A standardized psychiatric interview for use in community surveys

Women's health and well-being in five birth cohorts from low- and middle-income countries: Domains and their associations with early-life conditions

Background

Women's health and well-being (WHW) have been receiving growing attention, but limited progress has been made on how to measure its different domains in low- and middle-income countries (LMICs). We used data from five long-term birth cohorts in Brazil, Guatemala, the Philippines and South Africa to explore different domains of adult WHW, and how these domains relate to early life exposures.

Methods

Based upon an a priori conceptualisation of eight postulated WHW outcomes available in the data, we grouped them as follows: human capital (intelligence quotient, schooling, height, and teenage childbearing), metabolic health (body mass index and metabolic syndrome score), and psychological (happiness and Self-Reported Questionnaire (SRQ) scores). Correlation analyses confirmed the variables theoretically belonging to the same dimension of WHW were statistically related. We then applied principal component analysis to each group of variables separately and used the first principal component as a summary quantitative measure of the corresponding WHW dimension. Finally, we assessed the association of each domain with a range of early-life factors: wealth, maternal education, maternal height, water, and sanitation, birthweight, length at two years and development quotient in mid-childhood.

Results

The three domains were largely uncorrelated. Early determinants were positively associated with human capital, while birth order was negatively associated. Fewer associations were found for the metabolic or psychological components. Birthweight and weight at age two years were inversely associated with metabolic health. Maternal education was associated with better psychological health.

Conclusions

Our findings indicate that WHW is multidimensional, with most women in the cohorts being compromised in one or more domains while few women scored highly in all three domains. Our analyses are limited by lack of data on adolescent exposures and on other relevant WHW dimensions such as safety, agency, empowerment, and violence. Further research is needed in LMICs for identifying and measuring the multiple domains of WHW.

The Effects of Maternal Perinatal Depression on Child IQ: A Systematic Review

BACKGROUND

Maternal perinatal depression has been shown to have long lasting effects on children's development. Studies have described the relationship of perinatal depression on children's cognition, especially negative effects on intelligence quotient (IQ). However, a recent examination of the current studies to discern the patterns and strength of associations between perinatal depression and child IQ is not available.

OBJECTIVE

The purpose of this systematic review is to discern the effects of perinatal depression, prenatally and within the first 12 months of the postpartum period, on the IQ of the child aged 0-18 years old.

METHODS

We searched the electronic databases: PubMed and CINAHL. We identified 1633 studies, and included 17 studies in the final review based on pre-determined criteria. After the data was extracted, we assessed the strength of the study using the national heart, lung, and blood institute quality assessment tool for observational cohort and cross-sectional studies. This systematic review had a total sample of 10,757 participants.

RESULTS

Across the studies, we identified a relationship between limited maternal responsiveness due to postpartum depression and a decrease in full IQ scores in younger children. Male children were found to be more sensitive to the postpartum depression, resulting in a decrease in IQs, in comparison to female children.

CONCLUSIONS

Policies should be implemented to identify women suffering from perinatal depression to mitigate the effects of the disorder for both the mother and her child.

Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT

Background

In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.

Aim

We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.

Objectives

Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.

Design

A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.

Main outcome measures

The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.

Results

(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.

Conclusions

This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.

Limitations

As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.

Future work

The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.

Trial registration

This trial is registered as ISRCTN46099296.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.

Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data

OBJECTIVE

To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women.

DESIGN

Individual participant data meta-analysis.

DATA SOURCES

Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (from inception to 3 October 2018).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible datasets included EPDS scores and major depression classification based on validated diagnostic interviews. Bivariate random effects meta-analysis was used to estimate EPDS sensitivity and specificity compared with semi-structured, fully structured (Mini International Neuropsychiatric Interview (MINI) excluded), and MINI diagnostic interviews separately using individual participant data. One stage meta-regression was used to examine accuracy by reference standard categories and participant characteristics.

RESULTS

Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards. Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women.

CONCLUSIONS

An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific. To identify pregnant and postpartum women with higher symptom levels, a cut-off of 13 or higher could be used. Lower cut-off values could be used if the intention is to avoid false negatives and identify most patients who meet diagnostic criteria.

REGISTRATION

PROSPERO (CRD42015024785).

Burden of Depression in Outpatient HIV-Infected adults in Sub-Saharan Africa; Systematic Review and Meta-analysis

Despite the substantial burden of HIV in Africa, and the knowledge that depression causes worse HIV outcomes, the burden of depression in people living with HIV in Africa is unknown. We searched Pubmed and four other databases using key terms: depression, Africa, HIV, and prevalence from 2008 to 2018. We summarized depression prevalence by country. We estimated the burden of depression using our prevalence data and 2018 UNAIDS HIV estimates. Our search yielded 70 articles across 16 African countries. The overall prevalence of major depression in those HIV-infected using a diagnostic interview was 15.3% (95% CI 12.5-17.1%). We estimate that 3.63 million (99.7% CI 3.15-4.19 million) individuals with HIV in Sub-Saharan Africa have major depression and provide country-level estimates. We estimate that 1.57 million (99.7% CI 1.37-1.82 million) DALYs are lost among people with depression and HIV in Sub-Saharan Africa. There is a significant burden of depression in Africans with HIV. Further work to screen for and treat depression in Sub-Saharan Africa is needed to improve HIV outcomes and achieve the 90-90-90 UNAIDS goals.

Effort-Reward Imbalance, Over-Commitment and Depressive Episodes at Work: Evidence from the ELSA-Brasil Cohort Study

A growing burden of mental illness, and in particular depression, among workers is a concern of occupational public health. Scientific evidence has revealed consistent associations of work-related stress, as measured by theoretical models, with depression, but mostly so in developed countries. This contribution explores these associations in a developing Latin American country, Brazil, by applying an internationally established work stress model, the effort-reward imbalance (ERI). This model focuses on the work contract where unjust exchange between high efforts spent and low rewards received in turn contributes to stress-related disorders. The model's extrinsic ('effort', 'reward') and intrinsic components ('over-commitment'), as well as their combination, are hypothesized to be related to a higher risk of depressive episodes (DE). Using cross-sectional data from the ELSA-Brasil study, including 10,034 workers from the public sector, we observed increased prevalence ratio (PR) of DE according to ERI scales. The quartiles of highest 'effort' (PR = 1.85; 1.44-2.37), highest 'over-commitment' (PR = 3.62; 2.80-4.70) and lowest 'reward' (PR = 3.44; 2.55-4.64) were associated with DE, on adjusted models, as well was the E-R ratio (PR = 2.47; 1.92-3.17). An additive interaction was identified between the E-R ratio and 'over-commitment'. The results support the use of ERI as a screening tool for work stress in the Brazilian context and will offer guidance for worksite health promotion programs.

Common mental disorders and sociodemographic characteristics: baseline findings of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVE

To assess the prevalence of common mental disorders (CMD) and the association of CMD with sociodemographic characteristics in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort.

METHODS

We analyzed data from the cross-sectional baseline assessment of the ELSA-Brasil, a cohort study of 15,105 civil servants from six Brazilian cities. The Clinical Interview Schedule-Revised (CIS-R) was used to investigate the presence of CMD, with a score ≥ 12 indicating a current CMD (last week). Specific diagnostic algorithms for each disorder were based on the ICD-10 diagnostic criteria. Prevalence ratios (PR) of the association between CMD and sociodemographic characteristics were estimated by Poisson regression.

RESULTS

CMD (CIS-R score ≥ 12) was found in 26.8% (95% confidence intervals [95%CI] 26.1-27.5). The highest burden occurred among women (PR 1.9; 95%CI 1.8-2.0), the youngest (PR 1.7; 95%CI 1.5-1.9), non-white individuals, and those without a university degree. The most frequent diagnostic category was anxiety disorders (16.2%), followed by depressive episodes (4.2%).

CONCLUSION

The burden of CMD was high, particularly among the more socially vulnerable groups. These findings highlight the need to strengthen public policies aimed to address health inequities related to mental disorders.

How Do Psychiatrists Apply the Minimum Clinically Important Difference to Assess Patient Responses to Treatment?

Symptom report scales are used in clinical practice to monitor patient outcomes. Using them permits the definition of a minimum clinically important difference (MCID) beyond which a patient may be judged as having responded to treatment. Despite recommendations that clinicians routinely use MCIDs in clinical practice, statisticians disagree about how MCIDs should be used to evaluate individual patient outcomes and responses to treatment. To address this issue, we asked how clinicians actually use MCIDs to evaluate patient outcomes in response to treatment. Sixty-eight psychiatrists made judgments about whether hypothetical patients had responded to treatment based on their pre- and posttreatment change scores on the widely used Positive and Negative Syndrome Scale. Psychiatrists were provided with the scale's MCID on which to base their judgments. Our secondary objective was to assess whether knowledge of the patient's genotype influenced psychiatrists' responder judgments. Thus, psychiatrists were also informed of whether patients possessed a genotype indicating hyperresponsiveness to treatment. While many psychiatrists appropriately used the MCID, others accepted a far lower posttreatment change as indicative of a response to treatment. When psychiatrists accepted a lower posttreatment change than the MCID, they were less confident in such judgments compared to when a patient's posttreatment change exceeded the scale's MCID. Psychiatrists were also less likely to identify patients as responders to treatment if they possessed a hyperresponsiveness genotype. Clinicians should recognize that when judging patient responses to treatment, they often tolerate lower response thresholds than warranted. At least some conflate their judgments with information, such as the patient's genotype, that is irrelevant to a post hoc response-to-treatment assessment. Consequently, clinicians may be at risk of persisting with treatments that have failed to demonstrate patient benefits.

Prenatal maternal depression is associated with offspring inflammation at 25 years: a prospective longitudinal cohort study

Animal studies and a handful of prospective human studies have demonstrated that young offspring exposed to maternal prenatal stress show abnormalities in immune parameters and hypothalamic-pituitary-adrenal (HPA) axis function. No study has examined the effect of maternal prenatal depression on offspring inflammation and HPA axis activity in adulthood, nor the putative role of child maltreatment in inducing these abnormalities. High-sensitivity C-reactive protein (hs-CRP) and awakening cortisol were measured at age 25 in 103 young-adult offspring of the South London Child Development Study (SLCDS), a prospective longitudinal birth cohort of mother-offspring dyads recruited in pregnancy in 1986. Maternal prenatal depression was assessed in pregnancy at 20 and 36 weeks; offspring child maltreatment (birth 17 years) was assessed at offspring ages 11, 16 and 25; and offspring adulthood depression (18-25 years) was assessed at age 25. Exposure to maternal prenatal depression predicted significantly elevated offspring hs-CRP at age 25 (odds ratio=11.8, 95% confidence interval (CI) (1.1, 127.0), P=0.041), independently of child maltreatment and adulthood depression, known risk factors for adulthood inflammation. In contrast, maternal prenatal depression did not predict changes in offspring adulthood cortisol; however, offspring exposure to child maltreatment did, and was associated with elevated awakening cortisol levels (B=161.9, 95% CI (45.4, 278.4), P=0.007). Fetal exposure to maternal depression during pregnancy has effects on immune function that persist for up to a quarter of a century after birth. Findings are consistent with the developmental origins of health and disease (DOHaD) hypothesis for the biological embedding of gestational psychosocial adversity into vulnerability for future physical and mental illness.

Pain-related and Psychological Symptoms in Adolescents With Musculoskeletal and Sleep Problems

Objectives:

Two-thirds of adolescents with chronic musculoskeletal pain report a concurrent sleep problem. Both musculoskeletal pain and sleep problems can have deleterious effects on physiological and psychological well-being. We explored the prevalence of sleep problems and musculoskeletal pain, using data on 3568 adolescents from the Avon Longitudinal Study of Children.

Materials and Methods:

A comprehensive battery of questionnaires was administered to derive clinical phenotypes of musculoskeletal pain. Adolescents with single symptoms were compared with those reporting both musculoskeletal pain and sleep problems. Linear and logistic regression analyses were used to compare groups on pain-related variables and psychological complaints. The association between sociodemographic variables and comorbid musculoskeletal pain and sleep problems was assessed using logistic regression.

Results:

Over half the sample was female (n=2076, 58.2%) and the majority of European ancestry (n=3174, 97.7%). Only 5.5% (n=196) of participants were identified as having a pain condition, while 21.2% (n=749) reported a significant sleep problem, and 2.8% (n=99) reported comorbid musculoskeletal pain and sleep problems. Adolescents with comorbid problems experienced greater pain intensity and pain-related anxiety. Other psychological complaints were also higher in those who experienced concurrent problems, including depression, fatigue, concentration, and overall severity of psychological symptoms.

Discussion:

Comorbid sleep and pain problems were associated with a higher incidence of pain-related and psychological symptoms. Sleep problems may therefore be an important modifiable risk factor for alleviating distress in adolescents with musculoskeletal pain.

Predictors of Depression Symptoms Among Low-Income Women Exposed to Perinatal Intimate Partner Violence (IPV)

Women experiencing perinatal intimate partner violence (IPV) may be at increased risk for depression. Baseline data was analyzed from 239 low-income pregnant women participating in an intervention study designed to reduce exposure to IPV. Depression risk was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and IPV factors were measured with the Conflict Tactics Scale-Revised (CTS-2). Stepwise regression was conducted to identify predictors of risk for depression. Race (p = 0.028), psychological IPV (p = 0.035) and sexual IPV (p = 0.031) were strongly associated with risk for depression. Regression results indicated that women experiencing severe psychological IPV were more likely to develop depression (OR 3.16, 95 % CI 1.246, 8.013) than those experiencing severe physical or sexual IPV. Experiencing severe psychological IPV during pregnancy is strongly linked to risk for depression. Routine screening for psychological IPV may increase identification and treatment of women at high risk for depression during pregnancy.

Using Rasch-models to compare the 30-, 20-, and 12-items version of the general health questionnaire taking four recoding schemes into account

BACKGROUND

The present study compares the 30-, 20-, and 12-items versions of the General Health Questionnaire (GHQ) in the original coding and four different recoding schemes (Bimodal, Chronic, Modified Likert and a newly proposed Modified Chronic) with respect to their psychometric qualities.

METHODS

The dichotomized versions (i.e. Bimodal, Chronic and Modified Chronic) were evaluated with the Rasch-Model and the polytomous original version and the Modified Likert version were evaluated with the Partial Credit Model.

RESULTS

In general, the versions under consideration showed agreement with the model assumption. However, the recoded versions exhibited some deficits with respect to the Outfit index.

CONCLUSIONS

Because of the item deficits and for theoretical reasons we argue in favor of using the any of the three length versions with the original four-categorical coding scheme. Nevertheless, any of the versions appears apt for clinical use from a psychometric perspective.

Maternal depression during pregnancy and offspring depression in adulthood: role of child maltreatment

BACKGROUND

Studies have shown that maternal depression during pregnancy predicts offspring depression in adolescence. Child maltreatment is also a risk factor for depression.

AIMS

To investigate (a) whether there is an association between offspring exposure to maternal depression in pregnancy and depression in early adulthood, and (b) whether offspring child maltreatment mediates this association.

METHOD

Prospectively collected data on maternal clinical depression in pregnancy, offspring child maltreatment and offspring adulthood (18-25 years) DSM-IV depression were analysed in 103 mother-offspring dyads of the South London Child Development Study.

RESULTS

Adult offspring exposed to maternal depression in pregnancy were 3.4 times more likely to have a DSM-IV depressive disorder, and 2.4 times more likely to have experienced child maltreatment, compared with non-exposed offspring. Path analysis revealed that offspring experience of child maltreatment mediated the association between exposure to maternal depression in pregnancy and depression in adulthood.

CONCLUSIONS

Maternal depression in pregnancy is a key vulnerability factor for offspring depression in early adulthood.

[Validation of the Spanish version of the Screening for Somatoform Symptoms-2 scale for use in Primary Care]

OBJECTIVE

To study the diagnostic validity and to provide the sensitivity, specificity, positive predictive value and negative predictive value of the Spanish version of the Screening for Somatoform Symptoms-2 (SOMS-2) scale in a PC population sample.

DESIGN

Validation study.

SETTING

PC centres in Aragon and Balearic Islands, Spain.

PARTICIPANTS

A sample of 109 patients from a clinical trial with somatoform disorders and 56 patients without somatoform disorder were included for the scale validation.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive predictive value, negative predictive value and Cronbach's α coefficient.

RESULTS

Of the total sample of 165 subjects, 75% were women and 60% had a diagnosis of somatization disorder and/or anxiety or depressive disorder. The 53-item version of the SOMS-2 with a cut-off point of 4 showed a sensitivity of 97%, a specificity of 68%, a positive predictive value of 85%, a negative predictive value of 92%, and high internal consistency (Cronbach α=0.926).

CONCLUSIONS

The Spanish version of the SOMS-2 seems to be a reliable screening tool, easy to complete and useful for the assessment of somatoform disorders in PC settings. The results for specificity, sensitivity, and internal consistency are similar to previous studies in other European languages.

Psychiatric illness and length of stay in general hospitals: do case finding methods matter?

OBJECTIVE

Several prior studies have investigated whether patients with "non-cognitive" mental disorders (i.e., organic disorders, substance abuse, delirium, and psychotic disorders excluded) have longer Length Of Stay (LOS) than mentally healthy individuals in nonpsychiatric hospital settings. These studies yielded contrasting results. The present paper aims to examine whether methods of psychiatric case finding can explain these differences.

METHODS

Using the Clinical Interview Schedule (CIS) and the General Health Questionnaire (GHQ), 462 in-patients of medical, surgical, gynecological, and rehabilitation departments were assessed for the presence of psychiatric disorders.

RESULTS

In multiple regression analysis, all CIS-cases together did not show an association with LOS. Of the diagnostic groups assessed by CIS only major depression showed a significantly prolonged LOS. Using the GHQ sum-score as a continuous variable, LOS was significantly increased while using the GHQ as a dichotomous variable did not show such an association. After removing those suffering from multiple psychiatric diagnoses (such as major depression co-morbid with organic mental illness), none of the case definitions showed a significant association with LOS.

CONCLUSIONS

It seems that different case finding methods yield different results concerning the association of psychiatric disorders with LOS. When interpreting these results the small size of some subsamples must be taken into consideration.

[Prevalence and recognition of depression among inpatients of non-psychiatric hospital departments]

PURPOSE

The purpose of this study is to compare the prevalence of depression among different types of hospital departments. Furthermore, it compares different methods for assessment of its recognition by non-psychiatric physicians.

METHODS

993 inpatients of internal, surgical, gynecological and physical rehabilitation wards of community hospitals were interviewed by research psychiatrists using the Clinical Interview Schedule. Ward physicians were asked to fill in a short questionnaire in order to assess whether they could correctly identify patients with mental illnesses. In addition, routine discharge diagnoses were assessed.

RESULTS

Of the total sample, 13.3 % suffered from depression. Depression was most frequent on physical rehabilitation units (24.2 %), followed by surgical (9.8 %) and internal (9.5 %) wards. On gynecological wards, prevalence of depression was lowest (8.7 %). Of those suffering from depression, 45.7 % were identified as mentally ill by non-psychiatric ward physicians when using questionnaire data. Only 21.0 % of the depressed received a psychiatric discharge diagnosis, which equals less than half of those identified by questionnaire.

RESULTS

Of the total sample, 13.3 % of patients suffered from depression. Depression was most frequent in physical rehabilitation units (24.2 %), followed by surgical (9.8 %) and internal (9.5 %) wards. In gynecological wards, the prevalence of depression was the lowest (8.7 %). Of those suffering from depression, 45.7 % were identified as mentally ill by non-psychiatric ward physicians when using questionnaire data. Only 21.0 % of the depressed received a psychiatric discharge diagnosis, less than half of those identified by the questionnaire.

CONCLUSIONS

Depression is very common among inpatients of physical hospital departments. Unfortunately, depression is frequently overlooked in everyday clinical work. Routine discharge diagnoses give only very limited information about how often ward physicians recognize mental disorders. Furthermore, hospital discharge diagnoses should not be used for planning mental health services.

Perinatal depression and child development: exploring the economic consequences from a South London cohort

BACKGROUND

Depression in mothers during pregnancy and in the postnatal period has been recognized to have wide-ranging adverse impacts on offspring. Our study examines some of the outcomes and long-term economic implications experienced by offspring who have been exposed to perinatal depression.

METHOD

We analysed the effects of perinatal depression on child development outcomes of children at ages 11 and 16 years from the community-based South London Child Development Study. Economic consequences were attached to those outcomes through simple decision-analytic techniques, building on evidence from studies of epidemiology, health-related quality of life, public sector costs and employment. The economic analysis takes a life-course perspective from the viewpoints of the public sector, individual and society.

RESULTS

Additional risks that children exposed to perinatal depression develop emotional, behavioural or cognitive problems ranged from 5% to 21%. In addition, there was a high risk (24%) that children would have special educational needs. We present results in the form of cost consequences attached to adverse child outcomes. For each child exposed to perinatal depression, public sector costs exceeded £3030, costs due to reduced earnings were £1400 and health-related quality of life loss was valued at £3760.

CONCLUSIONS

Action to prevent or treat mothers' depression during pregnancy and after birth is likely to reduce public sector costs, increase earnings and improve quality of life for children who were exposed to the condition.

25-hydroxyvitamin D, APOE ɛ4 genotype and cognitive function: findings from the 1958 British birth cohort

Both high and low vitamin D statuses have been associated with lower memory function. Apolipoprotein E (APOE) ɛ4 alleles have been associated with reduced memory function, and separately with higher vitamin D concentrations. This report aims to examine if the presence of APOE ɛ4 alleles contributes to the relationship between vitamin D and memory function. A total of 4848 (46% female) participants from the 1958 British birth cohort had information on APOE genotypes and completed memory tests at 50 years, where 4644 also had 25-hydroxyvitamin D (25(OH)D) concentrations measured at 45 years. Both low and high 25(OH)D concentrations were associated with lower memory function after adjustment for number of APOE ɛ4 alleles (P curvature=0.02). There was evidence of interaction between APOE ɛ4 and 25(OH)D, suggesting the association between 25(OH)D concentrations and memory function is different for those with two APOE ɛ4 alleles compared with those with zero or one APOE ɛ4 alleles (recessive model P interaction=0.01). Among participants with two APOE ɛ4 alleles, higher 25(OH)D concentrations were associated with higher memory function, whereas in others, memory scores were slightly lower for individuals with higher versus lower concentrations. Further studies are required to replicate these findings.

The protocol for a randomised controlled trial comparing intermittent and graded exercise to usual care for chronic fatigue syndrome patients

Background

Chronic Fatigue Syndrome is a debilitating disorder with an unknown aetiology but suspected multifactorial origins. Common “triggers” include severe viral infections and emotional stress. Recent studies have also found evidence of immune dysfunction and elevated inflammatory cytokines in CFS patients, but there has been considerable variation in the outcome measures and magnitude of these studies. Currently, there is no cure for CFS but treatments include rest, specialist medical care, cognitive behavioural therapy, and graded (self-paced) exercise. To date, several studies have examined the efficacy of graded exercise with or without Cognitive Behavioural Therapy, with some success for patients. However, improvements in functional capacity have not necessarily correlated with improvements in immune function, fatigue or other symptoms. This 12-week pilot trial compares graded and intermittent exercise to normal care, measuring physiological outcomes, fatigue levels, immune function and wellness.

Methods/design

90 patients aged between 16 to 60 years, who meet the diagnostic criteria for CFS and have been diagnosed by their medical practitioner, will be randomly recruited into groups consisting of Intermittent exercise, Graded exercise and usual care (Control). The outcomes will be measured pre-study (Week 0) and post-study (Week 13). Primary outcomes are VO_2peak, anaerobic threshold, peak power, levels of fatigue, immune cell (CD3⁺CD4⁺, CD3⁺CD8⁺, CD19⁺, CD 16⁺CD56⁺) concentrations and activation. Secondary outcomes include onset of secondary CFS symptoms (e.g. fever, swollen lymph nodes), wellness, mood and sleep patterns. Primary analysis will be based on intention to treat using logistic regression models to compare treatments. Quantitative data will be analysed using repeated measures ANOVA with a linear model, and Cohen’s effect size. Qualitative data such as participants’ responses (e.g. changes in mood and other reactions) following the exercise modalities will be read and sections demarcated. A code will be applied to each segment. A prevalence of codes will be considered thematically.

Discussion

The results of the trial will provide information about the efficacy of intermittent and graded exercise compared to usual care (rest and lifestyle recommendations), contributing to the evidence for best-practice CFS management.

Trial registration

Australia and New Zealand Clinical Trials Registry ACTRN12612001241820.

Intergenerational transmission of maltreatment and psychopathology: the role of antenatal depression

BACKGROUND

Maternal experience of childhood maltreatment and maternal antenatal depression are both associated with offspring childhood maltreatment and offspring adjustment problems. We have investigated the relative impact of maternal childhood maltreatment and exposure to depression in utero on offspring maltreatment and psychopathology.

METHOD

The sample included 125 families from the South London Child Development Study. A prospective longitudinal design was used. Data on maternal childhood maltreatment, maternal antenatal depression (36 weeks of pregnancy), offspring childhood maltreatment (age 11 years) and offspring adolescent antisocial behaviour and depression (ages 11 and 16 years) were obtained from parents and offspring through clinical interview.

RESULTS

Mothers who experienced childhood maltreatment were significantly more likely to be depressed during pregnancy [odds ratio (OR) 10.00]. Offspring of mothers who experienced only childhood maltreatment or only antenatal depression were no more at risk of being maltreated or having psychopathology; however, offspring of mothers who experienced both maternal childhood maltreatment and antenatal depression were exposed to significantly greater levels of childhood maltreatment and exhibited significantly higher levels of adolescent antisocial behaviour compared with offspring not so exposed. Furthermore, maternal childhood maltreatment accounted for a significant proportion of the variance in offspring childhood maltreatment in only those offspring exposed to depression in utero.

CONCLUSIONS

Maternal childhood maltreatment and maternal antenatal depression are highly associated. The co-occurrence of both insults significantly increases the risk of offspring adversity. The antenatal period is an optimum period to identify vulnerable women and to provide interventions.

Psychological factors: anxiety, depression, and somatization symptoms in low back pain patients

Aim

To determine the prevalence of low back pain (LBP), investigate the sociodemographic characteristics of patients with LBP, and examine its association with psychological distress such as anxiety, depression, and somatization.

Subjects and methods

Of the 2742 patients approached, 2180 agreed to participate in this cross-sectional study (79.5% response rate). The survey was conducted among primary health care visitors from March to October 2012 and collected sociodemographic details and LBP characteristics. General Health Questionnaire-12 was used to identify the probable cases. Anxiety was assessed with Generalized Anxiety Disorder-7, depression was assessed with Patient Health Questionnaire-9, and somatization was measured with Patient Health Questionnaire-15.

Results

The study sample consisted of 52.9% males and 47.1% females. The prevalence of LBP was 59.2%, comprising 46.1% men and 53.9% women. LBP was significantly higher in Qataris (57.9%), women (53.9%), housewives (40.1%), and individuals with higher monthly income (53.9%). Somatization (14.9%) was observed more in LBP patients, followed by depression (13.7%) and anxiety disorders (9.5%). The most frequently reported symptoms were “headaches” (41.1%) and “pain in your arms, legs, or joints” (38.5%) in LBP patients with somatization. The most frequent symptoms among depressed LBP patients were “thinking of suicide or wanting to hurt yourself” (51.4%) and “feeling down, depressed, or hopeless” (49.2%). “Not being able to stop or control worrying” (40.2%), “worrying too much about different things” (40.2%), and “feeling afraid as if something awful might happen” (40.2%) were the most common anxiety symptoms in LBP patients. Psychological distress such as anxiety (9.5% versus 6.2%), depression (13.7% versus 8.5%), and somatization (14.9% versus 8.3%) were significantly higher in LBP patients.

Conclusion

The prevalence of LBP in this study sample was comparable with other studies. Furthermore, psychological distress such as anxiety, depression, and somatization were more prevalent in LBP patients compared to patients without LBP.

Evaluation of a screening instrument for autism spectrum disorders in prisoners

There have been concerns that individuals with autism spectrum disorders (ASDs) are over-represented but not recognised in prison populations. A screening tool for ASDs in prisons has therefore been developed.

Prevalence of common mental disorders in a rural district of Kenya, and socio-demographic risk factors

Association between common mental disorders (CMDs), equity, poverty and socio-economic functioning are relatively well explored in high income countries, but there have been fewer studies in low and middle income countries, despite the considerable burden posed by mental disorders, especially in Africa, and their potential impact on development. This paper reports a population-based epidemiological survey of a rural area in Kenya. A random sample of 2% of all adults living in private households in Maseno, Kisumu District of Nyanza Province, Kenya (50,000 population), were studied. The Clinical Interview Schedule-Revised (CIS-R) was used to determine the prevalence of common mental disorders (CMDs). Associations with socio-demographic and economic characteristics were explored. A CMD prevalence of 10.8% was found, with no gender difference. Higher rates of illness were found in those who were of older age and those in poor physical health. We conclude that CMDs are common in Kenya and rates are elevated among people who are older, and those in poor health.

Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis

PURPOSE

The Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.

METHODS

PubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.

RESULTS

The best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).

CONCLUSIONS

The HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.

Prevalence of somatisation and psychologisation among patients visiting primary health care centres in the State of Qatar

Background

Medically unexplained somatic complaints are among the most common clinical presentations in primary care in developing countries and they are considerable burden for patients and health care system.

Objectives

The aim of this study was to determine the prevalence of somatisation in comparison to psychologisation among a sample of Qatari patients who were visiting primary health care (PHC) centres and to investigate the clinical and socio-demographic characteristics of somatisers (STs) and psychologisers (PGs).

Method

The survey was conducted among PHC Qatari patients during the period from January to July 2007. About 2,320 patients were approached, of whom 1,689 agreed to participate and responded to the questionnaire. Among the studied Qatari patients, 404 patients were identified for clinical interview. The first stage of the study was conducted with the help of general practitioners, using the 12-item General Health Questionnaire. The second stage was carried out by a consultant using the Clinical Interview Schedule. A specific operational criterion was used to identify STs and PGs.

Results

The prevalence rate of STs among the total studied sample was 12.4%, while the PGs were 11.5%. Among the identified psychiatric cases, the proportion of STs (52%) was higher than PGs (48%). Most of the diagnostic categories were more prevalent among PGs. The dissatisfaction at work and stressful life events within 12 months before the onset of the presenting symptoms were the three postulated determinants which were significantly more among STs than PGs.

Conclusion

The prevalence of somatised mental disorder was little higher than the psychologised mental disorder. The prevalence of somatisation and psychologisation is comparable with other reported studies from the Middle-East and Western countries. Dissatisfaction at work and stressful life events were significantly higher among STs than PGs.

The effect of social networks and social support on mental health services use, following a life event, among the Baltimore Epidemiologic Catchment Area cohort

The study examined the association between life events and mental health services use, accounting for social networks and social support. Main and stress-buffering effects were estimated using longitudinal data from the Baltimore Epidemiologic Catchment Area cohort (1,920 participants in 1993-1996, of whom 1,071 were re-interviewed in 2004-2005). Following a life event, the odds of using general medical services were increased by almost 50% when there was increased social support from spouse/partner (referral function). The odds of using mental health services within general health setup were reduced by 60% when there was increased support from relatives (stress-reduction function). Increased social support from friends and relatives was associated with a 40-60% decreased odds of using specialty psychiatric services after experiencing different life events (stress-reduction function). Overall, social support rather than social networks were more strongly associated with increased mental health service use following a life event. The implications for service delivery and program development are discussed.

The role of social network and support in mental health service use: findings from the Baltimore ECA study

OBJECTIVE

A significant number of people with mental illness do not use mental health services to receive treatment for their symptoms. This study examined the hypothesis that social network and social support affect mental health service use.

METHODS

Data were from the Baltimore cohort of the Epidemiologic Catchment Area study, a prospective cohort study that gathered data over four time points. This study examined data gathered in 1993-1996 (N=1,920) and 2004-2005 (N=1,071). The study examined indicators of social network and social support in relation to four types of service use (general medical, mental health within general medical, specialty psychiatric, and other human services) with multivariate logistic regression. Examples of other human services include a self-help group or crisis center for help with any psychological problem. Weighted generalized estimating equations were used for the analyses.

RESULTS

Among persons with major depressive disorder, generalized anxiety disorder, panic disorder, or alcohol use disorder in the past year or psychological distress in the past few weeks, general medical service use was reduced when the frequency of contact with relatives or friends occurred less than daily, but it was increased by about 40% when there was a higher than median level of spousal support. In contrast, receiving general medical services for mental health problems was reduced by about 50% when there was a higher than median level of social support from relatives. Specialty psychiatric service use was reduced when there was regular contact with six or more relatives and there was a higher than median level of social support from friends and relatives. None of the social network or social support measures were significantly (p</=.01) associated with use of other human services.

CONCLUSIONS

Increased contact with the social network and higher levels of social support were associated with greater use of general medical services. However, more social support was associated with use of fewer services within the specialty psychiatric sector.

The role of social network and support in mental health service use: findings from the Baltimore ECA study

OBJECTIVE

A significant number of people with mental illness do not use mental health services to receive treatment for their symptoms. This study examined the hypothesis that social network and social support affect mental health service use.

METHODS

Data were from the Baltimore cohort of the Epidemiologic Catchment Area study, a prospective cohort study that gathered data over four time points. This study examined data gathered in 1993-1996 (N=1,920) and 2004-2005 (N=1,071). The study examined indicators of social network and social support in relation to four types of service use (general medical, mental health within general medical, specialty psychiatric, and other human services) with multivariate logistic regression. Examples of other human services include a self-help group or crisis center for help with any psychological problem. Weighted generalized estimating equations were used for the analyses.

RESULTS

Among persons with major depressive disorder, generalized anxiety disorder, panic disorder, or alcohol use disorder in the past year or psychological distress in the past few weeks, general medical service use was reduced when the frequency of contact with relatives or friends occurred less than daily, but it was increased by about 40% when there was a higher than median level of spousal support. In contrast, receiving general medical services for mental health problems was reduced by about 50% when there was a higher than median level of social support from relatives. Specialty psychiatric service use was reduced when there was regular contact with six or more relatives and there was a higher than median level of social support from friends and relatives. None of the social network or social support measures were significantly (p</=.01) associated with use of other human services.

CONCLUSIONS

Increased contact with the social network and higher levels of social support were associated with greater use of general medical services. However, more social support was associated with use of fewer services within the specialty psychiatric sector.

From childhood to adult age: 18-year longitudinal results and prediction of the course of mental disorders in the community

OBJECTIVE

This prospective longitudinal study of a representative community sample of children and adolescents (N = 269) examined the long-term course and predictive power of psychiatric symptoms in childhood/adolescence for diagnostic outcome (ICD-10) 18 years later at adult age.

METHOD

At both cross-sectional assessments, baseline (1980-1984) and the 18-year follow-up (2001-2004), psychiatric symptoms were assessed using the 'Standardized Psychiatric Interview' (Goldberg et al. in Br J Prev Soc Med 24:18-23, 1970). At follow-up, study participants were reassessed with the standardized M-CIDI (Wittchen and Pfister in Manual und Durchführungsbeschreibung des DIA-X-M-CIDI, Swets and Zeitlinger, Frankfurt, 1997) interview.

RESULTS

The participation rate at 18-year follow-up was 82% of those alive. The frequency of clinically relevant depressive symptoms and symptoms of anxiety or phobia was considerably higher when the participants were younger (baseline assessment at childhood, adolescent age) as compared to their scores in adult age. Increased levels of somatic symptoms, fatigue, irritability, sleep disturbances, depression, anxiety and worry as well as phobic symptoms in childhood/adolescence were related to a higher risk of suffering from a psychiatric disorder in adulthood. Depressive symptoms predicted both mood disorders and substance use disorders in adulthood. Phobias predicted later anxiety disorders.

CONCLUSION

These data spanning almost two decades add significant information to the existing literature on the course of mental disorders in the community during the transition from adolescence to adulthood.

Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: cochrane review

The published literature comparing surgery, with or without adjuvant endocrine therapy, with endocrine therapy alone in older women with operable breast cancer was systematically reviewed. The design used is Cochrane review. Randomised controlled trials retrieved from the Cochrane Breast Cancer Group Specialised Register on 29 June 2005. Eligible studies recruited women aged 70 years or over with operable breast cancer, fit for surgery under general anaesthia. The studies compared surgery (either mastectomy or wide local excision, with or without endocrine therapy) to endocrine therapy alone. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Double data extraction and quality assessment were undertaken. Seven eligible trials were identified of which six had published time-to-event data. The quality of the allocation concealment was adequate in three studies and unclear in the remainder. In each case the endocrine therapy used was tamoxifen. When surgery alone was compared to endocrine therapy alone, there was no significant difference in OS (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.74-1.30, P=0.9), but a significant difference in PFS (HR 0.55, 95% CI 0.39-0.77, P=0.0006). When surgery with adjuvant endocrine therapy was compared to endocrine therapy alone, there was no significant difference in OS (HR 0.86, 95% CI 0.73-1.00, P=0.06), but a significant difference in PFS (HR 0.65 (95% CI 0.53-0.81, P=0.0001) for surgery plus endocrine therapy vs primary endocrine. The regimens have different side effect profiles with one study suggesting increased psychosocial morbidity at 3 months in the surgical arm, which resolves by 2 years. Primary endocrine therapy with tamoxifen is associated with inferior local disease control but non-inferior survival to surgery for breast cancer in older women. Trials are needed to evaluate appropriate selection criteria for its use in terms of patient co-morbidity and quality of life. Trials are needed to evaluate the clinical effectiveness of aromatase inhibitors as primary therapy for this population.

Do teachers have more health problems? Results from a French cross-sectional survey

BACKGROUND

Although only a few studies have been published on teachers' health, certain ideas are widely accepted, such as for example, the preconceived notion that teachers suffer from an excessively high rate of mental health problems. The objective of this study is to compare teachers' mental and physical health to that of a control group.

METHODS

A cross-sectional postal survey was conducted among a sample of 3,679 teachers and 1,817 non-teachers aged 20 to 60 years old.

RESULTS

No lifetime prevalence of any psychiatric disorder (with the exception of undifferentiated somatoform disorder in men) or mean scores of psychological distress were found to be significantly higher in teachers. However, multiple analyses, adjusted for all confounding variables, revealed a higher risk of lifetime anxiety disorders in male teachers. On the other hand, significant differences were observed for some physical ailments: a higher lifetime prevalence of rhinopharyngitis/laryngitis in both male and female teachers, of conjunctivitis and lower urinary tract infection in male teachers and of bronchitis, eczema/dermatitis and varicose veins in female teachers. No significant difference was found for chronic pain between the two groups.

CONCLUSION

Teachers do not seem to have poorer mental health. However, their physical condition is characterized by a higher prevalence of health problems related to the ENT tract, and to a lesser extent, depending on the gender, to skin, eyes, legs and lower urinary tract.

MN. Analysis of the Psychometric Properties of the Malay Version of Beck Depression Inventory II (BDI-II) Among Postpartum Women in Kedah, North West of Peninsular Malaysia

Increased international collaboration in clinical trials has created a need for cross culturally valid instruments to assess the quality of life and behavioural disorders. Cross cultural studies of depressive symptomatology, in particular, must be preceded by an exhaustive study of the psychometric properties of the instruments to ensure the validity of the comparison. In this article, we examined the validity, reliability and factor structure of the Malay version of the Beck Depression Inventory II (BDI-II) among Malay postpartum women attending selected health centres in Kedah, North West of Peninsular Malaysia. Our findings indicated that the current version of the BDI-II is psychometrically strong and appropriate for use in assessing depressive symptomatology among this group of women.

Detection of postpartum depressive symptoms by screening at well-child visits

OBJECTIVE

To assess 1) the feasibility of universal postpartum depression screening during well-child visits in the first year of life, 2) the prevalence of postpartum depressive symptoms among mothers who attend first-year well-child visits, 3) detection of postpartum depressive symptoms in a pediatric clinic before and after universal screening at each first-year well-child visit, and 4) social work referrals before and after universal screening.

METHODS

The practice instituted universal screening for postpartum depressive symptoms during first-year well-child visits using the Edinburgh Postnatal Depression Scale (EPDS). We randomly selected 110 infant medical records before (cohort 1) and 110 after (cohort 2) screening was initiated. Measures included demographics, notation of depression or depressive symptoms in the well-child visit note, and referral for depression. EPDS scores were collected for cohort 2 only. Before-after comparisons were made for detection of depression or depressive symptoms and mental health referrals.

RESULTS

The EPDS was included in the medical record in 46% of well-child visits. Eighty-eight percent of these forms were completed. Twenty-one percent of completed EPDS forms had scores > or =10, and 27% of women who completed the EPDS had scores > or =10 sometime during the postpartum year. There was a significant increase in documentation of depressive symptoms with the EPDS after initiation of universal screening (1.6% of visits [cohort 1] vs 8.5% [cohort 2]). Social work referrals for mental health reasons increased significantly (0.2% of visits [cohort 1] to 3.6% [cohort 2]).

CONCLUSIONS

Women with high levels of postpartum depressive symptoms are common in an urban population and can be detected at well-child visits throughout the first postpartum year by pediatricians using a standardized screening tool. Because screening for depression during well-child visits is feasible using a standardized screening instrument, pediatricians can play an active role in early detection and referral for postpartum depression.

Revalidation of the Malay Version of the Edinburgh Postnatal Depression Scale (EPDS) Among Malay Postpartum Women Attending the Bakar Bata Health Center in Alor Setar, Kedah, North West Of Peninsular Malaysia

AIM

To reevaluate the psychometric characteristics of the Malay version of the Edinburgh Postnatal Depression Scale among a sample of postpartum Malay women attending the Bakar Bata Health Center in Alor Setar, Kedah, North West of Peninsular Malaysia.

MATERIALS AND METHODS

64 women between 4 to 12 weeks postpartum were recruited for there validation study. They were given questionnaires on socio-demography, the 21-item Malay version of the Beck Depression Inventory II (BDI-II) and the 10-item Malay version of the Edinburgh Postnatal Depression Scale (EPDS). All the participants were later interviewed using the Hamilton Depression Rating Scale (HDRS-17) and the Composite International Diagnostic Interview (CIDI). All diagnoses were made based on the Tenth Edition of the International Classification of Diseases (ICD-10)

RESULTS

9 women (14.1%) were diagnosed to have significant depression (7 mild depressive episodes and 2 moderate depressive episodes according to ICD-10). EPDS was found to have good internal consistency (Cronbach alpha =0.86) and split half reliability (Spearman split half coefficient = 0.83). The instrument also showed satisfactory discriminant and concurrent validity as evidenced by the statistically significant difference in EPDS scores between the depressed group and their non-depressed counterparts (Mann Whitney U test: 2 tailed p value < 0.01) and good correlations between the instrument and both the Malay version of BDI-II and the HRDS-17 (Spearman rank correlation coefficients of 0.78 and 0.88 respectively). At the 11/12 cut-off score the sensitivity of the EPDS is 100%, with a specificity of 98.18%, positive predictive value of 90%, negative predictive value of 100 % and misclassification rate of 1.56%.

CONCLUSION

This study confirmed the reliability and validity of the Malay version of the Edinburgh Postnatal Depression Scale in identifying postpartum depression among recently delivered Malay women attending the Bata Bata Health Center in Alor Setar, Kedah, North West of Peninsular Malaysia.

30-item General Health Questionnaire in general hospitals: selecting items using a stepwise hierarchical procedure

An attempt was made to improve the validity of the 30-item General Health Questionnaire by excluding items. This exclusion was performed by using correlations of sum-scores with an external case criterion. This hierarchical approach based on subsets of items (stepwise hierarchical variable selection) resulted in a 9-item questionnaire whose discriminating performance was significantly better than that of the original version.

[Prevalence of psychiatric pathology at a rural health centre]

OBJECTIVES

To find the prevalence of psychiatric pathology at a rural health centre and to compare the results with results from studies with a similar design.

DESIGN

Two-stage crossover study of prevalence: first, detection and then, psychiatric pathology evaluation.Setting. El Marquesado Health Centre (Granada). Scattered rural population with low social and economic level and high percentage of elderly people.

PARTICIPANTS

Simple randomised sample representing the population over 18. N=245; error alpha=5%. Sampling source: electoral register.

MEASUREMENTS

GHQ-28 Goldberg Questionnaire, social and demographic data, and CAGE test. The CIS questionnaire for psychiatry was administered to those who exceeded the cut-off point (GHQ-28=5) and they were allocated a DSM IV diagnosis. If CAGE was>=2, damaging alcohol consumption was studied. If there was a prior diagnosis, the second stage was avoided. Measurements of prevalence with their exact confidence intervals were made.

RESULTS

Prevalence of psychiatric pathology: 28.6% (34.5% in women and 22.6% in men). 30% of cases had two diagnoses. Anxiety disorders were the most common pathology (8.97%), representing 23.9% of the grouped diagnoses. Depression disorders had 8.16% prevalence; problematic consumption of substances, 6.12%. The most common isolated diagnosis was Dysthymia (9.78% of cases). Hidden psychiatric morbidity reached 40%.

CONCLUSIONS

The prevalence of psychiatric pathology is very high. The most common disorders are those of anxiety, followed by depression and damaging alcohol consumption.

Is postnatal depression a risk factor for sudden infant death?

BACKGROUND

In New Zealand, an association has been shown between postnatal depression and sudden infant death syndrome (SIDS).

AIM

To replicate the New Zealand study.

DESIGN OF STUDY

Case-control study.

SETTING

The city of Sheffield, UK.

METHOD

The database of the Sheffield Child Development Study was used Demographic and obstetric data were collected and at one month postpartum the Edinburgh Postnatal Depression Scale (EPDS) was administered. Detailed information on the cause of all infant deaths was available.

RESULTS

There were 32,984 live births during the study period (from the year 1988 to 1993) and 42 babies died with the cause registered as SIDS. Multivariate analysis showed that smoking was the most important risk factorfor SIDS (odds ratio [OR] = 7.24, 95% confidence interval [95% CI] = 2.76 to 19.01), followed by a high EPDS (OR = 3.20, 95% CI = 1.46 to 6.99) and residence in an area of poverty (OR = 2.33, 95% CI = 1.06 to 5.11).

CONCLUSIONS

The Sheffield data confirm the New Zealand findings. A high EPDS score and, by implication, postnatal depression, may be risk factors for SIDS, however, there are many possible explanations for the association.

Postpartum depression: a survey of the incidence and associated risk factors among malay women in beris kubor besar, bachok, kelantan

The aim of this study was to determine the incidence and associated risk factors of postpartum depression among Malay women in Beris Kubor Besar, Bachok, Kelantan The study was conducted between February to August 1998. A two-stage population survey approach was employed. Firstly, all the women who delivered between the months of February and May 1998 in the catchment area were identified. In stage 1, the 30 items GHQ was used as the screening instrument at 6 to 8 weeks postpartum. All the potential cases (scoring above 6 on the questionnaire) were later interviewed using the CIS in stage 2 of the study. Diagnosis of postpartum depression was only made if the women fulfilled required criteria. Of the 174 women who were recruited, 17 of them fulfilled the criteria for postpartum depression yielding an incidence rate of 9.8 %. The condition was found to be significantly linked to low income or socioeconomic status, having marital problems (mainly financial in nature) and not breast - feeding.

The Clinical Interview Schedule--Sinhala version: validation in a community setting in Sri Lanka

The Clinical Interview Schedule Revised (CIS-R) was validated in a clinic setting for adolescents 15-19 years of age in Sri Lanka. The interview schedule was translated into Sinhala and modified to include sections introducing each symptom group. One-hundred-and-thirty-one adolescents attending a psychiatric clinic for the first time were interviewed by a lay interviewer using CIS-R (Translated). They had previously been examined and rated by a psychiatrist using local (emic) diagnostic procedures. All the filtering questions showed a high level of sensitivity (80%-96%). None of the questions in the sleep problems and phobias sections were effective at discriminating between those who did and did not show significant symptoms in these areas according to the psychiatrist. The internal consistency of the sections of the interview schedule (when these two sections were excluded) varied between 0.60 and 0.82. Linear regression showed that, when both sections were excluded, 97% of the variation of total score could be explained. Therefore, it was decided to exclude the sleep problems and phobias sections from the modified interview schedule. As the population samples are likely to be different from clinic samples it is necessary to test the validity again in a community sample before confirming the validity of the modified interview schedule.

Health-related quality of life and associated psychosocial factors in irritable bowel syndrome: a review

Irritable Bowel Syndrome (IBS) is a chronic recurring disorder with variable illness episodes that may continue for many years. Diagnosis is based on symptoms such as abdominal pain and irregular bowel habits. These symptoms, plus the influence of psychological factors and extraintestinal symptoms, adversely affect the health-related quality of life (HRQoL) of individuals with IBS. This paper summarizes publications relating to the characteristics of IBS and associated HRQoL. Significantly lower scores on both the physical and mental health scales of the Short Form-36 are reported for individuals with IBS symptoms as compared with asymptomatic controls and US norms. IBS negatively affects general health, vitality, social functioning, bodily pain, diet, sexual function, sleep, and is associated with lost time from work. IBS-specific instruments that incorporate many of these domains have recently become available. HRQoL appears to correlate with IBS symptom severity and influences decisions to seek medical care. Psychosocial problems are also linked with IBS in relation to health care utilization. However, the full burden of this painful illness is still unknown since only 25-60% of individuals suffering from IBS symptoms see a physician for their illness.

The role of the general health questionnaire in general practice consultations

BACKGROUND

The patient self-rating questionnaire is commonly used as a research tool to identify patients with 'unrecognized' depression. There is no evidence to support its use as a clinical tool in general practice.

AIM

To determine whether use of the 30-item general health questionnaire (GHQ) is a practical means of increasing identification of 'new' episodes of emotional distress among patients consulting their general practitioner (GP).

METHOD

A randomized controlled trial was carried out in a Scottish new town practice with eight partners. In the waiting room, 1912 patients aged over 14 years and consulting over a 10-month period attempted to complete the GHQ. The 'clinical judgement' group posted the questionnaire into a box then attended the doctor as normal. The 'screened' group presented the questionnaire to the doctor. After the consultation, the doctor completed an assessment questionnaire. The main outcome measures were GHQ scores and doctors' assessments of mental health.

RESULTS

In total, 1589 patients were eligible to participate. However, 207 patients in the screened group were excluded because the doctor did not look at the questionnaire. The clinical judgement group (59.7% patients) and the screened group (40.3%) were compared. Although the doctors' diagnoses of distress were low in the clinical judgement group (8.1%), they were significantly greater in the screened group (13.9%) where the diagnosis of depression was doubled. The percentage of patients scoring greater than or equal to 9 (GHQ+) was 21.5% and 21.0% respectively. The level of agreement between the doctors' diagnoses of distress and the questionnaires scoring GHQ+ rose from 19% in the clinical judgement group to 35% in the screened group.

CONCLUSIONS

The general health questionnaire used in a practice setting increases the identification of patients with emotional distress. However, the use made of the questionnaires in the screened group raises questions of doctor and patient acceptability.

Alcoholism among outpatients with psychiatric morbidity

Out of 881 randomly selected outpatients in four rural district hospitals in Kenya who underwent a two stage screening procedure for a psychiatric disorder, 24.9 percent had psychiatric morbidity. Further analysis showed that 12.7 percent of them had an alcohol related disorder as defined by ICD-9 (WHO, 1978) under the categories 291 and 303. For the screening of alcoholic cases brief MAST was used. The author found this instrument a quick method for identifying potential alcoholics.At present, such cases go undetected and untreated. Some important issues related to alcohol drinking in rural Kenya are discussed. Most of our patients drank the locally brewed alcoholic beverages of variable ethanol contents. The health planners and primary health workers (PHW) will have to pay more attention to the widely prevalent alcohol abuse which seems to masquerade in various forms of physical, social or psychological problems. Indeed, more intensive training of the PHWs in detecting and advising alcoholics maybe the best method in the rural setting.

Menarche and the onset of depression and anxiety in Victoria, Australia

STUDY OBJECTIVE

Psychiatric disorder often begins at adolescence. This study aimed to examine the associations between puberty and social circumstances and the adolescent rise in depression and anxiety.

DESIGN

A two stage cluster sampling procedure was used to identify a representative group of Australian secondary school students in years 7 (age 12-13 years), 9 (14-15 years), and 11 (16-17 years) of 45 Victorian schools. The computerised clinical interview schedule (CIS) was used to evaluate psychiatric morbidity.

MAIN RESULTS

A total of 2525 subjects completed the survey - an overall participation rate of 83%. Levels of depression and anxiety increased with the secondary school years and girls had significantly higher rates at each school year level. For boys, the clearest independent associations with depression and anxiety were rising school year level and high parental educational achievement. For girls menarchal status emerged as the strongest predictor. Associations with age and school year level, evident on univariate analysis, did not persist when the recency of menarche was taken into account. After addition of measures of perceived social stress to a multivariate model, a significant association between depression/anxiety and parental divorce disappeared but the association with menarche persisted.

CONCLUSIONS

Menarche marks a transition in the risk of depression and anxiety in girls. The pattern of findings is consistent with a biological mediation of this association.

Long-term outcome of patients with neurotic illness in general practice

OBJECTIVE

To determine the 11 year outcome of neurotic disorder in general practice.

DESIGN

Cohort study over 11 years.

SETTING

Two general practices in Warwickshire England.

SUBJECTS

100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders.

MAIN OUTCOME MEASURES

Mortality, morbidity, and use of health services.

RESULTS

At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate.

CONCLUSION

These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.

Is smoking associated with depression and anxiety in teenagers?

OBJECTIVES

An association of smoking with depression and anxiety has been documented in adult smokers. This study examines this association in a representative group of teenage smokers.

METHODS

A two-stage cluster sample of secondary school students in Victoria, Australia, were surveyed by using a computerized questionnaire, which included a 7-day retrospective diary for tobacco use and a structured psychiatric interview.

RESULTS

Subjects reporting high levels of depression and anxiety were twice as likely to be smokers after the potential confounders of year level, sex, alcohol use, and parental smoking were controlled for. Regular smokers were almost twice as likely as occasional smokers to report high levels of depression and anxiety. In a stratified analysis, an association between regular smoking and psychiatric morbidity was found in girls of all ages but for boys only in the youngest group.

CONCLUSIONS

The cross-sectional association is consistent with the use of smoking by teenage girls as self-medication for depression and anxiety. Therefore, future health promotional campaigns might consider strategies that attend to perceived psychological benefits of smoking.

Visual impairment, visual functioning, and quality of life assessments in patients with glaucoma

BACKGROUND/PURPOSE

To determine the relation between visual impairment, visual functioning, and the global quality of life in patients with glaucoma.

METHODS

Visual impairment, defined with the American Medical Association Guides to the Evaluation of Permanent Impairment; visual functioning, measured with the VF-14 and the Field Test Version of the National Eye Institute-Visual Functioning Questionnaire (NEI-VFQ); and the global quality of life, assessed with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), were determined in 147 consecutive patients with glaucoma.

RESULTS

None of the SF-36 domains demonstrated more than a weak correlation with visual impairment. The VF-14 scores were moderately correlated with visual impairment. Of the twelve NEI-VFQ scales, distance activities and vision specific dependency were moderately correlated with visual impairment. Of the twelve NEI-VFQ scales, distance activities and vision specific dependency were moderately correlated with visual field impairment; vision specific social functioning, near activities, vision specific role difficulties, general vision, vision specific mental health, color vision, and driving were modestly correlated; visual pain was weakly correlated; and two were not significantly correlated. Correcting for visual actuity weakened the strength of the correlation coefficients.

CONCLUSIONS

The SF-36 is unlikely to be useful in determining visual impairment in patients with glaucoma. Based on the moderate correlation between visual field impairment and the VF-14 score, this questionnaire may be generalizable to patients with glaucoma. Several of the NEI-VFQ scales correlate with visual field impairment scores in patients with a wide range of glaucomatous damage.

The development of a culture specific screening questionnaire NSRQ-20 for use in psychiatric epidemiology: a preliminary report

A list of ten culture-specific symptoms frequently volunteered by Nigerian patients with Minor Psychiatric Disorders was added to the twenty items of the SRQ-20. The resultant 30-item questionnaire (SRQ-30) discriminated very well between a sample of new non-psychotic psychiatric referrals and a sample of subjects with very low probability of caseness (relatives of the new psychiatric referrals). Elimination of items of the SRQ-30 which poorly discriminated between the sample of psychiatric referrals and a matched sample of general hospital patients (ten items) produced the Nigerian version of the SRQ-20 (NSRQ-20) whose sensitivity is shown to be higher than that of the SRQ-30. Further validation study and future research trends on the NSRQ-20 are suggested.

Stress and mental health in neonatal intensive care units

The views of 34 neonatologists (a 78% response rate) and 192 neonatal intensive care nurses (a 66% response rate) were obtained on work, stress, and relationships in neonatal intensive care units. The survey was conducted by post and included Goldberg's General Health Questionnaire (GHQ). A comparison of the responses of neonatologists and nurses to 21 identical statements showed significant differences in 12. Most neonatologists felt that they involved nurses in critical patient care decisions, provided adequate pain relief for their patients, gave nurses adequate information on patients' progress after discharge, and were aware of little doctor-nurse conflict. However, the nurses' responses differed significantly in these areas, suggesting that the neonatologists may have a more rosy view of life in the neonatal intensive care unit than their nurse colleagues. Twenty seven per cent of neonatologists and 32% of nurses had GHQ scores indicating psychological dysfunction. The neonatologists who had dysfunctional scores differed from their colleagues in only one area surveyed--a higher proportion experienced conflict between the demands of their work and their personal lives.

Newly identified psychiatric illness in one general practice: 12-month outcome and the influence of patients' personality

BACKGROUND

Relatively little is known about the natural history and outcome of psychological problems in patients who present to general practitioners. Only a small proportion of such patients are seen by specialists. Clinical experience suggests that patient personality is one of the factors influencing outcome in patients diagnosed as having psychiatric illness.

AIM

This study set out to examine prospectively the progress and 12-month outcome of patients with newly identified psychiatric illness, and the association of patients' personality with outcome.

METHOD

One hundred and seventy one patients with clinically significant psychiatric illness attending one practice in a Scottish new town were followed up prospectively (96 presented with psychological symptoms and 75 with somatic symptoms), and were compared with a group of 127 patients with chronic physical illness. Patients were assessed in terms of psychiatric state, social problems and personality using both computer-based and pencil and paper tests in addition to clinical assessments at each consultation during the follow-up year and structured interview one year after recruitment.

RESULTS

Most of the improvement in psychiatric state scores on the 28-item general health questionnaire occurred in the first six months of the illness. Of the 171 patients with psychiatric illness 34% improved quickly and remained well, 54% had an intermittent course but had improved at 12-month follow up while 12% pursued a chronic course without improvement. The mean number of consultations in the follow-up year was 8.4 for patients presenting with psychological symptoms, 7.2 for those presenting with somatic symptoms and 6.6 for patients with chronic physical illness. The Eysenck N score proved a strong predictor of the outcome of new psychiatric illness.

CONCLUSION

Only one in three patients with newly identified psychiatric illness improved quickly and and remained well, reflecting the importance of continuing care of patients with psychological problems. This study has confirmed the feasibility of simple personality testing in everyday practice and shown a link between Eysenck N score and the outcome of new psychiatric illness. The predictive value of the Eysenck N score in general practice requires further research.