Role of Psychiatrist or Other Mental Health Therapist With Patients Who Have Thoughts of Killing Themselves and/or Someone Else.

Screen Shot 2015-04-16 at 2.48.39 PMAs details emerge various news stories of terrorism, and murder/suicide events, there are important questions being raised about how should a mental health therapist approach patients who may have the potential for violence towards themselves or others.

I would suggest that the following questions should be considered.

  1. What should a psychiatrist or another mental health therapist do when a patient says that they have had thoughts about killing themselves in a violent manner that could injure other people? Would the response be different if the self-destruction was only directed towards themselves in a non-violent manner such as taking an overdose as compared to potentially hurting other people as well? Should there be a different response to the above question if the patient is a school teacher, a bus driver, an airline pilot, or a scientist who works with Ebola?
  2. If a therapist knows that a patient has been suicidal in the past but is not so at present with therapy and medication, should the therapist be obligated to inform the patient’s employer if the job is a critical one such as those described above? Also, how we do factor in the fact that depression can be a recurrent condition?
  3. What are the possible consequences  if therapists were mandated to report patients who have had suicidal thoughts or violent fantasies?

General Discussion

Screen Shot 2015-04-16 at 7.25.57 PMJust having fleeting suicidal thoughts does not make someone a risk for hurting themselves. Similarly, having an angry murderous thought toward someone who you might resent does not make you a potential killer. There are many factors which a clinician must consider in evaluating the suicidal and danger potential of a patient. Is the patient psychotic? Is the patient having a severe depression which might include not sleeping or eating, crying, losing weight, etc ? Has the person acted on impulses in the past? Is there a history of violence towards self or others? Does the therapist and the patient feel comfortable that the patient would talk to the therapist if he or she felt that the feelings were intensifying? Does the patient have an immediate means to violence, such as access to a gun? Are there family members who can help monitor the patient in between sessions? These and many other factors enter into the evaluation of the seriousness of the threat that the patient may have to themselves or others. This is tricky business, but mental health professionals do it all the time.

The overwhelming majority of people with mental illness are not dangerous to themselves or other people. It should also be noted that mental health therapists do not have a sure method of predicting dangerous behavior in the future. We may be good in retrospect at explaining behavior and actions as the result of psychological factors (called psychic determinism), but we cannot claim the ability to predict behavior with great accuracy. We know a great deal about various forms of mental illness such as  schizophrenia where there is a break with reality. In most of these situations, the diagnosis is quite clear. Depression affects a very large number of people. There is a wide range of etiological factors of depression from grieving and situations involving loss and disappointment to biological types of major depression which can come on without any particular relationship to a loss or disappointment. There are also can be variations of mood such as bipolar or major depression which can even be at a psychotic level.Screen Shot 2015-04-17 at 12.50.56 PM

Suicidal thoughts often accompany various forms of depression. There can be passive thoughts such as a person who does not care about anything and might not want to eat or drink or take care of themselves. In such situations, a person frequently expresses the idea that they do not care if they wake up or not. Sometimes, persons may act suicidal or make suicidal threats or even try to hurt themselves as part of “cry for help.” In other words, the main thought of such person would be a desire to be stopped and given help. This doesn’t mean that they might not actually seriously hurt themselves.

People can become depressed to the point where they feel they cannot tolerate life or may feel worthless and that they do not deserve to live. Such a person might choose a suicidal method that would be more likely to be fatal. In some situations, this person, is intent on making a statement to someone else in their life, and they would want their suicide to have an impact on a family member or someone close to them. Sometimes, tremendous anger at themselves or others is part of the motivation for suicidal thinking.

Screen Shot 2015-04-16 at 2.51.07 PMAs it is well-known by police, some suicides are connected with a murder of someone else, usually a person well-known to the perpetrator. This may frequently be a family member or someone where there is an intense conflictual relationship. Sometimes, the suicide and the murder of the other person may involve a work situation such as a boss or a co-worker. The circumstances of someone being fired or humiliated at work or school might fit in to this category. These are not common, but they do happen.Screen Shot 2015-04-16 at 2.50.44 PM

This brings us to the situation of a suicide and multiple or mass murders. While such situations are extremely rare, they become very well publicized and well remembered. Sometimes they become examples for copycat acts by someone else. Limited research upon this group suggests that major depression is frequently present in the person who carries out this act. Also anger and rage and the feeling of being wronged may be present. There also may be some grandiose or narcissistic feelings where the perpetrator wants to become famous or remembered. While alcohol and drugs can always be a factor as it can loosen up one’s conscience and any inhibitions, it is not always present in this particular type of suicide connected with mass murder, since it often takes careful planning and requires a clear mind to carry them out. In retrospect, a study of each of these cases usually reveals particular stresses, rejection, and usually tremendous anger.

Can a therapist see the makings of a potential catastrophe and do something to prevent it? The answer is yes, we do that all the time when we work with people who have suicidal thoughts, but we can’t do it every time. Treatment works! But not all the time. There are many people who have experienced severe depression even with suicidal thoughts and even may have made a suicidal attempt and then recovered with treatment. Treatment can be psychotherapy, medication, or both. This is the reason that therapy has to be available, and a person should be able to enter the therapy and feel secure that they can express all their thoughts in a safe environment

But what if the therapist concludes at some point in the treatment that the patient is an immediate serious threat to themselves or someone else? At that point, there is an obligation for the therapist to hospitalize the patient. Hopefully, the patient would agree to such hospitalization. But even if the patient does not agree, there is a procedure (that varies from state to state) in which patients can be hospitalized against their will. In the State of California, it is called a “5150”, and if necessary, the police will assist a therapist based on the information provided from the mental health professional to take the patient  to the hospital. Then at the hospital, based on the information provided by the therapist and any family or friends available plus another evaluation by a mental health professional at the hospital, a patient can be legally hospitalized against his or her will. Then there can be subsequent legal proceedings to extend this hospitalization.Now, you may ask isn’t this breaking the confidentiality of the doctor-patient relationship? Yes of course it is, but this is obviously in the patient’s best interest. On occasion, during the course of therapy, the patient will ask me, “Is everything we say in therapy confidential?” I would reply, “Yes, unless I feel you were a true danger to yourself or someone else, and then I would act accordingly.”

Screen Shot 2015-04-16 at 2.47.41 PMThere is another situation to consider. What if the therapist becomes aware that the patient is seriously suicidal and/or a danger to someone else but they are not in present in the therapist’s office? Perhaps, they have left a message for the therapist or they do not show up for an appointment and the family described some behavior that the therapist understands means a danger situation to the patient or someone else. In such a case, the therapist is obligated to notify the police and have them attempt to find the patient and institute a “5150” based on the information that the therapist has provided. In California, the law further mandates that if the therapist feels that there is a clear danger to someone else , and the therapist knows who that person is, the therapist has to act according to the Tarasoff case. The Tarasoff case involved a situation at the University of California where a therapist knew that the patient would attempt to hurt another person. As a result of this case, in California, if a therapist believes that another person is in danger, the therapist must notify that person or be sure that that person has been informed by the police. Every effort must be made to contact the person who is believed to be in danger. So therefore, reflect on the thought, what if the therapist is treating an airline pilot and the therapist came to believe that the pilot who was not available to be brought to the hospital but might be flying a plane which he could be planning to  crash as part of a suicide murder. According to the Tarasoff precedent, the therapist would be obligated not only to notify the police and try to hospitalize the patient, but would also be obligated to be sure the airline was notified of the potential danger.

So now let’s return to the three questions which I raised at the beginning of this article.

My answers would be as follows:

  1. If the therapist believes that the patient is a serious threat to hurt themselves or someone else, he or she should act in a responsible manner to hospitalize the patient as soon as possible, even if this hospitalization has to be done on an involuntary basis. In California, if the patient has identified a threat to another person, every effort should be made to notify that person of the threat (in other states, there may be variation of this expectation). I believe the responsibility of the therapist is the same no matter what kind of work responsibility or employment the patient may have.
  2. If the therapist knows that the patient has been suicidal in the past but is not a suicidal threat to themselves or any danger to anybody else at the present time, the therapist is not obligated to inform the employer even if the job is a critical one, such as an airline pilot or a scientist working with dangerous bacteria, etc. The fact that depression is a recurrent condition does not change my opinion on this issue. An employer can make a decision that people with a history of epilepsy, or heart disease, or depression or suicidal ideation, should not work in critical positions. I would not necessarily agree with this position, but an employer certainly could make such a policy. Also, if a therapist is requested by his or her patient to provide information to an employer, the therapist should do that in a truthful manner.
  3. If therapists were mandated to report patients who have suicidal thoughts or violent fantasies, this would create a situation where people who had emotional conditions that might on occasion bring up suicidal thoughts or fantasies of violence would be quite reluctant to seek help. Therefore, people who would benefit by treatment would not be receiving it and I believe this would create, overall, a more dangerous situation.

Disclaimer

I am not an attorney nor do I claim expertise in legal issues which often differ from state to state. I also am not necessarily reflecting the ethical position of the American Psychiatric Association or other professional organizations. I am writing as one experienced psychiatrist who has confronted variations of these questions in clinical practice and has discussed such issues with my colleagues, mentors and students over the years.

I would also recommend a recent article in the New York Times by Erica Goode dated April 9, 2015 titled, “The Mind of Those Who Kill, and Kill Themselves.”

Dr. Blumenfield is the Sidney Frank Distinguished Professor Emeritus at New York Medical College. He currently is in private practice in Woodland Hills, California. For more information about Dr. Blumenfield go to  http://mblumenfieldmd.com/

 

Psychodynamic Psychiatry in the Medical Setting

The following is an extended version of a talk given by Dr. Michael Blumenfield at the World Psychiatric Meeting in Madrid Spain on September 15, 2014

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Introductory Case :

I would like to start off with a case history

Screen Shot 2014-07-14 at 6.17.34 PMThe patient is a 21 year old woman who has some paralysis in the right upper extremity and partial paralysis of the left lower extremity, weakness of the neck muscles, periods of persisting sleep walking as well as many other symptoms including a cough.

The symptoms came on after the patient’s father of whom she was very fond had become ill and subsequently died.

The patient’s internist Dr. B noted that the patient seemed to have alternating states of consciousness, which developed with regularity every day, during which she would talk and tell stories. She would talk about her past and how it was when she was a little girl as well as things that happened in the not too distant past. She would wake up feeling quite calm and then would go back to her usual clinical state.

Her internist became very interested in this patient and began to see her on a daily basis. He began to assist her to get into these altered states of consciousness by using a hypnotic technique. During the states he asked her to concentrate on each symptom. Eventually, she began to tell him about the circumstances that had occurred the first time that each of her symptoms had developed. When she came out of the trance, that particular symptom was gone. For example she told him that she began coughing for the first time while sitting at her ill father’s bedside and hearing the sound of dance music coming from a neighbor’s house. She had felt a sudden wish to be there and became overwhelmed with self reproaches and guilt feelings. Thereafter, whenever she heard music, she developed a cough. After this was brought out in the hypnotic state, the symptoms of coughing disappeared.

In the same way, her paralytic contractions, her numbness, hearing problems and other symptoms all disappeared.

The internist completed his treatment. While it was not in his original write up, some subsequent fact surrounding the case were not documented. Since the patient was cured of all her symptoms Dr. B. told her that he was Screen Shot 2014-07-14 at 6.23.51 PMterminating treatment and said good bye to her. However, that evening, he was called back to her house to find her in the throes of an hysterical childbirth.

We now understand that this was related to the patient’s “transference” which had been developing for some time. When the internist came into the room and asked what was wrong, the patient said, “ Dr. B’s baby is coming!” The doctor was overwhelmed by the situation and he had no way of understanding what was happening. He became profoundly shocked and took flight abandoning the patient to a colleague.

In retrospect, we understand that the internist had developed strong “countertransference feelings for his beautiful patient. He had been spending a good deal of time with her away from his family. He was emotionally involved with the patient and interested in her case. In his own background, his mother ( who happened to have the same first name as the patient) had died in childbirth when he was 5 years old. Unconsciously, he had become for his patient, the father whom she had lost and she was in turn the mother he had lost as a young boy.

Screen Shot 2014-07-26 at 9.53.55 PMThis case occurred more than 115 years ago. The internist was Dr. Joseph Breuer, who subsequently collaborated with a young neurologist by the name of Sigmund Freud who encouraged him to publish this case history. This case marked the beginning of psychodynamic psychiatry.

It is known as the Anno O case. In it we can see evidence of early childhood feelings impacting on neurotic symptoms, a conversion disorder as well as examples of transference and countertransference.

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Suicide: Main Theme of Meeting in San Francisco May16-18 2013

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Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

images-1Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their lifeimages-2.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.

 

Anatomy of a Psychiatric Consultation For Depression

When a psychiatrist does a consultation for depression, many things have to be considered. Ultimately the psychiatrist needs to decide whether to recommend medication, psychotherapy or a combination of both.

THE REFERRAL OR CHOOSING THE PSYCHIATRIST

Let us look at typical situation where a person comes to a psychiatrist for evaluation because of depression. The most common sources of this referral would probably be from one of the following (or a combination )

1- Primary care physician refers the patient
2- A non psychiatrist mental health professional who is treating the patient in psychotherapy refers the patient for medication
3- The patient is self referred either finding the psychiatrist at the recommendation of an acquaintance or the patient finds the psychiatrist through the Internet

The referral might be influenced by finances and by insurance considerations. The patient may be going to a low cost clinic or they may need to find a psychiatrist who is on a particular insurance panel although insurance companies will often allow their subscribers to see an “ out of network” doctor and will cover part of the fee. Many private psychiatrists have either opted out of the Medicare program or are not accepting Medicare patient so this will also have to be determined before choosing the psychiatrist.

The patient calls the psychiatrist and makes the appointment. The initial appointment is usually 45 minutes – 1 hour. It is perfectly appropriate to discuss the fee and any questions about insurance coverage on the phone

THE INITIAL PRESENTATION

The psychiatrist would take a careful history and look at the reason that the patient is coming ( in this case depression ) and examine the development of this symptom and circumstances around it. Similarly the presence of any other symptoms, problems or difficulties would be carefully examined.

After looking at any of the issues which the patient brings up, the psychiatrist would ask about many other symptoms which may not have been mentioned by the patient such as anxiety, phobias, obsessions and compulsions, sleeping difficulties, appetite or eating difficulties, sexual problems, paranoid thoughts, auditory and visual hallucinations, suicidal thoughts and actions, anger, irritability, racing thoughts, grandiose feelings, short term and long term memory problems, confusion, tiredness, excess energy, dreams, nightmares and a bunch of other things. There would be questions about a history of traumatic events, recent loss and grieving as well as any history of substance abuse including alcohol. The psychiatrist would ask about a history of previous treatment for mental disorders and any psychiatric hospitalization. There also would be a review of any family history of psychiatric disorders. Also, not necessarily in this order the psychiatrist would learn about the patient’s interpersonal relationships with the people in his or her life. This would include getting some preliminary understanding of the patient’s childhood and relationship with close family members. It would also be important for the psychiatrist to understand about the existence of any medical problems, previous medical treatment as well as any medication that the patient may be taking .

WHAT CAN THE PSYCHIATRIST CONCLUDE?

Most of the time at the conclusion of the first interview the psychiatrist will have at least a tentative diagnosis related to the depression and any other condition that the patient may have. It may be that the psychiatrist feels that some medical tests are in order such as a test for low thyroid functioning which can cause depression. The psychiatrist may want the patient to have a neurological consultation or even some brain imaging to rule out something like a brain tumor although that would be quite rare. The results of a physical exam and lab tests may be useful in making the diagnosis and in determining which medication can be utilized if that is being recommended. Most of the time a tentative diagnosis and a recommended treatment plan can be instituted before all the results of any requested medical consultation or tests are received.

For the this discussion, let us assume that the patient doesn’t have any other major psychiatric disorder other than a major depression. There is no substance abuse use, schizophrenia or bipolar disorder or underlying medical problems. Let us also assume that at the time of the consultation the patient does not require hospitalization for suicidal or other dangerous behavior including needing treatment for substance abuse. If the patient was having a first major depressive episode or if it were a repeat episode it would mean that he or she were having significantly depressed mood with possible problems in sleep, appetite, concentration as well as diminished interest and pleasure . The patient may be feeling worthless, guilty and having thoughts about death and suicide even if they didn’t have an active plan to kill themselves. There are other symptoms also and they all don’t have to be present. Most likely the patient isn’t functioning well socially or at work . Even if most of these symptoms are not full blown, it has the potential to get worst and the fact that patient has sought out help indicates that he or she is having a difficult time.

ANTIDEPRESSANT MEDICATION

Anti-depressant medication may well be the treatment of choice to alleviate many of these symptoms. It is most likely going to take at least 4 weeks to get a significant improvement if this medication is going to work.
The dosage may have to be adjusted and the patient will have to be monitored for side effects and possible worsening of symptoms including the potential of becoming a serious suicidal threat. In some situations more than one medication may need to be utilized.

PSYCHOLOGICAL FACTORS

Thus far we haven’t factored in how important are the psychological factors in the patient’s life. Self image, personality, realistic issues in the environment, interpersonal conflicts, failure to achieve goals in school, work and in love can all be an important part of the equation. While improvement in the patient’s mood may very well occur with medication, this is no guarantee that these other issues will improve. Therefore psychotherapy should be considered as the main treatment recommendation. It is true that when a depressed mood lifts, a person is often better able to deal with certain problems. But on the other hand a antidepressant is not going to change deep seated neurotic symptoms, self image and serious relationship problems.

COMBINATION OF MEDICATION AND PSYCHOTHERAPY

Even objectively looking at basic depressive symptoms there is a lot of research that shows that some form of psychotherapy with medication is better that either one of these modalities when the problem is depression.

Of course the recommendation for treatment will also have to take into account, the age of the patient, life circumstances, social supports etc. However in most cases a combination of psychotherapy and medication is often the treatment of choice in the above situation. In cases of a recurrent depression, it may be that the person has previously had psychotherapy and a reinstitution of medication is all that is required or that the patient has done well on medication alone in the past.

WHO DOES WHAT ?

Many psychiatrists such as myself do psychotherapy and also can prescribe medication. Ideally many prefer to do both with a patient when it is indicated. Some psychiatrists only do psychopharmacology and would refer the patient to someone who does psychotherapy. If a patient is referred to a psychiatrist by a non-psychiatrist therapist, then the psychiatrist would prescribe the medication and the original therapist would usually continue the psychotherapy. This requires collaborative therapy in which the patient gives permission for communication as needed between the two health professionals. The psychiatrist would have to decide on the frequency of follow-up visits to adjust medication which can usually be done in time limited visits and the two professionals may have to talk periodically to decide if the treatment needs further adjustment. On some occasions, the psychiatrist may feel that the depression does not or may not require medication but rather there should be a trial of therapy first. This means that if there is a non psychiatrist therapist who referred the patient to the psychiatrist, that person would have to be comfortable in continuing the therapy without medication. Medication could always be reconsidered at a later date.

Another variation would be a trial of medication perhaps with continued psychotherapy and then perhaps a trial off the medication as the psychotherapy continues. Sometimes a non-psychiatrist physician will be comfortable in prescribing medication but might periodically want a to consult with a psychiatrist who would see the patient for an occasional visit.

NO SIMPLE ANSWER

It would be nice if there were a simple blood test or MRI to determine the best form of treatment or even a simple test to determine whether psychotherapy will be successful. While psychopharmacology and psychotherapy techniques have come a long way in the past 50 years, there still needs to be good clinical judgment and a working alliance between the patient and any professionals working with them.

Comments are welcome from both mental health professionals as well as patients, potential patients and anyone else.

Public Awareness about the Relationship Between Heart Disease and Depression

A research study which examined the public awareness about the connection between heart disease and depression. This included data on the preferred sources of health information across educational levels.

A few months ago I published a research project in the journal Psychiatric Quarterly (Springer) which examined the public awareness of the connection between depression and physical health: specifically heart disease. It appeared online November 2011 and it will be soon be published in the regular edition of this journal.
The following is an abstract of this article. I welcome any comments or questions.

Public Awareness About the Connection Between Depression and Physical Health: Specifically Heart Disease

Michael Blumenfield, Julianne K. Suojanen, Charlene Weiss

Abstract

The medical community continues to acknowledge a connection between depression and physical health, for example, cardiac disease. This study addresses public awareness about depression’s effects on physical health, the relationship between cardiac disease and depression, and preferred sources of health information, in an effort to inform future health education programs. A survey, administered to 816 adults ages 40-69, focused on public awareness, perception of depression as an illness, its impact on other illnesses such as heart disease, and sources of health information. (1) Eighty-three percent (83%) of respondents felt depression was an illness; (2) a slightly higher percentage (85.8%) felt a mental disorder, like depression, could affect the course of a physical illness; (3) respondents’ awareness of links between depression and cardiac disease ranged from 29.8% (awareness of depression as a risk factor for coronary artery disease) to 31.6% (awareness that depression can increase the risk of having a second heart attack); (4) print media were the most frequently cited sources of health information (22.7%); and (5) more highly educated respondents were more informed about depression than respondents with less education. Although a majority of respondents (1) recognized depression as an illness (2) thought it could complicate recovery from a physical illness, less than a third of them were aware of links between cardiac disease and depression. Demographic groups differed in their preferred sources of health information, especially across educational levels, demonstrating a need for targeted health educational outreach in efforts to reach a variety of populations.