Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care: the Hampshire Depression Project

The Impact of the COVID-19 Pandemic and Socioeconomic Deprivation on Admissions to the Emergency Department for Psychiatric Illness: An Observational Study in a Province of Southern Italy

The restriction measures adopted to limit population movement in order to contain the COVID-19 pandemic contributed to a global public health system crisis. This retrospective study aimed at identifying changes in psychiatric admissions to Accident and Emergency Departments (A&Es) in a province in southern Italy during the first two years of the pandemic and was characterized by two different restriction levels (phases 2 and 3) compared to the pre-pandemic period (phase 1). We also investigated the role of socioeconomic deprivation (DI) on psychiatric admissions. The total number of patients admitted to the A&Es was 291,310. The incidence of admission for a psychiatric disorder (IPd) was 4.9 per 1000 admissions, with a significant younger median age of 42 [IQR 33–56] compared to non-psychiatric patients (54 [35–73]). The type of admission and type of discharge were factors related to the psychiatric admission to A&E, and their relationship was modified by the pandemic. In the first year of the pandemic, patients with psychomotor agitation increased compared to the pre-pandemic period (72.5% vs. 62.3%). In the period preceding the spread of SARS-CoV-2, the IPd was equal to 3.33 ± 0.19; after the pandemic started, there was an increase in the IPd: 4.74 ± 0.32 for phase 2 and 3.68 ± 0.25 for phase 3. The IPd was higher for psychiatric admissions from areas with a very low DI compared to areas with a low DI; however, during phase 2, this difference was reduced. In conclusion, an increase in admissions for psychiatric disease was observed during the initial spread of SARS-CoV-2. Patients who lived in the most deprived municipalities generally came to the A&Es less than others, probably because the patients and their families had less awareness of their mental health. Therefore, public health policies to address these issues are needed to reduce the pandemic’s impact on these conditions.

Risk factors for depression in Pacific adolescents in New Zealand: A network analysis

BACKGROUND

Network analysis provides opportunities to gain a greater understanding of the complex interplay of risk factors for depression and heterogeneous symptom presentations. This study used network analysis to discover risk factors associated with both depression severity and depression symptoms amongst Pacific adolescents in New Zealand.

METHODS

Mixed graphical models with regularization were fitted to data from a community sample of New Zealand born, Pacific adolescents, (n = 561; 51% male; Mean age (SD) = 17 (0.35)) and associations between a wide range of potentially explanatory variables and depression severity and depression symptoms investigated. The associations identified were then tested for reliability, using resampling techniques and sensitivity analysis.

RESULTS

In the networks, the explanatory variables associated with both depression severity and depression symptoms were those related to quality of the relationships with mother or friends, school connectedness, and self-assessed weight, but the symptoms they were associated with varied substantially. In the depression severity networks, impulsivity appeared to be a bridging node connecting depression severity with delinquency and negative peer influence.

LIMITATIONS

The data were analysed cross-sectionally, so causal inferences about the directions of relationships could not be inferred and most of the data were self-reported.

CONCLUSIONS

The results illustrate the varied way that adolescent depression can manifest itself in terms of symptoms and suggest specific items on the depression inventory that might be suitable targets for prevention strategies and interventions, based on the risk factor - depression symptom profiles of individuals or groups.

Socio-Economic Development and Mental Health: Case Study of the Spanish Region of Aragon (2010-20)

Introduction

Considering health as a cross-cutting element of all public policies leads to rethinking its interactions with the environment in which people live. The collection of large volumes of data by public administrations offers the opportunity to monitor and analyze the possible associations between health and territory. The increase in the incidence and prevalence of mental health diseases, particularly depression, justifies the need to develop studies that seek to identify links with the socioeconomic and environmental setting.

Objective

The objective of this study is to explain the behavior of the depression in a mediterranean region of Northeastern Spain from an ecological and diachronic perspective.

Methods

We conducted a correlation and multivariate logistic regression analysis to identify explanatory factors of the prevalence of depression in 2010 and 2020 and in the variation rate. Potential explanatory factors are related to the socioeconomic status and to the territorial development level.

Results

The regression models retained both socioeconomic and territorial development variables as predictors of the prevalence in both years and in the variation rate. Rural areas seem to play a protective role against the prevalence.

Conclusion

It is under the territorial prism that epidemiological studies could offer useful guidelines for proactive decision-making. The integration of data on diseases and territory must be considered when developing policies for the creation of healthier environments and for directing health services with more specific resources to where they may be needed.

Mental health disorders and alcohol misuse among UK military veterans and the general population: a comparison study

BACKGROUND

For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans.

METHODS

Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760).

RESULTS

We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans.

CONCLUSION

Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Mental health status and quality of life in close contacts of COVID-19 patients in the post-COVID-19 era: a comparative study

Close contacts of those with COVID-19 (CC) may experience distress and long-lasting mental health effects. However, the mental health status and quality of life (QOL) in CC have not been adequately examined. This study examined the mental health status and QOL in CC during the post-COVID-19 period. This cross-sectional study comprised 1169 CC and 1290 who were non-close contacts (non-CC). Demographic data were collected; depression, fatigue, post-traumatic stress symptoms (PTSS) and QOL were assessed using the Patient Health Questionnaire - 9 items (PHQ-9), fatigue numeric rating scale, Post-Traumatic Stress Disorder Checklist - 17 items (PCL-17), and the World Health Organization Quality of Life Questionnaire - brief version (WHOQOL-BREF), respectively. Analysis of covariance was used to compare depressive symptoms, QOL, fatigue, and PTSS between the CC and non-CC groups. Multiple logistic regression analyses were performed to determine the independent correlates for depression, fatigue, PTSS, and QOL in the CC group. Compared to the non-CC group, the CC group reported significantly more severe depression (F(1, 2458) = 5.58, p = 0.018) and fatigue (F(1, 2458) = 9.22, p = 0.002) in the post-COVID-19 period. No significant differences in PTSS and QOL between the CC and non-CC groups were found (F(1, 2458) = 2.93, p = 0.087 for PTSS; F(1, 2458) = 3.45, p = 0.064 for QOL). In the CC group, younger age, financial loss due to COVID-19, and perception of poor or fair health status were significantly associated with depression and fatigue, while frequent use of mass media was significantly associated with fatigue. In conclusion, close contacts of COVID-19 patients experienced high levels of depression and fatigue in the post-COVID-19 period. Due to the negative effects of depression and fatigue on daily functioning, early detection and timely interventions should be provided to this neglected population.

Community Deprivation Index and Discharge Destination After Elective Hip Replacement

OBJECTIVE

To examine how the deprivation level of the community in which one lives influences discharge disposition and the odds of 90-day readmission after elective total hip arthroplasty (THA).

METHODS

We performed a retrospective cohort study on 84,931 patients who underwent elective THA in the Pennsylvania Health Care Cost Containment Council database from 2012 to 2016. We used adjusted binary logistic regression models to test the association between community Area Deprivation Index (ADI) level and patient discharge destination as well as 90-day readmission. We included an interaction term for community ADI level and patient race in our models to assess the simultaneous effect of both on the outcomes.

RESULTS

After adjusting for patient- and facility-level characteristics, we found that patients from high ADI level communities (most disadvantaged), compared to patients from low ADI level communities (least disadvantaged), were more likely to be discharged to an institution as opposed to home for postoperative care and rehabilitation (age <65 years adjusted odds ratio [OR_adj ] 1.47; age ≥65 years OR_adj 1.31; both P < 0.001). The interaction effect of patient race and ADI level on discharge destination was statistically significant in those patients age ≥65 years, but not in patients age <65 years. The association with ADI level on 90-day readmission was not statistically significant.

CONCLUSION

In this statewide sample of patients who underwent elective THA, the level of deprivation of the community in which patients reside influences their discharge disposition, but not their odds of 90-day readmission to an acute-care facility.

Social inequalities in antidepressant treatment outcomes: a systematic review

PURPOSE

To identify, review and synthesize evidence on whether social disadvantage moderates antidepressant treatment outcomes, even when access to treatment is not a consideration.

METHODS

The systematic review was done in accordance with PRIMSA guidelines. An a priori systematic search strategy was used to search databases (MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Trials Library) from their earliest entries through December 31, 2018. A two-step screening procedure was followed, and all experimental studies of antidepressant treatment in ICD/DSM diagnosed cases of depression were included. Studies with subjects < 18 years or investigating other modalities of treatment were excluded.

RESULTS

Thirteen papers reporting analyses from nine studies met inclusion criteria. There was heterogeneity in sample sizes, target populations, treatment settings, clinical outcomes and definition of SES indices. The primary outcome was the relative effect of socioeconomic status (SES) (as measured by income, employment status and level of education)-on antidepressant treatment outcomes.

CONCLUSIONS

The evidence from this review suggests that lower SES may lead to social inequalities in antidepressant treatment outcomes even in the context of clinical trials in which all participants have equal access to the same high-quality, standardized care. The review calls for more careful consideration of the choice and operationalization of SES indicators, and the need to "employ sampling methods that ensure ample representation of individuals from a wide range of social worlds". The review concludes with tentative suggestions about how to reduce social inequalities in antidepressant treatment outcomes at the level of individuals and populations.

Prevalence and risk factors for depression in outpatient departments of three general hospitals in China: a cross-sectional study

Objectives: To determine the prevalence and risk factors associated with depression of outpatients in three general hospitals in southern China.Methods: This hospital-based, cross-sectional descriptive study was conducted in outpatient departments of Neurology, Gastroenterology, Cardiology and Gynaecology of three general hospitals between March and June 2016. A total of 5294 adult respondents (≥18 years) in clinic waiting rooms were recruited, and 4976 were eligible to participate in the study. The nine-item Patient Health Questionnare-9 (PHQ-9) Scale was used to assess the presence of depressive symptoms. Binary logistic regression analysis was performed to identify the risk factors associated with depressive symptoms.Results: The prevalence of depressive symptoms among outpatients was 26.0% (95% CI: 24.8-27.3%). Risk factors associated with depressive symptoms included younger age (OR = 0.960; 95% CI: 0.95-0.971), social alcohol drinking (OR = 1.339; 95% CI: 1.074-1.668) and sleep disturbance (OR = 3.678; 95% CI: 3.025-4.471).Conclusions: This study provides evidence that depressive symptoms are prevalent among outpatients of general hospitals. Moreover, younger age, alcohol consumption and sleep disturbance may potentially be useful for targeted screening and prevention for outpatients with depression seen in general hospitals.KeypointsThe prevalence of self-reported depressive symptoms is common in outpatients in clinical settings.Younger age, current alcohol drinking and sleep disturbance are the associated risk factors for depression in outpatient population.Alcohol prevention and sleep quality improvement need to be incorporated into strategies aimed at the prevention and management of depression.

Physical activity and depression: Towards understanding the antidepressant mechanisms of physical activity

Physical activity can treat and prevent depressive symptoms, but its antidepressant mechanisms are yet to be established. In this review, we comprehensively assess key biological and psychosocial mechanisms through which physical activity exerts antidepressant effects, with a particular focus on exercise. Exercise, a subset of physical activity, influences a range of biological and psychosocial processes also implicated in the pathophysiology of depression. We focus on the capacity for exercise to elicit changes in neuroplasticity, inflammation, oxidative stress, the endocrine system, self-esteem, social support and self-efficacy. We also discuss how a better understanding of these mechanisms can inform the way we design and implement exercise-based interventions to maximise their antidepressant effects on an individual basis. We conclude by presenting a conceptual framework of the key biological and psychosocial mechanisms underlying the relationship between physical activity and depressive symptoms, and the moderators and confounders that may influence it.

Marked improvement in HbA1c following commencement of flash glucose monitoring in people with type 1 diabetes

AIMS/HYPOTHESIS

Minimal evidence supports the efficacy of flash monitoring in lowering HbA_1c. We sought to assess the impact of introducing flash monitoring in our centre.

METHODS

We undertook a prospective observational study to assess change in HbA_1c in 900 individuals with type 1 diabetes following flash monitoring (comparator group of 518 with no flash monitoring). Secondary outcomes included changes in hypoglycaemia, quality of life, flash monitoring data and hospital admissions.

RESULTS

Those with baseline HbA_1c ≥58 mmol/mol (7.5%) achieved a median -7 mmol/mol (interquartile range [IQR] -13 to -1) (0.6% [-1.2 to -0.1]%) change in HbA_1c (p < 0.001). The percentage achieving HbA_1c <58 mmol/mol rose from 34.2% to 50.9% (p < 0.001). Median follow-up was 245 days (IQR 182 to 330). Individuals not using flash monitoring experienced no change in HbA_1c across a similar timescale (p = 0.508). Higher HbA_1c (p < 0.001), younger age at diagnosis (p = 0.003) and lower social deprivation (p = 0.024) were independently associated with an HbA_1c fall of ≥5 mmol/mol (0.5%). More symptomatic (OR 1.9, p < 0.001) and asymptomatic (OR 1.4, p < 0.001) hypoglycaemia was reported after flash monitoring. Following flash monitoring, regimen-related and emotional components of the diabetes distress scale improved although the proportion with elevated anxiety (OR 1.2, p = 0.028) and depression (OR 2.0, p < 0.001) scores increased. Blood glucose test strip use fell from 3.8 to 0.6 per day (p < 0.001). Diabetic ketoacidosis admissions fell significantly following flash monitoring (p = 0.043).

CONCLUSIONS/INTERPRETATION

Flash monitoring is associated with significant improvements in HbA_1c and fewer diabetic ketoacidosis admissions. Higher rates of hypoglycaemia may relate to greater recognition of hitherto unrecognised events. Impact upon quality of life parameters was mixed but overall treatment satisfaction was overwhelmingly positive.

Psychosocial, psychopharmacological and demographic predictors of changes in psychological distress over a course of computerised cognitive behavioural therapy (cCBT)

Social group identification, socioeconomic deprivation, and a number of other clinical and demographic factors have been found to predict severity of psychological distress prior to treatment in those referred to receive computerised cognitive behavioural therapy (cCBT) as an intervention for mild to moderate depression. The aim of the current study is to investigate whether the same key factors are able to predict magnitude of change in psychological distress across treatment in a sample receiving cCBT. Participants (N = 1158) consisted of individuals completing the 'Beating the Blues' (BtB) programme. Participants completed three versions of the group identifications scale (GIS), one for each of three groups: family, community, and a social group of choice. Changes in psychological distress showed statistically significant improvements between pre- and post-treatment assessment in all outcome measure subscales. Significantly greater changes (reductions) in psychological distress were found in those who had more severe pre-treatment psychological distress, those who lived in a lesser state of socioeconomic deprivation, those who identified with more social groups, and those taking antidepressant medication (ADM) concurrently. These findings provide valuable information on the likely course of treatment in those receiving cCBT, and highlight both the potential of social group identification as a 'social cure' for poor psychological health and the inequalities of the socioeconomic health gradient.

Mental and Physical Health Disparities in Patients With Carpal Tunnel Syndrome Living With High Levels of Social Deprivation

PURPOSE

Social, mental, and physical health have a complex interrelationship with each influencing individuals' overall health experience. Social circumstances have been shown to influence symptom intensity and magnitude of disability for a variety of medical conditions. We tested the null hypothesis that social deprivation would not impact Patient-Reported Outcomes Measurement Information System (PROMIS) scores or objective health factors in patients presenting for treatment of carpal tunnel syndrome (CTS).

METHODS

This cross-sectional study analyzed data from 367 patients who presented for evaluation of CTS to 1 of 6 hand surgeons at a tertiary academic center between August 1, 2016, and June 30, 2017. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index was used to quantify social deprivation. Medical record review determined duration of symptoms, tobacco and opioid use, and the Charlson Comorbidity Index (CCI) for each patient. Sample demographics, PROMIS scores, and objective health measures were compared in groups defined by national quartiles of social deprivation.

RESULTS

Patients with CTS living in the most deprived quartile had worse mean scores across all 4 PROMIS domains compared with those living in the least deprived quartile. A higher proportion of individuals from the most deprived quartile had a heightened level of anxiety than those in the least deprived quartile (37.3% vs 12.6%). The mean CCI was higher in the most deprived quartile, as was the proportion of individuals using tobacco. There were no differences in opioid use or symptom duration between patients from each deprivation quartile.

CONCLUSIONS

Social deprivation is associated with worse patient-reported health measures in patients with CTS. Compared with those from the least deprived areas, patients from the most deprived areas also have a greater comorbidity burden and higher rates of tobacco use at presentation to a hand surgeon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Variability of the Prevalence of Depression in Function of Sociodemographic and Environmental Factors: Ecological Model

Major depression etiopathogenesis is related to a wide variety of genetics, demographic and psychosocial factors, as well as to environmental factors. The objective of this study is to analyze sociodemographic and environmental variables that are related to the prevalence of depression through correlation analysis and to develop a regression model that explains the behavior of this disease from an ecological perspective. This is an ecological, retrospective, cross-sectional study. The target population was 1,148,430 individuals over the age of 16 who were registered in Aragon (Spain) during 2010, with electronic medical records in the community’s primary health care centers. The spatial unit was the Basic Health Area (BHA). The dependent variable was the diagnosis of Depression and the ecological independent variables were: Demographic variables (gender and age), population distribution, typology of the entity, population structure by sex and age, by nationality, by education, by work, by salary, by marital status, structure of the household by number of members, and state of the buildings. The results show moderate and positive correlations with higher rates of depression in areas having a higher femininity index, higher population density, areas with a higher unemployment rate and higher average salary. The results of the linear regression show that aging +75 and rural entities act as protective factors for depression, while urban areas and deficient buildings act as risk factors. In conclusion, the ecological methodology may be a useful tool which, together with the statistical epidemiological analysis, can help in the political decision making process.

Risk Factors for Depression Among Civilians After the 9/11 World Trade Center Terrorist Attacks: A Systematic Review and Meta-Analysis

INTRODUCTION

The development of depressive symptoms among the population of civilians who were not directly involved in recovery or rescue efforts following the 9/11 World Trade Center (WTC) terrorist attacks is not comprehensively understood. We performed a meta-analysis that examined the associations between multiple risk factors and depressive symptoms after the 9/11 WTC terrorist attacks in New York City among civilians including survivors, residents, and passersby.

METHODS

PubMed, Google Scholar, and the Cochrane Library were searched from September, 2001 through July, 2016. Reviewers identified eligible studies and synthesized odds ratios (ORs) using a random-effects model.

RESULTS

The meta-analysis included findings from 7 studies (29,930 total subjects). After adjusting for multiple comparisons, depressive symptoms were significantly associated with minority race/ethnicity (OR, 1.40; 99.5% Confidence Interval [CI], 1.04 to 1.88), lower income level (OR, 1.25; 99.5% CI, 1.09 to 1.43), post-9/11 social isolation (OR, 1.68; 99.5% CI, 1.13 to 2.49), post-9/11 change in employment (OR, 2.06; 99.5% CI, 1.30 to 3.26), not being married post-9/11 (OR, 1.59; 99.5% CI, 1.18 to 2.15), and knowing someone injured or killed (OR, 2.02; 99.5% CI, 1.42 to 2.89). Depressive symptoms were not significantly associated with greater age (OR, 0.86; 99.5% CI, 0.70 to 1.05), no college degree (OR, 1.32; 99.5% CI, 0.96 to 1.83), female sex (OR, 1.24; 99.5% CI, 0.98 to 1.59), or direct exposure to WTC related traumatic events (OR, 1.26; 99.5% CI, 0.69 to 2.30).

DISCUSSION

Findings from this study suggest that lack of post-disaster social capital was most strongly associated with depressive symptoms among the civilian population after the 9/11 WTC terrorist attacks, followed by bereavement and lower socioeconomic status. These risk factors should be identified among civilians in future disaster response efforts.

[Social problems in primary health care - prevalence, responses, course of action, and the need for support from a general practitioners' point of view]

BACKGROUND

Very often patients utilize primary care services for health conditions related to social problems. These problems, which are not primarily medical, can severely influence the course of an illness and its treatment. Little is known about the extent to which problems like unemployment or loneliness occur in a general practice setting.

OBJECTIVES

What are the most frequent health-related social problems perceived by general practitioners (GPs)? How are these problems associated with GP- or practice characteristics? How do general practitioners deal with the social problems they perceive and what kind of support do they need?

MATERIALS AND METHODS

Cross-sectional, postal questionnaire survey with questions derived from "Chapter Z social problems" of the International Classification of Primary Care - 2^nd edition. The questionnaire was mailed to available GP addresses in the federal states of Hamburg (n=1,602) and Schleswig-Holstein (n=1,242).

RESULTS

N=489 questionnaires (17.2 %) were analyzed. At least three times a week, GPs were consulted by patients with poverty/financial problems (53.4 %), work/unemployment problems (43.7 %), patients with loneliness (38.7 %) as well as partnership issues (25.5 %). Only rarely did GPs report having perceived assault/harmful event problems (0.8 %). The highest frequency of problems was encountered by practices with a high proportion of a migrant population.

CONCLUSIONS

Social problems are a common issue in routine primary care. GPs in Northwestern Germany usually try to find internal solutions for social problems but also indicated further interest in institutionalized support. A possible approach to solving these issues are community-based, locally organized networks.

Addressing Behavioral Health Disparities for Somali Immigrants Through Group Cognitive Behavioral Therapy Led by Community Health Workers

To test the feasibility and acceptability of implementing an evidence-based, peer-delivered mental health intervention for Somali women in Minnesota, and to assess the impact of the intervention on the mental health of those who received the training. In a feasibility study, 11 Somali female community health workers were trained to deliver an 8-session cognitive behavioral therapy intervention. Each of the trainers recruited 5 participants through community outreach, resulting in 55 participants in the intervention. Self-assessed measures of mood were collected from study participants throughout the intervention, and focus groups were conducted. The 55 Somali women who participated recorded significant improvements in mood, with self-reported decreases in anxiety and increases in happiness. Focus group data showed the intervention was well received, particularly because it was delivered by a fellow community member. Participants reported gaining skills in problem solving, stress reduction, and anger management. Participants also felt that the intervention helped to address some of the stigma around mental health in their community. Delivery of cognitive behavioral therapy by a community health workers offered an acceptable way to build positive mental health in the Somali community.

Comparing social group identifications and socioeconomic deprivation as predictors of psychological distress: Evidence from a Scottish primary care sample

Social group identification and socioeconomic deprivation have both been linked to self-reported depressive symptoms in general population samples; however, no study to date has explored the strength of the joint predictive value of these factors within a mental health population. The current study explored the impact of social group identifications and socioeconomic deprivation, together with important clinical and demographic variables, on psychological distress in a Scottish mental health sample. Participants (N = 976) were recruited from referrals to a computerized cognitive behavioural therapy (cCBT) programme in Scotland, 'Beating the Blues' (BtB) over a 25-month period. Participants completed the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) as a measure of psychological distress and three versions of the group identifications scale (GIS), one for each of three groups: family, community, and a social group of choice. Demographic information and clinical information were collected on commencing BtB. Higher numbers of group identifications were significantly associated with lower psychological distress. Additionally, increased socioeconomic deprivation was significantly associated with more severe psychological distress; however, interestingly, the association was not as strong as that of group identifications. Identifying with fewer social groups predicts more severe psychological symptom presentations, even more so than living in a greater state of socioeconomic deprivation.

The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies

BACKGROUND

Cognitive Behaviour Therapy (CBT) is the front-line psychological intervention for step 3 within UK psychological therapy services. Counselling is recommended only when other interventions have failed and its effectiveness has been questioned.

METHOD

A secondary data analysis was conducted of data collected from 33,243 patients across 103 Improving Access to Psychological Therapies (IAPT) services as part of the second round of the National Audit of Psychological Therapies (NAPT). Initial analysis considered levels of pre-post therapy effect sizes (ESs) and reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.

RESULTS

Counselling received more referrals from patients experiencing moderate to severe depression than CBT. For patients scoring above the clinical cut-off on the PHQ-9 at intake, the pre-post ES (95% CI) for CBT was 1.59 (1.58, 1.62) with 46.6% making RCSI criteria and for counselling the pre-post ES was 1.55 (1.52, 1.59) with 44.3% of patients meeting RCSI criteria. Multilevel modelling revealed a significant site effect of 1.8%, while therapy type was not a predictor of outcome. A significant interaction was found between the number of sessions attended and therapy type, with patients attending fewer sessions on average for counselling [M = 7.5 (5.54) sessions and a median (IQR) of 6 (3-10)] than CBT [M = 8.9 (6.34) sessions and a median (IQR) of 7 (4-12)]. Only where patients had 18 or 20 sessions was CBT significantly more effective than counselling, with recovery rates (95% CIs) of 62.2% (57.1, 66.9) and 62.4% (56.5, 68.0) respectively, compared with 44.4% (32.7, 56.6) and 42.6% (30.0, 55.9) for counselling. Counselling was significantly more effective at two sessions with a recovery rate of 34.9% (31.9, 37.9) compared with 22.2% (20.5, 24.0) for CBT.

CONCLUSIONS

Outcomes for counselling and CBT in the treatment of depression were comparable. Research efforts should focus on factors other than therapy type that may influence outcomes, namely the inherent variability between services, and adopt multilevel modelling as the given analytic approach in order to capture the naturally nested nature of the implementation and delivery of psychological therapies. It is of concern that half of all patients, regardless of type of intervention, did not show reliable improvement.

Explaining the variation between practices in the duration of new antidepressant treatment: a database cohort study in primary care

BACKGROUND

Practices vary in the duration of newly initiated antidepressant treatment, even after adjusting for patient characteristics. It was hypothesised that this may be because of differences between practices in demographic (practice deprivation and antidepressant prescribing rates), organisational (practice size and proportion of female GPs), and clinical factors (proportion of new episodes of depression coded).

AIM

To examine the effect of practice characteristics on the duration of new selective serotonin reuptake inhibitor antidepressant treatment in primary care.

DESIGN AND SETTING

Database cohort study of 28 027 patients from 237 GP practices in Scotland.

METHOD

Prescription data were used to estimate duration of treatment for individual patients beyond three time points: 30, 90, and 180 days. Data at patient and practice level were analysed by multilevel logistic regression to quantify the variation between practices.

RESULTS

The mean rate of diagnostic coding for depression in patients beginning a course of treatment was 29% (range 0-80%). Practice-level deprivation and rate of new antidepressant prescribing were not associated with duration of treatment. The practice level factor most strongly associated with duration of treatment at practice level was the proportion of patients coded as having depression: odds ratio for continuing beyond 30 days was 1.54 (95% confidence interval [CI] = 1.22 to 1.94); beyond 90 days, 1.37 (95% CI = 1.09 to 1.71); and beyond 180 days 1.41 (95% CI = 1.10 to 1.82).

CONCLUSION

Encouraging coding and structured follow-up at the onset of treatment of depression is likely to reduce early discontinuation of antidepressant treatment and improve outcomes.

Perceptions of mental illness in the Somali community in Minnesota

Purpose

– Somali immigrants are a strong, vibrant community in the Twin Cities area of Minnesota. However, the legacy of resettlement and the challenges of adjustment can lead to complex physical and mental health challenges. The Somali community is considered to be underserved, particularly with regard to mental health, but the health system must understand the perception of mental health in the Somali community in order to address current disparities. The paper aims to discuss these issues.

Design/methodology/approach

– This qualitative research drew on the Social Ecological Model (SEM) and was conducted with the goal of learning more about how mental illness is perceived in the Somali community living in Minnesota. Four focus groups were held, with a total of 35 participants, 19 female and 16 male.

Findings

– Several main themes emerged from the data. The community’s foundations of the perceptions of mental health inform and shape their perspective on mental illness, including the way mental illness is defined. Historical experiences, the impact of trauma, strong religious beliefs, and stigma toward mental illness influenced both the perceived causes of mental illness and views on seeking treatment.

Originality/value

– This research suggests there is value in drawing on the SEM to as the perception of mental illness is both layered, and shaped by the Somali community’s historical and social context. Forming community partnerships that address concerns about mental illness are essential next steps toward improving mental health in the Somali community. These partnerships should build on existing community assets, particularly religious leaders.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

Composite Measures of Individual and Area-Level Socio-Economic Status Are Associated with Visual Impairment in Singapore

Purpose

To investigate the independent relationship of individual- and area-level socio-economic status (SES) with the presence and severity of visual impairment (VI) in an Asian population.

Methods

Cross-sectional data from 9993 Chinese, Malay and Indian adults aged 40–80 years who participated in the Singapore Epidemiology of eye Diseases (2004–2011) in Singapore. Based on the presenting visual acuity (PVA) in the better-seeing eye, VI was categorized into normal vision (logMAR≤0.30), low vision (logMAR>0.30<1.00), and blindness (logMAR≥1.00). Any VI was defined as low vision/blindness in the PVA of better-seeing eye. Individual-level low-SES was defined as a composite of primary-level education, monthly income<2000 SGD and residing in 1 or 2-room public apartment. An area-level SES was assessed using a socio-economic disadvantage index (SEDI), created using 12 variables from the 2010 Singapore census. A high SEDI score indicates a relatively poor SES. Associations between SES measures and presence and severity of VI were examined using multi-level, mixed-effects logistic and multinomial regression models.

Results

The age-adjusted prevalence of any VI was 19.62% (low vision = 19%, blindness = 0.62%). Both individual- and area-level SES were positively associated with any VI and low vision after adjusting for confounders. The odds ratio (95% confidence interval) of any VI was 2.11(1.88–2.37) for low-SES and 1.07(1.02–1.13) per 1 standard deviation increase in SEDI. When stratified by unilateral/bilateral categories, while low SES showed significant associations with all categories, SEDI showed a significant association with bilateral low vision only. The association between low SES and any VI remained significant among all age, gender and ethnic sub-groups. Although a consistent positive association was observed between area-level SEDI and any VI, the associations were significant among participants aged 40–65 years and male.

Conclusion

In this community-based sample of Asian adults, both individual- and area-level SES were independently associated with the presence and severity of VI.

COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL

BACKGROUND

Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression care. The authors evaluated whether "MOMCare,"a culturally relevant, collaborative care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus).

METHODS

A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care.

RESULTS

All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ(2) = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ(2) = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ(2) = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ(2) = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ(2) = 10.00, df = 1, P < .01).

CONCLUSION

Compared to MSS-Plus, MOMCare showed significant improvement in quality of care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression care can be integrated into the services of a county public health system in the United States.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.govNCT01045655.

A randomized trial of collaborative depression care in obstetrics and gynecology clinics: socioeconomic disadvantage and treatment response

OBJECTIVE

The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance.

METHOD

The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire-9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale).

RESULTS

The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=-0.08, 0.84) for women with commercial insurance.

CONCLUSIONS

Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.

Depression and anxiety symptoms post-stroke/TIA: prevalence and associations in cross-sectional data from a regional stroke registry

BACKGROUND

Mood disorders are commonly seen in those with cerebrovascular disease. Literature to-date has tended to focus on depression and on patients with stroke, with relatively little known about post-stroke anxiety or mood disorder in those with transient ischaemic attack (TIA). We aimed to describe prevalence of depression and anxiety symptoms in stroke and TIA cohorts and to explore association with clinical and socio-demographic factors.

METHODS

We used a city wide primary care stroke registry (Glasgow Local Enhanced Service for Stroke - LES). All community dwelling stroke-survivors were included. We described cross-sectional prevalence of depression and anxiety symptoms using the Hospital Anxiety and Depression Scale (HADS). Data on clinical and demographic details was collected and univariable and multivariable analyses performed to describe associations with HADS scores. We examined those with a diagnosis of 'stroke' and 'TIA' as separate cohorts.

RESULTS

From 13,283 potentially eligible stroke patients in the registry, we had full HADS data on 4,079. Of the 3,584 potentially eligible TIA patients, we had full HADS data on 1,247 patients. Across the stroke cohort, 1181 (29%) had HADS anxiety scores suggestive of probable or possible anxiety; 993 (24%) for depression. For TIA patients, 361 (29%) had anxiety and 254 (21%) had depression. Independent predictors of both depression and anxiety symptoms were female sex, younger age and higher socioeconomic deprivation score (all p < 0.001).

CONCLUSION

Using HADS, we found a high prevalence of anxiety and depression symptoms in a community-based cohort of patients with cerebrovascular disease.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial

OBJECTIVE

To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care.

METHODS

A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.

RESULTS

Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36).

CONCLUSION

Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316.

LEVEL OF EVIDENCE

I.

Poststroke Anxiety is Prevalent at the Population Level, Especially among Socially Deprived and Younger Age Community Stroke Survivors

Background

Most studies of poststroke anxiety prevalence are hospital based, so knowledge of anxiety in community stroke survivors is limited. Few studies address the association between poststroke anxiety and patient age. No study has explored the relationship between poststroke anxiety prevalence and social deprivation.

Aims

This study aims to describe population level prevalence data of poststroke anxiety and to explore association of poststroke anxiety prevalence with patient age, gender, and social deprivation.

Methods

Observational study of 3831 community stroke survivors attending general practice reviews from April 1, 2009 to March 31, 2010 in Greater Glasgow, United Kingdom. Univariate and multivariate analyses investigated the association between poststroke anxiety prevalence (Hospital Anxiety and Depression Scale: anxiety sub-scale [HADS-A]), age, gender, and deprivation variables.

Results

Six hundred eighteen (16·1%) of 3831 community-dwelling stroke survivors had definite abnormal mood on HADS-A (≥11), with 952 (31·5%) scoring ≥8. Sixty-five (35·5%) of stroke survivors aged under 50 years had definite abnormal mood on HADS-A compared with 59 (7·2%) of over 80 year olds. Three hundred forty (19·8%) of women had definite abnormal mood on HADS-A compared with 278 (13·1%) of men. Three hundred seventy-two (22·6%) of most deprived stroke survivors had definite abnormal mood on HADS-A compared with 49 (7·6%) of least deprived. Age, gender, and social deprivation all contributed significantly to HADS-A score variance.

Conclusion

Using a conservative HADS-A cutoff, a high prevalence of definite abnormal anxiety in community stroke survivors is observed. This prevalence increases markedly in younger and more socially deprived stroke survivors.

Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity

Objective

This study aimed to estimate the impact of deprivation on the occurrence, health outcomes and health care costs of people with multiple morbidity in England.

Methods

Cohort study in the UK Clinical Practice Research Datalink, using deprivation quintile (IMD2010) at individual postcode level. Incidence and mortality from diabetes mellitus, coronary heart disease, stroke and colorectal cancer, and prevalence of depression, were used to define multidisease states. Costs of health care use were estimated for each state from a two-part model.

Results

Data were analysed for 141,535 men and 141,352 women aged ≥30 years, with 33,862 disease incidence events, and 13,933 deaths. Among incidences of single conditions, 22% were in the most deprived quintile and 19% in the least deprived; dual conditions, most deprived 26%, least deprived 16% and triple conditions, most deprived 29%, least deprived 14%. Deaths in participants without disease were distributed most deprived 22%, least deprived 19%; in participants with single conditions, most deprived 24%, least deprived 18%; dual conditions, most deprived 27%, least deprived 15%, and triple conditions, most deprived 33%, least deprived 17%. The relative rate of depression in most deprived participants with triple conditions, compared with least deprived and no disease, was 2.48 (1.74 to 3.54). Costs of health care use were associated with increasing deprivation and level of morbidity.

Conclusions

The higher incidence of disease, associated with deprivation, channels deprived populations into categories of multiple morbidity with a greater prevalence of depression, higher mortality and higher costs. This has implications for the way that resources are allocated in England’s National Health Service.

A review of the suitability of duloxetine and venlafaxine for use in patients with depression in primary care with a focus on cardiovascular safety, suicide and mortality due to antidepressant overdose

Depression and anxiety disorders are among the most common disorders treated by general practitioners (GPs) in the UK. Since both disorders are associated with a significantly increased risk of suicide, including with antidepressant overdose, the safety of antidepressants in overdose is of paramount importance. Numerous updates relating to antidepressant safety have been issued by regulators in the UK which may have eroded GP confidence in antidepressants. Venlafaxine, a serotonin nor adrenaline reuptake inhibitor (SNRI) had primary care prescribing restrictions placed on it in 2004 due to concerns about cardiotoxicity and mortality in overdose. Although a review of the evidence led to a reversal of the majority of restrictions in 2006, evidence suggests GPs may still be cautious in their prescribing of venlafaxine and possibly other SNRI antidepressants for patients with depression and anxiety disorders. This paper reviews the evidence pertaining to the safety of SNRI antidepressants from a perspective of cardiovascular safety and overdose. The currently available evidence suggests a marginally higher toxicity of venlafaxine in overdose compared with another SNRI duloxetine and the selective serotonin reuptake inhibitors (SSRIs), although this may be related to differential patterns of prescribing in high-risk patients. Based on this review SNRIs have a positive risk benefit profile in the treatment of depression and generalized anxiety disorder in primary care, especially as second-line agents to SSRIs.

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

BACKGROUND

Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported.

AIM

To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation.

DESIGN AND SETTING

Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month.

METHOD

Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy.

RESULTS

PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas.

CONCLUSION

In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.

Poor response to treatment: beyond medication

In psychiatry, one of the main factors contributing to poor response to pharmacological treatment is adherence. Noncompliance with maintenance treatments for chronic illnesses such as schizophrenia and affective disorders can exceed 50%, Poor adherence can be due to drug-related factors (tolerance, complexity of prescription, side effects, or cost), patient-related variables (illness symptoms, comorbidity, insight capacity, belief system, or sociocultural environment), and physician-related factors (communication or psychoeducational style). Psychosocial treatments must be used in conjunction with medication during the maintenance phase to improve adherence to treatment and to achieve - through the management of psychological variables - better social, work, and family functioning. This article reviews the concepts of adherence and noncompliance, and their impact on maintenance treatments, as well as the effect of dealing with psychosocial factors in psychiatric treatment.

Psychosocial stressors and depression at a Swedish primary health care centre. A gender perspective study

Background

Psychosocial stress may account for the higher prevalence of depression in women and in individuals with a low educational background. The aim of this study was to analyse the association between depression and socio-demographic data, psychosocial stressors and lifestyle circumstances from a gender perspective in a relatively affluent primary care setting.

Methods

Patients, aged 18- 75 years, visiting a drop-in clinic at a primary care health centre were screened with Beck's Depression Inventory (BDI). The physicians used also targeted screening with BDI. A questionnaire on socio-demographic data, psychosocial stressors and use of alcohol and tobacco was distributed. Among patients, who scored BDI ≥10, DSM-IV-criteria were used to diagnose depression. Of the 404 participants, 48 men and 76 women were diagnosed with depression. The reference group consisted of patients with BDI score <10, 187 men and 93 women. Age-adjusted odds ratios (ORs) with 95% confidence intervals (CI) as being depressed were calculated for the psychosocial stressors and lifestyle circumstances, separately for men and women. Multiple logistic regression analyses were used to determine the age-adjusted main effect models for men and women.

Results

The same three psychosocial stressors: feeling very stressed, perceived poor physical health and being dissatisfied with one's family situation were associated with depression equally in men and women. The negative predictive values of the main effect models in men and women were 90.7% and 76.5%, respectively. Being dissatisfied with one's work situation had high ORs in both men and women. Unemployment and smoking were associated with depression in men only.

Conclusions

Three questions, frequently asked by physicians, which involve patient's family and working situation as well as perceived stress and physical health, could be used as depression indicators in early detection of depression in men and women in primary health care.

Socioeconomic status and risk of psychological distress and depression in the Stockholm Public Health Cohort: a population-based study

BACKGROUND

There is limited evidence whether the association between low socioeconomic status and risk of common mental disorders varies with symptom severity, type of socioeconomic indicator or gender.

METHODS

A population-based survey was conducted among a random sample of Stockholm County residents aged 18-84 years in 2002. Respondents were reassessed via a follow-up questionnaire in 2007. Participants in both surveys (n = 23794) were categorized according to socioeconomic status at baseline and followed up for onset of psychological distress (according to the twelve-item general health questionnaire) and depression (according to health data registers). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Occupational class was not associated with risk of psychological distress, regardless of severity or gender. Occupational class was strongly associated with onset of depression in men (OR 3.0 [95% CI 1.5-5.9], comparing unskilled manual workers with higher non-manual workers) but not women. Income was associated with risk of onset of all outcomes, and risks increased with symptom severity. Belonging to the highest household income category was particularly protective of depression in women. Education was unrelated to either outcome in men and women overall.

LIMITATIONS

Retention rate at follow-up was 76% and depression was ascertained via health service use.

CONCLUSION

Low socioeconomic position is associated with onset of depression but not mild distress. Attributes of occupational class and household income may be respectively more relevant for the development of depression in men and women.

Social economic inequalities and mental health II. Methodological aspects and literature review

Summary

Objective - This study provides a framework for mental health inequalities beginners. It describes the methods used to measure socio economic inequalities and the inter-relations with different aspects of mental health: residence, mental health services organisation and main diagnostic categories. Method - Literature electronic-search on Medline, Psyclit, Econlit, Social Science Index and SocioSearch usingand relating the key-words inequalities, deprivation, poverty, socio-economic status, social class, occupational class, mental health for the period 1965-2002 (June). The articles selected were integrated with manual search (publications of the same authors, cross-references, working documents and reports of international andregional organisations). Results - Inequality is not an absolute concept and, mainly, it has been changing during the last years. For example, the integration and re-definition of variables that capture, in simple indices, a complex reality; the accent on social more than on economic aspects; the geo-validity and time-reference of the inequality's indices. Moreover, the inequalities could be the result of individual preferences, in this case, the social selectionand social causation issues will raise the suitability for a public intervention. Conclusions - Up to now, research has been mainly concentrated in describing and measuring health inequalities. For designing effective interventions, policy makers need to ground decisions on health-socioeconomic inequalities explanatory models.

Declaration of Interest

this work was partly funded by the Department of the Public Health Sciences “G. Sanarelli” of the University of Rome “La Sapienza” and the Department of Medicine and Public Health of the University of Verona.

Depressive symptoms and their social contexts: a qualitative systematic literature review of contextual interventions

BACKGROUND

Numerous observational studies demonstrate associations between social context and depressive symptoms, yet few intervention trials exist in this arena.

AIMS

This review examines intervention trials that explore the impact of contextual change on depressive symptoms.

METHODS

Electronic literature databases of PubMed and PsycINFO, bibliographies of retrieved articles and the publicly available internet were searched for English-language articles published between 1997 and 2008. Peer-reviewed studies were eligible for inclusion if they reported contextual interventions and depressive symptoms measures in adult populations without other significant underlying medical or psychological illness. In total, 2,128 studies met search term criteria. Of these, 13 studies meeting inclusion criteria were classified by type of intervention. Qualitative synthesis was used to interpret the mental health impact of contextual interventions.

RESULTS

The interventions focused on employment, housing, poverty, parenting and violence. Eight of these studies reported a decrease in depressive symptoms and/or psychological distress in intervention groups. Interventions varied in focus, length of follow-up and measures of depressive symptoms.

CONCLUSIONS

Contextual interventions for the prevention and treatment of depressive symptoms and psychological distress can be effective, though very limited data exist in this field. Policy implications include a greater emphasis on improving context to decrease depression and other mental disorders.

What is the impact of socio-economic inequalities on the use of mental health services?

Amartya Sen, who received the Nobel Prize for Economics, has demonstrated that the incidence of deprivation, in terms ofcapability, can be surprisingly high even in the most developed countries of the world. The study of socio-economic inequalities, in relation to the utilisation of health services, is a priority for epidemiological research. Socio-economic status (SES) has no universal definition. Within the international research literature, SES has been related to social class, social position, occupational status, educational attainment, income, wealth and standard of living. Existing research studies have shown that people from a more deprived social background, with a lower SES, are more likely to have a higher psychiatric morbidity. Many studies show that SES influences psychiatric services utilization, however the real factors linking SES and mental health services utilisation remain unclear. In this editorial we discuss what is currently known about the relationship between SES and the use of mental health services. We also make an argument for why we believe there is still much to uncover in this field, to understand fully how individuals are influenced by their personal socio-economic status, or the neighbourhood in which they live, in terms of their use of mental health services. Further research in this area will help clarify what interventions are required to provide greater equality in access to mental health services.

Can general practitioners identify people with distress and mild depression? A meta-analysis of clinical accuracy

BACKGROUND

There is increasing emphasis on distress and mild depression but uncertainty regarding how well general practitioners (GPs) identify these conditions. Further, the proportion of attendees suffering distress is also unclear.

AIM

To quantify the rate of distress in primary care and to clarify the ability of GPs to identify distressed and/or mildly depressed individuals using their clinical skills.

METHODS

Meta-analysis of clinical recognition of distress and mild depression defined on a continuum (severity scale) or categorically (semi-structured interview).

RESULTS

From 157 studies that examined the ability of GPs to diagnose any emotional or mental disorder, we identified 23 that focused on defined distress and 9 that reported on mild depression. The prevalence of broadly defined distress was 37.4% (n=23, 95% CI=29.5% to 45.5) although it was 47.3% (n=14, 95% CI=38.0% to 56.7%) using self-report methods. GPs correctly identified distressed individuals in 48.4% (n=21, 95% CI=42.6% to 54.2%) of presentations and identified non-distressed people in 79.4% (n=21, 95% CI=74.3% to 84.1%) of presentations without distress. GPs correctly identified 33.8% (95% CI=27.3% to 40.7%) of people with mild depression and had a detection specificity of 80.6% (95% CI=66.4% to 91.6%) for the non-depressed. Clinicians' ability to recognize mild depression was significantly lower than their ability to recognize moderate-severe depression. Out of 100 consecutive presentations, a typical GP making a single assessment would correctly identify 19 out of 39 people with distress, missing 20. He or she would correctly re-assure 48 out of 61 people without distress, falsely label 13 people as distressed. For mild depression, out of 100 consecutive presentations, a typical GP would correctly identify 4 out of 11 people with mild depression, missing 7. GPs would correctly re-assure 72 out of 89 people without distress, falsely diagnosing 19.

CONCLUSIONS

Clinicians have considerable difficulty accurately identifying distress and mild depression in primary care with only one in three people correctly diagnosed. Clinicians are better able to identify distress than mild depression but success remains limited. However not all such individuals want professional help, and some people who are overlooked get help elsewhere, or improve spontaneously, therefore the implications of these detection problems are not yet clear.

Influence of population and general practice characteristics on prescribing of minor tranquilisers in primary care

Prevalence of generalised anxiety disorders is widespread in Great Britain. Previous small-scale research has shown variations in minor tranquiliser prescribing, identifying several potential predictors of prescribing volume.

OBJECTIVE

This study aimed to investigate the relationship between general practice minor tranquiliser prescribing rates and practice population and general practice characteristics for all general practices in England.

METHODS

Multiple regression analysis of minor tranquiliser prescribing volumes during 2004/2005 for 8,291 English general practices with general practice and population variables obtained from the General Medical Services (GMS) statistics, Quality and Outcomes Framework (QOF), 2001 Census and 2004 Index of Multiple Deprivation (IMD).

RESULTS

The highest rates of minor tranquiliser prescribing were in areas with the greatest local deprivation while general practices situated in areas with larger proportions of residents of black ethnic origin had lower rates of prescribing. Other predictors of increased prescribing were general practices with older general practitioners and general practices with older registered practice populations.

CONCLUSION

Our findings show that there is wide variation of minor tranquilisers prescribing across England which has implications regarding access to treatment and inequity of service provision. Future research should determine the barriers to equitable prescribing amongst general practices serving larger populations of black ethnic origin.

Effectiveness of cognitive-behavioral therapy on depressive symptomatology, stress and coping strategies among Jordanian university students

The study examined the effectiveness of cognitive behavioral therapy (CBT) with university students suffering from moderate to severe depressive symptoms in Jordan. Eighty-four university students were recruited and assigned randomly to control and intervention groups. Intervention impact was assessed on measures of depressive symptoms, perceived stress, and coping strategies at three time points; baseline, postintervention, and 3-months postintervention. The interventional model used was the Modified Teaching Kids to Cope (MTKC), and the control group received no treatment. Overall, using CBT showed a significant improvement in the outcome measures. At postintervention, students had lower scores on perceived stress, lower depressive symptoms, less use of avoidance coping strategies, and more use of approach coping strategies. The findings are discussed in terms of treatment implications and recommendations for use at academic and health care settings.

Antenatal depression predicts depression in adolescent offspring: prospective longitudinal community-based study

BACKGROUND

Depression is familial. Evidence shows that untreated postnatal depression is associated with adverse outcomes for the child. Few studies have traced prospectively the course of maternal depression through pregnancy, the postnatal period and the following 16 years in relation to adolescent offspring depression.

METHOD

The sample was recruited from two general practice antenatal clinics. Of 151 mother-child dyads followed from pregnancy to 16 years, information on the course of maternal depression and on depression in adolescent offspring was available for 127 (84%).

RESULTS

Two-thirds (82/125) of the women had been depressed during the 17-year time period, with the majority (54/82) experiencing more than one episode. A third of the women were depressed in pregnancy (41/124). Over half of these women (23/41) had consulted a doctor about their mental health prior to being pregnant and almost 90% (35/39) had further episodes during the child's lifetime. 14% (18/127) of the adolescent offspring were diagnosed with a depressive disorder at 16 years. Every depressed adolescent had been exposed to maternal depression. The risk of depression for the 16-year-olds exposed to antenatal depression was 4.7 times greater than for offspring not so exposed. The effect of antenatal depression was mediated by repeated exposure.

LIMITATIONS

The number of study participants is small and limited to an inner-city population. Only depression spectrum diagnoses in the adolescent offspring have been considered.

CONCLUSIONS

Detection of depression in pregnancy identifies mothers at risk of further depressive episodes and a group of children who are at risk of depression in adolescence.

Does financial disadvantage at older ages eliminate the potential for better health?

OBJECTIVE

Taller adult stature reflects early life advantages and is an indicator of improved economic and health outcomes, and thus the potential for better health, including reduced depression risk. As inadequate retirement pension provision is an increasing concern, we investigated whether health potential (indicated by height) was realised among those experiencing financial disadvantage in later life.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study of the population in England aged over 50 years and not resident in an institution. Participants (n = 9106) were members of the English Longitudinal Study of Ageing.

MAIN OUTCOME MEASURE

Depression assessed using the eight-item Center for Epidemiological Studies Depression Scale.

RESULTS

Stratification by the lowest quintile of the net financial assets distribution defined adversity, and stature was dichotomised at the shortest quintile of height (sex standardised). After adjustment for sex, qualifications, occupation type, whether currently employed, age, ethnic origin and chronic illness, taller stature was associated with a statistically significant reduced risk of depression with an odds ratio of 0.7 (95% confidence interval 0.6 to 0.9) among those without financial disadvantage. No protection against depression was associated with taller stature among those with financial disadvantage (odds ratio 1.0; 95% confidence interval 0.8 to 1.3). Interaction testing confirmed effect modification by financial disadvantage for the association of height with depression (p = 0.005).

CONCLUSIONS

Although taller stature, indicating favourable childhood conditions, is associated with a decreased risk of depression, this benefit is eliminated by financial disadvantage at older ages. Adequate financial provision for older people is required to maximise the health potential imparted by beneficial conditions in earlier life.

Proposals for massive expansion of psychological therapies would be counterproductive across society

In 2007 the UK Government announced a substantial expansion of funding for psychological therapies in England to provide better support for people with conditions such as anxiety and depression. Will these services result in the medicalisation of normal distress? Or are they simply an evidenced-based solution for a previously unmet need? In this debate Derek Summerfield and David Veale discuss the issues raised by these controversial proposals.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.