Factors associated with the onset of an episode of depressive symptoms in the general population

An Interdisciplinary Multimodal Integrative Healthcare Program for Chronic Spinal Pain and Comorbid Mental Disorders

OBJECTIVE

Previous studies evaluating interdisciplinary multimodal interventions for chronic spinal pain often excluded patients with comorbid mental disorders. This study aims to assess the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for individuals experiencing co-occurring chronic spinal pain and mental disorders.

METHODS

Participants were 944 patients with chronic spinal pain and comorbid mental disorders. Primary outcomes were health-related quality of life, assessed using the Research and Development-36 (RAND-36), and pain-related disability, assessed using the Quebec Back Pain Disability Scale (QBPDS). Secondary outcomes included pain intensity, pain catastrophizing, kinesiophobia, fatigue, lumbar mobility, and isometric strength. Data were collected during the healthcare program at four time points: pretreatment (T0), midway through 20-week treatment (T1), end of 20-week treatment (T2), and at completion of 12-month relapse prevention program (T3). Multilevel regression analyses were conducted to examine the effects of the healthcare program on primary outcomes over time.

RESULTS

The 20-week treatment period yielded significant improvements in both mental ( B = 0.44, t (943) = 19.42, p < .001) and physical component summary scores ( B = 0.45, t (943) = 18.24, p < .001) of the RAND-36, as well as in QBPDS total score ( B = -0.77, t (943) = -26.16 p < .001). Pretreatment scores indicated the presence of problematic fatigue, kinesiophobia, and clinical levels of pain catastrophizing, all of which resolved by the end of the 12-month relapse prevention program.

CONCLUSIONS

An interdisciplinary multimodal integrative healthcare program seems effective for patients with chronic spinal pain and comorbid mental disorders.

The association between violence against women and chronic pain: a systematic review and meta-analysis

Violence against women is a phenomenon that involves at least 35% of women worldwide. Violence can be sexual, physical, and/or psychological, perpetrated by the partner, another family member, or a stranger. Violence is a public health problem because its consequences include higher morbidity, higher mortality, and short and long-term physical and psychological health diseases. Most studies prove an association between any type of violence and some chronic pain diagnoses but no one has done a complete collection of this evidence. This systematic review and meta-analysis aimed to evaluate whether this association is statistically significant, including the largest number of studies. Through the inclusion of 37 articles, the association has been demonstrated. Compared with no history of violence, women who did experience violence showed 2 times greater odds of developing chronic pain. The impact of violence was significant also on fibromyalgia separately, but not on pelvic pain.PROSPERO registrationPROSPERO CRD42023425477.

The Risk Factors of Chronic Pain in Victims of Violence: A Scoping Review

Violent situations are unfortunately very frequent in women and children all over the world. These experiences have long-term consequences for adult physical and psychological health. One of the most reported is chronic pain, defined in various sub-diagnoses and present in all types of violence. Unfortunately, the etiology of this condition is not clear and neither are the predisposing factors. The aim of this scoping review is to examine the literature trends about the probable risk factors of chronic pain in violence victims. Considering a bio-psycho-social model, it is possible to hypothesize the presence of all these aspects. The results will be discussed in the present article.

Risk of pain disorders in offspring of parents with substance use disorders

AIMS

Individuals with substance use disorders (SUD) have higher risk of developing pain disorders. This study aimed to investigate the risk of major psychiatric disorders (MPD), SUD, and pain disorders among their offspring.

METHODS

This study used data from the Taiwan National Health Research Database. The case cohort included participants who had a parent diagnosed with SUD. The matched control cohort was offspring of parents without any SUD or major psychiatric disorder (MPD). Poisson regression was applied to estimate the risk of MPD, SUD, and pain disorder between case and control cohorts.

RESULTS

We recruited 13,840 cases and 138,400 matched controls. After adjusting for demographic characteristics and family history of psychiatric disorder, the offspring of parents with SUD had higher risk for bipolar disorder (reported as risk ratio with 95% confidence interval: 2.48, 1.79-3.43), depressive disorder (2.22, 1.94-2.52), SUD (2.53, 2.18-2.92), and alcohol use disorder (1.43, 1.16-1.76) than controls. With adjustments of demographic characteristics, individual MPD, and family history of psychiatric disorder, they also presented higher risk than controls for several pain disorders, including migraine (1.43, 1.15-1.78), fibromyalgia (1.21, 1.03-1.42), dorsopathies (1.20, 1.06-1.37), dysmenorrhea (1.16, 1.04-1.29), irritable bowel syndrome (1.26, 1.11-1.43), and dyspepsia (1.14, 1.02-1.27).

CONCLUSIONS

Clinicians should be aware of the influence of parental SUD on the elevated risk for MPD, SUD, and pain disorders in their offspring.

Zinc, but not paracetamol, prevents depressive-like behavior and sickness behavior, and inhibits interferon-gamma and astrogliosis in rats

Considering all mental and addictive disorders, depression is the most responsible for years of life lost due to premature mortality and disability. Antidepressant drugs have limited effectiveness. Depression can be triggered by immune/inflammatory factors. Zinc and paracetamol interfere with immune system and have demonstrated beneficial effects on depression treatment when administered concomitant with antidepressant drugs. The objective of this study was to test zinc and/or paracetamol as treatments of depressive-like behavior, sickness behavior, and anxiety in rats, as well as to understand the central and peripheral mechanisms involved. Sickness behavior and depressive-like behavior were induced in rats with repetitive lipopolysaccharide (LPS, 1 mg/kg for two consecutive days) administrations. Rats received zinc and/or paracetamol for three consecutive days. Sickness behavior (daily body weight and open field general activity); anxiety (light-dark test); depressive-like/antidepressant behavior (forced swim test); plasma corticosterone and interferon (IFN)-gamma levels; and glial fibrillary acidic protein (GFAP) and tyrosine hydroxylase (TH) brain expression were evaluated. LPS induced sickness behavior and depressive-like behavior, as well as elevated IFN-gamma levels and increased GFAP expression. Zinc prevented both behavioral and biochemical impairments. Paracetamol and zinc + paracetamol association induced only slight beneficial effects. Anxiety, corticosterone, and TH do not seem be related with depression and the other behavioral and neuroimmune changes. In conclusion, zinc treatment was beneficial for sickness behavior and depressive-like behavior without concomitant administration of antidepressants. IFN-gamma and GFAP were linked with the expression of sickness behavior and depressive-like behavior and were also involved with the antidepressant effects. Therefore, zinc, IFN-gamma, and GFAP pathways should be considered for depression treatment.

Musculoskeletal pain as a predictor for depression in the general working population of Denmark

Aim: This study examines the association between musculoskeletal complaints and subsequent use of antidepressants and/or psychiatric hospital treatment for depressive mood disorders in the Danish labour force. Methods: The study is based on two cohorts. The first cohort is the total labour force in 21 Danish municipalities (n=693,860), where the risk of depression (psychiatric diagnosis or antidepressant treatment) during 2010–2015 was compared between individuals on long-term sickness absence due to musculoskeletal disorders (MSD) and non-sick-listed gainfully employed individuals. The second cohort is a random sample of the Danish labour force (n=9248) who were followed during 2011–2015 to estimate the association between self-rated musculoskeletal pain and depression. All analyses were controlled for age, sex, calendar period and socio-economic status. Results: Compared to non-sick-listed gainfully employed individuals, there was an increased risk of depression in individuals sick-listed with MSD, with rate ratios of 2.39 (99% confidence interval (CI) 2.22–2.58) for individuals with less severe MSD and 4.27 (99% CI 3.98–4.59) for individuals with more severe MSD. There was also an increased risk of depression associated with self-rated pain (yes vs. no), with a rate ratio of 2.17 (99% CI 1.69–2.78). The population attributable fraction of depression from musculoskeletal pain was 0.35 (99% CI 0.24–0.45). Conclusions: The results of the present study indicate that musculoskeletal pain is an important predictor of indicators of depression in the general working population of Denmark.

Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients

Retrospective review of National Inpatient Sample (2000-2012) revealed that 31.28% of musculoskeletal (MSK) patients were found to have in-hospital psychological burdens (PBs). Adult spinal deformity (ASD), degenerative disc disease (DDD) and lung cancer patients had highest PB-prevalence. MSK patients with PB were more often young, white females with increased Deyo index compared to no-PB patients. Patients who underwent spinal revision procedures had higher PB rates than with primary procedures; a converse trend was observed for total hip/knee arthroplasty. Psychological disorders were identified as significant predictors of increased total-hospital charges. Augmenting counseling with psychological screening/support is recommended to complement MSK management.

Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review

Depression is the most commonly experienced mental health condition in adults with autism spectrum conditions (ASC). However, it is unclear what tools are currently being used to assess depression in ASC, or whether tools need to be adapted for this group. This systematic review therefore aimed to identify tools used to assess depression in adults with and without ASC, and then evaluate these tools for their appropriateness and measurement properties. Medline, PsychINFO and Web of Knowledge were searched for studies of depression in: (a) adults with ASC, without co‐morbid intellectual disability; and (b) adults from the general population without co‐morbid conditions. Articles examining the measurement properties of these tools were then searched for using a methodological filter in PubMed, and the quality of the evidence was evaluated using the COSMIN checklist. Twelve articles were identified which utilized three tools to assess depression in adults with ASC, but only one article which assessed the measurement properties of one of these tools was identified and thus evaluated. Sixty‐four articles were identified which utilized five tools to assess depression in general population adults, and fourteen articles had assessed the measurement properties of these tools. Overall, two tools were found to be robust in their measurement properties in the general population—the Beck Depression Inventory (BDI‐II), and the patient health questionnaire (PHQ‐9). Crucially only one study was identified from the COSMIN search, which showed weak evidence in support of the measurement properties of the BDI‐II in an ASC sample. Implications for effective measurement of depression in ASC are discussed. Autism Res2018, 11: 738–754. © 2018 The Authors Autism Research published by International Society for Autism Research and Wiley Periodicals, Inc.

Lay Summary

Depression is the most common mental health problem experienced by adults with autism. However, the current study found very limited evidence regarding how useful tools developed for the general population are for adults with autism. We therefore suggest how these tools could be adapted to more effectively assess depression in adults with autism, and improve these individuals access to mental health assessment and support.

The Role of MAPK and Dopaminergic Synapse Signaling Pathways in Antidepressant Effect of Electroacupuncture Pretreatment in Chronic Restraint Stress Rats

Acupuncture has demonstrated the function in ameliorating depressive-like behaviors via modulating PKA/CREB signaling pathway. To further confirm the antidepressant mechanism of EA on the mitogen-activated protein kinase (MAPK) and dopaminergic synapse signaling pathways, 4 target proteins were detected based on our previous iTRAQ analysis. Rats were randomly divided into control group, model group, and electroacupuncture (EA) group. Except for the control group, all rats were subjected to 28 days of chronic restraint stress (CRS) protocols to induce depression. In the EA group, EA pretreatment at Baihui (GV20) and Yintang (GV29) was performed daily (1 mA, 2 Hz, discontinuous wave, 20 minutes) prior to restraint. The antidepressant-like effect of EA was measured by body weight and open-field test. The protein levels of DAT, Th, Mapt, and Prkc in the hippocampus were examined by using Western blot. The results showed EA could ameliorate the depression-like behaviors and regulate the expression levels of Prkc and Mapt in CRS rats. The effect of EA on DAT and Th expression was minimal. These findings implied that EA pretreatment could alleviate depression through modulating MAPK signaling pathway. The role of EA on dopaminergic synapse signaling pathways needs to be further explored.

Propentofylline Prevents Sickness Behavior and Depressive-Like Behavior Induced by Lipopolysaccharide in Rats via Neuroinflammatory Pathway

Recent studies have demonstrated the intimate relationship between depression and immune disturbances. Aware of the efficacy limits of existing antidepressant drugs and the potential anti-inflammatory properties of propentofylline, we sought to evaluate the use of propentofylline as a depression treatment. We used a rat model of depression induced by repetitive lipopolysaccharide (LPS) administrations. We have studied sickness behavior, by assessing daily body weight, open field behavior, and TNF-α plasmatic levels. Anxiety-like behavior (light-dark test), depressive-like behavior (forced swim test), plasmatic levels of the brain-derived neurotrophic factor (BDNF, depression biomarker), and central glial fibrillary acidic protein (GFAP) expression (an astrocyte biomarker) were also evaluated. LPS induced body weight loss, open field behavior impairments (decreased locomotion and rearing, and increased immobility), and increased TNF-α levels in rats, compared with control group. Thus, LPS induced sickness behavior. LPS also increased the immobility and reduced climbing in the forced swim test, when compared with the control group, i.e., LPS induced depressive-like behavior in rats. Propentofylline prevented sickness behavior after four days of consecutive treatment, as well as prevented the depressive-like behavior after five days of consecutive treatments. Propentofylline also prevented the increase in GFAP expression induced by LPS. Neither LPS nor propentofylline has influenced the anxiety and BDNF levels of rats. In conclusion, repetitive LPS administrations induced sickness behavior and depressive-like behavior in rats. Propentofylline prevented both sickness behavior and depressive-like behavior via neuroinflammatory pathway. The present findings may contribute to a better understanding and treatment of depression and associated diseases.

Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment

Chronic pain and mental health disorders are common in the general population, and epidemiological studies suggest that a bidirectional relationship exists between these 2 conditions. The observations from functional imaging studies suggest that this bidirectional relationship is due in part to shared neural mechanisms. In addition to depression, anxiety, and substance use disorders, individuals with chronic pain are at risk of other mental health problems including suicide and cigarette smoking and many have sustained sexual violence. Within the broader biopsychosocial model of pain, the fear-avoidance model explains how behavioral factors affect the temporal course of chronic pain and provides the framework for an array of efficacious behavioral interventions including cognitive-behavioral therapy, acceptance-based therapies, and multidisciplinary pain rehabilitation. Concomitant pain and mental health disorders often complicate pharmacological management, but several drug classes, including serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants, have efficacy for both conditions and should be considered first-line treatment agents.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery

STUDY DESIGN

Prospective cohort analysis.

OBJECTIVE

To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery.

SUMMARY OF BACKGROUND DATA

Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use. Despite this and recent national attention highlighting the negative effects of narcotics, they remain commonly used for the management of pain in patients undergoing spine surgery.

MATERIALS AND METHODS

A total of 583 patients undergoing spine surgery for a structural lesion were evaluated. Self-reported preoperative narcotic consumption was obtained and converted to morphine equivalents at the initial preoperative visit. LOS was recorded upon discharge and presence/type of a postoperative complication within 30/90 days was obtained. A multivariable logistic and linear regression analysis was performed for the incidence of complications and length of stay controlling for clinically important covariates.

RESULTS

Narcotic use was not associated with 30- or 90-day complications; however, smoking status was significantly associated with 30-day complications. Increased preoperative narcotic use was significantly associated with increased LOS, as was age, type of surgery, and depression.

CONCLUSIONS

Increased preoperative narcotic use and depression are associated with increased LOS in patients undergoing spine surgery. We calculated that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days. Narcotic use was not associated with 30- or 90-day postoperative complications. As reimbursement is bundled before surgery, providing interventions for patients with treatable causes for increased length of stay can save cost overall.

Association of pain and depression in those with chronic low back pain: the mediation effect of patient sexual functioning

OBJECTIVES

One theoretical model suggests that the pathway from pain to depression is through the disruption of social and relationship function. This study sought to test this hypothesis by considering the mediating effect of sexual functioning on the association between pain intensity and depressive symptoms in sexually active patients with chronic low back pain.

MATERIALS AND METHODS

This was a cross-sectional study on consecutive patients attending a chronic pain management clinic in Iran. All measures (pain intensity, depressive symptoms, sex-specific sexual function) were obtained by a self-report questionnaire, completed by patients while attending the clinic. Sobel testing, including bias-corrected bootstrapping, was used to produce 95% confidence intervals (95% CI) to test the mediating effect of sexual function.

RESULTS

A total of 742 patients (351 men, 391 women) took part in this study. Both the male and female mediation models showed a significant association between pain intensity and depressive symptoms, and both the models were significantly mediated by sexual functioning (P<0.001). Effect size calculations show a medium to large effect on male patients (κ 0.23; 95% CI, 0.15-0.39) and a medium effect for female patients (κ 0.16; 95% CI, 0.06-0.28). Both the models accounted for over 50% of the variance in depressive symptoms (model R).

DISCUSSION

This study has shown that sexual functioning significantly mediates the relationship between pain intensity and depressive symptoms in sexually active patients with chronic low back pain. Clinicians may wish to consider the assessment of sexual functioning within this patient group and align treatments that address sexual dysfunction and general pain management.

Is neck pain associated with worse health-related quality of life 6 months later? A population-based cohort study

BACKGROUND CONTEXT

Current evidence suggests that neck pain is negatively associated with health-related quality of life (HRQoL). However, these studies are cross-sectional and do not inform the association between neck pain and future HRQoL.

PURPOSE

The purpose of this study was to investigate the association between increasing grades of neck pain severity and HRQoL 6 months later. In addition, this longitudinal study examines the crude association between the course of neck pain and HRQoL.

STUDY DESIGN

This is a population-based cohort study.

PATIENT SAMPLE

Eleven hundred randomly sampled Saskatchewan adults were included.

OUTCOME MEASURES

Outcome measures were the mental component summary (MCS) and physical component summary (PCS) of the Short-Form-36 (SF-36) questionnaire.

METHODS

We formed a cohort of 1,100 randomly sampled Saskatchewan adults in September 1995. We used the Chronic Pain Questionnaire to measure neck pain and its related disability. The SF-36 questionnaire was used to measure physical and mental HRQoL 6 months later. Multivariable linear regression was used to measure the association between graded neck pain and HRQoL while controlling for confounding. Analysis of variance and t tests were used to measure the crude association among four possible courses of neck pain and HRQoL at 6 months. The neck pain trajectories over 6 months were no or mild neck pain, improving neck pain, worsening neck pain, and persistent neck pain. Finally, analysis of variance was used to examine changes in baseline to 6-month PCS and MCS scores among the four neck pain trajectory groups.

RESULTS

The 6-month follow-up rate was 74.9%. We found an exposure-response relationship between neck pain and physical HRQoL after adjusting for age, education, arthritis, low back pain, and depressive symptomatology. Compared with participants without neck pain at baseline, those with mild (β=-1.53, 95% confidence interval [CI]=-2.83, -0.24), intense (β=-3.60, 95% CI=-5.76, -1.44), or disabling (β=-8.55, 95% CI=-11.68, -5.42) neck pain had worse physical HRQoL 6 months later. We did not find an association between neck pain and mental HRQoL. A worsening course of neck pain and persistent neck pain were associated with worse physical HRQoL.

CONCLUSIONS

We found that neck pain was negatively associated with physical but not mental HRQoL. Our analysis suggests that neck pain may be a contributor of future poor physical HRQoL in the population. Raising awareness of the possible future impact of neck pain on physical HRQoL is important for health-care providers and policy makers with respect to the management of neck pain in populations.

Expanding the efficacy of Project UPLIFT: Distance delivery of mindfulness-based depression prevention to people with epilepsy

OBJECTIVE

Depression affects about 16% of the U.S. population over a lifetime. People with chronic diseases have especially high rates of comorbid depression; 32% to 48% of people with epilepsy experience depression. This study evaluated the efficacy of a mindfulness-based cognitive therapy intervention for preventing major depressive disorder (MDD) episodes in people with epilepsy.

METHOD

Participants (n = 128) were adults from Georgia, Michigan, Texas, and Washington with epilepsy and mild/moderate depressive symptoms. The 8-session weekly Project UPLIFT intervention, based on mindfulness-based cognitive therapy, was group-delivered via Web or telephone. Using a randomized, controlled crossover design, participants were assigned to Project UPLIFT or a treatment-as-usual (TAU) waitlist and assessed at baseline, and after intervening in the intervention group (∼10 weeks) and in the TAU group (∼20 weeks). Assessments included valid self-report measures of depression and MDD, knowledge/skills, and satisfaction with life.

RESULTS

The incidence of MDD episodes (new or relapse) from baseline to interim assessment was significantly lower in the intervention condition (0.0%) than in TAU (10.7%). Depressive symptoms decreased significantly more in the intervention condition than in TAU; Web and telephone did not differ. Change in knowledge/skills mediated the effect, which persisted over the 10 weeks of follow-up. Knowledge/skills and life satisfaction increased significantly more in the intervention condition than in TAU.

CONCLUSIONS

Distance delivery of group mindfulness-based cognitive therapy can prevent episodes of MDD, reduce symptoms of depression, and increase life satisfaction in people with epilepsy. This intervention is easily modified for persons with other chronic diseases and other disparity populations. (PsycINFO Database Record

The sex-specific interrelationship between spinal pain and psychological distress across time in the general population. Results from the Stockholm Public Health Study

BACKGROUND CONTEXT

Detailed knowledge about the interrelationship between neck pain, back pain, and psychological distress is important from a public health prospective, but missing because of lack of large population-based cohort studies.

PURPOSE

To assess and compare the sex-specific recovery rate of spinal pain and psychological distress as single and comorbid conditions, to describe the interrelationship between these conditions at the baseline (2002) and follow-up 5 years later, and to explore the questions of spinal pain as a risk factor for the onset of psychological distress and vice versa.

STUDY DESIGN

A prospective cohort study.

PATIENT SAMPLE

General population in Stockholm county aged 18 to 84 years, n=19,774.

OUTCOME MEASURES

Spinal pain (modified Nordic Pain Questionnaire) and psychological distress (General Health Questionnaire-12).

METHODS

A random sample of the population in Stockholm was approached with postal questionnaires at the baseline and at follow-up.

RESULTS

Comorbidity of spinal pain and distress was twice as common among women (11%) than among men (4%) (relative risk=2.4, 95% confidence interval [CI]: 2.1-2.7). Women also more commonly had spinal pain without psychological distress (women, 20%; men, 14%) and vice versa (women, 15%; men, 12%). Comorbidity makes recovery less probable (women, 26%; men, 27%) than having single conditions of spinal pain (women, 41%; men, 44%) or psychological distress (women, 49%; men, 52%). No statistical significant sex differences were seen. Twenty-four percent of the women and 17% of the men with spinal pain without psychological distress at the baseline had psychological distress at follow-up. Corresponding figures for spinal pain among participants with psychological distress without spinal pain at the baseline were 24% and 20%. Spinal pain was a determinant of psychological distress (odds ratio [OR]=2.6, 95% CI: 2.3-2.9) and vice versa (OR=2.0, 95% CI: 1.8-2.2).

CONCLUSIONS

Spinal pain and psychological distress as comorbid and single conditions are common in the general population, especially among women. Comorbidity affects recovery negatively both in men and women. This study confirms the bidirectional association between spinal pain and psychological distress in the general population.

Heterogeneous depression responses to chronic pain onset among middle-aged adults: a prospective study

Studies on depression response to chronic pain are limited by lack of clarification of different forms of response patterns and cross-sectional measures. The current study examined heterogeneous long-term patterns of depression response to chronic pain onset prospectively using the mixture modeling technique. Depression symptoms prior to and following pain onset over a course of six years were charted in a nationally representative middle-aged sample. Four distinct depression symptom trajectories emerged. The resilience (72.0%) trajectory describes a pattern of no/minimal depression symptoms prior to and following pain onset. The post-pain depression trajectory (11.4%) describes a pattern of low depression at baseline and increasing symptoms following pain onset. The chronic depression (6.8%) trajectory is characterized by persistently high depression symptoms irrespective of pain onset. The prior depression improved (9.8%) trajectory describes a pattern of high depression at baseline and gradually declining symptoms following pain onset. Self-rated health at both baseline and following pain onset predicted the resilience trajectory. Baseline self-rated health distinguished the post-pain depression and chronic depression trajectories. Individuals in the prior depression improved trajectory were older and had more chronic illnesses at baseline but fewer illnesses following pain onset, compared to those in the resilience or post-pain depression trajectory.

The role of sleep problems in the development of depression in those with persistent pain: a prospective cohort study

STUDY OBJECTIVES

One theoretical model suggests a pathway between pain and the development of depression through sleep problems. Here, we prospectively test the hypothesis that incident sleep problems, in those with persistent pain, increase risk of new onset probable depression, and investigate the role of "pain that interferes with daily life" (pain interference) on this pathway.

DESIGN

Prospective cohort study.

SETTING

Community based population study within UK.

PARTICIPANTS

Participants with persistent pain nested within a larger longitudinal community study.

MEASUREMENTS

Participants were mailed health questionnaires at baseline (time 1) with follow-up at 3 years (time 2) and 6 years from baseline (time 3). Questionnaires at baseline and at follow up contained measures of sleep problems (Jenkins Sleep Questionnaire), depressive symptoms (Hospital Anxiety and Depressive Scale), and pain interference.

RESULTS

In total, 2,622 participants returned health questionnaires at all time points and indicated the presence of pain at each time point. After adjustment for age, gender, marital status, employment status, alcohol intake, smoking status, and body mass index, having a new period of sleep problems at year 3 more than trebled the risk of a new period of probable depression at year 6 (relative risk 3.47, 95% CI 1.97 to 6.03). Mediation analysis showed that pain interference played a significant but relatively minor role in the pathway.

CONCLUSION

Clinicians treating patients with persistent pain may wish to consider options that involve addressing the prevention or treatment of sleep problems, in addition to their primary focus of pain management.

Low back pain across the life course

Back pain episodes are traditionally regarded as individual events, but this model is currently being challenged in favour of treating back pain as a long-term or lifelong condition. Back pain can be present throughout life, from childhood to older age, and evidence is mounting that pain experience is maintained over long periods: for example, people with pain continue to have it on and off for years, and people without pain do not suddenly develop long-term pain. A number of factors predict back pain presence in epidemiological studies, and these are often present, and predictive, at different life stages. There are also factors present at particular life stages, such as childhood or adolescence, which predict back pain in adulthood. However, there are little published data on long-term pain patterns or predictors over the life course. Such studies could improve our understanding of the development and fluctuations in back pain, and therefore influence treatment approaches.

Health-related quality of life among people with epilepsy with mild seizure-related head injuries

Seizure-related head injury (SRHI) is an under-recognized condition frequently experienced by people with epilepsy (PWE). The purpose of this study is to investigate the potential impact of SRHI on health-related quality of life (HRQOL) among PWE receiving care in a tertiary epilepsy center. Consecutive adult PWE receiving care at the Baylor Comprehensive Epilepsy Center (BCEC) were recruited for the study. After their informed consent was obtained, patients were administered the QOLIE-31 to measure HRQOL and the NDDI-E to screen for depression. Simple linear regression was used to identify clinical variables associated with HRQOL and that included SRHI obtained systematically at each clinic visit. Data were also compared between the SRHI and non-SRHI groups. Participants included 172 subjects. Recurrent mild SRHI occurred in 50 (29%) subjects. Factors with a negative effect on HRQOL included depression (slope=-19.99 [95% CI -25.16, -14.81]; p<.0001), recurrent SRHI (-17.02 [-22.35, -11.69]; p<.0001), past SRHI (-13.46 [-18.43, -8.48]; p<.0001), and seizure frequency (-0.17 [-0.26, -0.07]; p=0.001) on univariate analysis. With stepwise multiple regression, depression and recurrent SRHI significantly impacted HRQOL with slopes (95% CI; p-value) of (-17.53 [-22.34, -12.73]; p<.0001) and (-14.03 [-18.78, -9.28]; p<.0001), respectively. Patient-derived HRQOL is negatively associated with depression and recurrent SRHI, independently. There has been a justifiable increased awareness of the potential effects of head injuries among healthy individuals. Our data suggest that head injuries can certainly be detrimental among PWE, and greater efforts should be made to recognize and formulate prevention strategies for SRHI.

Physical health of patients with bipolar disorder

OBJECTIVE

This article reviews the characteristics of bipolar disorder and approaches to minimise physical health risks, as well as treatment options, and their influence on patient quality of life (QoL).

METHOD

The content of this article is based on the proceedings of a 1-day standalone symposium in November 2011 exploring how to establish a bipolar clinic within the context of existing services in the UK's National Health Service.

RESULTS

Bipolar disorder is a common mental disorder and often under-recognised in patients with major depressive episodes. Patients are largely dependent on family and carers to lead normal lifestyles and have difficulties maintaining relationships. Mental health and physical health are closely linked, with risk factors such as weight gain, metabolic syndrome, smoking and diabetes contributing to cardiovascular disease and early death. Antipsychotics may induce treatment-related comorbidities, thus further contributing to a low QoL of patients. Symptoms of comorbidity or depression are frequently relieved through self-medication and substance abuse, thus increasing patient health and suicide risk. Therefore, regular health monitoring and patient education in risk factor minimisation are required.

CONCLUSION

Early pharmacotherapeutic and psychoeducational interventions are required to improve treatment outcomes, as well as improving patient understanding of ways to minimise comorbidity development.

The impact of common mental disorders on work ability in mentally and physically demanding construction work

PURPOSE

To gain insight into (1) the prevalence and incidence of common mental disorders (CMD) and low work ability among bricklayers and construction supervisors; (2) the impact of CMD on current work ability and work ability 1 year later and (3) the added value of job-specific questions about work ability for detecting signs of low work ability.

METHODS

We randomly selected 750 bricklayers and 750 supervisors. This sample was surveyed by means of a baseline questionnaire and a follow-up questionnaire 1 year later. Work ability was measured with the first three questions of the Work Ability Index and job-specific questions. Self-reported CMD were measured with instruments designed to detect a high need for recovery after work, distress and depression. We used univariate logistic regression to analyse the presence or absence of CMD as independent variable.

RESULTS

The prevalence and incidence of CMD among 199 bricklayers and 224 supervisors was 22 %/10 % and 32 %/15 %, respectively. The prevalence of low general work ability was comparable for both occupations (5 %). CMD were associated with low current work ability and low work ability at follow-up (ORs 4.3-22.4), but not with a reduction in work ability 1 year later. Questions on job-specific work ability resulted in more indications of low work ability among both occupations than did questions on general work ability.

CONCLUSIONS

Regardless of occupation, workers who report CMD at baseline have a high likelihood of current low work ability and low work ability 1 year later.

How does comorbidity influence healthcare costs? A population-based cross-sectional study of depression, back pain and osteoarthritis

OBJECTIVES

To analyse how comorbidity among patients with back pain, depression and osteoarthritis influences healthcare costs per patient. A special focus was made on the distribution of costs for primary healthcare compared with specialist care, hospital care and drugs.

DESIGN

Population-based cross-sectional study.

SETTING

The County of Östergötland, Sweden.

PATIENTS

Data on diagnoses and healthcare costs for all 266 354 individuals between 20 and 75 years of age, who were residents of the County of Östergötland, Sweden, in the year 2006, were extracted from the local healthcare register and the national register of drug prescriptions.

MAIN OUTCOME MEASURES

The effects of comorbidity on healthcare costs were estimated as interactions in regression models that also included age, sex, number of other health conditions and education.

RESULTS

The largest diagnosed group was back pain (11 178 patients) followed by depression (7412 patients) and osteoarthritis (5174 patients). The largest comorbidity subgroup was the combination of back pain and depression (772 patients), followed by the combination of back pain and osteoarthritis (527 patients) and the combination of depression and osteoarthritis (206 patients). For patients having both a depression diagnosis and a back pain diagnosis, there was a significant negative interaction effect on total healthcare costs. The average healthcare costs among patients with depression and back pain was SEK 11 806 lower for a patient with both diagnoses. In this comorbidity group, there were tendencies of a positive interaction for general practitioner visits and negative interactions for all other visits and hospital days. Small or no interactions at all were seen between depression diagnoses and osteoarthritis diagnoses.

CONCLUSIONS

A small increase in primary healthcare visits in comorbid back pain and depression patients was accompanied with a substantial reduction in total healthcare costs and in hospital costs. Our results can be of value in analysing the cost effects of comorbidity and how the coordination of primary and secondary care may have an impact on healthcare costs.

Distance delivery of mindfulness-based cognitive therapy for depression: project UPLIFT

This study evaluated the efficacy of a newly developed, home-based depression intervention for people with epilepsy. Based on mindfulness-based cognitive therapy (MBCT), the eight-session, weekly intervention was designed for group delivery via the Internet or telephone. Forty participants were randomly assigned to intervention or waitlist. Depressive symptoms and other outcomes were measured at baseline, after intervening in the intervention group (~8 weeks), and after intervening in the waitlist group (~16 weeks). Depressive symptoms decreased significantly more in the intervention group than the waitlist group; Internet and telephone did not differ. This effect persisted over the 8 weeks when those waitlisted received the intervention. Knowledge/skills increased significantly more in the intervention than the waitlist group. All other changes, though not significant, were in the expected direction. Findings indicate that distance delivery of group MBCT can be effective in reducing symptoms of depression in people with epilepsy. Directions for future research are proposed.

Contributions of prognostic factors for poor outcome in primary care low back pain patients

BACKGROUND

Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone.

AIMS

To determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors.

METHODS

Prospective cohort study of back pain patients (30-59 years) at five general practices in Staffordshire, UK (n=389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear-avoidance; self-rated health) were assessed for their association with disabling and limiting pain after 12-months. The proportion of those with persistent problems whose outcome was related to each factor was calculated.

RESULTS

Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment (adjusted relative risk (RR) 4.2; 95% CI 2.0, 8.5) and high pain intensity (4.1; 1.7, 9.9). The largest proportions of persistent problems were related to high pain intensity (68%; 95% CI 27, 87%) and unemployment (64%; 33, 82%). Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self-rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems.

CONCLUSIONS

Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub-groups for intervention.

Whiplash-associated disorders: who gets depressed? Who stays depressed?

Depression is common in whiplash-associated disorders (WAD). Our objectives were to identify factors associated with depressive symptomatology occurring in the initial stages of WAD, and to identify factors predicting the course of depressive symptoms. A population-based cohort of adults sustaining traffic-related WAD was followed at 6 weeks, 3, 6, 9, and 12 months. Baseline measures (assessed a median of 11 days post-crash) included demographic and collision-related factors, prior health, and initial post-crash pain and symptoms. Depressive symptomatology was assessed at baseline and at each follow-up using the Centre for Epidemiological Studies Depression Scale (CES-D). We included only those who participated at all follow-ups (n = 3,452; 59% of eligible participants). Using logistic regression, we identified factors associated with initial (post-crash) depression. Using multinomial regression, we identified baseline factors predicting course of depression. Courses of depression were no depression; initial depression that resolves, recurs or persists, and later onset depression. Factors associated with initial depression included greater neck and low back pain severity, greater percentage of body in pain, numbness/tingling in arms/hand, dizziness, vision problems, post-crash anxiety, fracture, prior mental health problems, and poorer general health. Predictors of persistent depression included older age, greater initial neck and low back pain, post-crash dizziness, vision and hearing problems, numbness/tingling in arms/hands, anxiety, prior mental health problems, and poorer general health. Recognition of these underlying risk factors may assist health care providers to predict the course of psychological reactions and to provide effective interventions.

Psychiatric morbidity following miscarriage in Hong Kong

OBJECTIVE

The aim of this study is to examine the pattern of psychiatric morbidity up to 3 months following miscarriage and to identify the risk factors of post-miscarriage depressive disorder among Chinese women in Hong Kong.

METHOD

This is a longitudinal cohort study. Women were interviewed immediately after miscarriage to collect psychiatric and sociodemographic data. Three months later, 161 subjects (89%) were assessed by a 12-item General Health Questionnaire (GHQ-12) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) as screening and diagnostic instruments, respectively.

RESULTS

Three months after miscarriage, 10% of subjects suffered depressive disorder, 1.2% were diagnosed with anxiety disorder not otherwise specified, and another two subjects each suffered obsessive compulsive disorder (0.6%) and posttraumatic stress disorder (0.6%), respectively. Risk factors of post-miscarriage depression included younger age, history of infertility and past history of depression.

CONCLUSIONS

Given the local annual figure of more than 7000 first-trimester miscarriages, about 900 local women suffer post-miscarriage psychiatric disorder each year. This finding may prompt general hospitals in Hong Kong to screen for post-miscarriage psychiatric disorders, particularly depression.

Is the self-reported history accurate in patients with persistent axial pain after a motor vehicle accident?

BACKGROUND CONTEXT

A patient's self-reported history has, in general, assumed to be accurate. Clinical management of individuals with persistent axial pain after a motor vehicle accident (MVA) and measures to prevent future MVA, spinal cord injury, and traffic deaths often depend on a presumed accurate report of preexisting axial pain, drug, alcohol, and psychological problems to initiate intervention. In addition, research efforts to determine the effects of MVA on subsequent health are often predicated on a presumed accurate history from the patient of past medical and psychosocial problems. Despite so many clinical, public health, and research efforts being dependent on an accurate assessment of pre-injury health, the validity of the self-reported history after MVA has not been systematically investigated.

PURPOSE

To determine the validity of self-reported history in subjects with axial neck or back pain attributed to a recent MVA.

STUDY DESIGN

A prospective, multiclinic validation study examining the critical elements of a patient's self-reported history after an MVA judged against an audit of his or her medical records.

PATIENT SAMPLE

A cohort of consecutive patients with persistent axial pain after an MVA was prospectively identified from five spine-specialist's outpatient clinics. Of 702 patients, 335 subjects were randomly selected for auditing of their medical records.

OUTCOME MEASURES

Self-reported demographic and clinical features were recorded by standardized questionnaires and clinical interviews. Audits compared these responses to an extensive medical record search.

METHODS

The self-reported prevalence of preexisting axial pain, at-risk comorbidities (psychological distress, alcohol, and drug abuse), and control conditions (hypertension and diabetes) was recorded. The medical records of a random sample of 50% of the enrolled cohort underwent auditing of their medical records in a wide search of network paper and electronic and archived records, and compared with the self-reported history of pre-accident health.

RESULTS

Overall, approximately 50% of the subjects were found to have previous axial pain problems at audit when none was reported to the spine-specialist after an MVA. Similarly, approximately 75% of the subjects were found to have one or more preexisting comorbid conditions at audit that were not reported during the evaluation after the MVA (alcohol abuse, illicit drug use, and psychological diagnosis). For those who perceived that the accident was the fault of another, as opposed to their own or no one's fault, the documented previous back and neck pain troubles in the medical records was more than twice the self-reported rate of these problems (p<.01). The rate of previously documented psychological problems was more than seven times that of the self-reported rate (p = 0.001). In those subjects who perceived that the accident was their own or no one's fault, a lesser degree of under-reporting of axial pain and comorbid conditions was found.

CONCLUSION

The validity of the patient's self-reported history when presenting with persistent axial pain after an MVA appears poor in this large multiclinic random sample.The self-reported rates of alcohol abuse, illicit drug use, and psychological diagnosis, as well as prior axial pain were significantly lower than that seen in the medical records, especially in thosewho perceive that the MVA was another's fault. The failure to recognize this under-reporting may seriously compromise clinical care, public health efforts at injury prevention, and research protocols dependent on accurate pre-accident morbidity assessments.

Valued life activity disability played a significant role in self-rated health among adults with chronic health conditions

OBJECTIVE

Because self-rated health (SRH) is strongly associated with health outcomes, it is important to identify factors that individuals take into account when they assess their health. We examined the role of valued life activities (VLAs), the wide range of activities deemed to be important to individuals, in SRH assessments.

STUDY DESIGN AND SETTING

Data were from three cohort studies of individuals with different chronic conditions--rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and chronic obstructive pulmonary disease (COPD). Each cohort's data were collected through structured telephone interviews. Logistic regression analyses identified factors associated with ratings of fair/poor SRH. All analyses included sociodemographic characteristics, general and disease-specific health-related factors, and general measures of physical functioning.

RESULTS

Substantial portions of each group rated their health as fair/poor (RA 37%, SLE 47%, COPD 40%). In each group, VLA disability was strongly associated with fair/poor health (RA: OR=4.44 [1.86,10.62]; SLE: OR=3.60 [2.10,6.16]; COPD: OR=2.76 [1.30,5.85]), even after accounting for covariates.

CONCLUSION

VLA disability appears to play a substantial role in individual perceptions of health, over and above other measures of health status, disease symptoms, and general physical functioning.

Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis

OBJECTIVE

To review the relation between chronic pain and psychological comorbidities, and the influence on course and prognosis, based on epidemiologic and population studies.

METHOD

We present a narrative overview of studies dealing with the epidemiology of chronic pain associated with mental health and psychiatric factors. Studies were selected that were of good quality, preferably large studies, and those that dealt with prevalences, course and prognosis of chronic pain, risk factors predicting new pain and comorbid disorders, and factors that affect health outcomes.

RESULTS

Chronic pain is a prevalent condition, and psychological comorbidity is a frequent complication that significantly changes the prognosis and course of chronic pain. In follow-up studies, chronic pain significantly predicts onset of new depressions, and depression significantly predicts onset of new chronic pain and other medical complaints. Age, sex, severity of pain, psychosocial problems, unemployment, and compensation are mediating factors in course and prognosis.

CONCLUSION

In assessment of chronic pain, the evidence from epidemiologic studies makes it clear that chronic pain can best be understood in the context of psychosocial factors.

Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents

BACKGROUND CONTEXT

Determining the presence of comorbid conditions in patients with persistent axial pain after motor vehicle accident (MVA) is important to direct appropriate care and as a public health measure against future traffic injuries. In the clinical care of patients after MVA, they are usually asked about previous axial pain problems and relevant comorbid conditions (psychological distress and drug and alcohol abuse). The accuracy of self-reported previous axial pain history and comorbid conditions after MVA has not been systematically evaluated but has been assumed to be high.

PURPOSE

To establish the validity of certain elements of the self-reported history in patients with back or neck pain attributed to an MVA.

STUDY DESIGN

A validation study of crucial elements of the patient history obtained after MVA using internal (chart audit) and external (age- and sex-matched population data) as gold standard references.

PATIENT SAMPLE

Medium-sized (n>400) clinical cohort of patients without fracture or dislocation seen within 3 months after an MVA in a university spine clinic.

OUTCOME MEASURES

Responses to standardized questionnaires included previous back or neck pain, previous psychological distress, previous illicit drug usage, previous alcohol abuse, other chronic pain conditions, perceived fault of the MVA, and whether a compensation claim has been filed.

METHODS

A consecutive cohort of patients seen from 1998 to 2004 for evaluation of back or neck/shoulder pain reportedly caused by an MVA was enrolled. All clinic patients completed standardized questionnaires. The prevalence of self-reported pre-MVA axial pain and at-risk conditions (drug, alcohol, and psychological problems) and control conditions (hypertension and diabetes) were compared against the age- and sex-matched prevalence determined by the 2005 US Department of Health and Human Services National Surveys on Drug Use and Health (external gold standard). Randomly selected previous medical records were also audited (internal gold standard) and compared with post-MVA description of preaccident health.

RESULTS

Four hundred twenty-two subjects were enrolled, and random audits of 100 subjects were completed. In 68% of the random audits, comorbid conditions denied in the postaccident history (previous axial pain, drug or alcohol abuse, and psychological diagnoses) were documented. In subjects perceiving the MVA to be another's fault (but not their own), the reported prevalence of previous axial pain was markedly below matched data for population prevalence and audited data. Similar findings were observed for psychological problems, illicit drug use, and alcohol abuse. In subjects pursuing compensation claims and retaining an attorney, 80% had significant past axial pain history or serious comorbidities in their records not disclosed in the spine clinic evaluation. In subjects reporting that the MVA was either one's "own fault" or "no one's fault," this effect was seen but was smaller in all dimensions.

CONCLUSIONS

In patients being seen for continued pain related to an MVA, the validity of self-reported previous axial pain and comorbid conditions appeared poor. The self-reported prevalence of previous axial pain and drug, alcohol, and psychological problems is much less than the documented prevalence in prior medical records. These rates were also markedly below the expected prevalence in age- and sex-matched populations. This effect was seen most prominently in patients perceiving the accident to be another party's fault and in those filing compensation claims. The failure to appreciate previous axial pain problems and drug, alcohol, and psychological problems may compromise patient care and public health opportunities.

Disabling low back pain and depressive symptoms in the community-dwelling elderly: a prospective study

STUDY DESIGN

Analytic cross-sectional and cohort study.

OBJECTIVE

This study examines the prevalence and associations of low back pain (LBP) and depressive symptoms in a large population of elderly (65+), community-dwelling subjects.

SUMMARY OF BACKGROUND DATA

In adults, depression has been identified as predictive for LBP, while depression has also been found to be a possible consequence of LBP.

METHODS

Data of the Health Outcomes Survey that include a baseline (N = 91,347) and a follow-up survey (N = 55,690) after 2 years were analyzed cross-sectionally and prospectively. Degree of depressive symptoms and disabling LBP were described at both time points, as well as their interrelationships. An ordinal logistic regression analysis was performed to model the effects of different sociodemographic, clinical, and functional variables on LBP and depressive symptoms after 2 years.

RESULTS

Depressive symptoms were found in about 20% of the sample. Baseline depression symptoms increased the odds of disabling LBP after 2 years independently of sociodemographic characteristics, medical, and functional status. Disabling LBP at baseline increased the odds of depressive symptoms after 2 years to a similar degree.

CONCLUSION

Among community-dwelling elderly persons, depressive symptoms and disabling LBP are widespread. Depressive symptoms predict disabling LBP and vice versa. The set of predictors and their extent of contribution to the prognosis are strikingly similar. Research is warranted to identify possible common pathogenic mechanisms or mediating factors.

No health without mental health

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors?

OBJECTIVE

To assess, from the review literature, the extent to which effective strategies for reducing work absence after acute low back pain (LBP) match empirical risk factors.

METHODS

From 17 recent review articles (2000-2005), disability risk factors and interventions were cross-tabulated to assess levels of relative concordance.

RESULTS

Potentially modifiable risk factors included 23 variables describing 3 workplace and 3 personal domains. Effective interventions included 25 strategies that were personal (physical or behavioral), engineering, or administrative in nature. There was a strong risk factor concordance for workplace technical and organizational interventions, graded activity exposure, and cognitive restructuring of pain beliefs. There was less risk factor concordance for exercise, back education, and RTW coordination. Few interventions focused on relieving emotional distress or improving job dissatisfaction, two well-supported risk factors.

DISCUSSION

Gaps between the epidemiological and intervention research of back disability prevention could be reduced by testing mediators of intervention effects or by stratifying outcomes according to pre-intervention risk factors.

Frequency, timing, and course of depressive symptomatology after whiplash

STUDY DESIGN

Population-based incidence cohort.

OBJECTIVE

To report the incidence, timing, and course of depressive symptoms after whiplash.

SUMMARY OF BACKGROUND DATA

Evidence is conflicting about the frequency, time of onset, and course of depressive symptoms after whiplash.

METHODS

Adults making an insurance claim or seeking health care for traffic-related whiplash were followed by telephone interview at 6 weeks, and 3, 6, 9, and 12 months post-injury. Depressive symptoms were assessed at baseline and at each follow-up.

RESULTS

Of the 5,211 subjects reporting no pre-injury mental health problems, 42.3% (95% confidence interval, 40.9-43.6) developed depressive symptoms within 6 weeks of the injury, with subsequent onset in 17.8% (95% confidence interval, 16.5-19.2). Depressive symptoms were recurrent or persistent in 37.6% of those with early post-injury onset. Pre-injury mental health problems increased the risk of later onset depressive symptoms and of a recurrent or persistent course of early onset depressive symptoms.

CONCLUSIONS

Depressive symptomatology after whiplash is common, occurs early after the injury, and is often persistent or recurrent. This suggests that, like neck pain and headache, depressed symptomatology is part of the cluster of acute whiplash symptoms. Clinicians should be aware of both physical and psychologic injuries after traffic collisions.

Neighbourhood income and anxiety: a study based on random samples of the Swedish population

BACKGROUND

Few studies have investigated the association between the neighbourhood characteristics and the vast panorama of mental disorders. This study examined whether there is an association between neighbourhood income and anxiety, a common mental disorder.

METHODS

A national random sample of the entire Swedish population was used, consisting of 30 884 men and women aged 25-64 years. The sample was obtained from pooled data during the period 1995-2002 from the Swedish Annual Level of Living Survey. Small area market statistics were used in order to define neighbourhoods. The proportion of individuals with incomes in the lowest national income quartile was calculated for each neighbourhood. The distribution was then divided into quartiles. A log binomial model was applied in the estimation of prevalence ratios. Four models were calculated with stepwise inclusion of the variables. Model 4 was adjusted for all the individual variables, i.e. age, gender, marital status, immigrant status, social network, housing tenure, employment status, and income.

RESULTS

In neighbourhoods with the highest proportions of individuals with low income the prevalence ratio of anxiety was 1.33 (95% confidence interval 1.24-1.42). The association demonstrated between neighbourhood income and anxiety decreased after stepwise inclusion of the individual variables and disappeared after all the individual variables were accounted for.

CONCLUSION

Compositional explanations, rather than contextual explanations, lie behind the association between neighbourhood income and anxiety, a common mental disorder. However, we do not exclude the possibility that there is a contextual effect on severe mental disorders or among children with behavioural problems.

Incidence and course of low back pain episodes in the general population

STUDY DESIGN

Population-based, prospective cohort.

OBJECTIVES

To estimate incidence and course of severity-graded low back pain (LBP) episodes in adults.

SUMMARY OF BACKGROUND DATA

Past studies report variable estimates that do not differentiate LBP severity.

METHODS

An incidence cohort of 318 subjects free of LBP and a course cohort of 792 prevalent cases was formed from respondents to a mailed survey. Incident, recurrent, persistent, aggravated, improved, and resolved episodes were defined by the Chronic Pain Questionnaire. The follow-up at 6 and 12 months was 74% and 62%, respectfully. Annual estimates were age and sex standardized.

RESULTS

The cumulative incidence was 18.6% (95% confidence interval [CI], 14.2%-23.0%). Most LBP episodes were mild. Only 1.0% (95% CI, 0.0%-2.2%) developed intense and 0.4% (95% CI, 0.0%-1.0%) developed disabling LBP. Resolution occurred in 26.8% (95% CI, 23.7%-30.0%), and 40.2% (95% CI, 36.7%-43.8%) of episodes persisted. The severity of LBP increased for 14.2% (95% CI, 11.5%-16.8%) and improved for 36.1% (95% CI, 29.7%-42.2%). Of those that recovered, 28.7% (95% CI, 21.2%-36.2%)had a recurrence within 6months,and 82.4% of it was mild LBP. Younger subjects were less likely to have persistent LBP (incidence rate ratio, 0.88; 95% CI, 0.80-0.97) and more likely to have resolution (incidence rate ratio, 1.26; 95% CI, 1.02-1.56).

CONCLUSIONS

Most new and recurrent LBP episodes are mild. Less than one third of cases resolve annually, and more than 20% recur within 6 months. LBP episodes are more recurrent and persistent in older adults.

The prognosis of minor depression in the general population: a systematic review

Minor depression is common in the general population. There is no consensus about prognostic indicators that can identify people at high and low risk of chronicity. We systematically reviewed the available literature on the prognosis of minor depression in the general population and identified five studies. Two of these were considered to be of relatively high methodological quality. There was a wide variety among the studies in the definitions of minor depression, the characteristics of the study population, length of follow-up and type of outcome measure. The results show that the majority of people with minor depression have a favorable prognosis; 46-71.4% achieve remission after a follow-up of 1-6 years. However, 16-62.3% still have a minor depression after 5 months to 1 year of follow-up, suggesting that for many people minor depression is chronic or recurrent; 12.7-27% develop a more severe form of depression; they were diagnosed with dysthymia or major depression after 1-6 years of follow-up. There was inconsistent evidence regarding mortality and functional impairment. No study presented results of prognostic factors, so it remains unclear which people have a more favorable course than others. The results of our review need to be interpreted with caution because of the small number of studies and the large heterogeneity among studies.

Urbanisation and incidence of psychosis and depression: follow-up study of 4.4 million women and men in Sweden

BACKGROUND

Previous studies of differences in mental health between urban and rural populations are inconsistent.

AIMS

To examine whether a high level of urbanisation is associated with increased incidence rates of psychosis and depression, after adjustment for age, marital status, education and immigrant status.

METHOD

Follow-up study of the total Swedish population aged 25-64 years with respect to first hospital admission for psychosis or depression. Level of urbanisation was defined by population density and divided into quintiles.

RESULTS

With increasing levels of urbanisation the incidence rates of psychosis and depression rose. In the full models, those living in the most densely populated areas (quintile 5) had 68-77% more risk of developing psychosis and 12-20% more risk of developing depression than the reference group (quintile 1).

CONCLUSIONS

A high level of urbanisation is associated with increased risk of psychosis and depression for both women and men.