This report addresses some issues relating to the prevalence rate of depressive disorders in primary care settings. It is very likely that the majority of people suffering from depression do consult the non-psychiatric practitioner. Many patients consult doctors for unrelated physical illness or for nonspecific somatic manifestations of depressive disorders. However, relevant epidemiological studies of these depressed patients are not sufficiently reliable because of methodological problems. Since 1972,we have participated in the WHO collaborative study on public health implications of depressed disorders. In collaboration with internists from two general hospitals, we have been able to estimate the prevalence rate of depressive disorders in outpatient clinics of these hospitals on two different occasions. In the first study (1977-1980), 831 cases were systematically selected from new ambulatory medical patients and interviewed by research psychiatrists using a screen from and the SADD schedule. Subsequently, 50 patients were found to have a depressive disorder (ICD-9). The prevalence rate of depressive disorders in these settings was 6%. The second study (1991) was part of a more extensive, ongoing research project organized by WHO, Using the "Two phase sampling design" (W. E. Deming) and using both the GHQ-12 and CIDI, we were able to screen 1043 ambulatory patients in one of above mentioned hospitals. The estimated prevalence rate of depressive disorders (DSM-III-R) was 5.4%. In this paper we questioned whether screening for depressive disorders has any value in general medical settings. The performance of a screening test instrument is measured by the predictive value of a positive or negative result. The predictive values of a positive result falls as the prevalence declines. Understanding this point is of practical importance. The conclusion of this paper is that depression questionnaires should not be routinely administered to ambulatory medical patients. There may be merit, however, to employ such assessment practice in selected circumstances and with a well-defined population.

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The number of depressive patients who predominantly complain of physical symptoms rather than typical psychiatric ones has been recently increasing. According to our recent survey, 14.6% of all outpatients visiting our clinic were diagnosed as having depression. Among physical complaints of those depressive patients, gastrointestinal symptoms ranked the highest (63%) in incidence, followed by cardiovascular (20%) and pulmonary (14%) ones. Although the mechanism by which digestive symptoms develop in many depressive patients is still poorly understood, we have recently observed that gallbladder contractility in response to caerulein injection is impaired in those depressive patients, thereby suggesting that biliary diskinesia may be involved in the development of abdominal symptoms in depression. On the other hand, a number of digestive diseases such as peptic ulcer, achalasia, chronic pancreatitis and malignant tumors often accompany depression. Particularly, special attention should be paid to pancreatic cancer. For the past 15 years or so, we have found 21 cases with malignant cancer in the digestive tract who had been treated as depression in other medical institutions, out of whom 13 patients had pancreatic cancer. This figure would be surprisingly high even if we take into consideration the fact that early diagnosis of pancreatic cancer is still difficult. To clarify this intriguing problem, we have been conducting various immunoneuroendocrine studies, leading to the hypothesis that cytokines including interleukin-1 produced by cancer cells in the pancreas may affect the central nervous system, thereby inducing depressive state possibly through a mechanism mediated by corticotropin-releasing factor in the brain. Finally, we described here several useful points in the diagnosis and management of depressive patients who tend to visit general physicians. We emphasized that every clinician should bear in mind that he or she has a good chance to see depressive patients in the outpatient clinic regardless of his or her specialty and that he or she is accordingly required to manage these patients adequately and properly.

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[in Japanese]

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The author investigated psychological factors in patients with orthopedic diseases by studying 251 patients utilizing the Self-Rating Questionnaire for Depression (SRQ-D) and with rheumatic arthritis (RA) by studying 80 patients utilizing the Self-Rating Depression Scale (SDS). The author's data utilizing SRQ-D shows that 25.5% of 251 patients with orthopedic diseases and 27.1% of 80 patients with RA met the criteria for depression and 21.9% of back pain patients met the criteria. Percentages of depression patients decrease by aging. Percentage of depression patients under 30 years-old shows 23.1% and patients over 60 years-old shows 12.5%. According to orthopedic diseases, whiplash injuries show the highest percentage of depression patients and traumatic diseases such as fracture and dislocation show the lowest. Although similar spinal disease, percentage of depression patients of cervical spondylosis (32.7%) is different from percentage of back pain (21.9%). Utilizing SDS, 17 patients (21.3%) of 80 RA patients met the criteria for depression (scored over 50). Percentages of depression patients in 15 definite RA patients (20%) was slightly higher than percentages of depression patients in 65 classical RA patients (21.5%). Percentage of de-pression patients of female definite RA patients (27.3%) was highest, meanwhile no depression patients presented in male definite RA patients. In conclusion, it is important to find out the symptoms and signs of depression early with careful interviews and suitable questionnaires and to manage the depression patients well.

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I investigated the frequency of depression in the patients at a clinic for patients with psychosomatic ailments and in pregnant and postpartum women. 1) I selected 29 depressive patients at random in our clinic. Their psychological symptoms were masked completely by many somatic symptoms. 2) I examined the records for all patients (842 cases) at our clinic from 1976 to 1991. The rate of reported depression increased almost without exception every year. In term of age group, there was a significantly higher rate of depression among women in their fifties than in women in their twenties. Depression is included into many types of gynecological diseases ; the most prevalent are postpartum depression, premenstrual syndrome (PMS) and climacteric syndrome. The treatment success rates for neurotic-, depressive-, psychosomatic-, and somatic types were 70%, 72%, 80% and 92%, respectively. 3) The depression's incidence of PMS was much higher than that of dysmenorrhea. 4) We investigated serum melatonin through the sleeping period in 6 pregnant women with sleep disturbance and in 6 women without sleep disturbance in the third trimester of pregnancy. The peaks in this hormone came markedly lated and the amplitudes were markedly higher in the women with sleep disturbances than in the women without sleep disturbances, though these where not signifficant in this study (t=1.97). 5) The scores of 'Difficulty in concentration' and 'Depression' in the group who were accompanied by their husbands during labor (n=14) were significantly lower. than those whose husbands were not present (n=107). Both groups were free of complications and all deliveries were normal. This seems to show that the husband's presence during delivery is good for the "maternity blues". 6) I describe two severe patients who needed treatment for depression. One case had a severe psychosomatic disease and had had polysurgery. The other had terminal ovarian cancer, though she had not been informed of her condition by her doctor. This survey concludes that depressive state in the area of gynecology and obstetrics may be related to the endocrinological variables.

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Both diagnoses of depressive disorders and anxiety disorders are commonly made in psychiatric patients on the basis of DSM-III-R criteria. Patients with this condition clinically seem to have several characteristics and recently draw a growing attention of numerous investigators. The authors gave an overview on comorbidity of depressive disorders and anxiety disorders, and presented their own clinical experiences with cases of panic disorder with comorbid depression. In summary : 1.According to an epidemiological study (ECA study), 33% of patients with affective disorders and 21% of those with anxiety disorders have the other additional diagnosis. The lifetime prevalence of comorbid depression among patients with panic disorder is estimated at about 30%, 2. The authors classified their series of patients with panic disorder into several groups in accordance with courses leading to depression. That is, with secondary depression lapped over PD(IV-1), with depression subsequent to PD (IV-2), with depression temporally independent of PD (IV-3) , and others. 3. Comorbid depressive disorders included demoralization depression (Sheehan), anxious depressive and/or hypochondriacal states (chronic neurotic states, the most common), anxiety attack-retardation type depression (Hirose), major depression without above mentioned features, and bipolar II (only one case). 4. Family history of our cases was almost not special, but a large family study (Leckman) suggests that cooccurrence of major depression and panic disorder in probands increase the risk in relatives for a number of psychiatric disorders. 5. As to the psychopharmacologic treatment for comorbid patients, combination of antidepressants and antianxiety drugs are effective. MAOIs may be available if those patients are reluctant to conventional drugs. 6. As indicated by many authors, and admitted by the author's own experiences, comorbid depressive disorders lead to increasing severity and chronicity of panic disorder, and they lead to worse response to medication and less favorable outcome. Further studies are needed to develop new methods for preventing from or coping with these unfavorable outcomes.

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The irritable bowel syndrome (IBS) is a typical functional disorder in the gastrointestinal tract, which is characterized by alteration of bowel habits, abdominal pain, or both. Although IBS is the most common problem encountered by gastroenterologists, its positive diagnosis remains un-established. The present study aimed at providing latest progress in its pathogenesis, diagnostic criteria and treatment of IBS from a view point of psychosomatic medicine. We studied 78 consecutive patients with IBS who visited our outpatient clinic in 1990-1991 ; 55 were classified as unstable type of IBS (28 of spastic constipation and 27 of alternative stool ab-normality), 22 as the continuous diarrhea type and only one case as the secretory type. There was considerable evidence that psychological factors were deeply involved in the onset of IBS symptoms (85.9%). Moreover, we found that IBS patients had poor tolerance against stressors, which was assessed by the novel stress marker that we had originally developed. The stress marker level of urinary 17-ketosteroid sulfate (17-KS-S) , was significantly lower in IBS patients than that in age- and sex-matched controls. In an attempt to clarify motility disorders in IBS, we also performed manometric studies on IBS patients. We observed that IBS patients demonstrated not only hypertonicity of the colonic wall but also abnormality in the stomach during the digestive state or increased simultaneous contrac-tions of the esophagus. Of great interest was that certain IBS patients showed markedly abnor-mal contractile patterns of the gallbladder in response to a cholecystkinin stimulation. These re-sults suggest that IBS is not a disease in the colon only, but represents a physiological expres-sion (gastrointestinal symptom) of an affective disorder. On the basis of these findings, we em-phasize here that psychosomatic approach is extremely crucial in the management of IBS patients.

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Irritable bowel syndrome (IBS) is the most common disease among colonic diseases. However, the data concerning distribution of IBS in each age are less than satisfactory. The major purpose of this study was to clarify the clinical figures of IBS in each age. Therefore we made three studies. Study 1 ; Ambulatory psychosomatic clinic population survey, from which we examined the distribution of 329 cases in sex and each age of three subtypes (diarrhea, constipation, alternative type) and psychological characteristics of patients. Study 2 ; The distribution of 1,320 persons examined by nonclinical population questionnaire survey of bowel habits in sex and each age. This survey was made by investigator's asking method. The hardness of feces was also measured in 649 persons. Study 3 ; Colonic motility study of 66 patients with IBS. Results : Study 1 revealed the peak of the patient's age was thirties in both sex. The age over sixties was only 2. 7%. Diarrhea type was dominant in males, but the incidence of diarrhea type was decreased with age in males. Constipation type was dominant in females, and the incidence of 3 subtypes was identical in all ages. The psychological characteristics were anxiety state in 45%, hysteria in 25%, and depressive state in 20% and identical in all ages, except for over sixties which showed depressive state in 56%. From the results of study 2,the distribution rate of bowel disturbance of nonclinical population was akin to that of subtype distribution of patients with IBS. The hardness of feces increased with age in males. Study 3 showed that colonic motility was significantly decreased with age in ascending colon in diarrhea type at basal, and no significant correlation was found between other subtypes and sites of the colon. These results demonstrated that patients seen by physicians are the tip of the iceberg and the clinical characteristics of patients with IBS differ with each age.

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IBS is one of psychosomatic diseases, which is increasing in our population. In the past 10 years, we examined 3,011 patients i.e., 1,364 males and 1,647 females. Their ages distribute from teenages to over 80 years with the peak at fifties. The duration is very long with 51% of the patients over 5 years. They have physical predispositions such as weak gastrointestinal functions and mental characters of introversion such as overseriousness and scrupulousness. There also are exacerbating incidences as interpersonal relations in their families and in offices. The syndrome is divided into 4 types as constipation, diarrhea, alternative and gaseous ones and the constipation type is the most frequent one especially among female patients. We define the syndrome with follwing criteria of (1) exclusion of organic diseases, (2) abdominal symptoms as pain and fullness, (3) defecational symptoms as feeling of incomplete evacuation and, (4) palpation of spastic colon as tender induration in the left andlor right lower abdomen. We diagnose the syndrome by observing of roentgenologically depicted contour of the whole colon contrasted by small amount of orally taken barium. The analyses of thus obtained roentgenological diagrams reveal the types of the syndrome and they can also be utilized as the object of other functional tests. We are treating the patients with multiply combined methods as educational programs, group therapies, autonomic training and Chinese methods. The results are excellent in 18%, good in 34%, fair in 40% and not improved in 8% of the patients.

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Although the significance of brain-gut interaction in irritable bowel syndrome (IBS) has been recognized, no systematic research was done on this issue. We tested the hypothesis that both gastrointestinal motility and brain function are deviated from the normal range. The patients with IBS (n=28) and the normal control subjects (n=13) were compared. The diagnosis of IBS was based on Manning, NIH, and Whitehead & Schuster's criteria. Two motility pressure transducers were inserted to the duodenum and the sigmoid colon. They were connected to the PC-polygram and gastrointestinal motility was stored and displayed on the com-puter screen. Simultaneous measurement of electroencephalogram was performed. After the baseline, the subjects were stressed by mental arithmetic task. After the recovery and the second baseline periods, neostigmine (2,4,10μg/kg) was administered. Stress and neostigmine augmented colonic motility in both groups but the IBS patients showed significantly greater colonic motility index than the controls (p < 0.02). Duodenal motility was slightly suppressed by stress and enhanced by neostigmine. The IBS patients exhibited signifi-cantly more duration and amplitude of phase II motor activity than the controls (p < 0. 05). Electroencephalogram in the IBS patients revealed more beta-power (%) and higher incidence (28.6%) of mild dysrhythmia than that in the controls. These results suggest that IBS patients have simultaneous dysfunction of the gut and the brain. Our observations warrant significance of brain-gut interactions in functional gastrointestinal disorders.

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There have been several reports concerning the psychiatric factors involved in the onset and clinical course of irritable bowel syndrome (IBS). We investigated patients with IBS who had been markedly disturbed in thier daily life, and it was concluded that the most important psychiatric factor related to the onset and the clinical course of severely impaired IBS is a major depression, fulfilling the criteria of the DSM-III.R. Most of IBS patients with a major depression can be effectively treated with antidepressants and brief psychotherapy. IBS patients with an anxiety disorder were treated with psychotherapy such as Morita therapy. About 80% of IBS patients were markedly improved with these psychosomatic approaches.

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