Integrated 3D Anatomical Model for Automatic Myocardial Segmentation in Cardiac CT Imagery

Segmentation of epicardial and endocardial boundaries is a critical step in diagnosing cardiovascular function in heart patients. The manual tracing of organ contours in Computed Tomography Angiography (CTA) slices is subjective, time-consuming and impractical in clinical setting. We propose a novel multi-dimensional automatic edge detection algorithm based on shape priors and principal component analysis (PCA). We have developed a highly customized parametric model for implicit representations of segmenting curves (3D) for Left Ventricle (LV), Right Ventricle (RV), and Epicardium (Epi) used simultaneously to achieve myocardial segmentation. We have combined these representations in a region-based image modeling framework with high level constraints enabling the modeling of complex cardiac anatomical structures to automatically guide the segmentation of endo/epicardial boundaries. Test results on 30 short-axis CTA datasets show robust segmentation with error (mean ± std mm) of (1.46 ± 0.41), (2.06 ± 0.65), (2.88 ± 0.59) for LV, RV and Epi respectively.

Numerical treatment of boundary conditions to replace lateral branches in hemodynamics

In this paper, we discuss a technique for weakly enforcing flow rate conditions in computational hemodynamics. In particular, we study the effectiveness of cutting lateral branches from the computational domain and replacing them with non-perturbing boundary conditions to simplify the geometrical reconstruction and the numerical simulation. All these features are investigated both in the case of rigid and compliant walls. Several numerical results are presented to discuss the reliability of the proposed method.

An objective approach to digital removal of saccular aneurysms: technique and applications

Human studies of haemodynamic factors in the pathogenesis of cerebral aneurysms require knowledge of the pre-aneurysmal vasculature. This paper presents an objective and automated technique to digitally remove an aneurysm and reconstruct the parent artery, based on lumen geometries segmented from angiographic images. Relying on robust computational geometry concepts, notably Voronoi diagrams of the digitised lumen surface, the aneurysm attachment region is first defined objectively using lumen centrelines. Centrelines within this region are replaced by smooth interpolations, which then guide the interpolation of Voronoi points within the attachment region. Combined with Voronoi points from outside the attachment region, the parent artery lumen, without the aneurysm, can be reconstructed. Plausible reconstructions were obtained, automatically, for a set of 10 side-wall or terminal aneurysms, of various sizes and shapes, from the ANEURISK project data set. Application of image-based computational fluid dynamics analysis to a five side-wall aneurysm cases data set revealed an association between the recently proposed gradient oscillatory number (GON) and the site of aneurysm formation in four of five cases; however, elevated GON was also evident at non-aneurysmal sites. A potential application to the automated delineation of aneurysms for morphological characterisations is also suggested. The proposed approach may serve as a broad platform for investigating haemodynamic and morphological factors in aneurysm initiation, rupture and therapy in a way amenable to large-scale clinical studies or routine clinical use. Nevertheless, while the parent artery reconstructions are plausible, it remains to be proven that they are faithful representations of the pre-aneurysmal artery.

ACE inhibition reduces glomerulosclerosis and regenerates glomerular tissue in a model of progressive renal disease

Today angiotensin II inhibition is primarily used to slow the rate of progression of kidney diseases. There is evidence that these therapies can induce a partial regression of glomerular lesions. However, we do not know yet the extent of sclerotic lesion regression and whether new glomerular tissue is formed to help support the renal function. We used male Munich Wistar Fromter (MWF) rats, an experimental model for progressive kidney disease, to quantify kidney structural lesions upon angiotensin-converting enzyme (ACE) inhibition therapy. Animals were studied at 50 weeks of age, when renal function and structure are severely altered, and after a 10-week observation period, without or with treatment with lisinopril (80 mg/l in drinking water). A group of untreated Wistar rats was used as controls. With age, proteinuria, and serum creatinine worsen, but lisinopril almost normalized proteinuria and stabilized serum creatinine. Serial section analysis of whole glomerular tufts showed that at baseline, glomerulosclerosis affected the entire glomerular population, and that these changes further increased with age. Lisinopril significantly reduced incidence and extent of glomerulosclerosis, with the presence of glomerular tufts not affected by sclerosis (23% of glomeruli). Glomerular volume was not significantly affected by treatment, and glomerular mass spared from sclerosis increased from 46.9 to 65.5% upon treatment, indicating consistent regeneration of glomerular tissue. Lisinopril normalized baseline glomerular transforming growth factor-beta and alpha-smooth muscle actin overexpression, and prevented worsening of interstitial changes. Hence, ACE inhibition, which is widely used in human kidney disease, may not only halt the progression of renal failure, but also actually induce the regeneration of new renal tissue.

Mortality in psychiatric patients 5 to 21 years after hospital admission in Italy

BACKGROUND

Mental disorders have an increased mortality risk. However, most data have been provided by few countries, some mental disorders have received little attention, long-term studies of large samples are scarce, and insufficient control for confounding variables has lead to artefactual inconsistencies across studies. The aims of this study were: to quantify the mortality risk in psychiatric patients 5 to 21 years after hospital admission and to investigate temporal trends in mortality risk and predictive factors associated with mortality.

METHOD

All patients admitted to an in-patient psychiatric unit in Italy between 1978 and 1994 were included and vital status and death causes were determined up to 21 years after admission. The observed number of deaths in the sample was compared with the expected number of deaths in the general population. Cox proportional hazard models were fitted to identify predictors of mortality.

RESULTS

Mortality from natural and unnatural causes was higher than expected across all mental disorders. Standardized mortality risk was higher in males (SMR = 4.55; 95% CI 4.17-4.97) than in females (SMR = 3.43; 95% CI 3.07-3.83). Individuals aged less than 40 years were at higher risk in both sexes. The first several years following admission were characterized by a faster decline in survival. Several demographic and clinical factors were predictors of mortality.

CONCLUSIONS

Mortality is high in individuals with mental disorders. Prevention of unnatural death causes is an important goal though insufficient to abate excess mortality, since natural death causes account for it to a larger extent.

Gender differences in depression. Critical review

BACKGROUND

With few exceptions, the prevalence, incidence and morbidity risk of depressive disorders are higher in females than in males, beginning at mid-puberty and persisting through adult life.

AIMS

To review putative risk factors leading to gender differences in depressive disorders.

METHOD

A critical review of the literature, dealing separately with artefactual and genuine determinants of gender differences in depressive disorders.

RESULTS

Although artefactual determinants may enhance a female preponderance to some extent, gender differences in depressive disorders are genuine. At present, adverse experiences in childhood, depression and anxiety disorders in childhood and adolescence, sociocultural roles with related adverse experiences, and psychological attributes related to vulnerability to life events and coping skills are likely to be involved. Genetic and biological factors and poor social support, however, have few or no effects in the emergence of gender differences.

CONCLUSIONS

Determinants of gender differences in depressive disorders are far from being established and their combination into integrated aetiological models continues to be lacking.

The Personal Health Questionnaire: a new screening instrument for detection of ICD-10 depressive disorders in primary care

BACKGROUND

The next generation of studies on antidepressant drug prescriptions in general practice needs to assess both the patterns of prescription and its appropriateness. This study aimed to assess the performance of the Personal Health Questionnaire (PHQ), a new questionnaire for detecting individuals with ICD- 10 depressive disorders, to be used in association with companion instruments for assessing the 'quality' of antidepressant prescriptions in primary care settings.

METHODS

The PHQ was completed by 1,413 primary care attenders (100 were re-tested after 7-14 days) and 139 were selected and interviewed using the SCAN-2 and the 17-item HDRS. All data were analysed using appropriately weighted procedures to control for two-phase sampling design and non-response bias. Individual weights were estimated by logistic regression analysis and trimming strategy.

RESULTS

PHQ internal consistency and test-retest on both Likert score and number of symptoms were high. The PHQ discriminated well between individuals with and without depressive disorders. A Likert score > or = 9 provided a good trade-off between sensitivity (0.78) and specificity (0.83). The screening accuracy of the PHQ in detecting subjects likely to benefit from antidepressant drug treatment (SCAN cases with a HDRS total score of 13 or higher) was satisfactory (ROC area 0.87: sensitivity 0.84; specificity 0.78).

CONCLUSIONS

The PHQ can be strongly suggested as an accurate and economic screener to identify primary care attenders at high risk of being clinically depressed. However, in order to identify patients requiring antidepressant drug treatment, a second-phase assessment of PHQ high scorers (total score of > or = 10), using the HDRS, is needed.

An international study of the relation between somatic symptoms and depression

BACKGROUND AND METHODS

Patients with depression, particularly those seen by primary care physicians, may report somatic symptoms, such as headache, constipation, weakness, or back pain. Some previous studies have suggested that patients in non-Western countries are more likely to report somatic symptoms than are patients in Western countries. We used data from the World Health Organization's study of psychological problems in general health care to examine the relation between somatic symptoms and depression. The study, conducted in 1991 and 1992, screened 25,916 patients at 15 primary care centers in 14 countries on 5 continents. Of the patients in the original sample, 5447 underwent a structured assessment of depressive and somatoform disorders.

RESULTS

A total of 1146 patients (weighted prevalence, 10.1 percent) met the criteria for major depression. The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers). A somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.7). Half the depressed patients reported multiple unexplained somatic symptoms, and 11 percent denied psychological symptoms of depression on direct questioning. Neither of these proportions varied significantly among the centers. Although the overall prevalence of depressive symptoms varied markedly among the centers, the frequencies of psychological and physical symptoms were similar.

CONCLUSIONS

Somatic symptoms of depression are common in many countries, but their frequency varies depending on how somatization is defined. There is substantial variation in how frequently patients with depression present with strictly somatic symptoms. In part, this variation may reflect characteristics of physicians and health care systems, as well as cultural differences among patients.

Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey

BACKGROUND

This study aimed to assess psychiatric morbidity and to collect information on disability, life events and family support in a representative sample of patients admitted to a general hospital.

METHODS

On the basis of information collected in a pilot study a systematic sample of patients consecutively admitted to seven general medical and seven surgical wards of the Academic General Hospital of Verona was selected and interviewed using a two-phase screening procedure and standardized instruments (GHQ-12, HADS, BDQ and CIDI-PHC). All data were analysed using appropriately weighted logistic regression procedures.

RESULTS

A total of 1039 patients completed the GHQ-12 and 298 (28.7%) were high-scorers: 363 patients were interviewed with CIDI-PHC. The prevalence of ICD-10 cases was 26.1%. The most common psychiatric diagnoses were current depression (12.8%) and generalized anxiety disorder (10.8%), followed by alcohol related disorders (5 %). A higher prevalence of ICD-10 cases was found in medical wards, among females, patients older than 24 years, unemployed and separated/divorced people. Life events were associated with psychopathology, and so was the number of disability days. Although 49.8% of ICD-10 cases were identified by the hospital doctors as having a psychological disorder, 23.1% of ICD-10 cases were referred to the liaison psychiatric service.

CONCLUSION

The results of the present study stress the need to collect epidemiologically-based data on psychological disorders and their recognition not only in general practice, but also in general hospital settings, in order to have a more complete picture of the pathways to specialist care.

Anxiety and depression disorders 5 years after severe injuries: a prospective follow-up study

Individuals with severe injuries were investigated 5 years after the traumatic events, and predictors of anxiety and depression disorders were identified. Trauma victims were selected who had an Injury Severity Score of > or = 16 and were brought to all hospitals in the Mersey region and North Wales over 1 year. The 212 patients aged > or = 15 years who left the hospital alive and lived within an accessible distance of the study hospital in Warrington were contacted 5 years later and 158 (74.5%) received follow-up assessment. Thirty-eight subjects (36.9%) reported "definite" anxiety and/or depression disorders and, of these, only 21.1% reported taking psychotropic medications. Factors associated with anxiety and/or depression disorders at follow-up were: sequelae of head injury (i.e., cognitive problems, posttraumatic seizures, facial pain): writing impairment: disability due to thorax problems; and a new trauma during follow-up. Initial severity or types of injuries and overall residual disability rated by the investigator were not strong predictors of anxiety and/or depression disorders at follow-up.

Typologies of anxiety, depression and somatization symptoms among primary care attenders with no formal mental disorder

BACKGROUND

Typologies of anxiety, depression and somatization symptoms were investigated in individuals with no formal mental disorders, making no a priori assumptions about symptom distribution and inter-relationship.

METHOD

The subjects were 1617 adult primary care attenders from the WHO Collaborative Project on Psychological Problems in General Health Care, with at least three symptoms of anxiety, depression and/or somatization, but with no formal ICD-10 disorders. Analyses were based on the grade of membership model, a multivariate statistical procedure exploring indistinct boundaries between disease categories and preserving the heterogeneity of clinical picture within each category.

RESULTS

Six prototype categories (or pure types) best described the structure of symptoms included in analyses. Pure type I included the full set of somatization symptoms. Pure type II was characterized by most anxiety and depression symptoms. Pure type III resembled generalized anxiety disorder. Pure type IV consisted of individuals reporting sporadic symptoms of anxiety, depression or somatization. Pure type V defined individuals with sleep problems. Finally, pure type VI was characterized by anxiety symptoms, including panic-like symptoms.

CONCLUSIONS

These findings provide support to the existence of a mixed anxiety-depression category crossing the diagnostic boundaries of current anxiety and depression disorders. Moreover, criteria of anxiety and somatization disorders may be re-examined to assess whether lower diagnostic thresholds can be identified that both preserve the symptom profile and clinical features of current diagnostic categories and allow for a better characterization of individuals with substantial psychopathology though not meeting the high symptom thresholds required for a diagnosis of formal mental disorders.

Identification of psychiatric distress by primary care physicians

The aims of the present study were to evaluate the extent to which primary care physicians' (PCPs) identification of psychiatric distress is related to a number of nonpsychopathological factors, such as patient sociodemographic and health-related characteristics, and to assess the impact of depression on PCP identification of psychiatric distress, controlling for patient sociodemographic and health-related characteristics. Two patient samples were chosen to explore these issues: 1) patients not fulfilling any ICD-10-defined or subthreshold psychiatric diagnosis and, 2) patients with an ICD-10 diagnosis of current depression. Patients attending 46 primary care clinics during an index period were screened by the General Health Questionnaire (GHQ)-12 and selected for a second stage interview according to GHQ score. Among the 559 interviewed patients, 123 had no mental disorder and 66 had an ICD-10 current depressive disorder. Identification of psychiatric distress by the PCP was associated with retirement among subjects without mental disorders but not among depressed patients. Patient's negative overall health self-perception and severity of physical illness were significantly related to identification of psychiatric distress in the two groups, whereas neither disability nor reason for medical consultation had a significant effect. Patients with current depression, compared with those without, were 4.3 times more likely to be identified by PCPs as having psychiatric distress when adjusting for all the above nonpsychopathological variables. Patients with depression and comorbid anxiety disorders were more likely to be recognized by the PCP as compared with those with pure depression. Finally, among depressive symptoms, diurnal variation and symptoms related to suicidal tendencies were predictive of identification of psychiatric distress, whereas increase of appetite was negatively associated with PCP recognition.

Frequency of contact with community-based psychiatric services and the lunar cycle: a 10-year case-register study

The relationship between the lunar cycle and the frequency of contact with community-based psychiatric services was assessed using the South Verona Psychiatric Case Register data. For each day of the study period (January 1982-December 1991) we recorded the number of contacts made by South Verona residents with psychiatric services and the corresponding day of the lunar cycle. First, the synodic month was divided into four interval phases (usually called new moon, first quarter, full moon and third quarter), and interphase differences in the mean number of contacts were tested using one-way analysis of variance. Second. the null hypothesis of no relationship between the lunar cycle and the frequency of contact with psychiatric services was tested against the alternative hypothesis of a sinusoidal distribution according to the lunar phase. The average number of contacts with psychiatric services on each day of the lunar cycle over the 10-year period was obtained and a sine-wave curve was fitted to the data. Both for total and drop-in contacts, no significant differences in mean number of contacts were found between the four interval phases of the synodic month (new moon, first quarter, full moon and third quarter). Similarly, no significant results were found by setting the expected surge in consultations at 1-3 days after the full moon and the period of the sine-wave curve equal to 30 days. When the period of the sine-wave curve was allowed to vary in order to fit the data best, none of the statistical tests reached the level of significance required to dismiss the possibility of false-positive results. These findings did not support the theory that a relationship exists between the lunar cycle and the frequency of contact with community-based psychiatric services.

Gender and cross-cultural differences in somatic symptoms associated with emotional distress. An international study in primary care

BACKGROUND

Gender and cross-cultural differences in the association between somatic symptoms and emotional distress were investigated, using data from the World Health Organization Collaborative Project on Psychological Problems in General Health Care.

METHODS

Data were collected at 15 centres in 14 countries around the world. At each centre, a stratified random sample of primary care attenders aged 15-65 years was assessed using, among other instruments, the 28-item General Health Questionnaire and the Composite International Diagnostic Interview-Primary Health Care Version.

RESULTS

Females reported higher levels of somatic symptoms and emotional distress than males. A strong correlation between somatic symptoms and emotional distress was found in both sexes, with females reporting more somatic symptoms at each level of emotional distress. However, linear regression analysis showed that gender had no significant effect on level of somatic symptoms, when the effects of centre and emotional distress were controlled for. In both sexes, no specific pattern of association emerged between somatic symptom clusters and either anxiety or depression. Primary care attenders from less developed centres reported more somatic symptoms and showed greater gender differences than individuals from more developed centres, but inter-centre differences were small. Finally, gender was not a significant predictor of reason for consultation (somatic versus mental/behavioural symptoms), after controlling for levels of somatic symptoms and emotional distress as well as for centre effect.

CONCLUSIONS

These data do not support the common belief that females somatize more than males or the traditional view that somatization is a basic orientation prevailing in developing countries. Instead, somatic symptoms and emotional distress are strongly associated in primary care attenders, with few differences between the two sexes and across cultures.

Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study

OBJECTIVE

To determine the properties of the alcohol use disorders identification test in screening primary care attenders for alcohol problems.

DESIGN

A validity study among consecutive primary care attenders aged 18-65 years. Every third subject completed the alcohol use disorders identification test (a 10 item self report questionnaire on alcohol intake and related problems) and was interviewed by an investigator with the composite international diagnostic interview alcohol use module (a standardised interview for the independent assessment of alcohol intake and related disorders).

SETTING

10 primary care clinics in Verona, north eastern Italy.

PATIENTS

500 subjects were approached and 482 (96.4%) completed evaluation.

RESULTS

When the alcohol use disorders identification test was used to detect subjects with alcohol problems the area under the receiver operating characteristic curve was 0.95. The cut off score of 5 was associated with a sensitivity of 0.84, a specificity of 0.90, and a positive predictive value of 0.60. The screening ability of the total score derived from summing the responses to the five items minimising the probability of misclassification between subjects with and without alcohol problems provided an area under the receiver operating characteristic curve of 0.93. A score of 5 or more on the five items was associated with a sensitivity of 0.79, a specificity of 0.95, and a positive predictive value of 0.73.

CONCLUSIONS

The alcohol use disorders identification test performs well in detecting subjects with formal alcohol disorders and those with hazardous alcohol intake. Using five of the 10 items on the questionnaire gives reasonable accuracy, and these are recommended as questions of choice to screen patients for alcohol problems.

Test-retest reliability of the Social Problem Questionnaire in primary care in Italy

The 1-week test-retest reliability of the Social Problem Questionnaire (SPQ) was investigated in a sample of 100 primary care attenders in Italy. The questionnaire was found to be simple and readily acceptable to primary care attenders. Reliability coefficients were high for housing, financial and work problems (Pearson's r and the intraclass correlation coefficient > or = 0.75) and relatively low for problems with spouse or partner (Pearson's r and the intraclass correlation coefficient = 0.30). Pearson's r and the intraclass correlation coefficient were 0.77 and 0.76, respectively, for the overall severity score reported on the SPQ; the two coefficients were 0.63 and 0.62, respectively, for the overall number of problems reported on the SPQ. When the proportion of specific agreement was computed, agreement on absence of social problems was higher compared to agreement on presence. Reliability coefficients tended to be higher in males compared to females. Systematic differences between scores on the first and second tests were found for problems in housing conditions and social relationships excluding relatives (lower scores on the second test), as well as for the residual category "other social problems" (higher scores on the second test).

Lunar cycle and consultations for anxiety and depression in general practice

The influence of the moon on patient consultations for anxiety or depression in general practice was assessed through a retrospective survey based on general practice medical records and on lunar records detailing the dates and times of different phases of the moon. Seven-hundred-eighty-two patients continuously registered in a general practice in Beckenham, South London, between 1971 and 1988 were included in analyses. No statistically significant lunar effect was found by setting the expected surge in consultations one to three days after the full moon and the period of the sine-wave curve to 30 days. Similarly, no statistically significant lunar effect was found, when the period of the sine-wave curve was allowed to vary in order to best fit the data. The moon had little influence on when individuals consulted their general practitioner with anxiety or depression.

The validity of two versions of the GHQ in the WHO study of mental illness in general health care

BACKGROUND

In recent years the 12-item General Health Questionnaire (GHQ-12) has been extensively used as a short screening instrument, producing results that are comparable to longer versions of the GHQ.

METHODS

The validity of the GHQ-12 was compared with the GHQ-28 in a World Health organization study of psychological disorders in general health care. Results are presented for 5438 patients interviewed in 15 centres using the primary care version of the Composite International Diagnostic Instrument, or CIDI-PC.

RESULTS

Results were uniformly good, with the average area under the ROC curve 88, range from 83 to 95. Minor variations in the criteria used for defining a case made little difference to the validity of the GHQ, and complex scoring methods offered no advantages over simpler ones. The GHQ was translated into 10 other languages for the purposes of this study, and validity coefficients were almost as high as in the original language. There was no tendency for the GHQ to work less efficiently in developing countries. Finally gender, age and educational level are shown to have no significant effect on the validity of the GHQ.

CONCLUSIONS

If investigators wish to use a screening instrument as a case detector, the shorter GHQ is remarkably robust and works as well as the longer instrument. The latter should only be preferred if there is an interest in the scaled scores provided in addition to the total score.

Somatic symptoms of distress: an international primary care study

The objective of this study was to examine cross-national differences in somatic symptoms associated with psychological distress. Data from the World Health Organization (WHO) collaborative study of psychological problems in general health care (5438 patients at 15 sites) were used to examine somatic symptoms associated with psychological distress. At each site, a stratified random sample of consecutive primary care patients completed the 28-item General Health Questionnaire (GHQ) and the Composite International Diagnostic Interview (CIDI). At all sites, the number of current CIDI somatic symptoms (whether medically explained or not) was strongly associated with current psychological distress (measured by selected GHQ-28 items). Pearson correlation of somatic symptom count with psychological distress score was .42 for all sites and ranged from .20 to .58 (p < .0001 at all sites). Across all sites, anxiety and depressive symptoms showed roughly the same association with somatic symptom counts, and specific somatic symptoms or symptom clusters did not show differential association with anxiety or depression. Although somatic symptoms did cluster into meaningful groups (gastrointestinal, neurological/conversion, autonomic, and musculoskeletal), these symptom groups did not show differential association with psychological distress. Examination of individual somatic symptoms and symptom clusters across sites did not reveal clear patterns of association according to geography or level of economic development. These data show a strong association between somatic symptoms and psychological distress, which did not vary across disparate cultures and levels of economic development. Cultural factors, however, may influence the meaning attached to symptoms or the likelihood of presentation for health care.

[The epidemiological method in the field of mental health]

The role of epidemiological methods in clinical practice and research are discussed in this article. In particular, the main applications of the epidemiological approach in the field of mental health are illustrated. First, it has been possible to investigate the prevalence and incidence of mental disorders outside specialist settings (general population and primary care services); this allowed for a better definition of the spectrum of mental disorders beyond the most severe ones which are usually treated by psychiatrists. In this way, incidence and prevalence studies contributed to the identification of groups of subjects at risk for mental disorders to be provided with prevention and treatment programs. Second, data from epidemiological studies contributed to the development of classificatory systems with high reliability and validity to be used in clinical practice and research activities. Third, epidemiological data are often integral part of theories concerning the origin, course, outcome, and treatment response of disorders. Fourth, the comprehensive and longitudinal evaluation of service activity is necessary to introduce possible changes in the organization of the health care system and to allocate available resources. Finally, it is recommended that epidemiological research could maintain a real integration with clinical practice and develop a strong collaboration with other disciplines such as genetics, psychology, sociology and anthropology.

An evaluation of community-based psychiatric care for people with treated long-term mental illness

BACKGROUND

We evaluated integrated, multidisciplinary, community-based care for a cohort of people with treated long-term mental illness over two years in a field trial set in a semi-rural setting. The aim was to organise local psychiatric services on an extramural basis with general practitioner teams as the key element.

METHOD

Trained research workers used a structured interview to collect standardised base-line and three-monthly socio-demographic, clinical, social, family adjustment and burden, and treatment measures from patients, informants, and key-workers. Analysis included descriptive statistics and, for longitudinal data, analysis of best-fitted straight lines.

RESULTS

We studied 34 patients (14 with schizophrenia, 11 with major affective disorders, and 9 with minor (non-major) affective disorders and anxiety disorders) who had a mean of 12 years continuous illness. At baseline, they were mainly characterised by research workers as mildly ill with fair social adaptive functioning, and by lay informants as having moderate target symptom severity and disturbance of social performance. Over two years, there were statistically significant, slight improvements in clinical global impressions ratings by research workers, and in informants ratings of target symptoms and social performance. Most patients continued to receive prescriptions for psychotropic drugs throughout follow-up, and they had a mean of 47 therapeutic contacts, mainly from nurses. Two patients were admitted to psychiatric hospital. There were few differences between patients in different diagnostic groups.

CONCLUSIONS

Integrated, multidisciplinary, community-based psychiatric care for people with treated long-term mental illness is feasible in a semi-rural setting: patients receiving pharmacotherapy and regular psychosocial treatments remained relatively stable on clinical and social measures over two years. The unique way in which the service was monitored, by making regular, systematic assessments of patients and carers, serves as an example for other services.

Efficacy of drug treatment in obsessive-compulsive disorder. A meta-analytic review

BACKGROUND

A review of the efficacy of antidepressant drug treatment in patients with obsessive-compulsive disorder (OCD), using a meta-analytic approach.

METHOD

Randomised double-blind clinical trials of antidepressant drugs, carried out among patients with OCD and published in peer-reviewed journals between 1975 and May 1994, were selected together with three studies currently in press. Forty-seven trials were located by searching the Medline and Excerpta Medica-Psychiatry data bases, scanning psychiatric and psychopharmacological journals, consulting recent published reviews and bibliographies, contacting pharmaceutical companies and through cross-references. Hedges' g was computed in pooled data at the conclusion of treatment under double-blind conditions or at the latest reported point of time during this treatment period. For each trial, effect sizes were computed for all available outcome measures of the following dependent variables: obsessive-compulsive symptoms considered together; obsessions; compulsions; depression; anxiety; global clinical improvement; psychosocial adjustment; and physical symptoms.

RESULTS

Clomipramine was superior to placebo in reducing both obsessive-compulsive symptoms considered together (g = 1.31; 95% CI = 1.15 to 1.47) as well as obsessions (g = 0.89, 95% CI = 0.36 to 1.42) and compulsions (g = 0.79; 95% CI = 0.34 to 1.24) taken separately. Also, selective serotonin re-uptake inhibitors (SSRIs) as a class were superior to placebo, weighted mean g being respectively 0.47 (95% CI = 0.33 to 0.61), 0.54 (95% CI = 0.34 to 0.74) and 0.52 (95% CI = 0.34 to 0.70) for obsessive-compulsive symptoms considered together, and obsessions and compulsions taken separately. Although on Y-BOCS the increase in improvement rate over placebo was 61.3%, 28.5%, 28.2% and 21.6% for clomipramine, fluoxetine, fluvoxamine, and sertraline respectively, the trials testing clomipramine against fluoxetine and fluvoxamine showed similar therapeutic efficacy between these drugs. Finally, both clomipramine and fluvoxamine proved superior to antidepressant drugs with no selective serotonergic properties.

CONCLUSION

Antidepressant drugs are effective in the short-term treatment of patients suffering from OCD; although the increase in improvement rate over placebo was greater for clomipramine than for SSRIs, direct comparison between these drugs showed that they had similar therapeutic efficacy on obsessive-compulsive symptoms; clomipramine and fluvoxamine had greater therapeutic efficacy than antidepressant drugs with no selective serotonergic properties; concomitant high levels of depression at the outset did not seem necessary for clomipramine and for SSRIs to improve obsessive-compulsive symptoms.

Social problems as factors affecting medical consultation: a comparison between general practice attenders and community probands with emotional distress

Comparison between general practice attenders and community subjects with emotional distress (as measured by GHQ-12) showed that women from a general practice sample reported more social problems than those from the community. In both men and women, problems with their spouse or partner were far more likely among general practice attenders than among community probands. Furthermore, women who consulted the general practitioners could count less often on the availability of friend confidants and had more well-defined physical disorder than their community counterparts. Results from a logistic regression analysis showed that in women (but not in men) problems in the relationship with spouse or partner increased the probability of being a general practice attender more than twofold. Physical health status did not exert a significant effect either in men or in women.

Reliability, validity and factor structure of the 12-item General Health Questionnaire among young males in Italy

The internal consistency, validity and factor structure of the 12-item General Health Questionnaire (GHQ-12) were investigated in a homogeneous sample consisting of 18-year-old males in Italy. The GHQ-12 proved to be a reliable instrument, as indicated by a Cronbach's alpha of 0.81. When the screening characteristics of the GHQ-12 (scored by the Likert method) were evaluated against the psychiatrist's ratings, the best balance between sensitivity and specificity was found at the GHQ cut-off score of 8/9: at this threshold, sensitivity was 0.68 and was paired to a specificity of 0.59 and an overall misclassification rate of 0.40. Validity coefficients based on a single severity score were rather low compared with those reported in other settings. When a principal components analysis with varimax (and oblimin) rotation was performed, two factors were identified: factor A (general dysphoria) was defined by 7 items related to anxiety and depression; factor B (social dysfunction) included 6 items testing the ability to perform daily activities and to cope with everyday problems. The identified factors revealed distinct ability in the discrimination between subjects with and without emotional disturbance according to the psychiatrist's ratings and correlated differently with 3 Minnesota Multiphasic Personality Inventory subscales (depression, D; conversion hysteria, Hy; psychasthenia, Pt). Thus, the factor structure of the GHQ-12 might provide useful information along with that offered by a single severity score, and the detection of cases might be improved by examining an individual's profile of scores on different subscales derived from factor analysis.

Outcome of depression in psychiatric settings

We reviewed follow-up studies of adults with depressive disorders seen in psychiatric settings, and noted outcomes in terms of recovery, recurrence, and persistent depression, at six months, one year, two to five years, and ten or more years after an index episode of depression. Recovery increased with time: about half recovered at least briefly by six months, and a large majority did so in the long term. Only about a quarter recovered from an index episode and remained well more than ten years thereafter. A quarter of patients suffered recurrence of depression within a year of an index episode, and three-quarters did so at least once during follow-up periods lasting more than ten years. For more than one in ten patients, the depression proved persistent, the proportion affected remaining relatively stable over time. The review highlighted a relative paucity of conclusive investigations on the outcome of the commonest psychiatric disorder in clinical settings.

Validity and test-retest reliability of the Italian version of the 12-item General Health Questionnaire in general practice: a comparison between three scoring methods

Validity coefficients of the 12-item General Health Questionnaire (GHQ-12) were established against the Clinical Interview Schedule (CIS) in a sample of primary care patients. Comparison between the conventional scoring method, Likert scoring, and the revised scoring procedure proposed by Goodchild and Duncan-Jones (C-GHQ) showed very similar screening properties: sensitivity ranged between 71% and 75%, and specificity ranged between 73% and 76%. The test-retest reliability of the GHQ-12, as expressed by Pearson's r and intraclass correlation coefficient, was satisfactory irrespective of the scoring method used, even though mean scores on the second test tended to be significantly lower than the corresponding mean scores on the first test. The C-GHQ by itself did not result in an improvement of the screening capacity of the GHQ; however, the best results were obtained by combining the conventional scoring and C-GHQ case criteria.

[Primary community health districts and changes in the utilization of a psychiatric service for diagnosis and therapy]

The Authors analyze the activity of Pavia's General Hospital Psychiatric Unit over a ten year period. Data, presented as rates standardized by sex and age, are processed according to patients' residential socio-health districts. The analysis of the results shows marked differences in the Service utilization among different districts. Correlations between these differences and some socio-demographic and clinical variables enable the Authors to put forward some hypotheses in order to understand this pattern of Service utilization. In particular, "high-users" and patients with a past history of admissions to psychiatric hospitals tend to be found especially in the districts which provide the Service with a heavy workload. A closer attention to these patients and to their pathways to care will enable the Service staff to optimize its supply of care and to plan new kinds of treatments.