Levels of anxiety and depression as predictors of mortality: the HUNT study

Lack of association between type 2 diabetes and major depression: epidemiologic and genetic evidence in a multiethnic population

The positive association between depression and type 2 diabetes (T2D) has been controversial, and little is known about the molecular determinants linking these disorders. Here we investigated the association between T2D and depression at the clinical and genetic level in a multiethnic cohort. We studied 17,404 individuals from EpiDREAM (3209 depression cases and 14,195 controls) who were at risk for T2D and had both phenotypic and genotypic information available at baseline. The glycemic status was determined using the 2003 American Diabetes Association criteria and an oral glucose tolerance test. Major depressive episode during the previous 12 months was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria. Twenty single-nucleotide polymorphisms (SNPs) previously associated with T2D were genotyped using the cardiovascular gene-centric 50-K SNP array and were analyzed separately and in combination using an unweighted genotype score (GS). Multivariate logistic regression models adjusted for age, sex, ethnicity and body mass index were performed. Newly diagnosed impaired fasting glucose (IFG)/impaired glucose tolerance (IGT), T2D and dysglycemia status were not associated with major depression (0.30 ⩽ P ⩽ 0.65). Twelve out of twenty SNPs and the GS were associated with IFG/IGT, T2D and/or dysglycemia status (6.0 × 10(-35) ⩽ P ⩽ 0.048). In contrast, the 20 SNPs and GS were not associated with depression (P ⩾ 0.09). Our cross-sectional data do not support an association between T2D and depression at the clinical and genetic level in a multiethnic population at risk for T2D.

Interaction of depressive and anxiety symptoms on the mortality of patients with COPD: a preliminary study

BACKGROUND

Depressive and anxiety symptoms increase the risk of death in patients with Chronic Obstructive Pulmonary Disease (COPD), but the combined effects of the two factors are unknown.

PURPOSE

To assess the possible interactive effects of depressive and anxiety symptoms on the death of patients with COPD.

METHODS

Prospective data for 7787 Chinese patients with COPD was analyzed and the deaths were recorded. Depressive and anxiety symptoms were evaluated using the Hospital Anxiety and Depression Scale. A product of depressive and anxiety symptoms was added to the logistic regression model to evaluate the multiplicative interaction, and relative excess risk of interaction (RERI), attributable proportion (AP) of interaction, and synergy index (S) were applied to evaluate the additive interaction of the two factors. Bootstrap was used to calculate 95% confidence intervals (CIs) of RERI, AP and S. RERI > 0, AP > 0, or S > 1 indicated biological interaction.

RESULTS

After 4 years' follow-up, the cumulative mortality was 20.0%, and the percentages of deaths in patients with depressive and anxiety symptoms were 28.5% and 30.9%, respectively. When adjusting for variables such as age, sex, disease duration, marital status, income, education level, co-morbidity, smoke status, biomass smoke, 6MWD, MRC, BMI and FEV1. the RERI, AP, and S (with 95% CIs) resulted in depression and anxiety scores of 6.54 (1.23-13.79), 0.54 (0.18-0.83), and 2.64 (1.33-4.75) respectively.

CONCLUSION

Interaction effects were found between depressive and anxiety symptoms on the death of patients with COPD. Patients with both depressive and anxiety symptoms have an increased risk of death from COPD.

Associations between comorbid anxiety, diabetes control, and overall medical burden in patients with serious mental illness and diabetes

OBJECTIVE

While previous work has demonstrated elevation of both comorbid anxiety disorders and diabetes mellitus type II in individuals with serious mental illness, little is known regarding the impact of comorbid anxiety on diabetes mellitus type II outcomes in serious mental illness populations. We analyzed baseline data from patients with serious mental illness and diabetes mellitus type II to examine relationships between comorbid anxiety, glucose control as measured by hemoglobin A1c score, and overall illness burden.

METHODS

Using baseline data from an ongoing prospective treatment study involving 157 individuals with serious mental illness and diabetes mellitus type II, we compared individuals with and without a comorbid anxiety disorder and compared hemoglobin A1c levels between these groups to assess the relationship between anxiety and management of diabetes mellitus type II. We conducted a similar analysis using cumulative number of anxiety diagnoses as a proxy for anxiety load. Finally, we searched for associations between anxiety and overall medical illness burden as measured by Charlson score.

RESULTS

Anxiety disorders were seen in 33.1% (N=52) of individuals with serious mental illness and diabetes mellitus type II and were associated with increased severity of depressive symptoms and decreased function. Hemoglobin A1c levels were not significantly different in those with or without anxiety, and having multiple anxiety disorders was not associated with differences in diabetes mellitus type II control. However, depressive symptoms were significantly associated with higher hemoglobin A1c levels. Neither comorbid anxiety nor anxiety load was significantly associated with overall medical burden.

CONCLUSION

One in three people with serious mental illness and diabetes mellitus type II had anxiety. Depressive symptoms were significantly associated with Hb1Ac levels while anxiety symptoms had no relation to hemoglobin A1c; this is consistent with previously published work. More studies are needed to better understand the relationship between depression, anxiety, and health management in people with serious mental illness and diabetes mellitus type II.

Biological determinants of depression following bereavement

There is considerable variability among people in their response to bereavement. While most people adapt well to bereavement, some develop exaggerated and/or pathological responses and may meet criteria for a major depressive episode. Many studies have investigated the effect of psychosocial factors on bereavement outcome but biological factors have not received much attention, hence the focus of this paper. The biological factors studied to date in relation to bereavement outcomes include genetic polymorphisms, neuroendocrine factors, and immunologic/inflammatory markers. In addition, animal studies have shown the alterations of brain neurotransmitters as well as changes in the plasma levels of the neurotrophic growth factors under the influence of peer loss. Recent studies have also investigated the biological basis of stress resilience, and have found a few genetic polymorphisms and potential biomarkers as protective factors in the face of adversity. Longitudinal studies that include data collection prior to, and also after, bereavement and which chart both biological and psychological measures are needed to develop profiles for the prediction of response to bereavement and personalised interventions.

Spécificités et approche préventive du suicide chez le sujet âgé

L’impact de l’allongement de l’espérance de vie, qui s’accompagne d’un accroissement du nombre de personnes souffrant de troubles mentaux, fait de la prise en charge des troubles psychiatriques du sujet âgé un enjeu majeur de l’organisation de notre offre de soins. Les troubles psychiatriques sont fréquents chez le sujet âgé, notamment la dépression, avec des chiffres de prévalence dépassant 40 % chez les sujets de plus de 75 ans institutionnalisés. Or les troubles mentaux constituent l’une des premières causes de morbidité et de mortalité prématurée chez le sujet âgé, et représentent les 3/5èmes des sources d’incapacité liées au vieillissement.

Un risque est particulièrement préoccupant chez le sujet âgé : celui du suicide. En Europe, c’est chez les personnes âgées que le taux de suicide est le plus élevé (en 2005, de 16,4 à 22,9 pour 100 000), les suicides de la population des 60 ans et plus représentant 30 % du total des suicides. Ce taux augmente avec l’âge et c’est parmi les hommes de plus de 85 ans que le suicide est le plus fréquent (6 à 7 fois plus que les hommes âgés de 15 à 24 ans). En France entre 2002 et 2003, les taux de suicide étaient de 60 pour 100 000 hommes de 75 à 84 ans et de 124 pour 100 000 hommes de 85 ans ou plus. Au total, 10 % des décès du sujet âgé sont le fait de suicides.

Compte-tenu des particularités liées à la présentation clinique de la dépression chez le sujet âgé, ainsi que des fréquentes comorbidités somatiques et cognitives associées, il est essentiel de développer des actions spécifiques d’information et de prévention du passage à l’acte suicidaire dans cette tranche d’âge.

Mental symptoms in patients with cardiac symptoms and normal coronary arteries

Objectives

Patients with chest pain and normal coronary arteries often suffer from physical and psychological symptoms. Therefore, this study aimed to examine the incidence of mental symptoms in patients with angiographic exclusion of a coronary heart disease.

Design

In 253 patients with angiographic exclusion of a coronary heart disease the type and intensity of their symptoms were evaluated before and after coronary angiography. In addition, the incidence of psychopathological symptoms was quantified by standardised questionnaires such as general anxiety and depression (HADS), heart-focused anxiety (CAQ), hypochondria (Whiteley Index) and somatoform disorder (SOMS) and quality of life (SF-12). Finally, the incidence of psychological symptoms in these patients was compared to the incidence in the normal population.

Results

Despite the absence of a coronary artery disease, 70% of patients continue to suffer from cardiac symptoms. The incidence of general anxiety was increased by 37% in women and by 22% in men in comparison to the normal population. Heart-focused anxiety was raised by 27%. Somatoform disorder appeared 120% more often in patients after cardiac catheterisation in comparison to the normal population. In addition, the incidence of hypochondria was elevated by 68% in patients after coronary angiography compared to normal population. This increased appearance of psychological symptoms was reflected in a significantly lower quality of life (SF-12) in patients with inconspicuous coronary angiography.

Conclusions

Patients with cardiac symptoms and normal coronary arteries more often suffer from mental symptoms in comparison to the healthy population.

Contribution of depression and anxiety to impaired quality of life in survivors of myocardial infarction

OBJECTIVE

To quantify the adverse influence of depression and anxiety assessed at the time of myocardial infarction, on the quality of life 5 years after the infarction.

METHODS

The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were completed in a group of 196 patients admitted in the hospital following non-fatal myocardial infarction, and the SF-12 quality of life questionnaire was administered during the 5- year follow-up.

RESULTS

Regression analysis showed a strong association between baseline depression and QoL in both the physical and mental domains; the higher the depression scores, the poorer the QoL. However, anxiety present at the time of myocardial infarction did not predict later QoL.

CONCLUSIONS

Depression but not anxiety following MI predicts longer-term quality of life in myocardial infarction survivors.

An update on the interaction between the serotonin transporter promoter variant (5-HTTLPR), stress and depression, plus an exploration of non-confirming findings

In the three years since the most recent meta-analysis of the association between the serotonin transported promoter polymorphism (5-HTTLPR), stress and the development of depression, another 27 studies have been published on this issue, which is an increase of 50% more studies than were previously reviewed. In addition, previous findings of inconsistency of results across studies argued for further exploration of this relationship. From the 81 studies identified to June 2013, the significant relationship between the short form of the 5-HTTLPR was confirmed (p=.0000009), which is stronger than the relationship reported in the most recent meta-analysis in 2011. However, nearly 26% of the 81 studies reviewed failed to show any significant association between the 5-HTTLPR, stress and depression, and four studies found opposite results to those expected. Examination of the methodologies of all studies failed to indicate any flaws in the opposite or unequivocal studies, and the latter had larger sample sizes than those studies which supported the expected association, arguing that the null results were not an outcome of insufficient statistical power. The need to consider aspects of samples and measures of depression, particularly the presence of subtypes of depression in future research is discussed.

Predictors of natural and unnatural mortality among patients with personality disorder: evidence from a large UK case register

BACKGROUND

People with personality disorder have reduced life expectancy, yet, within this population, little is known about the clinical predictors of natural and unnatural deaths. We set out to investigate this, using a large cohort of secondary mental health patients with personality disorder.

METHODS

We identified patients with an ICD-10 diagnosis of personality disorder, aged ≥15 years in a large secondary mental healthcare case register. The case register was linked to national mortality tracing. Using Cox regression, we modelled the effect of a number of pre-specified clinical variables on all-cause, natural cause and unnatural cause mortality.

FINDINGS

2,440 patients were identified. Eighty-five deaths (3.5% of cohort) occurred over a 5-year observation period, of which over 50% were from natural causes. All-cause mortality was associated with alcohol or drug use (adjusted Hazard Ratio [aHR] 2.3; 95% CI 1.3-4.1), physical illness (aHR 1.9; 95% CI 1.0-3.6), and functional impairment (aHR 1.9; 95% CI 1.0-3.6). Natural cause mortality was associated with mild problems of alcohol or drug use (aHR 3.4; 95% CI 1.5-7.4), and physical illness (aHR 2.4; 95% CI 1.0-5.6). Unnatural cause mortality was associated only with severe alcohol or drug use (aHR 3.1; 95% CI 1.3-7.3).

INTERPRETATION

Alcohol and drug use, physical illness, and functional impairment are predictors of mortality in individuals with personality disorder. Clinicians should be aware of the existence of problems in these domains, even at mild levels, when assessing the needs of patients with personality disorder.

Elevated IL-6 levels in patients with atypical depression but not in patients with typical depression

Elevated levels of the proinflammatory cytokine Interleukin-6 (IL-6) are among the most consistent findings in patients with major depressive disorder (MDD). Additionally, some evidence suggests that elevated cytokine levels in patients with major depression are responsible for the development of metabolic syndrome in patients suffering from MDD. Therefore, the aim of the study was to examine the concentrations of IL-6 in specific subtypes of MDD and to investigate their relationship to metabolic factors. Twenty-four patients with typical (24) and atypical (eight) major depression according to DSM-IV criteria were studied and compared to 24 normal controls. Blood samples were collected during a stepwise glucose-clamp procedure, and IL-6 concentrations were measured by high sensitivity ELISA. IL-6 levels were elevated in patients suffering from atypical depression but not in patients with typical depression, compared to normal controls. IL-6 correlated significantly with HbA1c, insulin, waist girth, BMI, number of alcoholic drinks per week and C-reactive protein. Our data indicate that high concentrations of IL-6 during the glucose clamp may be limited to the atypical subgroup of patients with MDD.

Depression and all-cause mortality in hemodialysis patients

BACKGROUND

There are limited data regarding the relationship between depression and mortality in hemodialysis (HD) patients.

METHODS

Among 323 patients receiving maintenance HD, depression symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale, with a score of ≥16 consistent with depression. Adjusted Cox proportional-hazards models with additional analyses incorporating antidepressant medication use were used to evaluate the association between depression and mortality. Baseline CES-D scores were used for the primary analyses, while secondary time-dependent analyses incorporated subsequent CES-D results.

RESULTS

The mean age was 62.9 ± 16.5 years, 46% of the subjects were women and 22% were African-American. The mean baseline CES-D score was 10.7± 8.3, and 83 (26%) participants had CES-D scores ≥16. During a median (25th, 75th) follow-up of 25 (13, 43) months, 154 participants died. After adjusting for age, sex, race, primary cause of kidney failure, dialysis vintage and access, baseline depression was associated with an increased risk of all-cause mortality (HR 1.51 and 95% CI 1.06-2.17). This attenuated with further adjustment for cardiovascular disease, smoking, Kt/V, serum albumin, log C-reactive protein and use of antidepressants (HR 1.21 and 95% CI 0.82-1.80). When evaluating time-dependent CES-D, depression remained associated with increased mortality risk in the fully adjusted model (HR 1.44 and 95% CI 1.00-2.06).

CONCLUSIONS

Greater symptoms of depression are associated with an increased risk of mortality in HD patients, particularly when accounting for the most proximate assessment. This relationship was attenuated with adjustment for comorbid conditions, suggesting a complex relationship between clinical characteristics and depression symptoms. Future studies should evaluate whether treatment for depression impacts mortality among HD patients.

Rate of stroke death after depression: a 40-year longitudinal study extension of Chichester/Salisbury Catchment area study

BACKGROUND

This study examined clinically diagnosed depression as a risk factor for incidence of death by stroke in a prospective clinically based design study. Risk for stroke was examined separately by sex in a long-term follow-up study spanning 40 years.

METHODS

Patients who were diagnosed with depression in the Chichester (population 100,000)/Salisbury (population 85,000) Catchment Area Study were followed up for 40 years. Death certificates were used to determine the cause of death in the cohort. Death rates in the general population, adjusted for age, gender, and year, were used as a control.

RESULTS

Clinical depression was found to be a risk factor for subsequent death from stroke in men but not in women. Death by stroke was a statistically significant cause of death in the men with diagnoses of endogenous depression but not in those men diagnosed with reactive depression. The strength of the relationship of depression with stroke increased over time.

CONCLUSIONS

These findings suggest that the identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke in later life. The notion that depression has stronger effects over a long period is consistent with a view that severe clinical depression and physical illness occur concurrently, one exacerbating the other, and health is degraded through slow-acting, cumulative processes. Data were unavailable for the type of stroke or the health-risk behaviors (smoking, diet, and so forth) in the cohort which constituted a limitation of the study. Neither is it known what proportion of the cohort suffered a nonlethal stroke nor to what extent the treatment of clinical depression militates against suffering a lethal stroke.

Chronic pain and mortality: a systematic review

BACKGROUND

Chronic pain is common, often widespread and has a substantial impact on health and quality of life. The relationship between chronic pain and mortality is unclear. This systematic review aimed to identify and evaluate evidence for a relationship between chronic pain and mortality.

METHODS

A search of ten electronic databases including EMBASE and MEDLINE was conducted in March 2012, and updated until March 2014. Observational studies investigating the association between chronic or widespread pain (including fibromyalgia) and mortality were included. Risk of bias was assessed and a meta-analysis was undertaken to quantify heterogeneity and pool results. A narrative review was undertaken to explore similarities and differences between the included studies.

RESULTS

Ten studies were included in the review. Three reported significant associations between chronic or widespread pain and mortality in unadjusted results. In adjusted analyses, four studies reported a significant association. The remaining studies reported no statistically significant association. A meta-analysis showed statistically significant heterogeneity of results from studies using comparable outcome measures (n = 7)(I2 = 78.8%) and a modest but non-significant pooled estimate (MRR1.14,95%CI 0.95-1.37) for the relationship between chronic pain and all-cause mortality. This association was stronger when analysis was restricted to studies of widespread pain (n = 5,I2 = 82.3%) MRR1.22(95%CI 0.93-1.60). The same pattern was observed with deaths from cancer and cardiovascular diseases. Heterogeneity is likely to be due to differences in study populations, follow-up time, pain phenotype, methods of analysis and use of confounding factors.

CONCLUSION

This review showed a mildly increased risk of death in people with chronic pain, particularly from cancer. However, the small number of studies and methodological differences prevented clear conclusions from being drawn. Consistently applied definitions of chronic pain and further investigation of the role of health, lifestyle, social and psychological factors in future studies will improve understanding of the relationship between chronic pain and mortality.

Risks of all-cause and suicide mortality in mental disorders: a meta-review

A meta-review, or review of systematic reviews, was conducted to explore the risks of all-cause and suicide mortality in major mental disorders. A systematic search generated 407 relevant reviews, of which 20 reported mortality risks in 20 different mental disorders and included over 1.7 million patients and over a quarter of a million deaths. All disorders had an increased risk of all-cause mortality compared with the general population, and many had mortality risks larger than or comparable to heavy smoking. Those with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa. These higher mortality risks translate into substantial (10-20 years) reductions in life expectancy. Borderline personality disorder, anorexia nervosa, depression and bipolar disorder had the highest suicide risks. Notable gaps were identified in the review literature, and the quality of the included reviews was typically low. The excess risks of mortality and suicide in all mental disorders justify a higher priority for the research, prevention, and treatment of the determinants of premature death in psychiatric patients.

Risks of all-cause and suicide mortality in mental disorders: a meta-review

A meta-review, or review of systematic reviews, was conducted to explore the risks of all-cause and suicide mortality in major mental disorders. A systematic search generated 407 relevant reviews, of which 20 reported mortality risks in 20 different mental disorders and included over 1.7 million patients and over a quarter of a million deaths. All disorders had an increased risk of all-cause mortality compared with the general population, and many had mortality risks larger than or comparable to heavy smoking. Those with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa. These higher mortality risks translate into substantial (10-20 years) reductions in life expectancy. Borderline personality disorder, anorexia nervosa, depression and bipolar disorder had the highest suicide risks. Notable gaps were identified in the review literature, and the quality of the included reviews was typically low. The excess risks of mortality and suicide in all mental disorders justify a higher priority for the research, prevention, and treatment of the determinants of premature death in psychiatric patients.

The interface of physical and mental health

PURPOSE

The interaction between physical and mental health is complex. In this paper we aim to provide an overview of the main components of this relationship and to identify how care could be improved for people with co-morbidities.

METHODS

We performed a literature search of MedLine, Ovid and Psycinfo and identified studies that examined the association between mental illness and physical illness. We also examined the key policy documents and guidelines in this area.

RESULTS

People with mental health conditions are at higher risk of developing physical illness, have those conditions diagnosed later and have much higher mortality rates. Conversely, people with a diagnosis of physical illness, especially cardiovascular disease, diabetes and cancer have a greater chance of developing a mental health problem. When both mental and physical illnesses conditions are present together, there are higher overall rates of morbidity, healthcare utilisation, and poorer quality of life.

CONCLUSIONS

Physicians and psychiatrists need to be aware of the co-occurrence of mental and physical health problems and the challenges posed for both general and mental health services. There is a need to screen appropriately in both settings to ensure timely diagnosis and treatment. Liaison psychiatry provides psychological assessment and treatment for people with physical illness, but there is a gap in the provision of physical healthcare for people with severe mental illness. There is a need for public policy to drive this forward to overcome the institutional barriers to equitable access to healthcare and for educators to reverse the tendency to teach mind and body as separate systems.

Trait anxiety and somatic concerns associate with increased mortality risk: a 23-year follow-up in aging men

PURPOSE

We aimed to examine the impact of anxiety and somatic concerns on the mortality risk during a 23-year follow-up of a representative sample of men.

METHODS

Finnish men aged 42-61 years (n = 2388) were followed up for a median of 23.4 years. Anxiety was assessed using baseline scores for the Minnesota Multiphasic Personality Inventory Psychasthenia subscale and somatic concerns were measured with the Hypochondriasis subscale. Mortality data were obtained from the National Population Register.

RESULTS

All-cause, injury, disease, cardiovascular, and cancer mortalities were examined as endpoints. Adjustments were performed for age, smoking, alcohol consumption, physical activity, low- and high-density lipoprotein cholesterol, body mass index, systolic blood pressure, a history of cardiovascular disease, marital status, socioeconomic status, the Framingham Type A Behavior Pattern Scale, and life events during the 12 months before the baseline examination. Anxiety and somatic concerns predicted the all-cause mortality risk after full adjustments for sociodemographic background, lifestyle factors, and descriptors of somatic health. Regarding other forms of mortality, the risk ratios were significant after full adjustments in anxiety for injury and in somatic concerns for disease death.

CONCLUSIONS

This study supported previous findings of anxiety predicting the all-cause mortality risk in men. Somatic concerns are a novel factor that needs to be taken into account while examining associations between personality and the risk of increased mortality.

Socio-demographic, lifestyle and psychological predictors of benzodiazepine and z-hypnotic use patterns

AIMS

Risk and demographic factors for benzodiazepine and z-hypnotic use are incompletely understood. The aim of the paper was therefore to investigate socio-demographic, lifestyle and psychological factors predicting onset and differential pattern of prescribed benzodiazepine and z-hypnotic use in a Norwegian population sample.

METHODS

This retrospective cohort study obtained socio-demographic, psychological and lifestyle variables from the Nord-Trøndelag Health Study. Information about benzodiazepine prescriptions from the Norwegian prescription database were linked to epidemiological questionnaire data. Benzodiazepine use was classified into single-period, intermittent and chronic use, and high dose use was defined as being prescribed a yearly average above 180 daily defined doses.

RESULTS

Older age, sleep difficulties and smoking were positively associated with all patterns of benzodiazepine use. Male gender was related to a reduced risk of all patterns of use, whereas educational achievement was negatively associated with single-period use. Alcohol consumption, anxiety and tension were positively related to intermittent and chronic use, while exercise was negatively related to chronic use. Smoking, sleep difficulties and old age were positively associated with prescriptions of high benzodiazepine doses, while exercise was associated with lower doses.

CONCLUSIONS

Patterns of prescribed benzodiazepine use are linked to demographic, lifestyle and clinical variables. Non-pharmacological treatment for sleep difficulties and smoking cessation may reduce the risk of chronic benzodiazepine use.

Anxiety and depression in the general population in Colombia: reference values of the Hospital Anxiety and Depression Scale (HADS)

PURPOSE

The objective of this study was to generate normative values and to test psychometric properties of the Hospital Anxiety and Depression Scale (HADS) for the general population of Colombia. While there are several normative studies in Europe, Latin American normative values are missing. The identification of people with mental distress requires norms obtained for the specific country.

METHODS

A representative face-to-face household study (n = 1,500) was conducted in 2012. The survey questionnaire contained the HADS, several other questionnaires, and sociodemographic variables.

RESULTS

HADS mean values (anxiety: M = 4.61 ± 3.64, depression: M = 4.30 ± 3.91) were similar to those reported from European studies. Females were more anxious and depressed than males. The depression scale showed a nearly linear age dependency with increasing scores for old people. Mean scores and percentiles (75 and 90%) are presented for each age decade for both genders. Both anxiety and depression correlated significantly with the total score of the multidimensional fatigue inventory and with the mental component summary score of the quality of life questionnaire SF-8. Internal consistency coefficients of both scales were satisfying, but confirmatory factorial analysis results only partially supported the two-dimensional structure of the questionnaire.

CONCLUSION

This study supports the reliability of the HADS in one Latin American country. The normative scores can be used to compare a patient's score with those derived from a reference group. However, the generalizability to other Latin American regions requires further research.

'Third wave' cognitive and behavioural therapies versus treatment as usual for depression

BACKGROUND

So-called 'third wave' cognitive and behavioural therapies represent a new generation of psychological therapies that are increasingly being used in the treatment of psychological problems. However, the effectiveness and acceptability of third-wave cognitive and behavioural therapy (CBT) approaches as treatment for acute depression remain unclear.

OBJECTIVES

1. To examine the effects of all third wave CBT approaches compared with treatment as usual/waiting list/attention placebo/psychological placebo control conditions for acute depression.2. To examine the effects of different third wave CBT approaches (ACT, compassionate mind training, functional analytic psychotherapy, dialectical behaviour therapy, MBCT, extended behavioural activation and metacognitive therapy) compared with treatment as usual/waiting list/attention placebo/psychological placebo control conditions for acute depression.3. To examine the effects of all third wave CBT approaches compared with different types of comparators (treatment as usual, no treatment, waiting list, attention placebo, psychological placebo) for acute depression.

SEARCH METHODS

We searched the Cochrane Depression Anxiety and Neurosis Group Trials Specialised Register (CCDANCTR to 01/01/12), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE, (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies. An updated search of CCDANCTR restricted to search terms relevant to third wave CBT therapies was conducted in March 2013 (CCDANCTR to 01/02/13).

SELECTION CRITERIA

Randomised controlled trials that compared third wave CBT therapies with control conditions for acute depression in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies, assessed trial quality and extracted data. Study authors were contacted for additional information when required. We rated the quality of evidence using GRADE methods.

MAIN RESULTS

Four small studies (224 participants) were included in the review. Little information was provided about the process of allocating participants to groups. None of the studies used independent outcome assessors, and evidence suggested researcher allegiance towards the active treatments. The four studies examined a diversity of third wave CBT approaches (extended behavioural activation, acceptance and commitment therapy and competitive memory training) and control conditions. None of the studies conducted follow-up assessments. The results showed a significant difference in clinical response rates in favour of third wave CBT when compared with treatment as usual (TAU) conditions (three studies, 170 participants, risk ratio (RR) 0.51, 95% confidence interval (CI) 0.27 to 0.95; very low quality). No significant difference in treatment acceptability based on dropout rates was found between third wave CBT approaches and TAU (four studies, 224 participants, RR 1.01, 95% CI 0.08 to 12.30; very low quality). Both analyses showed substantial statistical heterogeneity.

AUTHORS' CONCLUSIONS

Very low quality evidence suggests that third wave CBT approaches appear to be more effective than treatment as usual in the treatment of acute depression. The very small number of available studies and the diverse types of interventions and control comparators, together with methodological limitations, limit the ability to draw any conclusions on their effect in the short term or over a longer term. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies of third wave CBT approaches in the treatment of acute depression, on a short- and long-term basis, to provide evidence of their effectiveness to policy-makers, clinicians and users of services.

'Third wave' cognitive and behavioural therapies versus other psychological therapies for depression

BACKGROUND

So-called 'third wave' cognitive and behavioural therapies represents a new generation of psychological therapies that are increasingly being used in the treatment of psychological problems. However, the effectiveness and acceptability of third wave cognitive and behavioural therapy (CBT) approaches as a treatment for depression compared with other psychological therapies remain unclear.

OBJECTIVES

1. To examine the effects of all third wave CBT approaches compared with all other psychological therapy approaches for acute depression.2. To examine the effects of different third wave CBT approaches (ACT, compassionate mind training, functional analytic psychotherapy, extended behavioural activation and metacognitive therapy) compared with all other psychological therapy approaches for acute depression.3. To examine the effects of all third wave CBT approaches compared with different psychological therapy approaches (psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural) for acute depression.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group Specialised Register (CCDANCTR to 01/01/12), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies. An updated search of CCDANCTR restricted to search terms relevant to third wave CBT was conducted in March 2013 (CCDANCTR to 01/02/13).

SELECTION CRITERIA

Randomised controlled trials that compared various third wave CBT with other psychological therapies for acute depression in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies, assessed trial quality and extracted data. Study authors were contacted for additional information where required. We rated the quality of evidence using GRADE methods.

MAIN RESULTS

A total of three studies involving 144 eligible participants were included in the review. Two of the studies (56 participants) compared an early version of acceptance and commitment therapy (ACT) with CBT, and one study (88 eligible participants) compared extended behavioural activation with CBT. No other studies of third wave CBT were identified. The two ACT studies were assessed as being at high risk of performance bias and researcher allegiance. Post-treatment results, which were based on dropout rates, showed no evidence of any difference between third wave CBT and other psychological therapies for the primary outcomes of efficacy (risk ratio (RR) of clinical response 1.14, 95% confidence interval (CI) 0.79 to 1.64; very low quality) and acceptability. Results at two-month follow-up showed no evidence of any difference between third wave CBT and other psychological therapies for clinical response (2 studies, 56 participants, RR 0.22, 95% CI 0.04 to 1.15). Moderate statistical heterogeneity was indicated in the acceptability analyses (I(2) = 41%).

AUTHORS' CONCLUSIONS

Very low quality evidence suggests that third wave CBT and CBT approaches are equally effective and acceptable in the treatment of acute depression. Evidence is limited in quantity, quality and breadth of available studies, precluding us from drawing any conclusions as to their short- or longer-term equivalence. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies to compare various third wave CBT approaches with other psychological therapy approaches to inform clinicians and policymakers on the most effective forms of psychological therapy in treating depression.

Behavioural therapies versus other psychological therapies for depression

BACKGROUND

Behavioural therapies represent one of several categories of psychological therapies that are currently used in the treatment of depression. However, the effectiveness and acceptability of behavioural therapies for depression compared with other psychological therapies remain unclear.

OBJECTIVES

1. To examine the effects of all BT approaches compared with all other psychological therapy approaches for acute depression.2. To examine the effects of different BT approaches (behavioural therapy, behavioural activation, social skills training and relaxation training) compared with all other psychological therapy approaches for acute depression.3. To examine the effects of all BT approaches compared with different psychological therapy approaches (CBT, third wave CBT, psychodynamic, humanistic and integrative psychological therapies) for acute depression.

SEARCH METHODS

We searched the Cochrane Depression Anxiety and Neurosis Group Trials Specialised Register (CCDANCTR, 31/07/2013), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE, (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that compared behavioural therapies with other psychological therapies for acute depression in adults.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently identified studies, assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty-five trials involving 955 participants compared behavioural therapies with one or more of five other major categories of psychological therapies (cognitive-behavioural, third wave cognitive-behavioural, psychodynamic, humanistic and integrative therapies). Most studies had a small sample size and were assessed as being at unclear or high risk of bias. Compared with all other psychological therapies together, behavioural therapies showed no significant difference in response rate (18 studies, 690 participants, risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09) or in acceptability (15 studies, 495 participants, RR of total dropout rate 1.02, 95% CI 0.65 to 1.61). Similarly, in comparison with each of the other classes of psychological therapies, low-quality evidence showed better response to cognitive-behavioural therapies than to behavioural therapies (15 studies, 544 participants, RR 0.93, 95% CI 0.83 to 1.05) and low-quality evidence of better response to behavioural therapies over psychodynamic therapies (2 studies, 110 participants, RR 1.24, 95% CI 0.84 to 1.82).When compared with integrative therapies and humanistic therapies, only one study was included in each comparison, and the analysis showed no significant difference between behavioural therapies and integrative or humanistic therapies.

AUTHORS' CONCLUSIONS

We found low- to moderate-quality evidence that behavioural therapies and other psychological therapies are equally effective. The current evidence base that evaluates the relative benefits and harms of behavioural therapies is very weak. This limits our confidence in both the size of the effect and its precision for our key outcomes related to response and withdrawal. Studies recruiting larger samples with improved reporting of design and fidelity to treatment would improve the quality of evidence in this review.

Mental health nursing and physical health care: a cross-sectional study of nurses' attitudes, practice, and perceived training needs for the physical health care of people with severe mental illness

Mental health nurses have a key role in improving the physical health of people with a serious mental illness, however, there have been few studies of their attitudes or the extent of their involvement in this work. The aim of this study was to examine mental health nurses' attitudes to physical health care and explore associations with their practice and training. A postal questionnaire survey including the Physical Health Attitude Scale for mental health nurses (PHASe) was used within a UK mental health trust. The 52% (n = 585) of staff who responded reported varying levels of physical health practice; this most frequently involved providing dietary and exercise advice and less frequently included advice regarding cancer screening and smoking cessation. Having received post-registration physical health-care training and working in inpatient settings was associated with greater reported involvement. More positive attitudes were also evident for nurses who had attended post-registration physical health training or had an additional adult/general nursing qualification. Overall, the attitudes of mental health nurses towards physical health care appear positive and the willingness of nurses to take on these roles needs to be recognized. However, there are areas where nurses in our sample were more ambivalent such as cancer screening and smoking cessation.

Achieving smoke-free mental health services: lessons from the past decade of implementation research

The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders' continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder.

Anxiety and mortality risk in community-dwelling elderly people

BACKGROUND

There are conflicting data on the role of anxiety in predicting mortality.

AIMS

To evaluate the 10-year mortality risk associated with anxiety in community-dwelling elderly people.

METHOD

Using data from 718 men and 1046 women aged 65 years and over, gender-stratified associations of anxiety symptoms (Spielberger State-Trait Anxiety Inventory, third tertile) and current DSM-IV anxiety disorder including generalised anxiety disorder (GAD) and phobia with all-cause and cardiovascular mortality were determined.

RESULTS

In women, mortality risk was increased for anxiety disorder and GAD in multivariate Cox models (hazard ratio (HR) = 1.53, 95% CI 1.02-2.27 and HR = 2.04, 95% CI 1.08-3.86 respectively), whereas for phobia it was nearly significant (HR = 1.52, 95% CI 0.94-2.47). Anxiety trait symptoms became non-significant as a result of the confounding effect of depressive symptoms. Anxiety disorder was associated with cardiovascular mortality in univariate analysis (HR = 2.42, 95% CI 1.16-5.07). No significant associations were found in men.

CONCLUSIONS

Our study suggests a gender-specific association of anxiety and mortality.

Differences in neurobiological pathways of four "clinical content" subtypes of depression

Although often considered as a mental disorder, depression is best described as a behavioral-neurobiological phenomenon. In addition, although usually reported as a unitary diagnosis, major depressive episode is composed of a range of different symptoms that can occur in nearly 1500 possible combinations to fulfill the required diagnostic criterion. To investigate and describe the underlying behavioral and neurobiological substrates of these symptoms, they were clustered into "clinical content" subtypes of depression according to their predominant common behavioral characteristics. These subtypes were then found to possess different neurobiological pathways that argue for different treatment approaches.

Systemic oxidatively generated DNA/RNA damage in clinical depression: associations to symptom severity and response to electroconvulsive therapy

BACKGROUND

Depression has been associated with increased oxidative stress and hypothesized to accelerate aging. Nucleic acid damage from oxidation is a critical part of the aging process, and a suggested early event in age-related somatic morbidities that are also prevalent in depression, such as dementia and type 2 diabetes. We hypothesized that increased severity of depression is associated with increased systemic oxidatively generated DNA and RNA damage, and that this increase is attenuated by an effective antidepressant treatment.

METHODS

The urinary excretion of markers of systemic oxidatively generated DNA and RNA damage, 8-oxo-7,8-dihydro-2-deoxyguanosine (8-oxodG) and 8-oxo-7,8-dihydroguanosine (8-oxoGuo), respectively, were determined in healthy controls (N=28), moderately depressed, non-medicated patients (N=26) and severely depressed patients eligible for electroconvulsive therapy (ECT) (N=29). In the severely depressed patient group, samples were also obtained 1 week after the completion of ECT.

RESULTS

Systemic RNA damage from oxidation, as measured by 8-oxoGuo excretion, was higher with increasing severity of depression (controls<moderately depressed<severely depressed) (P for trend=0.004). The 8-oxoGuo excretion was further increased after clinically effective ECT compared with pre-ECT values (P=0.006). There were no differences in 8-oxodG excretion between the groups or pre- vs. post-ECT.

LIMITATIONS

Small sample size and the inclusion of both unipolar and bipolar patients in the severely depressed group.

CONCLUSIONS

Severe depression is associated with increased systemic oxidatively generated RNA damage, which may be an additional factor underlying the somatic morbidity and neurodegenerative features associated with depression. Due to the lack of normalization by clinically effective ECT, the phenomenon does not appear to be causally linked to the depressive state per se.

Value of information analysis from a societal perspective: a case study in prevention of major depression

OBJECTIVES

Productivity losses usually have a considerable impact on cost-effectiveness estimates while their estimated values are often relatively uncertain. Therefore, parameters related to these indirect costs play a role in setting priorities for future research from a societal perspective. Until now, however, value of information analyses have usually applied a health care perspective for economic evaluations. Hence, the effect of productivity losses has rarely been investigated in such analyses. The aim of the current study therefore was to investigate the effects of including or excluding productivity costs in value of information analyses.

METHODS

Expected value of information analysis (EVPI) was performed in cost-effectiveness evaluation of prevention from both societal and health care perspectives, to give us the opportunity to compare different perspectives. Priorities for future research were determined by partial EVPI. The program to prevent major depression in patients with subthreshold depression was opportunistic screening followed by minimal contact psychotherapy.

RESULTS

The EVPI indicated that regardless of perspective, further research is potentially worthwhile. Partial EVPI results underlined the importance of productivity losses when a societal perspective was considered. Furthermore, priority setting for future research differed according to perspective.

CONCLUSIONS

The results illustrated that advise for future research will differ for a health care versus a societal perspective and hence the value of information analysis should be adjusted to the perspective that is relevant for the decision makers involved. The outcomes underlined the need for carefully choosing the suitable perspective for the decision problem at hand.

What characterizes individuals developing chronic whiplash?: The Nord-Trøndelag Health Study (HUNT)

OBJECTIVE

Most individuals experiencing whiplash accidents recover rapidly. A considerable proportion, however, develop chronic symptoms. Psychological factors may slow recovery, possibly by increasing the likelihood of other symptoms being misattributed to, and amplified by the whiplash injury. We aimed to investigate how pre-injury mental and somatic symptoms, self-rated health, use of health-services and medications, health-behavior and socio-demographics predict the development of chronic whiplash.

METHODS

Data from two waves of a large, population based study (HUNT2 (baseline) and HUNT3) were used. Individuals reporting no whiplash at baseline were identified in HUNT3. Characteristics reported at baseline were compared between those who had developed chronic whiplash in HUNT3 (n=199) and those who had not (n=20,600), using Pearson's chi-squared tests, independent sample t-tests and logistic regression analyses.

RESULTS

Individuals developing chronic whiplash reported worse baseline health than those reporting no chronic whiplash. Poor self-rated health was a strong risk factor for subsequent chronic whiplash (OR=2.26, 95%CI: 1.68-3.04). Musculoskeletal pain also increased the risk (OR=1.21, 95%CI: 1.15-1.26), as did diffuse somatic symptoms (OR=2.09, 95%CI: 1.47-2.96), use of different health services (OR=1.31, 95%CI: 1.19-1.45), high use of medications (OR=1.28, 95%CI: 1.14-1.43) and symptoms of anxiety (OR=1.93, 95%CI: 1.39-2.68). Physical activity was protective (OR=0.67, 95%CI: 0.49-0.91). Most socio-demographic variables were not significantly associated with chronic whiplash.

CONCLUSION

Poor somatic and mental pre-injury health increased the risk of subsequent chronic whiplash. This suggests that chronic whiplash is not merely an organic disorder, and highlights the importance of individual expectations, symptom reattribution and amplification in development of chronic whiplash.

Depression and chronic diseases: it is time for a synergistic mental health and primary care approach

OBJECTIVE

To identify the growing significance of depression as a global leading cause of years lost to disability and its role as a major independent risk factor in many chronic illnesses. The distinct effects of depression on morbidity and mortality in cancer, diabetes, heart disease, and stroke are investigated, including behavioral factors and plausible biological mechanisms (psychoneuroimmunology of depression).

DATA SOURCES

PubMed articles in English were searched from 1992 to 2012 (20-year span) using the following search criteria: psychoneuroimmunology of depression, immune-mediated inflammation, depression treatment recommendations, depression screening, years lost to disability, underserved populations and depression, chronic illnesses and depression, and selective serotonin reuptake inhibitors and immune system.

DATA SYNTHESIS

Evidence of the robust bidirectional relationship between depression and individual chronic diseases is presented and discussed. A brief overview of currently recommended psychotherapeutic and psychopharmacologic treatment approaches in regard to depression in chronic diseases is provided.

RESULTS

Discordance between mental health and primary care within the US public health system is a systematic problem that must be addressed. This situation leads to a potentially high hidden prevalence of underdiagnosed and undertreated depression, especially in the underserved populations.

CONCLUSION

Measures must be implemented across the communities of mental health and primary care practitioners in order to achieve a synergistic approach to depression.

Common mental disorders and mortality in the West of Scotland Twenty-07 Study: comparing the General Health Questionnaire and the Hospital Anxiety and Depression Scale

BACKGROUND

While various measures of common mental disorders (CMD) have been found to be associated with mortality, a comparison of how different measures predict mortality may improve our understanding of the association. This paper compares how the Hospital Anxiety and Depression Scale (HADS) and the 30-item General Health Questionnaire (GHQ-30) predict all cause and cause-specific mortality.

METHODS

Data on 2547 men and women from two cohorts, aged approximately 39 and 55 years, from the West of Scotland Twenty-07 Study who were followed up for mortality over an average of 18.9 (SD 5.0) years. Scores were calculated for HADS depression (HADS-D), HADS Anxiety (HADS-A) and GHQ-30. Cox Proportional Hazards Models were used to determine how each CMD measure predicted mortality.

RESULTS

After adjusting for serious physical illness, smoking, social class, alcohol, obesity, pulse rate and living alone, HRs (95% CI) per SD increase in score for all-cause mortality were: 1.15 (1.07 to 1.25) for HADS-D; 1.13 (1.04 to 1.23) for GHQ-30 and 1.05 (0.96 to 1.14) for HADS-A. After the same adjustments, cardiovascular disease mortality was also related to HADS-D (HR 1.24 (1.07 to 1.43)), to GHQ-30 (HR 1.24 (1.11 to 1.40)) and to HADS-A (HR 1.15 (1.01 to 1.32)); respiratory mortality to GHQ-30 (HR 1.33 (1.13 to 1.55)) and mortality from other causes, excluding injuries, to HADS-D (HR 1.28 (1.05 to 1.55)).

CONCLUSIONS

There were associations between CMD and both all-cause and cause-specific mortality which were broadly similar for GHQ-30 and HADS-D and were still present after adjustment for important confounders and mediators.

The evolutionary origins of mood and its disorders

The term 'mood' in its scientific usage refers to relatively enduring affective states that arise when negative or positive experience in one context or time period alters the individual's threshold for responding to potentially negative or positive events in subsequent contexts or time periods. The capacity for mood appears to be phylogenetically widespread and the mechanisms underlying it are highly conserved in diverse animals, suggesting it has an important adaptive function. In this review, we discuss how moods can be classified across species, and what the selective advantages of the capacity for mood are. Core moods can be localised within a two-dimensional continuous space, where one axis represents sensitivity to punishment or threat, and the other, sensitivity to reward. Depressed mood and anxious mood represent two different quadrants of this space. The adaptive function of mood is to integrate information about the recent state of the environment and current physical condition of the organism to fine-tune its decisions about the allocation of behavioural effort. Many empirical observations from both humans and non-human animals are consistent with this model. We discuss the implications of this adaptive approach to mood systems for mood disorders in humans.

Depression- and anxiety-related sick leave and the risk of permanent disability and mortality in the working population in Germany: a cohort study

BACKGROUND

Anxiety and depression are the most common psychiatric disorders and are the cause of a large and increasing amount of sick-leave in most developed countries. They are also implicated as an increasing mortality risk in community surveys. In this study we addressed, whether sick leave due to anxiety, depression or comorbid anxiety and depression was associated with increased risk of retirement due to permanent disability and increased mortality in a cohort of German workers.

METHODS

128,001 German workers with statutory health insurance were followed for a mean of 6.4 years. We examined the associations between 1) depression/anxiety-related sick leave managed on an outpatient basis and 2) anxiety/depression-related psychiatric inpatient treatment, and later permanent disability/mortality using Cox proportional hazard regression models (stratified by sex and disorder) adjusted for age, education and job code classification.

RESULTS

Outpatient-managed depression/anxiety-related sick leave was significantly associated with higher permanent disability (hazard ratio (95% confidence interval)) 1.48 (1.30, 1.69) for depression, 1.25 (1.07, 1.45) for anxiety, 1.91 (1.56, 2.35) for both). Among outpatients, comorbidly ill men (2.59 (1.97,3.41)) were more likely to retire early than women (1.42 (1.04,1.93)). Retirement rates were higher for depressive and comorbidly ill patients who needed inpatient treatment (depression 3.13 (2,51, 3,92), both 3.54 (2.80, 4.48)). Inpatient-treated depression was also associated with elevated mortality (2.50 (1.80, 3.48)). Anxiety (0.53 (0.38, 0.73)) and female outpatients with depression (0.61 (0.38, 0.97)) had reduced mortality compared to controls.

CONCLUSIONS

Depression/anxiety diagnoses increase the risk of early retirement; comorbidity and severity further increase that risk, depression more strikingly than anxiety. Sickness-absence diagnoses of anxiety/depression identified a population at high risk of retiring early due to ill health, suggesting a target group for the development of interventions.

Adjunctive pregabalin in partial responders with major depressive disorder and residual anxiety

BACKGROUND

Anxiety symptoms in depression result often in treatment resistance, residual symptoms, and persistent functional impairment.

OBJECTIVE

To assess the effectiveness and safety of adjunctive pregabalin to antidepressants for residual anxiety in patients with major depressive disorder (MDD).

METHODS

A retrospective chart review was conducted to identify partial responders among patients with MDD with residual anxiety. Twenty such patients (age, 58.4 ± 11.2 years; 15 women; baseline Hamilton Depression Rating Scale [HDRS], 17.1 ± 3.5) who received adjunctive pregabalin for residual anxiety were included. Antidepressants augmented were the selective serotonin reuptake inhibitors (n = 12), mirtazapine (n = 2), and selective serotonin-norepinephrine reuptake inhibitors (n = 6).

RESULTS

Twenty patients received at least 4 weeks of pregabalin treatment after 8 weeks of antidepressant therapy. At week 1 (9 weeks after initiating treatment), pregabalin was prescribed at a mean ± SD dose of 71.2 ± 31.7 mg, and the mean maximum pregabalin dose prescribed was 156.2 ± 76.5 mg (range, 75-300 mg). At week 8, there were 13 responders (13/20 [65%]), and 7 of these 13 patients achieved remission (HDRS17 < 8). There were significant decreases in HDRS scores (13.5 ± 3.1 vs 9.1 ± 2.9, P < 0.000), and HDRS anxiety/somatization subscale scores (6.3 ± 2 to 3.6 ± 1.7, P < 0.000). Adverse effects included somnolence (n = 7), weight gain (n = 3), dizziness (n = 4), dry mouth (n = 6), edema (n = 3), blurred vision (n = 3), difficulty with concentration/attention (n = 8), headache (n = 6), and diarrhea (n = 5).

CONCLUSIONS

The results suggest a possible augmentation role for pregabalin when used in conjunction with conventional antidepressants for residual anxiety in MDD.

A population based validation study of self-reported pensions and benefits: the Nord-Trøndelag health study (HUNT)

Background

Measures of disability pensions, sickness certification and long-term health related benefits are often self-reported in epidemiological studies. Few studies have examined these measures, and the validity is yet to be established.

We aimed to estimate the validity of self-reported disability pension, rehabilitation benefit and retirement pension and to explore the benefit status and basic characteristics of those not responding to these items.

A large health survey (HUNT2) containing self-reported questionnaire data on sickness benefits and pensions was linked to a national registry of pensions and benefits, used as “gold standard” for the analysis. We investigated two main sources of bias in self-reported data; misclassification - due to participants answering questions incorrectly, and systematic missing/selection bias - when participants do not respond to the questions.

Sensitivity, specificity, positive (PPV) and negative (NPV) predicative value, agreement and Cohen’s Kappa were calculated for each benefit. Co-variables were compared between non-responders and responders.

Results

In the study-population of 40,633, 9.2% reported receiving disability pension, 1.4% rehabilitation benefits and 6.1% retirement pension. According to the registry, the corresponding numbers were 9.0%, 1.7% and 5.4%. Excluding non-responders, specificity, NPV and agreement were above 98% for all benefits. Sensitivity and PPV were lower. When including non-responders as non-receivers, specificity got higher, sensitivity dropped while the other measures changed less.

Between 17.7% and 24.1% did not answer the questions on benefits. Non-responders were older and more likely to be female. They reported more anxiety, more depression, a higher number of somatic diagnoses, less physical activity and lower consumption of alcohol (p < 0.001 for all variables). For disability pension and retirement pension, non-responders were less likely to receive benefits than responders (p < 0.001). For each benefit 2.1% or less of non-responders were receivers. False positive responses were more prevalent than false negative responses.

Conclusions

The validity of self-reported data on disability pension, rehabilitation benefits and retirement pension is high – it seems that participants’ responses can be trusted. Compared to responders, non-responders are less likely to be receivers. If necessary, power and validity can be kept high by imputing non-responders as non-receivers.

Screening for depression in medical research: ethical challenges and recommendations

Background

Due to the important role of depression in major illnesses, screening measures for depression are commonly used in medical research. The protocol for managing participants with positive screens is unclear and raises ethical concerns. The aim of this article is to identify and critically discuss the ethical issues that arise when a positive screen for depression is detected, and offer some guidance on managing these issues.

Discussion

Deciding on whether to report positive screens to healthcare practitioners is both an ethical and a pragmatic dilemma. Evidence suggests that reporting positive depression screens should only be considered in the context of collaborative care. Possible adverse effects, such as the impact of false-positive results, potentially inappropriate labelling, and potentially inappropriate treatment also need to be considered. If possible, the psychometric properties of the selected screening measure should be determined in the target population, and a threshold for depression that minimises the rate of false-positive results should be chosen. It should be clearly communicated to practitioners that screening scores are not diagnostic for depression, and they should be informed about the diagnostic accuracy of the measure. Research participants need to be made aware of the consequences of the detection of high scores on screening measures, and to be fully informed about the implications of the research protocol.

Summary

Further research is needed and the experiences of researchers, participants, and practitioners need to be collated before the value of reporting positive screens for depression can be ascertained. In developing research protocols, the ethical challenges highlighted should be considered. Participants must be agreeable to the agreed protocol and efforts should be made to minimise potentially adverse effects.

Anxiety symptoms and disorder predict activity limitations in the elderly

BACKGROUND

In the elderly, little attention has been paid to anxiety both on a symptom dimension and as a disorder, as an independent risk factor for the incidence of activity limitations.

METHODS

In a community-dwelling cohort of 1581 persons aged 65+, the association between trait anxiety symptoms (Spielberger Trait, third highest tertile) and baseline DSM-IV anxiety disorder, and 7-year incident activity limitations was determined using mixed logistic regression models. Repeated measures of activity limitations included, by increased severity level: social restriction (neighbourhood and house confined), mobility (Rosow and Breslau scale) and limitations in instrumental activities of daily living (IADL).

RESULTS

Of the sample, 14.2% had an anxiety disorder at baseline. Adjusting for baseline socio-demographic and health variables, depression (past and current), antidepressant and anxiolytic drugs, baseline anxiety disorder was associated with an increased risk of incident IADL limitation (OR (95% CI): 1.84 (1.01-3.39), p=0.048) and trait anxiety with increased incidence of social restriction (OR (95% CI): 2.41 (1.42-4.09), p=0.001). Associations remained significant in participants free of depressive symptoms at baseline (OR (95% CI): 2.92 (1.41-6.05), p=0.004; OR (95% CI): 3.21 (1.31-7.89), p=0.011, respectively).

LIMITATIONS

Activity limitations were self-reported and may have been over-reported in participants with anxiety.

CONCLUSION

Both trait anxiety symptomatology and anxiety disorder were independently associated with increased incidence of activity limitations with a gradient of severity: trait anxiety associated with incident social restriction and anxiety disorder with more severe IADL limitations, suggesting that anxiety is a predictor of activity limitations in the elderly independently of depression comorbidity.

Moving towards a population health approach to the primary prevention of common mental disorders

There is a need for the development of effective universal preventive approaches to the common mental disorders, depression and anxiety, at a population level. Poor diet, physical inactivity and smoking have long been recognized as key contributors to the high prevalence noncommunicable diseases. However, there are now an increasing number of studies suggesting that the same modifiable lifestyle behaviors are also risk factors for common mental disorders. In this paper we point to the emerging data regarding lifestyle risk factors for common mental disorders, with a particular focus on and critique of the newest evidence regarding diet quality. On the basis of this most recent evidence, we consequently argue for the inclusion of depression and anxiety in the ranks of the high prevalence noncommunicable diseases influenced by habitual lifestyle practices. We believe that it is both feasible and timely to begin to develop effective, sustainable, population-level prevention initiatives for the common mental illnesses that build on the established and developing approaches to the noncommunicable somatic diseases.

A population-based cohort study of anxiety, depression, sleep and alcohol outcomes among benzodiazepine and z-hypnotic users

OBJECTIVE

The present study aimed to examine anxiety, depression, sleep and alcohol outcomes among individuals who were prescribed benzodiazepines or z-hypnotics in a Norwegian population-based sample (n = 58,967).

METHODS

This 13 year historical cohort study obtained baseline measures of self-report anxiety, depression, sleep difficulties and alcohol use from the Nord-Trøndelag Health Study (HUNT 2, 1995-1997). Information about outcomes was collected from the third wave (HUNT 3, 2006-2008) of the same epidemiological study. Prescription records of benzodiazepines and z-hypnotics were obtained from the Norwegian prescription database (NorPD, 2004-2008) and were linked to the HUNT 2 and HUNT 3 questionnaire data.

RESULTS

Among the 58,967 respondents who were eligible for the study, 13,774 (23%) received at least one prescription of benzodiazepines or z-hypnotics in the period 2004-2008. Benzodiazepine use was associated with a higher risk of severe anxiety, depression and sleep outcomes. The assumption that benzodiazepine use is prospectively associated with a higher risk of problematic alcohol use was not supported.

CONCLUSIONS

Consideration and discussion of the future place of benzodiazepines in treatment of anxiety and sleep difficulties in Norway could be warranted. Benzodiazepines may be efficient in reducing symptoms in the short term, but evidence from this long temporal follow-up study indicates limited positive influences in the long term.

Affective and physiological responses to stress in girls at elevated risk for depression

Children of depressed parents are significantly more likely to develop depression and other mental health disorders than are children of never-depressed parents. Investigations of the physiological mechanisms underlying this elevated risk have generally focused on basal functioning. It is important to note, however, that physiological reactivity or responses to stress are also critical determinants of mental and physical health. In the current study, we examined whether children of depressed parents exhibit altered physiological responses to stress. In two studies, never-depressed adolescent daughters of either recurrently depressed mothers (RISK) or never-depressed mothers (CTL) underwent social stressors while their physiological responses were measured (cortisol in Study 1, heart rate in Study 2). In both studies, affective responses to the stressors predicted physiological responses in RISK girls, but not in never-depressed girls. For RISK girls, decreased positive affect in response to stress predicted increased cortisol reactivity; in addition, decreased positive affect and increased negative affect were associated with poorer heart rate recovery and habituation, respectively. Future research is needed to examine explicitly whether this coherence between affect and physiology is a mechanism underlying the increased risk for psychopathology in children of depressed parents.

Clinical risk assessment rating and all-cause mortality in secondary mental healthcare: the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) Case Register

BACKGROUND

Mental disorders are widely recognized to be associated with increased risk of all-cause mortality. However, the extent to which highest-risk groups for mortality overlap with those viewed with highest concern by mental health services is less clear. The aim of the study was to investigate clinical risk assessment ratings for suicide, violence and self-neglect in relation to all-cause mortality among people receiving secondary mental healthcare.

METHOD

A total of 9234 subjects over the age of 15 years were identified from the South London and Maudsley Biomedical Research Centre Case Register who had received a second tier structured risk assessment in the course of their clinical care. A cohort analysis was carried out. Total scores for three risk assessment clusters (suicide, violence and self-neglect) were calculated and Cox regression models used to assess survival from first assessment.

RESULTS

A total of 234 deaths had occurred over an average 9.4-month follow-up period. Mortality was relatively high for the cohort overall in relation to national norms [standardized mortality ratio 3.23, 95% confidence interval (CI) 2.83-3.67] but not in relation to other mental health service users with similar diagnoses. Only the score for the self-neglect cluster predicted mortality [hazard ratio (HR) per unit increase 1.14, 95% CI 1.04-1.24] with null findings for assessed risk of suicide or violence (HRs per unit increase 1.00 and 1.06 respectively).

CONCLUSIONS

Level of clinician-appraised risk of self-neglect, but not of suicide or violence, predicted all-cause mortality among people receiving specific assessment of risk in a secondary mental health service.

The importance of anxiety in both major depression and bipolar disorder

BACKGROUND

Generalized anxiety disorder (GAD) is frequently co-morbid with major depression (MDD), and this becomes more so when the duration requirement is relaxed. Both anxiety diagnoses and anxious symptoms are more common in both unipolar and bipolar depression. This paper explores the relationship between anxious symptoms and GAD with both unipolar and bipolar depression.

METHOD

MDD and bipolar disorder (BPD) are compared in three important respects: the extent of their co-morbidity with anxious symptoms and GAD, the effects that anxiety has on outcome of MDD and BPD, and the effects that anxiety has on the probability of suicide in each disorder.

RESULTS

Anxious diagnoses occur frequently in association with depressive disorders, albeit to a different extent in the various subtypes of depression. In both disorders, anxiety affects the outcome and makes suicidal thoughts, and completed suicide more likely.

CONCLUSIONS

Anxious phenomena should be assessed whenever a depressive disorder is diagnosed. It is likely that the raised expectancy of anxious phenomena is related to an individual's premorbid level of negative affect, and it is possible that suicidal phenomena are related to subthreshold hypomanic symptoms.