Psychosomatics
Journal Home Search Current Issue Past Issues Subscribe All APPI Journals Help Contact Us
 
Quicksearch
Advanced Search
Or Search All APPI Journals
This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via HighWire
* Citing Articles via Google Scholar
Google Scholar
* Articles by Hoogendijk, W. J.G.
* Articles by Wolters, E.Ch.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Hoogendijk, W. J.G.
* Articles by Wolters, E.Ch.
Related Collections
* Depression
* Parkinson's Disease
* Delirium
Psychosomatics 39:416-421, October 1998
© 1998 The Academy of Psychiatric Medicine

Depression in Parkinson's Disease

The Impact of Symptom Overlap on Prevalence

W. J.G. Hoogendijk, M.D., I.E. C. Sommer, M.D., G. Tissingh, M.D., D. J.H. Deeg, Ph.D., and E.Ch. Wolters, M.D., Ph.D.

Received December 3, 1997; accepted February 11, 1998. From the Graduate School of Neurosciences Amsterdam, Research Institute Neurosciences, Departments of Psychiatry and Neurology, Free University, The Netherlands. Address reprint requests to Dr. Hoogendijk, Valerius Clinic, Valeriusplein 9, 1075 BG Amsterdam, The Netherlands.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The reported prevalence of depression concomitant with Parkinson's disease varies greatly in the literature, which may partly be explained by symptom overlap. To determine the impact of symptom overlap on the prevalence, the authors tested 100 Parkinson's disease patients for major depression (DSM-III-R) with both a standard, inclusive method and a diagnostic–etiologic, exclusive method. The authors found that the prevalence detected with the inclusive method (23%) decreased when the exclusive method was used (13%), which was mainly caused by lower scores on the item "loss of interest." The study's findings give empirical support for the relevance of the new category in DSM-IV "mood disorder due to a general medical condition."

Key Words: depression • parkinson's disease • symptom overlap

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The comorbidity of an episode of major depression (MD) in Parkinson's disease (PD) is a common clinical finding,1–3 with a mean prevalence of 40%, according to a review of 26 studies.4 However, reported prevalence rates of depression in PD patients show a strong variation, ranging from 2.7% to 70%.1,5,6 Several reasons for this variation can be given. Patient populations studied were heterogeneous (e.g., hospitalized7 vs. community-based,8,9 and different definitions of depression were used9,10). Another part of the prevalence variation may be explained because depression and PD have several signs and symptoms in common. Important features of depression, such as "insomnia," "weight loss," "psychomotor retardation," and "loss of energy" are also frequently found in PD, even in the absence of depressed mood.11 Symptom overlap is a well-recognized diagnostical problem in PD1,7,4,12 and makes global assessments, solely based on observer or self-ratings, of doubtful validity.1 For the diagnosis of MD in somatically ill patients, one of the DSM criteria states that symptoms clearly caused by a somatic disease have to be excluded.13,14 However, no guidelines are given for how to apply this criterion.15 In PD this exclusion criterion is even more difficult to bring into practice, since it is frequently unclear whether or not a symptom is caused by the somatic disease (e.g., PD).12 In the present study, decision rules are formulated, with which it is less difficult to attribute a symptom to either PD or MD, to test the hypothesis that the prevalence of depression in PD is lower if these rules are consequently applied.


  PATIENTS AND METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
A sample of 50 male and 50 female consecutive PD patients was obtained from our university's hospital outpatient clinic after written informed consent was obtained. A minimal score of 24 on the Mini-Mental State Exam (MMSE)16 was required to be enrolled in the study. The mean ± standard deviation (SD) age was 64 ± 8.2 years. The mean ± SD duration of PD was 8.2 ± 6.1 years. The mean ± SD MMSE score of the included patients was 29 ± 1.4. Six patients were drug-naive; the remaining 94 were treated with levodopa and/or a dopamine agonist (Pergolide). None of the patients used antidepressive medication.

Clinical Assessment
Depression was diagnosed in a semistructured clinical interview, according to DSM-III-R criteria for MD.13 In addition, the items of the 17-item Hamilton Depression Rating Scale (Ham-D)17 were scored for all patients. Questions were answered by the patient only. In the interview, the items of DSM-III-R and Ham-D were scored with two methods: 1) a standard, inclusive method in which the presence of a symptom was scored, irrespective of its origin and 2) a diagnostic–etiologic, exclusive method in which symptoms that were thought to be caused by PD were excluded. To determine whether a symptom was likely to be caused by PD, two questions were asked: 1) does the symptom fluctuate along with the fluctuation of the Parkinsonian signs and symptoms? and 2) can the symptom be alleviated by dopaminergic medication? If at least one question was answered yes, the symptom was attributed to PD and excluded in the exclusive method. Symptoms caused by other physical impairment or by medication were excluded, according to both the inclusive and the exclusive scoring methods.

Analyses
The prevalence of MD was calculated for both the inclusive and exclusive scoring method. The difference was tested by means of one-sided, Wilcoxon signed ranks test. The differences between the mean scores on individual DSM-III-R and Ham-D items for both scoring methods were tested by means of one-sided paired t-test, with Bonferroni correction for multiple testing (P<0.05). Internal consistency, as a measure for scale reliability, was determined by calculation of Cronbach's alpha for both the inclusive and the exclusive scoring methods.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Out of 100 patients interviewed, 23 (10 women and 13 men) were diagnosed as having MD, according to the DSM-III-R, with the use of the inclusive scoring method. According to the exclusive scoring method, 13 patients (6 women and 7 men) were diagnosed as having MD, which is significantly less (P=0.029, Wilcoxon). No differences were found between the depressed (using either the inclusive or the exclusive scoring method) and the nondepressed patients for age, gender, or kind and dose of medication used. The largest differences between the inclusive and exclusive methods were found for the DSM-III-R items "loss of interest," "psychomotor agitation or inhibition," and "loss of energy or fatigue" (Table 1). Internal consistency (Cronbach's alpha) for the DSM-III-R items of MD was good: 0.72 when all items were scored according to the inclusive method and 0.75 when all items were scored according to the exclusive method.


View this table:
[in this window]
[in a new window]
 

Table 1



The mean ± SD total score of all 100 patients on the Ham-D was significantly lower with the exclusive method: 7.4 ± 3.5 (P=0.036, Wilcoxon), compared with the inclusive method (mean ± SD: 11.2 ± 4.0). With the exclusive method, significantly lower scores were found for the items "work and interest," "retardation of speech and movement," and "somatic symptoms: general" (Table 2). Internal consistency of the inclusive method (0.76, Cronbach's alpha) did not change when using the exclusive method (0.77).


View this table:
[in this window]
[in a new window]
 

Table 2




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We studied the symptom overlap of PD and depression and determined its influence on the prevalence of MD and on Ham-D scores in PD patients. The inclusive and exclusive methods for the diagnosis of MD have been compared by others in medically ill patients,18,19 and its relevance has been particularly emphasized for MD in those with Alzheimer's disease.20,21 Meakin22 found evidence for an overestimation of depression in medically ill patients because of symptom overlap. However, symptom overlap does not necessarily collide with the physical items of depression.11,23 Recently, Koenig et al.24 found that the exclusive approach identifies the most severe and persistent depressions in medically ill patients, whereas the inclusive approach is the most sensitive and reliable approach. Concerning PD, some authors have dealt with this problem by excluding all somatic items from the depression scales. For example, Hantz et al.8 found a low depression prevalence (2.7%), while excluding all physical items from the General Health Questionnaire. Brown and MacCarthy7 suggested including a symptom only when it was out of proportion to the motor symptoms, having worsened shortly beforehand without any accompanying deterioration of PD, and concordant with other features not related to PD. In the present study, two criteria were formulated to decide whether depressive symptoms could in fact be attributed to PD. The first criterion is whether fluctuations of a depressive symptom coincide with fluctuations of the PD symptoms. If so, it suggests that the "depression" symptom probably has a parkinsonian origin. Theoretically, a moment with relatively few PD symptoms may improve mood and consequently diminish the MD symptom. However, this is not likely to occur, since, according to the DSM-III-R, MD had to be present for 2 weeks; moreover, it is characteristic that MD patients cannot be cheered up easily. The second criterion was whether a symptom was relieved by dopaminergic medication. Prior studies have shown that dopaminergic medication has little effect on depression, not even indirectly, when motor manifestations improve.2,25 Therefore, improvement by dopaminergic medication suggests a parkinsonian origin. Also, this second criterion has some theoretical limitations. If a symptom is not reactive to dopaminergic medication, a depressive origin of that symptom is not certain, since the neurobiological basis of both depression and PD may be related to dopaminergic activity as well as other systems.26 Furthermore, dividing the symptoms into manifestations of either PD or MD leaves no room for the possibility that depression may be a true component of PD. Therefore, an affirmative answer to one or both of these questions is not sound evidence, but rather a suggestion of a Parkinsonian origin.

By using the exclusive method, the prevalence of the DSM-III-R diagnosis of MD decreased from 23% to 13%. Other prevalence studies that used standard (inclusive) DSM-III-R criteria for MD found prevalence rates of 22%,2721%,28 and 24.5%,29 which is in agreement with our findings using the inclusive scoring method. As expected from earlier studies,11,23,30 the somatic items "psychomotor retardation/agitation" and "loss of energy/fatigue" showed an overlap with PD symptoms. A considerable overlap was also found for the item "loss of interest." This item was scored affirmatively in 37% of the patients by means of the inclusive scoring method, which is in agreement with a 40% score on the same item by Brown and MacCarthy.7 However, in the majority of cases, this symptom fluctuated along with PD symptoms and/or was relieved by dopaminergic medication, resulting in a score, according to the exclusive method, of only 18%. Nine out of 23 patients lost the MD diagnosis attributable to their lower scores on "loss of interest." Only one patient lost the MD diagnosis because of a low score on the somatic items. This large decrease in prevalence (i.e., from 23% to 14%) is attributable to the fact that "depressed mood" and "loss of interest" are mandatory items for the DSM-III-R diagnosis of MD, "depressed mood" was absent, and "loss of interest" was excluded, because it behaved as a PD symptom. However, all these nine excluded patients would have fitted criteria for the new DSM-IV category "mood disorder due to a general medical condition," demanding 1) the presence of depressed mood or anhedonia (i.e., loss of interest) and 2) the strong suggestion that these symptoms are a direct physiological consequence of a somatic disease.

Depressed mood has never been proven to be a direct biological consequence of PD.3,12 Anhedonia, however, is indeed frequently reported to be an expression of PD.31–33 Several hypotheses have been proposed12,31,34,35 to explain why "loss of interest" is frequently seen in PD. The dopaminergic fibers that arise from the ventral tegmental area and end in the limbic area (mesolimbic dopamine system) possess specific reward- or pleasure-related functions. These dopaminergic neurons appear to be decreased in PD patients.32 Cantello et al.33 found that PD patients with MD fail to sustain the euphoria effect from the dopamine and norepinephrine reuptake inhibitor methylphenidate, and the researchers suggested that the degeneration of the mesolimbic dopamine system, as a manifestation of PD, is responsible for this "anhedonic" response. A comparable overlap of symptomatology with depression is seen in dementia.20,21 In dementia "loss of interest" is generally considered as not valid as a sole mandatory symptom (i.e., in the absence of "depressed mood") for the DSM-III-R diagnosis of MD.20 The findings of our study suggest that "depressed mood" is also the only valid mandatory symptom in PD.

The mean Ham-D score in the present study decreased from 11.2 to 7.4. The use of the exclusive method did not affect the internal consistency of either rating scale. Within the Ham-D, a comparable cluster of items as in DSM-III-R showed a significant decrease when scored according to the exclusive method. The decision to use the inclusive or the exclusive scoring method is also of clinical relevance, since pharmacotherapy is indicated above a certain cut-off point on the Ham-D (i.e., 13).

We propose that, as in AD, "depressed mood" and not "loss of interest" should be considered as the sole, valid mandatory symptom for the DSM-III-R and DSM-IV diagnosis for MD. Although a golden standard for this line of research is lacking, future studies may determine whether the exclusive method is more valid than the inclusive method, that is, in predicting treatment outcome. Moreover, we suggest that two types of depressed PD patients can be distinguished: 1) true comorbidity, in which a PD patient is diagnosed as MD, according to the exclusive scoring method and 2) "mood disorder due to a general medical condition," according to the DSM-IV, in which a PD patient has depressive symptoms that fluctuate along with the PD symptoms and/or respond to dopaminergic medication. For treatment evaluation in clinical practice, a consequent use of either the inclusive or the exclusive method is recommended, with special emphasis on the symptoms "loss of interest," "psychomotor agitation or retardation," and "loss of energy or fatigue." We recommend using the exclusive scoring method for neurobiological research purposes36 to create more homogeneous groups of depressed PD patients and also in epidemiological studies to diminish the range of depression prevalence in PD.


  ACKNOWLEDGMENTS

 
The authors thank Piet Eikelenboom, M.D., Ph.D., Robert A. Schoevers, M.D., Catherine Witterick, Michel A. Hofman, and Dick F. Swaab, M.D., Ph.D., for their thoughtful comments.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Gotham AM, Brown RG, Marsden CD: Depression in Parkinson's disease: a quantitative and qualitative analysis. J Neurol Neurosurg Psychiatry 1986; 49:381–389[Abstract]
  2. Mayeux R, Stern Y, Cote L, et al: Altered serotonin metabolism in depressed patients with Parkinson's disease. Neurology 1984; 34:642–646[Abstract/Free Full Text]
  3. Mayeux R, Stern Y, Williams JB, et al: Clinical and biochemical features of depression in Parkinson's disease. Am J Psychiatry 1986; 143:756–759[Abstract/Free Full Text]
  4. Cummings JL: Depression and Parkinson's disease: a review. Am J Psychiatry 1992; 149:443–454[Abstract/Free Full Text]
  5. Dooneief G, Mirabello E, Bell K, et al: An estimate of the incidence of depression in idiopathic Parkinson's disease. Arch Neurol 1992; 49:305–307[Abstract]
  6. Ehmann TS, Beninger RJ, Gawel MJ, et al: Depressive symptoms in Parkinson's disease: a comparison with disabled control subjects. J Geriatr Psychiatry Neurol 1990; 3:3–9
  7. Brown RG, MacCarthy B: Psychiatric morbidity in patients with Parkinson's disease. Psychol Med 1990; 20:77–87[Medline]
  8. Hantz P, Caradoc-Davies G, Caradoc-Davies T, et al: Depression in Parkinson's disease. Am J Psychiatry 1994; 151:1010–1014[Abstract/Free Full Text]
  9. Tandberg E, Larsen JP, Aarsland D, et al: The occurrence of depression in Parkinson's disease: a community-based study. Arch Neurol 1996; 53:175–179[Abstract]
  10. Harvey NS: Psychiatric disorders in parkinsonism 1. Functional illnesses and personality. Psychosomatics 1986; 27:91–98[Abstract/Free Full Text]
  11. Starkstein SE, Preziosi TJ, Forrester AW, et al: Specificity of affective and autonomic symptoms of depression in Parkinson's disease. J Neurol Neurosurg Psychiatry 1990; 53:869–873[Abstract]
  12. Taylor AE, Saint-Cyr JA: Depression in Parkinson's disease: reconciling physiological and psychological perspectives. J Neuropsychiatry Clin Neurosci 1990; 2:92–98[Free Full Text]
  13. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987
  14. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
  15. Von Ammon Cavanaugh S: Depression in the medically ill: critical issues in diagnostic assessment. Psychosomatics 1995; 36:48–59[Abstract/Free Full Text]
  16. Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198[Medline]
  17. Hamilton M: Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967; 6:278–296[Medline]
  18. Plumb MM, Holland J: Comparative studies of psychological function in patients with advanced cancer—I. Self-reported depressive symptoms. Psychosom Med 1977; 39:264–276[Abstract/Free Full Text]
  19. Cavanaugh S, Clark D, Gibbons RD: Diagnosing depression in the hospitalized medically ill. Psychosomatics 1983; 24:809–815[Abstract/Free Full Text]
  20. Zubenko GS: Clinicopathologic and neurochemical correlates of major depression and psychosis in primary dementia. International Psychogeriatrics 1996; 8(suppl 3):219–223
  21. Alexopoulos GS: The treatment of depressed demented patients. J Clin Psychiatry 1996; 57 (suppl 14):14–20
  22. Meakin CJ: Screening for depression in the medically ill. The future of paper and pencil tests. Br J Psychiatry 1992; 160:212–216[Abstract/Free Full Text]
  23. Levin BE, Llabre MM, Weiner WJ: Parkinson's disease and depression: psychometric properties of the Beck Depression Inventory. J Neurol Neurosurg Psychiatry 1988; 51:1401–1404[Abstract]
  24. Koenig HG, George LK, Peterson BL, et al: Depression in medically ill hospitalized older adults: prevalence, characteristics and course of symptoms according to six diagnostic schemes. Am J Psychiatry 1997; 154:1376–1383[Abstract]
  25. Mindham RH, Marsden CD, Parkes JD: Psychiatric symptoms during L-dopa therapy for Parkinson's disease and their relationship to physical disability. Psychol Med 1976; 6:23–33[Medline]
  26. Braak H, Braak E, Yilmazer D, et al: Pattern of brain destruction in Parkinson's and Alzheimer's disease. J Neural Transm 1996; 103:455–490 [Medline]
  27. Mayeux R, Williams JB, Stern Y, et al: Depression and Parkinson's disease. Adv Neurol 1984; 40:241–250[Medline]
  28. Starkstein SE, Berthier ML, Bolduc PL, et al: Depression in patients with early versus late onset of Parkinson's disease. Neurology 1989; 39:1441–1445[Abstract/Free Full Text]
  29. Sano M, Stern Y, Williams J, et al: Coexisting dementia and depression in Parkinson's disease. Arch Neurol 1989; 46:1284–1286[Abstract]
  30. Huber SJ, Freidenberg DL, Paulson GW, et al: The pattern of depressive symptoms varies with progression of Parkinson's disease. J Neurol Neurosurg Psychiatry 1990; 53:275–278[Abstract]
  31. Jellinger K: Overview of morphological changes in Parkinson's disease, in Advances in Neurology: Parkinson's Disease, edited by Yahr MD, Bergmann KJ. New York, Raven, 1987, pp. 1–18
  32. Uhl GR, Hedreen JC, Price DL: Parkinson's disease: loss of neurons from the ventral tegmental area contralateral to therapeutic surgical lesions. Neurology 1985; 35:1215–1218[Abstract/Free Full Text]
  33. Cantello R, Aguggia M, Gilli M, et al: Major depression in Parkinson's disease and the mood response to intravenous methylphenidate: possible role of the "hedonic" dopamine synapse. J Neurol Neurosurg Psychiatry 1989; 52:724–731[Abstract]
  34. Mayberg HS, Starkstein SE, Sadzot B, et al: Selective hypometabolism in the inferior frontal lobe in depressed patients with Parkinson's disease. Ann Neurol 1990; 28:57–64[Medline]
  35. Starkstein SE, Mayberg HS, Preziosi TJ, et al: Reliability, validity, and clinical correlates of apathy in Parkinson's disease. J Neuropsychiatry Clin Neurosci 1992; 4:134–139[Abstract/Free Full Text]
  36. Hoogendijk WJG, Purba JS, Hofman MA, et al: Depression does not affect the number of corticotropin-releasing hormone (CRH) neurons in the hypothalamic paraventricular nucleus in Parkinson patients. Biol Psychiatry 1998; 43:913–917[Medline]



This article has been cited by other articles:


Home page
 AJGPHome page
D. Weintraub, K. A. Oehlberg, I. R. Katz, and M. B. Stern
Test Characteristics of the 15-Item Geriatric Depression Scale and Hamilton Depression Rating Scale in Parkinson Disease
Am J Geriatr Psychiatry, February 1, 2006; 14(2): 169 - 175.
[Abstract] [Full Text] [PDF]

Home page
 J. Neurol. Neurosurg. PsychiatryHome page
F S Ertan, T Ertan, G Kiziltan, and H Uygucgil
Reliability and validity of the Geriatric Depression Scale in depression in Parkinson's disease
J. Neurol. Neurosurg. Psychiatry, October 1, 2005; 76(10): 1445 - 1447.
[Abstract] [Full Text] [PDF]

Home page
 J. Neuropsychiatry Clin. Neurosi.Home page
C. Veazey, S. Ozlem Erden Aki, K. F. Cook, E. C. Lai, and M. E. Kunik
Prevalence and Treatment of Depression in Parkinson's Disease
J Neuropsychiatry Clin Neurosci, August 1, 2005; 17(3): 310 - 323.
[Abstract] [Full Text] [PDF]

Home page
 J Geriatr Psychiatry NeurolHome page
A. F. G. Leentjens
Depression in Parkinson's Disease: Conceptual Issues and Clinical Challenges
J Geriatr Psychiatry Neurol, September 1, 2004; 17(3): 120 - 126.
[Abstract] [PDF]

Home page
 BrainHome page
A. W. Michell, S. J. G. Lewis, T. Foltynie, and R. A. Barker
Biomarkers and Parkinson's disease
Brain, August 1, 2004; 127(8): 1693 - 1705.
[Abstract] [Full Text] [PDF]

Home page
 J Geriatr Psychiatry NeurolHome page
D. Weintraub, P. J. Moberg, J. E. Duda, I. R. Katz, and M. B. Stern
Recognition and Treatment of Depression in Parkinson's Disease
J Geriatr Psychiatry Neurol, September 1, 2003; 16(3): 178 - 183.
[Abstract] [PDF]

Home page
 J Geriatr Psychiatry NeurolHome page
M. Myslobodsky, F. M. Lalonde, and L. Hicks
Are Patients with Parkinson's Disease Suicidal?
J Geriatr Psychiatry Neurol, September 1, 2001; 14(3): 120 - 124.
[Abstract] [PDF]

Home page
 NEJMHome page
S. C. Yudofsky
Parkinson's Disease, Depression, and Electrical Stimulation of the Brain
N. Engl. J. Med., May 13, 1999; 340(19): 1500 - 1502.
[Full Text]

This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via HighWire
* Citing Articles via Google Scholar
Google Scholar
* Articles by Hoogendijk, W. J.G.
* Articles by Wolters, E.Ch.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Hoogendijk, W. J.G.
* Articles by Wolters, E.Ch.
Related Collections
* Depression
* Parkinson's Disease
* Delirium

Get information about faster international access.

Privacy Policy

Copyright © 1998 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us

American Psychiatric Publishing, Inc. Academy of Psychosomatic Medicine
1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901 * 800-368-5777 * appi at psych.org