Psychiatric morbidity in primary public health care: a Nordic multicentre investigation. Part I: method and prevalence of psychiatric morbidity

A systematic review on the effect of routine outcome monitoring and feedback on client outcomes in alcohol and other drug treatment

ISSUES

Routine outcome monitoring (ROM) involves regularly measuring clients' outcomes during treatment, which can then be fed back to clinicians and/or clients. In the mental health field, ROM and feedback have been shown to improve client outcomes; however, no systematic reviews have examined whether improvement is also seen in alcohol and other drug (AOD) treatment outcomes. This review examines whether feedback to clients and/or clinicians of ROM data in AOD treatment improves future client outcomes.

APPROACH

This systematic review of papers identified in Medline, PsycInfo and Scopus examines the effect on client outcomes of feeding back ROM data to clinicians and/or clients in AOD treatment settings. Key client outcomes included substance use, treatment attendance and wellbeing measures.

KEY FINDINGS

Ten studies were included-five randomised controlled trials and five pre-post within-subjects designs. Six studies were deemed good- or fair-quality. Of these six, three provided feedback to clinicians only, one to clients only, and two to both clients and clinicians. Only one of the six found feedback was associated with significant reductions in substance use and only among off-track clients. Four of the six found feedback improved other outcomes, including treatment retention, global functioning, therapeutic alliance and mood symptoms.

CONCLUSIONS

There may be some positive effects for clients of providing feedback to clients and/or clinicians; however, the small number of randomised trials and the heterogeneity of methods, outcome measures and findings, mean that firm conclusions cannot be drawn about the efficacy of feedback until larger randomised studies are conducted.

A very short Symptom Checklist-90-R version for routine outcome monitoring in psychotherapy; The SCL-3/7

OBJECTIVE

Routine outcome monitoring (ROM) is applied in many physical and mental health treatments. The treatment course is monitored with patient reported outcome measures (PROMs). A potential problem with PROM is response burden. This can be decreased by presenting such measures with less and better selected items. The SCL-90-R is an often used PROM for psychotherapies and a number of very short forms have been developed; the SCL-5, SCL-8, SCL-9 and SCL-10. This study aims to develop a new very short form, the symptom checklist 3 out of 7 (SCL-3/7) and to evaluate the effectiveness of these PROM with the precision relative to the complete SCL-90-R score.

METHODS

Item Response Theory analysis was applied to select the 7 best discriminating items, evenly distributed over the latent trait. A routing serves that patients only need to administer 3 items.

RESULTS

In a sample of 15,055 cases, the relative precisions of the SCL-3/7 were best for outpatients (122.7%), day care patients (111.8%) and inpatients (108.3). The SCL-5 was best for juvenile patients (110.0%), and the SCL-9 was best for addicted patients (107.2%).

CONCLUSION

The SCL-3/7 decreases patient burden in ROM and has a better precision in adult therapies than other SCL-90 short forms.

Associations between Risk Factors in Late Adolescence and Problem Behaviors in Young Adulthood: A Six-Year Follow-Up of Substance Related and Behavioral Addictions in Swedish High School Seniors

INTRODUCTION

Risk factors of traditional substance use related problems in young adults are more well-known than for behavioral addictions such as gambling and gaming problems. The present study aims to provide knowledge about the longitudinal patters of substance use related and behavioral addictions in early adulthood.

METHODS

Using self-report surveys, substance-related, psychiatric, and demographic predictors were assessed in Swedish high school seniors and re-assessed six years later along with gambling and gaming problems, n = 800. Associations (Risk Ratios) between risk factors in late adolescence and problem behaviors in young adulthood were analyzed.

RESULTS

Tobacco use, illicit drug use, and hazardous drinking in young adulthood were associated with tobacco use, illicit drug use, alcohol use, conduct problems, and impaired impulse control in late adolescence. Gambling problems in young adulthood were only associated with heredity of alcohol problems, while gaming was not associated to any problem behavior in late adolescence.

CONCLUSION

It is concluded that predictors for traditional substance-related addictions differ from predictors for behavioral addictions, and that this difference is more pronounced for gaming problems than for gambling problems.

Daily Automated Telephone Assessment and Intervention Improved 1-Month Outcome in Paroled Offenders

This randomized trial evaluates whether automated telephony could be used to perform daily assessments in paroled offenders (N = 108) during their first 30 days after leaving prison. All subjects were called daily and answered assessment questions. Based on the content of their daily assessments, subjects in the intervention group received immediate feedback and a recommendation by automated telephony, and their probation officers also received a daily report by email. The outcome variables were analyzed using linear mixed models. The intervention group showed greater improvement than the control group in the summary scores (M = 9.6, 95% confidence interval [CI] = [0.5, 18.7], p = .038), in mental symptoms (M = 4.6, CI = [0.2, 9.0], p = .042), in alcohol drinking (M = 0.8, CI = [0.1, 1.4], p = .031), in drug use (M = 1.0, CI = [0.5, 1.6], p = .000), and in most stressful daily event (M = 1.9, CI = [1.1, 2.7], p = .000). In conclusion, automated telephony may be used to follow up and to give interventions, resulting in reduced stress and drug use, in paroled offenders.

Gender Differences in Prevalence of Somatoform Disorders in Patients Visiting Primary Care Centers

The aim of this study was to examine the gender differences in the prevalence of somatoform disorders among a sample of Qatari patients who were visiting primary health care centers and to investigate the severity of diagnostic categories and the most frequent somatic symptoms in these patients. The first stage of the study was conducted with the help of general practitioners, using the somatic symptom module of the Patient Health Questionnaire 12-item General Health Questionnaire. Overall, 2320 subjects were approached, and a total of 1689 patients, of whom 892 were men and 797 were women, agreed to participate in the study. The prevalence rate of somatoform disorders among the total screened sample was 23.9%. The prevalence rate was slightly higher in Qatari women (24.2%) than in Qatari men (23.7%). Housewives (43.5%) and men in administrative posts (37.9%) reported higher somatic symptoms compared to other professions. Prolonged depressive reaction was significantly higher in women compared to men ( P = .003). There was a significant gender difference in certain psychiatric diagnostic categories such as depressive episode, recurrent depressive disorder, dysthymia, and brief depressive reaction. Backache was the most common reported symptom in men, whereas headache was more common in women. The present study revealed that the prevalence of somatoform disorders in Qatar is as high as the overall prevalence reported in prior studies done in other primary care settings. The prevalence of somatoform disorders was slightly higher in Qatari women than in men.

Interactive Voice Response with Feedback Intervention in Outpatient Treatment of Substance Use Problems in Adolescents and Young Adults: A Randomized Controlled Trial

PURPOSE

Substance use disorders and problematic substance use are common problems in adolescence and young adulthood. Brief personalized feedback has been suggested for treatment of alcohol and drug problems and poor mental health. This repeated measurement randomized controlled trial examines the effect of an interactive voice response (IVR) system for assessing stress, depression, anxiety and substance use.

METHODS

The IVR system was used twice weekly over 3 months after treatment initiation, with or without addition of a personalized feedback intervention on stress and mental health symptoms. Both IVR assessment only (control group) and IVR assessment including feedback (intervention group) were provided as an add-on to treatment-as-usual procedures (TAU) in outpatient treatment of substance use problems in adolescents and young adults (N = 73).

RESULTS

By using a mixed models approach, differences in change scores were analyzed over the three-month assessment period. Compared to the control group, the intervention group demonstrated significantly greater improvement in the Arnetz and Hasson stress score (AHSS, p = 0.019), the total Symptoms Checklist 8 score (SCL-8D, p = 0.037), the SCL-8D anxiety sub-score (p = 0.017), and on a summarized feedback score (p = 0.026), but not on the depression subscale. There were no differences in global substance use scores between the intervention group (feedback on mental health symptoms) and the control group.

CONCLUSION

In conclusion, IVR may be useful for follow-up and repeated interventions as an add-on to regular treatment, and personalized feedback could potentially improve mental health in adolescents and young adults with problematic substance use.

Daily Assessment of Acute Dynamic Risk in Paroled Offenders: Prediction, Predictive Accuracy and Intervention Effect

Few studies have assessed acute dynamic risk repeatedly among paroled offenders to investigate the relationship between changes in acute dynamic risk and recidivism in crime. The present study investigates whether one-month changes in ten stress-related acute dynamic risk factors, collected through automated telephony while the participants were still in prison and over 30 consecutive days following parole, predict one-year criminal recidivism, including its predictive accuracy. The study also investigates whether a brief feedback intervention in conjunction with the daily assessments reduces recidivism compared to an assessment-only control group. Changes in five risk factors were found to be associated with increased risk of criminal recidivism after controlling for the results in prison, the initial value after parole, and the intervention. The predictive accuracy is marginally accurate: Summary score (AUC) = .666; Level of stress (AHSS) = .644; Psychiatric symptoms (SCL-8D) = .641; Anxiety symptoms = .673; Severity of most stressful daily event = .690. No differences in one-year recidivism rates were established between the intervention group and the control group. The study shows that daily assessments can usefully be made of dynamic risk factors in paroled offenders.

Work characteristics and morbidity as predictors of self-perceived health status in Norwegian physicians

Aims: The purpose of this study was to assess whether work characteristics and morbidity are predictors of physical, psychological, and social functioning in physicians. Methods: A cross-sectional study was undertaken of 1,126 Norwegian physicians. For comparison of health status scores, the Short Form 36 questionnaire was used, adjusting for differences in age and gender where applicable. Somatic morbidity was classified on the basis of self-reported conditions and psychiatric morbidity with score on the 25-item Hopkins symptom checklist using a cut-off indicating clinical psychiatric disease. Multiple logistic regression analysis was used with SF-36 dimension score below/above the 10th percentile as the dependent variable. Results: In the multivariate model, psychiatric comorbidity was a significant predictor in 7 of 8 dimensions of health status (odds ratio 0.17 to 0.49), and somatic comorbidity in 6 of 8 dimensions of health status (odds ratio 0.33 to 0.59). Working hours was a significant predictor of only one dimension of health status, general health, after adjustment for demographic and work-related variables. Conclusions: The most important predictors for most dimensions of health status among Norwegian physicians were the presence or absence of self-reported somatic or psychiatric morbidity, while working hours, choice of specialty, and position were less important.

[(Expected) Consultation length, mental (co-)morbidity and patient satisfaction in the family practice encounter]

INTRODUCTION

Mental disorders are common in family practice, but their meaning for variables of consultation is rarely considered. Thus, we examined the influence of mental disorders on patients' expectations regarding time, openness and seriousness as well as ratings of satisfaction with the consultation.

METHODS

Prior to consultation for 219 patients a screening for anxiety (GAD-7), depression (PHQ-9) and hypochondriasis (WI-7) was performed. Before and after the consultation patient expectations and ratings were recorded. Subgroup analysis was based on Mann-Whitney U tests.

RESULTS

Almost half of the sample were screen-positive. Prior the consultation, screen positive patients had higher ratings for expectations compared with screen negative patients, but did not differ in their experiences after the consultation. There was no association between consultation length and ratings for satisfaction.

DISCUSSION

Patients screened positive for mental disorders do not necessarily require longer consultation length, if their expectations regarding openness and seriousness are met. This is underlines the importance of communication skills in undergraduate medical education and specialist training for future GPs.

Physical symptom attributions: a defining characteristic of somatoform disorders?

OBJECTIVES

We examined whether primary care patients were more likely to perceive a current health problem as 'physical illness only' as opposed to entailing psychological difficulties if they had a comorbid somatoform disorder compared to patients who had (a) both comorbid somatoform disorder and anxiety/depression or (b) comorbid anxiety and/or depression, and a reference group of (c) patients with well-defined physical disease. We examined whether attributions predicted future health expenditures.

METHODS

A total of 1209 of 1785 patients completed questions on patient-perceived illness. The physicians diagnosed the current health problem. A stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. Health expenditure was obtained from registers for a 2-year period.

RESULTS

The belief that the current health problem was only physical was endorsed by 86% of patients presenting physical disease, 58% of patients with somatoform disorders, 29% of patients with both somatoform disorders and anxiety/depression and 24% of patients with anxiety or depressive disorders (χ2=269.2, df=3, P<.0001). In a multiple regression model, a 'physical illness only' perception predicted lower health expenditures [β = -0.31, 95% confidence interval (-0.55; -0.07), P=.013].

CONCLUSIONS

The prevalent assumption that physical symptom attributions are a central aspect in somatoform disorders is not supported by the current study.

Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study

OBJECTIVE

The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD).

METHOD

Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained.

RESULTS

At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave.

CONCLUSIONS

Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

Association of depressiveness with chronic facial pain: a longitudinal study

OBJECTIVE

Depression and pain are often co-morbid. Temporomandibular disorders (TMD) include facial pain as one main symptom. Reports are lacking on the association between chronic facial pain and earlier depressiveness. The aim of the study was to investigate whether depressiveness increases the risk for chronic facial pain in a longitudinal population-based study.

MATERIALS AND METHODS

Subjects included in the Northern Finland Birth Cohort 1966 (n = 5696) answered a questionnaire on facial pain and depressiveness using the Symptom Checklist-25 depression sub-scale at the age of 31 years. In addition, reported depression diagnosed by a doctor was enquired about. Three years later a sub-sample of the cohort, including 63 cases with chronic facial pain and 85 pain-free controls, was formed based on the question concerning facial pain.

RESULTS

Of the chronic facial pain cases 17.5% and of the pain-free controls 7.1% were depressive 3 years earlier at baseline (p = 0.050, χ(2) test, crude OR = 2.8, 95% CI = 1.0-8.0). Of the chronic facial pain cases 6.3% and of the pain-free controls 1.2% reported having had diagnosed depression (p = 0.085, crude OR = 5.7, 95% CI = 0.6-52.2). After adjusting the gender, the association between depressiveness reported at the baseline and chronic facial pain was significant (OR = 4.2, 95% CI = 1.1-16.2). When widespread pain was included in the analysis, the association was not significant.

CONCLUSIONS

Depressiveness increases the risk for chronic facial pain in a 3-year follow-up. This association seems to be mediated through widespread pain.

Prevalence and predictors of health care use in patients with early hip or knee osteoarthritis: two-year follow-up data from the CHECK cohort

OBJECTIVE

To describe health care utilization (HCU) and predict analgesic use and health professional (HP) contact at baseline and 2 years in individuals with early symptomatic hip and/or knee osteoarthritis (OA).

DESIGN

Baseline and two-year data on HCU of the 1002 participants from the multi-centre Cohort Hip & Cohort Knee study were used. Six forms of health care services were described: analgesic use, supplement use, contact with a General Practitioner (GP), contact with a HP, contact in secondary care, and alternative medicine use. Multivariable logistic regression was performed in order to identify predisposing, enabling and disease-related variables that predict analgesic use and HP contact at 2 years; treatment modalities of first choice in early OA.

RESULTS

For the hip (n=170), the knee (n=414) and the hip and knee (n=418) group analgesic use (38%, 29% and 47%, respectively), contact with a GP (32%, 38% and 36%, respectively) and contact with a HP (26%, 18% and 20%, respectively), were reported most often at baseline. Contact with a GP significantly decreased, supplement use increased (to about one third), and other treatment modalities remained stable at 2 years. In all three groups, analgesic use at baseline was the strongest predictor for analgesic use at 2 years, whereas contact with a HP at baseline was the strongest predictor of contact with a HP after 2 years. Belonging to a first generation minority was a predisposing risk factor [Odds Ratio (95%-CI), 8.72 (1.55-48.97)] for analgesic use in the hip and knee group.

CONCLUSIONS

In early OA, familiarity with HCU and other predisposing factors are, apart from disease-related factors strongly associated with HCU at 2 years. Further research is necessary to examine whether our findings reflect sub-optimal management of early OA in terms of efficacy and equity.

Predicting depression with psychopathology and temperament traits: the northern Finland 1966 birth cohort

We studied the concurrent, predictive, and discriminate validity of psychopathology scales (e.g., schizotypal and depressive) and temperament traits for hospitalisations due to major depression. Temperament, perceptual aberration, physical and social anhedonia, Depression Subscale of Symptom Checklist (SCL-D), Hypomanic Personality Scale, Schizoidia Scale, and Bipolar II Scale were completed as part of the 31-year follow-up survey of the prospective Northern Finland 1966 Birth Cohort (n = 4941; 2214 males). Several of the scales were related to depression. Concurrent depression was especially related to higher perceptual aberration (effect size when compared to controls, d = 1.29), subsequent depression to high scores in SCL-D (d = 0.48). Physical anhedonia was lower in subjects with subsequent depression than those with other psychiatric disorders (d = -0.33, nonsignificant). Participants with concurrent (d = 0.70) and subsequent (d = 0.54) depression had high harm avoidance compared to controls, while differences compared to other psychiatric patients were small. Subjects with depression differed from healthy controls in most of the scales. Many of the scales were useful predictors for future hospital treatments, but were not diagnosis-specific. High harm avoidance is a potential indicator for subsequent depression.

The relationship between cognitive functions, somatization and behavioural coping in patients with multiple functional somatic symptoms

BACKGROUND AND AIMS

Patients with multiple functional somatic symptoms (MFS) often express cognitive complaints. The aim of this descriptive study was to investigate whether these patients have cognitive deficits and whether the patients' cognitive functioning relates to their experience of physical and psychological distress and to their use of pain-related coping strategies.

METHODS

Neuropsychological assessment of verbal ability, psychomotor speed, attention, working memory, perceptual organization and memory, was conducted on 22 MFS patients and 27 healthy age- and gender-matched controls. Psychological distress, health anxiety, health status and pain coping were measured with questionnaires [Symptom Checklist 90-Revised (SCL-somatization, SCL-depression, SCL-anxiety), the Whiteley-7 scale, the Short Form (SF-36) and the Coping Strategies Questionnaire (CSQ)].

RESULTS

For patients, a high score on the SCL-somatization subscale was associated with poor performance on tests of attention and psychomotor speed, and with a high score on the coping scale Increasing behavioural activities. A high score on this coping scale was associated with poor performance on tests of verbal ability and executive functioning. After controlling for years of education, controls performed significantly better than patients on verbal as well as performance IQ scales but not on tests of memory.

CONCLUSION

In the present study, we found that physical complaints are related to deficits in attention and psychomotor speed. Moreover, our results suggest that poor verbal skills may play a role in the development of MFS because of an increased tendency to apply behavioural/avoidant coping strategies. We suggest that treatment of MFS should involve training of attention as well as practicing the use of cognitive coping strategies.

Distress and psychosocial needs of a heterogeneous high risk familial cancer population

In order to assess the levels of distress and psychosocial support needs of a high risk population, we undertook a study to look at both the objective and subjective levels of distress and the wants and needs of individuals from a high familial cancer risk population. Three hundred and eighteen individuals (160 affected, 158 unaffected) completed several distress and psychosocial needs questionnaires (including the Brief Symptom Inventory-18). Sixty key informants were also surveyed about their perspective on the support needs of this population. In the largely female (90%), largely HBOC syndrome group (approximately 90%), 20% had significant levels of generalized distress, with no significant differences between affected and unaffected individuals. Generalized distress was also not significantly different as a function of mutation status. Individuals who received inconclusive test results, however, were more likely to indicate somatic symptoms of distress. Those individuals who did not have social support were more likely to be those who had never had cancer and who either had a mutation, received inconclusive test results, or were not tested. Key informants were most likely to indicate that patients need more support. These results provide evidence for the importance of establishing regular psychosocial distress screening, including a focus on somatic symptoms, in such high risk populations.

A comparison of the Major Depression Inventory (MDI) and the Beck Depression Inventory (BDI) in severely depressed patients

BACKGROUND

We set out to examine the psychometric properties of the MDI in comparison to the BDI in a mixed group of patients with primary depression.

METHODS

At the Department of Biological Psychiatry in Vienna currently depressed inpatients with either a depressive or a schizo-affective disorder filled out both MDI and BDI on day of admission and at a time-point two weeks later during their treatment. Furthermore the Hamilton Depression Scale (HAM-D) was administered by the treating clinician at both time-points.

RESULTS

In total, 51 patients were included in the study. The non-parametric item response analysis was preferred to the classical Cronbach coefficient α as the latter is influenced by the number of items in a questionnaire. MDI obtained a Mokken analysis coefficient above 0.40, indicating unidimensionality. To determine external validity severely depressed patients with psychotic symptoms (N = 10) were compared to the remaining non-psychotic depressed patients (N = 41). Although BDI and MDI showed a lower score for psychotic than for non-psychotic inpatients, the standard deviations for both were greater for psychotic inpatients. On the intercorrelations between the different scales, MDI showed for all coefficients values above 0.70. On the other hand BDI and MDI both showed the same degree of linear relationship as the usual versions of HAM-D.

CONCLUSION

Our results demonstrate that the MDI had the highest coefficients values and was sufficient as a measure for depressive disorders in psychiatric patients.

Mental health in the workforce: an occupational psychiatric study

BACKGROUND

Prevalence of mental disorders at work is commonly reported on the subclinical level. Data on clinical caseness as to ICD-10 among employees is scarce.

AIMS

(i) To establish the prevalence of psychiatric morbidity in the Danish workforce in large enterprises based on a self-report measure. (ii) To verify the screening results by use of a structured diagnostic interview. (iii) To analyze associations with demographics and work- and health-related characteristics.

METHODS

A two-phase design study was carried out in three Danish counties. Ten large enterprises within private and public sectors participated. A questionnaire was administrated to 1,500 employees. The Present State Examination (PSE) interview was conducted with selected respondents according to their scores on Symptom Checklist 90-revised (SCL-90R) and CAGE.

RESULTS

Nine hundred and seventy six (65%) employees responded. A large proportion (28.6%) was identified as sub-cases and 77 as cases as to ICD-10. Absenteeism and work dissatisfaction were associated with ICD-10 diagnoses.

CONCLUSIONS

Common mental disorders caseness as to ICD-10 provides evidence for the clinical nature of occupational mental health phenomena. There were strong associations between some demographic and work- and health-related factors.

The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.

Stress and hazardous alcohol use: Associations with early dropout from university

Background: The transition to studying at university is associated with increased levels of both stress and hazardous alcohol use. The aim of this study is to investigate the influence of these factors on first-year dropout from university studies. Methods: Two complete cohorts of university freshmen at two homogeneous universities, one in the north and one in the south of Sweden, were asked to participate in an intervention study. Participants responded to a baseline questionnaire including measures of stress and alcohol use. Official university records showing dropout over 12 months were collected. Results: A multivariate analysis established that high stress and admission to the northern university were associated with dropout from university studies, while symptoms of depression and anxiety as well as hazardous drinking were not. Conclusions: There is a need to address the issue of stress associated with the start of university studies. It seems important to offer stress-reducing interventions, specifically aimed at reducing transitional stress, as soon as students start university.

Intervention for hazardous alcohol use and high level of stress in university freshmen: a comparison between an intervention and a control university

BACKGROUND

The first year of university studies is associated with increased levels of alcohol drinking and stress. This study examines the one-year outcome of both primary and secondary interventions of one alcohol programme and one stress intervention programme at an intervention university in comparison with a control university.

METHODS

At the intervention university all freshmen were offered a primary prevention programme for hazardous alcohol use and stress management and, in addition, those who had high ratings for stress and/or hazardous alcohol use were offered a secondary intervention programme for alcohol consumption and/or stress management. Freshmen still attending the two universities one year later responded to follow-up questionnaires.

RESULTS

The primary alcohol and stress interventions were associated with lower alcohol expectancies and mental symptoms, but no differences in AUDIT scores (-0.2, CI 95% -0.5 to 0.1), estimated blood alcohol concentrations or stress in comparison to freshmen at the control university. The secondary alcohol interventions were associated with decreased AUDIT (-1.1, CI 95% -2.0 to -0.2) as well as alcohol expectancies, blood alcohol concentrations, stress and mental symptoms in comparison to high-risk freshmen at the control university. The secondary stress interventions were associated with decreased mental symptoms and alcohol expectancies, but not stress, AUDIT scores (-0.6, CI 95% -1.4 to 0.2) and blood alcohol concentrations in comparison to high-risk freshmen at the control university.

CONCLUSION

This study suggests that both primary and secondary alcohol and stress interventions have 1-year effects in university freshmen and could be implemented in university settings.

Measurement properties of the Arnetz and Hasson stress questionnaire in Swedish university freshmen

BACKGROUND

The aim of this study was to evaluate the measurement properties of the Arnetz and Hasson seven-item stress questionnaire in order to select high-risk freshmen for a stress and alcohol intervention research project.

METHODS

Two complete cohorts of university freshmen at two universities were asked to participate in an intervention study. All subjects responded to seven Visual Analogue Scales (VAS) measuring common areas associated with stress. Measurement properties were evaluated by analysing internal consistency and construct validity.

RESULTS

A total of 2,032 (72%) freshmen agreed to participate. In total 14,184 out of 14,224 (99.7%) of the Visual Analogue Scales were answered. The Chronbach's alpha coefficient for the complete scale was 0.787. The Varimax rotation factor analysis, using an eigen value of 1, resulted in one factor that covered all items with factor scores of 0.50 and over. This factor explained 46% of the variance. A logistic regression analysis established that mental symptoms, living outside a serious relationship, and female gender were associated with a high stress level.

CONCLUSIONS

The Arnetz and Hasson stress questionnaire is easy to use and offers sufficient internal consistency and construct validity.

Cross-cultural patterns in college student drinking and its consequences--a comparison between the USA and Sweden

AIMS

The aim of the study was to compare alcohol use, consequences and common risk factors between American and Swedish college students.

METHODS

A secondary comparative analysis from one American and two Swedish studies in college settings.

RESULTS

Swedish freshmen report higher alcohol use than US freshmen students. Swedish residence hall students report higher alcohol use than US residence hall students, but lower than American fraternity/sorority members. US students were less likely to be drinkers. Controlling for age, country moderated the relationship between family history and harmful drinking scores for women (stronger in the USA), and between expectancies and harmful drinking scores for men (stronger in Sweden), though in both cases this represented a small effect and patterns were similar overall.

CONCLUSIONS

Swedish students are at higher risk for alcohol use than US students, but similar patterns between aetiological predictors and outcomes in both countries suggest that research from the USA is generalizable to Swedish students and vice versa. More research is needed to better understand unique relationships associated with age and family history.

CHECK (Cohort Hip and Cohort Knee): similarities and differences with the Osteoarthritis Initiative

OBJECTIVE

To describe the osteoarthritis study population of CHECK (Cohort Hip and Cohort Knee) in comparison with relevant selections of the study population of the Osteoarthritis Initiative (OAI) based on clinical status and radiographic parameters.

METHODS

In The Netherlands a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association on participants with early osteoarthritis-related complaints of hip and/or knee: CHECK. In parallel in the USA an observational 4-year follow-up study, the OAI, was started by the National Institutes of Health, on patients with or at risk of symptomatic knee osteoarthritis. For comparison with CHECK, the entire cohort and a subgroup of individuals excluding those with exclusively hip pain were compared with relevant subpopulations of the OAI.

RESULTS

At baseline, CHECK included 1002 participants with in general similar characteristics as described for the OAI. However, significantly fewer individuals in CHECK had radiographic knee osteoarthritis at baseline when compared with the OAI (p<0.001). In contrast, at baseline, the CHECK cohort reported higher scores on pain, stiffness and functional disability (Western Ontario and McMaster osteoarthritis index) when compared with the OAI (all p<0.001). These differences were supported by physical health status in contrast to mental health (Short Form 36/12) was at baseline significantly worse for the CHECK participants (p<0.001).

CONCLUSION

Although both cohorts focus on the early phase of osteoarthritis, they differ significantly with respect to structural (radiographic) and clinical (health status) characteristics, CHECK expectedly representing participants in an even earlier phase of disease.

Screening and diagnosing depression in women visiting GPs' drop in clinic in Primary Health Care

Background

Only half of all depressions are diagnosed in Primary Health Care (PHC). Depression can remain undetected for a long time and entail high costs for care and low quality of life for the individuals. Drop in clinic is a common form of organizing health care; however the visits are short and focus on solving the most urgent problems. The aim of this study was to investigate the prevalence and severity of depression among women visiting the GPs' drop in clinic and to identify possible clues for depression among women.

Methods

The two-stage screening method with "high risk feedback" was used. Beck's Depression Inventory (BDI) was used to screen 155 women visiting two GPs' drop in clinic. Women who screened positive (BDI score ≥10) were invited by the GP to a repeat visit. Major depression (MDD) was diagnosed according to DSM-IV criteria and the severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). Women with BDI score <10 constituted a control group. Demographic characteristics were obtained by questionnaire. Chart notations were examined with regard to symptoms mentioned at the index visit and were categorized as somatic or mental.

Results

The two-stage method worked well with a low rate of withdrawals in the second step, when the GP invited the women to a repeat visit. The prevalence of depression was 22.4% (95% CI 15.6–29.2). The severity was mild in 43%, moderate in 53% and severe in 3%. The depressed women mentioned mental symptoms significantly more often (69%) than the controls (15%) and were to a higher extent sick-listed for a longer period than 14 days. Nearly one third of the depressed women did not mention mental symptoms. The majority of the women who screened as false positive for depression had crisis reactions and needed further care from health professionals in PHC. Referrals to a psychiatrist were few and revealed often psychiatric co-morbidity.

Conclusion

The prevalence of previously undiagnosed depression among women visiting GPs' drop in clinic was high. Clues for depression were identified in the depressed women's symptom presentation; they often mention mental symptoms when they visit the GP for somatic reasons e.g. respiratory infections. We suggest that GPs do selective screening for depression when women mention mental symptoms and offer to schedule a repeat visit for follow-up rather than just recommending that the patient return if the mental symptoms do not disappear.

Use of real-time interactive voice response in a study of stress and alcohol consumption

BACKGROUND

The goal of this study was to investigate whether Interactive Voice Response is a technology with which to perform real-time assessments of alcohol consumption and stress.

METHODS

Fifteen subjects (men and women) were recruited from a previous 4-year intervention study (n = 2,032). The Interactive Voice Response technique was based on mobile telephones. During 1 week, stress and alcohol were measured automatically 3 times daily. In addition, the subjects called the system at the start of the drinking session, and an automated hourly contact was established for the drinking period.

RESULTS

Of the data collection calls, 305 (97%) were answered. Real-time drinking was assessed 9 times of 9 (100%). The average length of the IVR assessment was only 28 seconds because of modified technology. Individuals with an estimated blood alcohol concentration above 0.1% under-reported drinking in their day-after reports by between 1 and 10 drinks. The same subjects had more pronounced stress reduction than those with lower BAC levels.

CONCLUSION

Interactive Voice Response methodology offers a promising new technology for daily as well as real-time assessments.

Patients' written life stories: a gateway for understanding

OBJECTIVE

To explore how statements drawn from patients' written life stories can help general practitioners understand their patients' maladaptive thought patterns and their negative schemata.

DESIGN

Qualitative study of written life stories.

SETTING

General practice in Copenhagen, Denmark.

SUBJECTS

A total of 22 consecutive patients aged 23-49 years, who were invited by their GP to participate in cognitive therapy owing to depressive or anxiety-related disorders, including unexplained bodily symptoms.

THEORETICAL FRAME OF REFERENCE

Beck's information-processing model of anxiety.

RESULTS

Analysis of the written life stories disclosed aspects of negative expectations of life, the self, or the values and capabilities of others or of the patient him- or herself. Three main beliefs were identified: (1) the world is evil, (2) only the perfect is of value, and (3) emotions are dangerous. The patients describe events and experiences in negative terms that others might have interpreted as neutral or positive. For some this translated into a sort of all-or-nothing kind of thinking. Anger and other strong feelings were forbidden. Responsibility for the life of others was a dominant feature.

CONCLUSIONS

Written life stories reveal knowledge of the patient's dysfunctional thought patterns. This may be a useful shortcut in therapy.

Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study

OBJECTIVE

Little is known about whether illness perceptions affect health outcomes in primary care patients. The aim of this study was to examine if patients' illness perceptions were associated with their self-rated health in a 2-year follow-up period.

METHODS

One thousand seven hundred eighty-five primary care patients presenting a new or recurrent health problem completed an adapted version of the illness perception questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline and 3, 12, and 24 months' follow-up. Linear regressions were performed for (1) all patients, (2) patients without chronic disorders presenting physical disease, and (3) patients presenting medically unexplained symptoms (MUS).

RESULTS

Negative illness perceptions were associated with poor physical and mental health at baseline. They most strongly predicted changes in health status at follow-up for the whole group of patients. Patients presenting with MUS had more negative illness perceptions and lower mental and physical components subscale of the SF-36 scores at all time points.

CONCLUSIONS

Patients' perception of a new or recurrent health problem predicts self-reported physical and mental health up to 2 years after consulting the general practitioner and offers an obvious starting point for addressing nonbiomedical aspects of illness.

The association between C-reactive protein levels and depression: Results from the northern Finland 1966 birth cohort study

BACKGROUND

To investigate whether depressive episodes (previous, current single, and recurrent) are associated in both genders with highly sensitive C-reactive protein (hs-CRP) levels, earlier recommended for risk assessment of cardiovascular disease. The impact of the severity of current single and recurrent depressive episodes on this putative association was also investigated.

METHODS

The genetically homogeneous Northern Finland 1966 Birth Cohort was followed until age 31, when, in a cross-sectional setting (n = 5269), the highly sensitive enzyme immunoassay (hs-EIA) method was used to measure CRP concentration. Depressive episodes were defined through mailed questionnaires, including Hopkins Symptom Checklist-25 (HSCL-25) and information on self-reported, doctor-diagnosed depression.

RESULTS

After adjusting for confounders, logistic regression analyses showed that in male subjects, elevated hs-CRP levels (> or =1.0 mg/L) increased the probability for severe current and recurrent depressive episodes 1.7-fold and 3.1-fold, respectively. Correspondingly, an hs-CRP level of >3.0 mg/L increased the probability for recurrent depression up to 4.1-fold. In female subjects, no statistically significant associations were found.

CONCLUSIONS

Our results support the hypothesis that an activation of systemic inflammatory processes may contribute to the pathophysiology of severe depression in men. Further investigations are needed regarding the impact of our findings on diagnostic/treatment strategies concerning severe and, especially recurrent, depression in men.

Association between optimism and self-reported facial pain

OBJECTIVE

The objective of this study was to assess the association between optimism and self-reported facial pain.

MATERIAL AND METHODS

Data were obtained for 5,696 subjects born in 1966 in Northern Finland and included in the study of the Northern Finland Birth Cohort. Data on facial pain were collected using a questionnaire. Optimism was measured using the revised version of the Life Orientation Test.

RESULTS

The data showed that optimism was inversely associated with facial pain. Associations were found only among non-depressive subjects.

CONCLUSIONS

It can be concluded that optimism is an independent psychosocial determinant of pain experience that should be taken into account in assessing the prognosis of facial pain and its treatment.

Somatoform disorders among first-time referrals to a neurology service

Consecutive new neurology inpatients and outpatients (N=198) were assessed for somatoform disorders by using the Schedules for Clinical Assessment in Neuropsychiatry. Sixty-one percent of the patients (59% of the female patients and 63% of the male patients) had at least one medically unexplained symptom, and 34.9% fulfilled the diagnostic criteria for an ICD-10 somatoform disorder (27.7% of the male patients, 41.3% of the female patients, 20.5% of the inpatients, and 43.2% of the outpatients). The prevalence figures were about the same when DSM-IV criteria for somatoform disorders were used. Of the patients with a somatoform disorder, 60.5% also had another mental disorder. Somatization disorder, somatoform autonomic dysfunction, pain disorder, and neurasthenia were equally prevalent (6%-7%); dissociative (conversion) disorders and undifferentiated somatoform disorders were found in 2-3% of the patients. Fifty percent of the patients with somatoform disorders were identified by the neurologists.

The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills

OBJECTIVE

To identify predictors of patient satisfaction among a range of patient and practitioner variables. In particular, to focus on patients' illness perceptions and the impact of a randomized controlled trial on the training of physicians in general communication skills and how to treat patients presenting with poorly defined illness.

METHODS

A randomized controlled follow-up study conducted in 28 general practices in Aarhus County, Denmark. Half of the physicians were randomized into an educational program on treatment of patients presenting with medically unexplained symptoms (somatization). One thousand seven hundred eighty-five general practice attenders presenting a new health problem completed questionnaires on illness perceptions, physical functioning, and mental distress before the consultation. After the consultation, a questionnaire including relational and communicative domains of patient satisfaction with the current consultation was completed. The physicians completed a questionnaire for each patient on diagnostics and prognostics. Predictors of patient satisfaction were determined by logistic regression.

RESULTS

A large number of patient and practitioner variables predicted satisfaction in univariate logistic regression models. Results from a multivariate logistic model showed that the illness perceptions "uncertainty" (patient not knowing what is wrong) and "emotional representations" (the complaint making the patient feel worried, depressed, helpless, afraid, hopeless) predicted dissatisfaction at OR (CI) = 1.8 (1.3-2.4), p < .001 and OR (CI) = 1.5 (1-2.3), p = .03 respectively. Trained physicians were associated with dissatisfaction at OR (CI) 0.7 (0.5-1), p = .06 in the multivariate model. Furthermore, uncertain patients consulting a trained physician were less likely to be dissatisfied OR (CI) = 0.6 (0.3-1), p = .04.

CONCLUSIONS

A randomized controlled trial on the training of general practitioners' communication skills improved patient satisfaction. Illness perceptions predict satisfaction. In particular, patients feeling uncertain and negatively emotionally involved in their health problem were more inclined to being dissatisfied with the consultation.

Screening for common mental disorders: who will benefit? Results from a randomised clinical trial

BACKGROUND

Outcomes of studies on mental health screening in primary care are conflicting. A feasible and effective case-finding approach could benefit both GPs and their patients.

OBJECTIVES

(1) to examine the effect of using a composite screening questionnaire (SQ) on GPs' recognition and provision of care, and (2) to outline useful strategies for case-finding.

METHODS

38 GPs in Aarhus County, Denmark, volunteered to participate in this trial. 1785 consecutive patients aged 18-65 years consulting with new health problems were included. Patients were screened before consultation using an SQ including scales for somatisation, anxiety, depression and alcohol abuse. Patients were randomised into one of two groups: 900 questionnaires were disclosed to and scored by GPs, 885 were blinded. Number of diagnoses, subjects of conversation, and actions taken were analysed. Additional analyses aimed to identify GP and patient factors that could predict improved outcomes.

RESULTS

Overall, disclosure of SQ results increased GPs' recognition of mental disorders by 3.8% [95% confidence interval (CI) -0.5% to 8.0%], and 6.6% (95% CI 1.2% to 12.0%) for patients screened positive. There was a marked variation in GPs' detection rates, and for GPs with moderate or low recognition rates increases were significant (P = 0.001). Conversation on psychological topics increased by 3.2% (95% CI -0.7% to 7.1%), and by 7.0% (95% CI 1.8% to 12.3%) for patients screened positive. Rates of planned follow-up consultations increased by 3.9% (95% CI 0.6% to 7.3%) and by 4.9% (95% CI 0.7% to 9.1%) for patients screened positive. GPs' self-reported benefit from screening was related to better outcomes. A range of patient and GP factors suggesting added value from using SQs were identified.

CONCLUSION

GPs' recognition and provision of mental health care can be influenced by the use of composite SQs. Perceived benefit from screening may serve as a useful predictor of better patient management. Pragmatic case-finding approaches need further evaluation.

A brief case-finding questionnaire for common mental disorders: the CMDQ

OBJECTIVES

The aim of the study was to validate a new case-finding instrument for common mental disorders (CMDQ).

METHODS

A cross-sectional, stratified, two-phase study was carried out in 28 general practices in Aarhus County, Denmark. 1785 consecutive patients, 18-65 years old, consulting 38 GPs with a new health problem participated. Patients were screened before consultation using a one-page screening questionnaire including subscales for somatisation (SCL-SOM and Whiteley-7), anxiety (SCL-ANX4), depression (SCL-DEP6) and alcohol abuse (CAGE). A stratified subsample of 701 patients was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external validity of the scales using the SCAN interview as gold standard. All data were analysed using appropriate weighted procedures to control for the two-phase sampling design and non-response bias.

RESULTS

Estimates of sensitivity and specificity for relevant ICD-10 diagnoses at theoretical optimal cut-off points on subscales: Depressive disorder: 78/86 (SCL-DEP6); Alcohol abuse or dependence: 78/97 (CAGE); Severe anxiety disorder: 77/85 (SCL-ANX4); Somatisation disorder: 83/56 (SCL-SOM); and 75/52 (Whiteley-7); any mental disorder: 72/72 (SCL-8). At the theoretical optimal cut-off points the CMDQ demonstrated higher diagnostic accuracy than GPs on any diagnosis evaluated.

CONCLUSION

The study results suggest that the CMDQ has excellent external validity for use as a diagnostic aid in primary care settings.

Mental illness and health care use: a study among new neurological patients

We investigated 198 new neurological patients to learn if mental illness had an impact on nonpsychiatric health care use. Mental illness was assessed in a two-phase design, including the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), providing ICD-10 diagnoses and two brief rating scales: the Symptom Check List (SCL-8) for anxiety and depression and the Whiteley-7 for somatization. The patients' use of health care was studied 5-10 years before and 18 months after the psychiatric assessment, using data from national patient registers. Mental illness was linked to data on health care use through weighted logistic regression. ICD-10 psychiatric disorders increased the risk of subsequent high use of nonpsychiatric hospital admissions - somatoform disorders with more than five times (OR=5.6; 95% CI=1.6-20.1) and anxiety/depression with almost four times (OR=3.7; 95% CI=1.1-12.0). There was also a trend, though less marked, linking mental illness to previous hospital use. Use of primary care was also markedly increased by mental disorders, however, only in patients entering the study as inpatients. In conclusion, neurological patients are at risk of being high users of health care if they have a mental illness, somatoform disorders being the most powerful risk factor. The results are consistent with the findings among internal medical patients.

Mental health in prison populations. A review--with special emphasis on a study of Danish prisoners on remand

OBJECTIVE

To review the literature on mental health and psychiatric morbidity in prison populations and relate findings to a Danish study on remand prisoners.

METHOD

The literature is reviewed and subdivided in the following section: validity of psychometrics in prison populations, prevalence of psychiatric disorders prior to imprisonment, incidence of psychiatric disorders during imprisonment, psychopathy related to psychiatric comorbidity, dependence syndromes with special emphasis on different administrations of heroin use (smoke vs. injection). The results are compared with a longitudinal Danish study on remand prisoners in either solitary confinement (SC) or non-SC.

RESULTS

Many factors must be taken into consideration when dealing with prisoners and mental health, e.g. international differences, the prison setting, demographics and methodological issues. The prison populations in general are increasing worldwide. Psychometrics may perform differently in prison populations compared with general populations with the General Health Questionnaire-28 having a low validity in remand prisoners. Psychiatric morbidity including schizophrenia is higher and perhaps increasing in prison populations compared with general populations with dependence syndromes being the most frequent disorders. The early phase of imprisonment is a vulnerable period with a moderately high incidence of adjustment disorders and twice the incidence in SC compared with non-SC. Prevalence of psychopathy is lower in European than North American prisons. Medium to high scores of psychopathy is related to higher psychiatric comorbidity. Opioid dependence is the most frequent drug disorder with subjects using injection representing a more dysfunctional group than subjects using smoke administration. Many mentally ill prisoners remain undetected and undertreated.

CONCLUSION

There is a growing population of mentally ill prisoners being insufficiently detected and treated.

Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study

Knowledge of which factors are prompting patients to seek primary care is important to the ongoing effort to improve management in general, and management of frequent attenders (FAs) in particular. We conducted a cross-sectional population-based study with the aim at examining associations between physical, mental and social factors and frequent attendance in general practice. We collected questionnaire and registry data in the County of Aarhus (630,000 inhabitants), Denmark. Half of the county general practices (132 practices, 220 GPs) were selected randomly. FAs were defined as the top 10% attenders over the past 12 months. A questionnaire including SF-36 and questions about physical and mental health and social conditions was sent to age and gender stratified samples of FAs and non-FAs from these practices. Impairments (SF-36) associated with frequent attendance were physical in 54-71% (prevalence difference (PD): 16-33%, adjusted prevalence ratio (adj. PR): 1.1-1.7), mental in 58-70% (PD: 17-25%, adj. PR:1.1-1.4) and social in 40-59% (PD: 13-28%, adj. PR:0.9-1.5). Among FAs, 46-88% had used three or more different drugs (PD: 26-39%, adj. PR:1.5-2.3) and 27-41% had been referred one or more times to outpatient specialists (PD: 4-19%, adj. PR:1.2-2.5). Although our data cannot determine the direction of causality, they clearly demonstrate that FAs carry a large burden of physical, mental and social impairments which underpins the complexity and heterogeneity of the problems which they present. The results make clear that biopsychosocial management is a core issue in FA management in general practice.

Age at menarche and depression at the age of 31 years: findings from the Northern Finland 1966 Birth Cohort Study

OBJECTIVE

Early age at menarche has been found to be associated with higher oestrogen levels among girls around the onset of puberty and in early adulthood. The role of oestrogen in depression is not clear, although it affects serotonergic functions in the central nervous system (CNS). We wanted to test the hypothesis that age at menarche is associated with depression in young adulthood.

METHODS

The material consisted of 3952 women born in 1966 in Northern Finland. Depression was defined by the Hopkins Symptom Checklist-25 (HSCL-25), the use of antidepressants and by self-reported lifetime depression diagnosed by physician. Menarcheal age was divided as 9-11, 12-15 and 16 years or over.

RESULTS

The prevalence of depression was 1.8-fold in current depression, 2.8-fold in the use of antidepressants and 2.1-fold in self-reported physician-diagnosed depression in women with menarche at the age of 16 years or later. After adjusting for confounders, the significant positive association between current depression and late menarche remained, but the use of antidepressants and depression diagnosed by physician had not statistically significant association with the age of menarche.

CONCLUSION

A possible explanation for the result may be oestrogen as a protective factor against depression.

A brief diagnostic screening instrument for mental disturbances in general medical wards

OBJECTIVE

Mental illness is prevalent among general hospital ward patients but often goes unrecognised. The aim of this study was to validate the SCL-8d as a brief questionnaire for mental disturbances for use in general hospitals.

METHODS

The study included 2040 patients, 18 years or older, consecutively admitted to 11 general internal medicine wards in seven European countries. All patients were screened on admission by means of the SCL-8d questionnaire. The psychometric performance (i.e., the internal validity) of the SCL-8d scale was tested using modern item response theory (IRT) in the form of the Rasch model.

RESULTS

Differences between sample characteristics were considerable. Even so, the SCL-8d scale showed a remarkable, statistically significant fit in terms of internal homogeneity (P>.01) in all individual settings, except in Spain and Germany where the item "Everything is an effort" had to be excluded to obtain a fit. When pooling data from all centres, an excellent statistical significance of fit (P>.05) was obtained by exclusion of the "Effort" item. The scale was homogeneous as to gender (P>.05), but not age as it performed better among young patients than among patients older than 60 years (P<.01). In these two patient groups both internal and external homogeneity (gender, median age) was achieved. The SCL-8d sum score showed a marked correlation with current and previous treatment for mental illness.

CONCLUSION

Apart from the "Effort" item ranking differently on the latent severity dimension as to age, the SCL-8d seems very robust from a psychometric point of view. Besides being short, the SCL-8d scale contains only emotional symptoms. It would therefore seem to be an excellent diagnostic tool for use in medical settings.

Follow-Up on Mental Illness in Medical Inpatients: Health Care Use and Self-Rated Health and Physical Fitness

Consecutively admitted internal medical inpatients (N=294) who were psychiatrically assessed with the Schedules for Clinical Assessment in Neuropsychiatry in a two-phase design were followed up in a review of public files on their use of medical care over 18 months. Self-rated outcome was assessed from health and fitness ratings at admission and after 1 year. ICD-10 mental disorders had a statistically significant impact on the risk (odds ratio) of high use (above the 80th percentile) of primary care, as did ICD-10 anxiety/depression, and worry about illness (as assessed by the Whiteley-7 Scale). The authors found a less-than-significant tendency for mental illness to influence the use of inpatient admissions and self-rated outcome.

The prevalence of somatoform disorders among internal medical inpatients

OBJECTIVE

To find the prevalence of somatoform disorders (SDs) among internal medical inpatients and to study the comorbidity with other psychiatric disorders.

METHODS

Of 392 eligible consecutive medical inpatients, 294 (75%) accepted to participate and, using a two-phase design, were assessed for ICD and DSM-IV somatoform diagnoses and for ICD-10 psychiatric diagnoses.

RESULTS

A total of 18.1% (95% CI: 12.8-24.9%) of the patients fulfilled the diagnostic criteria for an ICD-10 disorder, and 20.2% (95% CI:14.7-27.2% ) for a DSM-IV SD. The prevalence of specified disorders revealed marked differences between the two diagnostic systems, e.g., concerning somatisation disorder (SD), which was more prevalent in the ICD-10 (5%) than in the DSM-IV (1.5%) equivalent. Quite the contrary was found in undifferentiated SD (0.7% in ICD-10 and 10% in DSM-IV). According to ICD-10 criteria, 3.5% had hypochondriasis, 2.6% a dissociative disorder, 3.2% a somatoform autonomic dysfunction, 1.5% had neurasthenia or persistent somatoform pain disorder, and 5% had an SD, unspecified. SDs were more prevalent among younger females. Thirty-six percent of the patients with SDs also had another psychiatric disorder, 11% a depression, and 25% an anxiety disorder. The physicians detected about 1/3 of the cases.

CONCLUSION

Somatoform disorders were prevalent among internal medical inpatients especially among younger women.

Detecting mental disorders in general hospitals by the SCL-8 scale

OBJECTIVE

The objective of this study is to validate the eight-item dichotomised version of the Symptoms Check List (SCL-8d) as a screening tool for psychiatric disorders.

METHODS

The study population included 198 consecutive new neurological inpatients and outpatients and 294 consecutive internal medical inpatients, aged 18 or older. All patients received the SCL-8d questionnaire, and a stratified subsample was interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. We tested the external SCL-8d validity using the SCAN interview as gold standard. The test was performed based on weighted data to correct for the skewness introduced by stratification.

RESULTS

The diagnostic performance of the SCL-8d was excellent in the internal medical setting but not quite as good in the neurological sample. It performed better among the older compared with the younger patients, whereas the scale was not affected by gender. In the combined sample at the cut point 0/1, the sensitivity (SE) of the SCL-8d was 0.73 (confidence interval [CI](95%): 0.60-0.82), the specificity (SP) 0.61 (CI(95%): 0.53-0.68) and the positive predictive value (PPV) 0.42 (CI(95%): 0.34-0.50), using any International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) psychiatric disorder, excluding somatoform and substance abuse disorders, as gold standard. The risk of a patient having a mental disorder (except phobia, substance abuse or somatoform disorder) was less than 6% in case of a negative screening test. In patients with a current depressive disorder, 87.1% (27/31) were screening positive, and all except 1 (93.0%) of the 14 patients with a modest to severe depression scored 1 or higher on the SCL-8d. All 17 patients with an anxiety disorder, excluding phobias, were screening positive.

CONCLUSION

The study suggests that the SCL-8d is a valid, brief screening tool for use in nonpsychiatric medical settings, especially to detect emotional psychiatric disorders (EPDs).

Genetic Features of Mitochondrial Respiratory Chain Disorders

ABSTRACT. Oxidative phosphorylation, i.e., ATP synthesis by the oxygen-consuming respiratory chain (RC), supplies most organs and tissues with a readily usable energy source, being functional before birth. Consequently, RC deficiencies can theoretically give rise to any symptom, in any organ or tissue, at any age and with any mode of inheritance, because of the twofold genetic origin of RC components (nuclear DNA and mitochondrial DNA). It was long wrongly considered that RC disorders originate from mutations of mitochondrial DNA, because for a long time only mutations or deletions of mitochondrial DNA were identified. However, the number of known disease-causing mutations in nuclear genes is steadily growing. These genes encode the various subunits of each complex, ancillary proteins functioning at different stages of holoenzyme biogenesis, including transcription, translation, chaperoning, addition of prosthetic groups, and protein assembly, and various enzymes involved in mitochondrial DNA metabolism.

What do ratings of cancer-specific distress mean among women at high risk of breast and ovarian cancer?

Women recruited from a hereditary cancer registry provided ratings of distress associated with different aspects of high-risk status and genetic testing and completed measures of general psychological distress, emotional and social health, and role functioning. Overall, high-risk status was rated as more distressing than undergoing genetic testing. Women without a personal history of cancer rated the level of distress associated with a positive test result to be greater than that associated with high-risk status. In contrast, level of distress associated with a positive test result was not significantly different from that associated with high-risk status for women with a personal history of cancer. Furthermore, women with a personal cancer history also anticipated that if they had an altered gene associated with increased risk of cancer, it would be less distressing than their diagnosis of cancer had been. Women with the highest ratings of cancer-related stress were less inclined to obtain testing, but were not more generally distressed or maladjusted. The need to interpret psychological distress and the stressfulness of genetic testing among high-risk women with respect to relevant comparison data is discussed.

Determinants of mental distress in adults with a severe auditory impairment: differences between prelingual and postlingual deafness

OBJECTIVE

To investigate the determinants of mental health among severe hearing-impaired adults in the Netherlands, separately by prelingual and postlingual age of onset.

METHODS

Five hundred twenty-three face-to-face interviews were carried out by persons with practical skills in communication with hearing-impaired people.

RESULTS

Of prelingually and postlingually deaf men, 27.1% and 27.7%, respectively, reported mental distress (scores on the General Health Questionnaire > or = 2), and among women these figures were 32.4% and 43.2%. These rates are higher than in the general population (men: 22.0%; women: 26.6%). Among the prelingual category, none of the demographic or hearing loss-related characteristics was associated with mental health status as measured by the General Health Questionnaire (GHQ). Of these variables, only additional impairment or serious illness was associated with the brief Symptom Checklist (SCL-8D). Among the postlingual category, female gender and equilibrium disturbance was associated with both the GHQ and SCL-8D, and additional impairment or serious illness with the SCL-8D. For both categories, the risk of mental distress also was higher in those with more communication problems, lower levels of self-esteem, and poorer acceptance of the hearing loss. Opportunities for identification in youth and social support were not associated with mental health.

CONCLUSIONS

Mental health status differs between the hearing-impaired and the general population, but not as much as is sometimes suggested. Mental distress is greater in those in certain categories of the hearing-impaired.

Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study

AIMS AND OBJECTIVES

The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission.

DESIGN

The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. RESEARCH METHODS AND INSTRUMENTS: In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care.

RESULTS

Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse.

CONCLUSIONS

The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programmes.

Complexity of care and mental illness in medical inpatients

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient's own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.