Collaborative care for primary care treatment of late-life depression in Singapore: Randomized controlled trial

BACKGROUND

The effectiveness and portability of the collaborative care model in the primary care treatment of depression has not been demonstrated in many randomized controlled trials in healthcare settings across the world. We determined the effectiveness of collaborative care management of elderly depression in the primary care setting in Singapore.

METHOD

Eligible participants with depressive symptoms were randomized to 6-month duration usual care (UC, N = 112) or collaborative care (CC, N = 102). Outcome measures were HDRS-17, GDS, BDI and SF-12 MCS QOL measured at 3, 6, and 12-month, care satisfaction at 6-month, and also measured on 120 participants who refused referral (non-receipt of care, NC). Primary outcome was HDRS-17 measure of depression severity, response and remission at 6-month.

RESULTS

HDRS scores in CC group compared to UC group were reduced more at 6-month (1.5 points difference in change from baseline), and also at 3 and 12-month, with similar observations of differences for GDS and BDI. There was significantly greater improvement for both CC and UC groups compared to NC group. The CC group was about 1.5 times more likely to show HDRS treatment response and remission, and more than two times likely to show GDS treatment response and remission than the UC and NC groups, as well as better quality of life improvement (P < .001) and better care satisfaction (P < .001).

CONCLUSION

Collaborative care is effective for primary care treatment of older persons with depression and is portable in diverse health care settings.

Differential item functioning of the Geriatric Depression Scale in an Asian population

BACKGROUND

The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore.

METHODS

The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF.

RESULTS

We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless.

LIMITATIONS

The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses.

CONCLUSIONS

In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study

BACKGROUND

Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour.

METHODS

A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed.

RESULTS

After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families.

LIMITATIONS

These included use of self-reported doctor visits, and relatively high educational levels of the participants.

CONCLUSIONS

Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.

Health beliefs and help seeking for depressive and anxiety disorders among urban Singaporean adults

OBJECTIVE

This study examined whether help seeking for mental problems was predicted by beliefs about mental illness and services and by family and social support.

METHODS

Singaporean adults (N= 2,801) were interviewed with the Schedule for Clinical Assessment in Neuropsychiatry and with questions on mental health status, beliefs about the curability of mental illness, embarrassment and stigma, ease of discussing mental problems, effectiveness and safety of treatment, and trust in professionals.

RESULTS

Although 10% of respondents had a depressive or anxiety disorder or combination, only 3% acknowledged having mental problems, 5% rated their mental health as fair or poor, and 6% sought help for their mental health problems. Help seeking was predicted by poor self-rated mental health and acknowledged mental illness but not by health beliefs and social support.

CONCLUSIONS

Self-rated mental health status was predictive of help seeking, but other health beliefs and social support were neither strong nor robust predictors.

Should non-expert clinician examiners be used in objective structured assessment of communication skills among final year medical undergraduates?

BACKGROUND

Adoption of the objective structured clinical examination may be hindered by shortages of clinicians within a specialty. Clinicians from other specialties should be considered as alternative, non-expert examiners.

AIMS

We assessed the inter-rater agreement between expert and non-expert clinician examiners in an integrated objective structured clinical examination for final year medical undergraduates.

METHODS

Pairs of expert and non-expert clinician examiners used a rating checklist to assess students in 8 oral communication stations, representing commonly encountered scenarios from medicine, paediatrics, and surgery. These included breaking bad news, managing an angry relative, taking consent for lumbar puncture; and advising a mother on asthma and febrile fits, and an adult on medication use, lifestyle changes and post-suture care of a wound. 439 students participated in the OSCE (206 in 2005, 233 in 2006).

RESULTS

There was good to very good agreement (intraclass coefficient: 0.57-0.79) between expert and non-expert clinician examiners, with 5 out of 8 stations having intraclass coefficients > or =0.70. Variation between paired examiners within stations contributed the lowest variance to student scores.

CONCLUSION

These findings support the use of clinicians from other specialties, as 'non-expert' examiners, to assess communication skills, using a standardized checklist, thereby reducing the demand on clinicians' time.

Late-onset mania with psychosis associated with hypothyroidism in an elderly Chinese lady

Late-onset bipolar disorder is rare and can be precipitated by organic brain disorders. While the association between hyperthyroidism and mania is well described, mania or hypomania precipitated by hypothyroidism is rare. The authors present late-onset bipolar disorder in a 72-year-old woman presenting with mania and psychosis, which appear to have been precipitated by autoimmune hypothyroidism. This case shows the importance of ascertaining the thyroid status in patients with mood and psychotic disorders, especially in elderly patients and in patients lacking prominent signs of thyroid disease.

A conceptual history of Koro

Koro is a culture-bound syndrome characterized by a fear that the genitals or breasts will retract into the body and cause death. Here we consider the history of ideas about Koro, from early concepts in traditional Chinese medicine (TCM) to contemporary ideas from medicine and sociology. This conceptual history reveals important issues about the classification (nosology) of Koro. In doing so, it demonstrates the need to integrate standardized phenomenological criteria with etiological models in order to capture the important features of complex behavioral disorders in the cross-cultural setting.

Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore

BACKGROUND

To investigate the prevalence, socio-cultural and psychosocial risk factors for perinatal depression in Singaporean women.

METHOD

A prospective cohort of 559 women was interviewed antenatally and at six weeks' postpartum at a tertiary hospital. Women were interviewed for diagnosis of depression using a two-stage design, with a screening questionnaire and diagnostic interview.

RESULTS

Postnatally, a negative confinement experience was associated with depression. Other independent factors included poor emotional support, a past history of depression, unplanned pregnancy and perceived potential conflicts with relatives over childcare antenatally and dissatisfaction, poor instrumental support postnatally. The prevalence of depression antenatally and postnatally was 12.2% and 6.8%, respectively.

LIMITATIONS

Measures of satisfaction with social support were based on self-report; there were high dropout rates at six weeks' postpartum; and other modulating social factors such as pre-existing interpersonal conflicts were not studied.

CONCLUSIONS

Perinatal depression in Singaporean women is common. Contrary to expectations, a negative 'confinement' experience is a significant risk factor for postnatal depression, and is not universally welcomed by women. Depression is modulated by dissimilar sets of psychosocial factors antenatally and postnatally.

fMRI study of maintenance and manipulation processes within working memory in first-episode schizophrenia

OBJECTIVE

Working memory, a critical cognitive capacity that is affected in schizophrenia, can be divided into maintenance and manipulation processes. Previous behavioral research suggested that manipulation is more affected than maintenance in patients with chronic schizophrenia. In this study of first-episode schizophrenia patients, the authors evaluated the extent to which the two working memory processes are affected early in the course of schizophrenia.

METHOD

Study subjects were 11 first-episode schizophrenia patients and 11 matched healthy comparison subjects. Each group performed two verbal working memory tasks while undergoing functional magnetic resonance imaging. One task required maintenance of information; the other required manipulation of information in addition to maintenance.

RESULTS

Under behaviorally matched conditions, both groups activated a predominantly left-sided frontal-parietal network. The manipulation plus maintenance task elicited activation of greater magnitude and spatial extent. With both tasks, patients showed less bilateral dorsolateral prefrontal cortex activation and greater ventrolateral prefrontal cortex activation, relative to the comparison subjects. A group-by-task interaction was observed for activation at the left dorsolateral and ventrolateral prefrontal cortex. The increase in activation when patients engaged in the manipulation plus maintenance task was disproportionately less in the dorsolateral prefrontal cortex and greater in the ventrolateral prefrontal cortex.

CONCLUSIONS

These functional neuroanatomical findings add support to earlier suggestions that manipulation of information is selectively more affected than maintenance of information in persons with schizophrenia. They also suggest the presence of interacting regions of dysfunctional and compensatory prefrontal responses in the dorsolateral and ventrolateral prefrontal cortex, respectively, that are more prominent when information is manipulated. This disrupted prefrontal network is present relatively early in the course of schizophrenia.

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-c30): validation of English version in Singapore

OBJECTIVE

This study aimed to validate the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, English version 3.0) in Singaporean cancer patients.

METHODS

In a cross-sectional study, a heterogeneous sample of cancer patients (n = 57) self-administered a questionnaire containing the QLQ-C30, the Short Form 36 Health Survey (SF-36) and assessing health and sociodemographic status. Construct validity was assessed by testing a priori hypotheses that QLQ-C30 scales would be moderately or strongly correlated with SF-36 scales measuring similar dimensions of health-related quality of life (HRQoL) and that subjects reporting mild symptoms would have better HRQoL scores than those reporting severe symptoms. Internal consistency reliability was assessed using Cronbach's alpha.

RESULTS

Strength of Spearman's correlations between the QLQ-C30 and SF-36 scales assessing similar dimensions of HRQoL ranged from 0.35 to 0.67. Subjects with mild symptoms had better scores than those with severe symptoms for all six QLQ-C30 HRQoL scales (p < 0.05 for five scales, Mann-Whitney U tests). Cronbach's alpha ranged from 0.19 for the cognitive functioning scale to 0.91 for the global QoL scale.

CONCLUSION

This study provides preliminary evidence for the validity and reliability of the EORTC QLQ-C30 in English-speaking Singaporean cancer patients.

Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto

OBJECTIVES

A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses.

METHODS

A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression.

RESULTS

Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress.

CONCLUSIONS

Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.