As yet, studies on prevention of posttraumatic stress disorder (PTSD) and/or depression are in their infancy. This chapter discusses multimodal rehabilitation strategies that can improve psychological recovery which are beginning to be established. Recognizing those patients needing further help and having a structured pathway for rehabilitation is the first step toward returning patients to as normal a life as possible after critical illness. Providing intensive care unit (ICU) diaries for as many patients as possible is a cost-effective way of helping patients come to terms with their ICU experience. Also discussed in the chapter are psychological therapies, which may be reserved for those survivors of critical illness who are experiencing more severe effects from critical illness and intensive care.

This chapter explores the epidemiology and range of psychological distress phenomena experienced by survivors of critical illness. The phenomena most commonly reported on are posttraumatic stress disorder (PTSD), depressive, and general (or nonspecific) anxiety symptoms. Approximately 1 in 5 critical illness survivors has clinically significant PTSD symptoms, 1 in 3 has clinically significant depressive symptoms, and 1 in 3 has clinically significant anxiety symptoms. These phenomena are associated with diminished quality of life and functioning. Risk factors include pre-critical illness anxiety and depression, in-critical illness sedative doses and nightmare-like experiences, and post–critical illness psychological distress and poor coping early in the recovery period. Given the association between critical illness and psychological distress, it is important to address survivors’ mental health needs.

Some individuals with obsessive-compulsive disorder (OCD) have autistic-like traits, including deficits in social and communication behaviors (pragmatics). The objective of this study was to determine if pragmatic impairment aggregates in OCD families and discriminates a clinically and genetically distinct subtype of OCD. We conducted clinical examinations on, and collected DNA samples from, 706 individuals with OCD in 221 multiply affected OCD families. Using the Pragmatic Rating Scale (PRS), we compared the prevalence of pragmatic impairment in OCD-affected relatives of probands with and without pragmatic impairment. We also compared clinical features of OCD-affected individuals in families having at least one, versus no, individual with pragmatic impairment, and assessed for linkage to OCD in the two groups of families. The odds of pragmatic impairment were substantially greater in OCD-affected relatives of probands with pragmatic impairment. Individuals in high-PRS families had greater odds of separation anxiety disorder and social phobia, and a greater number of schizotypal personality traits. In high-PRS families, there was suggestive linkage to OCD on chromosome 12 at marker D12S1064 and on chromosome X at marker DXS7132 whereas, in low-PRS families, there was suggestive linkage to chromosome 3 at marker D3S2398. Pragmatic impairment aggregates in OCD families. Separation anxiety disorder, social phobia, and schizotypal personality traits are part of a clinical spectrum associated with pragmatic impairment in these families. Specific regions of chromosomes 12 and X are linked to OCD in high-PRS families. Thus, pragmatic impairment may distinguish a clinically and genetically homogeneous subtype of OCD.

Critically ill patients commonly experience poor sleep quality in the intensive care unit (ICU) because of various modifiable factors. To address this issue, an ICU-wide, multifaceted quality improvement (QI) project was undertaken to promote sleep in the Johns Hopkins Hospital Medical ICU (MICU). To supplement previously published results of this QI intervention, the present article describes the specific QI framework used to develop and implement this intervention, which consists of 4 steps: (a) summarizing the evidence to create a list of sleep-promoting interventions, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education and regular project evaluation. Measures of performance included daily completion rates of daytime and nighttime sleep improvement checklists and completion rates of individual interventions. Although long-term adherence and sustainability pose ongoing challenges, this model provides a foundation for future ICU sleep promotion initiatives.

Acute lung injury (ALI) is common in the intensive care unit (ICU), typically requiring life support ventilation. Survivors often experience anxiety after hospital discharge. We evaluated general anxiety symptoms 3 months after ALI for: (1) associations with patient characteristics and ICU variables, and (2) cross-sectional associations with physical function and quality of life (QOL).General anxiety was assessed as part of a prospective cohort study recruiting patients from 13 ICUs at four hospitals in Baltimore, MD using the Hospital Anxiety and Depression Scale--Anxiety Subscale (HAD-A), with associations evaluated using multivariable linear and logistic regression models.Of 152 patients, 38% had a positive screening test for general anxiety (HAD-A≥8). Pre-ICU body mass index and psychiatric comorbidity were associated with general anxiety (OR, 95% confidence interval (CI): 1.06 (1.00, 1.13) and 3.59 (1.25, 10.30), respectively). No ICU-related variables were associated with general anxiety. General anxiety was associated with the number of instrumental ADL dependencies (Spearman's rho=0.22; p=0.004) and worse overall QOL as measured by EQ-5D visual analog scale (VAS) (rho=-0.34; p0.001) and utility score (rho=-0.30; p0.001), and by the SF-36 mental health domain (rho=-0.70; p0.001) and Mental Component Summary score (rho=-0.73; p0.001).Many patients have substantial general anxiety symptoms 3 months after ALI. General anxiety was associated with patient characteristics and impaired physical function and quality of life. Early identification and treatment of general anxiety may enhance physical and emotional function in patients surviving critical illnesses.

Background Survivors of acute lung injury (ALI) and other critical illnesses often experience substantial posttraumatic stress disorder (PTSD) symptoms. However, most questionnaires have not been validated against a PTSD diagnostic reference standard in this patient population. Hence, in the current study of survivors of ALI, we evaluated the Impact of Events Scale-Revised (IES-R), a questionnaire measure of PTSD symptoms, against the Clinician-Administered PTSD Scale (CAPS), the current state-of-the-art PTSD diagnostic reference standard, which also provides a quantitative assessment of PTSD symptoms. Methods We evaluated the IES-R questionnaire vs the CAPS diagnostic interview in 60 of 77 consecutively recruited survivors of ALI from two prospective cohort studies of patients 1 to 5 years after ALI. Results The IES-R total score (range: 0.0-3.2) and the CAPS total severity score (range: 0-70) were strongly related (Pearson r = 0.80, Spearman ρ = 0.69). Using CAPS data, eight of the 60 patients (13%) had PTSD at the time of assessment, and an additional eight patients had partial PTSD (total prevalence, 27%). In a receiver operating characteristics curve analysis with CAPS PTSD or partial PTSD as criterion variables, the area under the curve ranged from 95% (95% CI, 88%-100%) to 97% (95% CI, 92%-100%). At an IES-R threshold of 1.6, with the same criterion variables, sensitivities ranged from 80% to 100%, specificities 85% to 91%, positive predictive values 50% to 75%, negative predictive values 93% to 100%, positive likelihood ratios 6.5 to 9.0, negative likelihood ratios 0.0 to 0.2, and efficiencies 87% to 90%. Conclusions The IES-R appears to be an excellent brief PTSD symptom measure and screening tool in ALI survivors.

Objective:Deep sedation and delirium are common in the ICU. Mechanically ventilated patients with acute lung injury are at especially high risk for deep sedation, delirium, and associated long-term physical and neuropsychiatric impairments. We undertook an ICU-wide structured quality improvement pro

To determine if a quality improvement intervention improves sleep and delirium/cognition.Observational, pre-post design.A tertiary academic hospital in the United States.300 medical ICU patients.This medical ICU-wide project involved a "usual care" baseline stage, followed by a quality improvement stage incorporating multifaceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff.Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0-100 scale using the valid and reliable Richards-Campbell Sleep Questionnaire) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep quality improvement stages, there were 122 and 178 patients, respectively, with more than one night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day quality improvement period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis of the quality improvement vs. baseline stages, improvements in overall Richards-Campbell Sleep Questionnaire sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± SD: 65.9±26.6 vs. 60.5±26.3, p = 0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23-0.89; p = 0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04-2.58; p = 0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance.An ICU-wide quality improvement intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.

Background: Hoarding behavior may indicate a clinically and possibly etiologically distinct subtype of obsessive–compulsive disorder (OCD). Empirical evidence supports a relationship between hoarding and emotional over-attachment to objects. However, little is known about the relationship between hoarding and parental attachment in OCD. Method: The study sample included 894 adults diagnosed with DSM-IV OCD who had participated in family and genetic studies of OCD. Participants were assessed for Axis I disorders, personality disorders, and general personality dimensions. The Parental Bonding Instrument (PBI) was used to assess dimensions of perceived parental rearing (care, overprotection, and control). We compared parental PBI scores in the 334 hoarding and 560 non-hoarding participants, separately in men and women. We used logistic regression to evaluate the relationship between parenting scores and hoarding in women, adjusting for other clinical features associated with hoarding. Results: In men, there were no significant differences between hoarding and non-hoarding groups in maternal or paternal parenting scores. In women, the hoarding group had a lower mean score on maternal care (23.4 vs. 25.7, p

To evaluate the study designs and measurement instruments used to assess physical, cognitive, mental health, and quality of life outcomes of survivors of critical illness over more than 40 years old as a first step toward developing a core outcome set of measures for future trials to improve outcomes in ICU survivors.Scoping review.Published articles that included greater than or equal to one postdischarge measure of a physical, cognitive, mental health, or quality of life outcome in more than or equal to 20 survivors of critical illness published between 1970 and 2013. Instruments were classified using the World Health Organization's International Classification of Functioning, Disability, and Health framework.ICU survivors.None.We reviewed 15,464 abstracts, and identified 425 eligible articles, including 31 randomized trials (7%), 116 cross-sectional studies (27%), and 278 cohort studies (65%). Cohort studies had a median (interquartile range) sample size of 96 survivors (52-209), with 38% not fully reporting loss to follow-up. A total of 250 different measurement instruments were used in these 425 articles. Among eligible articles, 25 measured physical activity limitations (6%), 40 measured cognitive activity limitations (9%), 114 measured mental health impairment (27%), 196 measured participation restriction (46%), and 276 measured quality of life (65%).Peer-reviewed publications reporting patient outcomes after hospital discharge for ICU survivors have grown from 3 in the 1970s to more than 300 since 2000. Although there is evidence of consolidation in the instruments used for measuring participation restriction and quality of life, the ability to compare results across studies remains impaired by the 250 different instruments used. Most articles described cohort studies of modest size with a single follow-up assessment using patient-reported measures of participation restriction and quality of life. Development of a core outcome set of valid, reliable, and feasible measures is essential to improving the outcomes of critical illness survivors.

Objective This study will estimate distribution-based minimal important difference (MID) for the Hospital Anxiety and Depression Scale anxiety (HADS-A) and depression (HADS-D) subscales, and the Impact of Event Scale-Revised (IES-R) in survivors of acute respiratory failure (ARF). Methods Secondary analyses of data from two US and three UK studies of ARF survivors (total N =1223). HADS-D and HADS-A were used to assess depression and anxiety symptoms. IES-R assessed post-traumatic stress disorder symptoms. Standard error of measurement, minimal detectable change 90 , 0.5 standard deviation (S.D.), and 0.2 S.D. were used to estimate MID for the combined sample, by studies, 6- and 12-month follow-ups, country and mental health condition. Results Overall, MID estimates converged to 2.0–2.5 for the HADS-A, 1.9–2.3 for the HADS-D and 0.17–0.18 for the IES-R. MID estimates were comparable across studies, follow-up, country and mental health condition. Conclusion Among ARF survivors, 2.0–2.5 is a reasonable range for the MID for both HADS subscales, and 0.2 is reasonable for IES-R. Until anchor-based MIDs for these instruments are available, these distribution-based estimates can help researchers plan future studies and interpret the clinical importance of findings in ARF patient populations.

Objectives:To review the diagnosis and management of four selected psychiatric emergencies in the intensive care unit: agitated delirium, neuroleptic malignant syndrome, serotonin syndrome, and psychiatric medication overdose.Data Sources:Review of relevant medical literature.Data Synthesis:Standard

The family response to critical illness includes development of adverse psychological outcomes such as anxiety, acute stress disorder, posttraumatic stress, depression, and complicated grief. This cluster of complications from exposure to critical care is now entitled postintensive care syndrome-family. Adverse psychological outcomes occur in parents of neonatal and pediatric patients and in family members of adult patients, and may be present for4 yrs after intensive care unit discharge. Psychological repercussions of critical illness affect the family member's ability to fully engage in necessary care-giving functions after hospitalization.It has been suggested that the manner in which healthcare workers communicate with family members and the way in which families are included in care and decision-making, may affect long-term outcomes. Preventive strategies for optimal communication and inclusion in care are reviewed.Many tools are available to assess the risk for and to diagnose postintensive care syndrome-family conditions during hospitalization and at intervals after discharge.Visits after discharge, support groups, and clinics have been proposed for assessing the need for professional referrals as well as for treating family members when psychological illness persists. Studies evaluating these measures are reviewed.

The aim of this study is to determine whether neurocognitive performance distinguishes individuals with compulsive hoarding (CH) from those with obsessive-compulsive disorder (OCD). Compared to control subjects, OCD patients and CHs scored significantly worse on the Serial Reaction Time Task suggesting disturbed implicit memory in both patient groups. On the Iowa Gambling Task, an overall learning progression difference over time was found between the CHs, OCD group, and control subjects, suggesting differences in decision-making between the groups. The groups did not differ in performance on the Stop Signal Reaction Time Task (motor inhibition). This study found evidence for impaired implicit memory in CHs, but also in OCD patients, albeit less severe. There was evidence that OCD patients learned more slowly on a decision-making task than CHs and control subjects. This latter finding provides some evidence to suggest that CH and OCD have, at least on this one measure, differing cognitive substrates.

We present findings on the longitudinal relationships of religious worship attendance and seeking spiritual comfort with subsequent major depression, anxiety disorders and suicidal ideation/attempts using data from Waves 3 and 4 of the Baltimore Epidemiologic Catchment Area Study (N = 1091). Respondents who attended religious services at least once per year had decreased odds of subsequent suicide attempts compared with those who did not attend religious services (AOR = 0.33, 95% CI: 0.13–0.84). Seeking spiritual comfort at baseline was associated with decreased odds of suicidal ideation (AOR = 0.55, 95% CI: 0.31–0.99). These finding were independent of the effects of the presence of the suicidal ideation/attempts, comorbid mental disorders, social supports and chronic physical conditions at baseline. These results suggest that religious attendance is possibly an independent protective factor against suicide attempts.

SLC1A1 encodes a neuronal glutamate transporter and is a promising candidate gene for obsessive-compulsive disorder (OCD). Several independent research groups have reported significant associations between OCD and single nucleotide polymorphisms (SNPs) in this gene. Previously, we evaluated 13 SNPs in, or near, SLC1A1 and reported a strong association signal with rs301443, a SNP 7.5 kb downstream of the gene [Shugart et al. (2009); Am J Med Genet Part B 150B:886–892]. The aims of the current study were first, to further investigate this finding by saturating the region around rs301443; and second, to explore the entire gene more thoroughly with a dense panel of SNP markers. We genotyped an additional 111 SNPs in or near SLC1A1, covering from 9 kb upstream to 84 kb downstream of the gene at average spacing of 1.7 kb per SNP, and conducted family-based association analyses in 1,576 participants in 377 families.We found that none of the surrounding markers were in linkage disequilibrium with rs301443, nor were any associated with OCD. We also found that SNP rs4740788, located about 8.8 kb upstream of the gene, was associated with OCD in all families (P = 0.003) and in families with male affecteds (P = 0.002). A three-SNP haplotype (rs4740788–rs10491734–rs10491733) was associated with OCD in the total sample (P = 0.00015) and in families with male affecteds (P = 0.0007). Although of nominal statistical significance considering the number of comparisons, these findings provide further support for the involvement of SLC1A1 in the pathogenesis of OCD.

Background: A history of separation anxiety disorder (SAD) is frequently reported by patients with obsessive–compulsive disorder (OCD). The purpose of this study was to determine if there are clinical differences between OCD-affected individuals with, versus without, a history of SAD. Methods: Using data collected during the OCD Collaborative Genetic Study, we studied 470 adult OCD participants; 80 had a history of SAD, whereas 390 did not. These two groups were compared as to onset and severity of OCD, lifetime prevalence of Axis I disorders, and number of personality disorder traits. Results: OCD participants with a history of SAD were significantly younger than the non-SAD group (mean, 34.2 versus 42.2 years; P

In DSM-III, DSM-III-R, and DSM-IV, obsessive–compulsive disorder (OCD) was classified as an anxiety disorder. In ICD-10, OCD is classified separately from the anxiety disorders, although within the same larger category as anxiety disorders (as one of the ‘‘neurotic, stress-related, and somatoform disorders’’). Ongoing advances in our understanding of OCD and other anxiety disorders have raised the question of whether OCD should continue to be classified with the anxiety disorders in DSM-V. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Evidence is reviewed for retaining OCD in the category of anxiety disorders, and for moving OCD to a separate category of obsessive–compulsive (OC)-spectrum disorders, if such a category is included in DSM-V. Our preliminary recommendation is that OCD be retained in the category of anxiety disorders but that this category also includes OC-spectrum disorders along with OCD. If this change is made, the name of this category should be changed to reflect this proposed change. Depression and Anxiety 27:495–506, 2010. r 2010 Wiley-Liss, Inc.

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

The unique association between externalizing psychopathology (i.e., diagnoses of alcohol dependence, drug dependence, and antisocial personality disorder) and suicide attempts has been understudied. We sought to examine whether externalizing disorders were risk factors for later development of new onset suicide attempts. This study examined cross-sectional and longitudinal data gathered from 1920 to 4034 adult respondents from the Baltimore site of the Epidemiologic Catchment Area Survey. In cross-sectional analyses, externalizing psychopathology was significantly associated with suicide attempts, even after adjusting for sociodemographics and internalizing disorders. After controlling for demographics and internalizing disorders, at 1-year follow-up (n = 3163) baseline externalizing psychopathology was associated with new onset suicides; at 13-year follow-up (n = 1920) baseline externalizing psychopathology was not associated with new onset suicide attempts. Externalizing psychopathology appears to be an independent short-term risk factor for suicidal behavior (odds ratio [OR] = 3.00; 95% confidence interval [CI] = 1.07-8.43), but appears less powerful in predicting long-term suicide risk (OR = 0.90; 95% CI = 0.25-3.18). These findings underline the importance of assessment of suicidality among individuals presenting with externalizing disorders.

To critically review data on the prevalence of depressive symptoms in general intensive care unit (ICU) survivors, risk factors for these symptoms, and their impact on health-related quality of life (HRQOL).We conducted a systematic review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO, and a hand-search of 13 journals.Fourteen studies were eligible. The median point prevalence of "clinically significant" depressive symptoms was 28% (total n = 1,213). Neither sex nor age were consistent risk factors for post-ICU depression, and severity of illness at ICU admission was consistently not a risk factor. Early post-ICU depressive symptoms were a strong risk factor for subsequent depressive symptoms. Post-ICU depressive symptoms were associated with substantially lower HRQOL.Depressive symptoms are common in general ICU survivors and negatively impact HRQOL. Future studies should address how factors related to individual patients, critical illness and post-ICU recovery are associated with depression in ICU survivors.

El presente estudio comparo la estructura latente de los trastornos de personalidad (TP) clasificada en el Manual Diagnostico y Estadistico de los Trastornos Mentales, cuarta edicion, con el modelo de cinco factores (MCF) de las dimensiones de la personalidad general. En el estudio se incluyo a 742 individuos que residian en la comunidad y participaban en el Hopkins Epidemiology of Personality Disorders Study. Utilizando el International Personality Disorder Examination los psicologos evaluaron los TP clasificados en el Manual Diagnostico y Estadistico de los Trastornos Mentales, cuarta edicion y las dimensiones TP se derivaron previamente utilizando un analisis de factor dicotomico. Se administro a todos los individuos el Revised NEO Personality Inventory, un parametro del MCF. La relacion entre las dos series de conceptos teoricos relacionados con la personalidad se examino utilizando un marco de validez del concepto teorico y, asimismo, coeficientes de correlacion de Pearson, modelos de regresion lineal multiples y modelos de regresion spline. Cada uno de los cinco factores de TP manifesto correlaciones ligeras o moderadas con diversas dimensiones NEO; en conjunto, el dominio NEO y las puntuaciones de faceta explicaron de una quinta a una tercera parte de la variancia en las dimensiones TP. Se identificaron ejemplos de relaciones no lineales entre las dimensiones de la personalidad. Se observo una correspondencia modesta entre las dimensiones TP y los rasgos de MCF, y estos solo explicaron parcialmente la variancia de los TP. Los parametros dimensionales de la personalidad general pueden ser una alternativa apropiada al Manual Diagnostico y Estadistico de los Trastornos Mentales, cuarta edicion. Si los rasgos de inadaptacion adicionales definen mejor el dominio de los TP sigue siendo un objetivo importante de la investigacion futura.

Objective Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). Methods We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. Results Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained “clinically significant” PTSD symptoms was 22% (n=1104), and the median point prevalence of clinician-diagnosed PTSD was 19% (n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. Conclusions The prevalence of PTSD in ICU survivors is high and negatively impacts survivors' HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients' needs for early intervention.

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.

In the last decade, there has been an increase in interest in the burden of chronic and disabling health conditions that are not necessarily fatal, such as the mental disorders. This review systematically summarizes data on the burden associated with 11 major mental disorders of adults. The measures of burden include estimates of prevalence, mortality associated with the disorders, disabilities and impairments related to the disorders, and costs. This review expands the range of mental disorders considered in a report on the global burden of disease, updates the literature, presents information on the range and depth of sources of information on burden, and adds estimates of costs. The purpose is to provide an accessible guide to the burden of mental disorders, especially for researchers and policy makers who may not be familiar with this subfield of epidemiology.

Objective: Acute lung injury (ALI), including its more severe subcategory, acute respiratory distress syndrome (ARDS), is a critical illness associated with considerable morbidity and mortality. Our objective was to summarize data on the prevalence of depressive, posttraumatic stress disorder (PTSD), and other anxiety syndromes amongst survivors of ALI/ARDS, potential risk factors for these syndromes, and their relationships to quality of life. Methods: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, and PsycINFO. Eligible studies reported data on psychiatric morbidity at least once after intensive care treatment of ALI/ARDS. Results: Ten observational studies met inclusion criteria (total n 331). Using questionnaires, the point prevalence of “clinically significant” symptoms of depression ranged from 17% to 43% (4 studies); PTSD, 21% to 35% (4 studies); and nonspecific anxiety, 23% to 48% (3 studies). Studies varied in terms of instruments used, thresholds for clinical significance, baseline psychiatric history exclusions, and timing of assessments (range 1 month to 8 years). Psychiatrist-diagnosed PTSD prevalence at hospital discharge, 5 years, and 8 years were 44%, 25%, and 24%, respectively. Three studies prospectively assessed risk factors for post-ALI/ARDS PTSD and depressive symptoms; significant predictors included longer durations of mechanical ventilation, intensive care unit stay, and sedation. All four studies that examined relationships between psychiatric symptoms and quality of life found significant negative associations. Conclusions: The prevalence of psychiatric morbidity in patients surviving ARDS seems high. Future research should incorporate more in-depth diagnostic and risk factor assessments for prevention and monitoring purposes. Key words: acute respiratory distress syndrome, depression, posttraumatic stress disorder, anxiety, critical care, outcome assessment (health care).

The authors set out to determine what general factors are important in the selection of a psychiatric residency program, the views applicants have of several aspects of the Johns Hopkins Hospital Psychiatric Residency Program, and what relationships exist among these elements. A survey mailed to Johns Hopkins Hospital psychiatric residency-interviewed applicants asked applicants to rate six factors in relation to choosing a psychiatric residency program. A second section asked applicants to rate five factors more specific to the Johns Hopkins Hospital residency. The most important general factors in choosing a residency program included the perceived philosophical orientation of a psychiatric department, exposure to different psychotherapy modalities and the perceived prestige of the department. Several statistically significant correlations were evident among factors. Knowledge of applicants’ views could assist residency program directors in their assessment of factors influencing program choices.