Epidemiology of mental health disorders in the citizens of Tehran: a report from Tehran Cohort Study

BACKGROUND

Mental health disorders (MHD) impose a considerable burden on public health systems. With an increasing worldwide trend in urbanization, urban mental health stressors are affecting a larger population. In this study, we evaluated the epidemiology of mental health disorders in the citizens of Tehran using the Tehran Cohort Study (TeCS) data.

METHODS

We utilized data from the TeCS recruitment phase. A total of 10,247 permanent residents of Tehran metropolitan (aged 15 years and older) were enrolled in the study from March 2016 to 2019 via systematic random sampling from all 22 districts of Tehran. The participant's demographic, socioeconomic, and medical characteristics were evaluated by conducting comprehensive interviews. The standardized Persian version of the General Health Questionnaire version 28 was utilized to assess the mental status of the patients according to four central mental health disorders.

RESULTS

Almost 37.1% of Tehran residents suffered mental health problems (45.0% of women and 28.0% of men). The greatest incidence of MHDs was seen in the 25-34 and over 75 age groups. The most common mental health disorders were depression (43%) and anxiety (40%), followed by somatization (30%) and social dysfunction (8.1%). Mental health disorders were more frequent in the southeast regions of the city.

CONCLUSIONS

Tehran residents have a significantly higher rate of mental health disorders compared to nationwide studies, with an estimated 2.7 million citizens requiring mental health care services. Awareness of mental health disorders and identifying vulnerable groups are crucial in developing mental health care programs by public health authorities.

Depression, Anxiety, Perceived Stress and Family Support in COVID-19 Patients

Objective: Coronavirus disease 2019 (COVID-19) was first reported in Iran in February 2020 and then quickly spread to many cities. Different factors contribute to the numerous psychological problems of this pandemic in patients, healthcare workers and the community. This study investigated the prevalence of perceived stress, anxiety and depression in COVID-19 patients hospitalized between March and April 2020 and revealed associations of these factors with social support received from family. Method : In this cross-sectional study, patients with COVID-19 admitted between 21st of March and 22nd of April 2020 were evaluated by three questionnaires: Anxiety and depression were evaluated using the hospital anxiety and depression scale (HADS), stress levels were evaluated using the four-item perceived stress scale (PSS-4) and family support was evaluated using the perceived social support scale-family (PSS-Fa). In addition to obtaining prevalence of the noted psychological disorders and their relationship with demographic details, relationship of stress, anxiety and depression with family support was also investigated using the Pearson's correlation coefficient. Results: Participants comprised 100 COVID-19 patients (38 females and 62 males). Findings suggested high levels of perceived stress in 26% of the participants, anxiety symptoms existed in 29% and borderline conditions existed in 17%. Moreover, depressive and its borderline symptoms were respectively observed in 17% and 23%. Family support was found to negatively and significantly correlated with anxiety (Pearson correlation = -0.249, P < 0.05) and depression. (Pearson correlation = -0.221, P < 0.05). Conclusion: Given the high prevalence of anxiety and depression in hospitalized COVID-19 patients, it is recommended to further focus on non-clinical interventions, such as providing psychological first aids, boosting psychological resilience, and enabling greater family support, in efforts to prevent transformation of these psychological symptoms into long-term psychological disorders.

Persian Translation and Cultural Adaptation of Mini International Neuropsychiatric Interview and its Psychometric Properties

BACKGROUND

The main objectives of this study were the translation, cultural adaptation, and assessment of the psychometric properties of the Persian version of Mini International Neuropsychiatric Interview (MINI).

METHODS

All processes of linguistic methodology were conducted according to the published guidelines. A total of 180 patients with psychiatric problems were interviewed using MINI and Structured Clinical Interview for DSM-5(R) - Clinician Version (SCID-5-CV) by different interviewers. Another 30 patients were selected for examining the test-retest reliability. The study sample was recruited from a psychiatric hospital and a general hospital in Tehran, Iran. Face validity, feasibility, time of the interview, test-retest reliability, and concurrent validity were evaluated.

RESULTS

Mean interview time was 19.76±10.30 minutes, indicating satisfactory feasibility. The test-retest reliability was very good (phi=2, Cramer's V=0.89, P<0.0001). The kappa values showed good or excellent agreement between MINI and SCID-5-CV for psychotic disorders (0.88), substance-related disorders (0.86), bipolar disorder (0.85), major depressive disorder (0.84), obsessive-compulsive disorder (0.74), and mental disorder due to other medical disorders (0.7). However, the kappa values were found to be lower for generalized anxiety disorder (0.44) and posttraumatic stress disorder (0.32) diagnoses.

CONCLUSION

The Persian version of MINI is a feasible, reliable, and valid instrument for diagnosing some mental disorders. Further research is needed to evaluate the validity of this instrument in other categories of psychiatric diagnoses in the general population.

Tehran cohort study (TeCS) on cardiovascular diseases, injury, and mental health: Design, methods, and recruitment data

Cardiovascular disease, mental health, and injury are among the top health issues globally. In Tehran Cohort Study, we aimed to determine the prevalence, incidence, and trend of cardiovascular diseases, psychiatric symptoms, injury, and risk factors in Tehran households. We enrolled 4215 households in the recruitment phase from March 2016 to March 2019. Demographic characteristics, past medical history, medications, and familial history of the participants were collected. Rose angina pectoris, general health Questionnaire-28 (GHQ-28), and injury questionnaires were completed. Fasting blood samples were collected to measure routine biochemistry and store samples in the biobank. Anthropometric and physiological measurements and electrocardiograms were performed. The participants are followed every three years for up to 12 years. In total, 8296 individuals participated in the cardiovascular section, 10247 completed the GHQ-28, and 4167 households completed the injury questionnaire. The mean age of the participants was 48.2 (16.41), and 46.5% were male. 64.3% of recruited individuals had no symptoms of psychiatric disorders, and 3729 (89.5%) households did not have any severe injury requiring treatment. The participants' diversity and their invaluable data will help us provide a general picture of the current prevalence and incidence of the main study objectives.

Pentoxifylline for treatment of major depression after percutaneous coronary intervention or coronary artery bypass grafting: A randomized, double-blind, placebo-controlled trial

INTRODUCTION

Near one-fifth of patients with coronary artery disease (CAD) develop major depressive disorder (MDD), an independent risk factor of mortality in these patients. We investigated the efficacy of oral pentoxifylline in treating MDD in CAD patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a 6-week trial.

METHODS

We only included patients with mild to moderate MDD (having a score between 14 and 17 on the Hamilton depression rating scale (HAM-D)). Sixty-four CAD patients undergoing PCI or CABG aged 40-60 years were randomly assigned to either the pentoxifylline (800 mg daily) or the placebo group. The outcome was assessed with the HAM-D at weeks 2, 4, and 6.

RESULTS

Patients receiving pentoxifylline had greater improvement in HAM-D scores from baseline at each follow-up than patients receiving placebo (p-value = 0.036 at week 2, p-value < 0.001 at week 4, and p-value < 0.001 at week 6). We found a significant effect for treatment, time, and time×treatment interaction in depression improvement (p-value < 0.001). Rate of remission, treatment response, and adverse effects did not differ between the two groups.

DISCUSSION

Our study supports the safety and efficacy of pentoxifylline in treatment of MDD in CAD patients. However, further investigations are required to confirm the generalizability of our results since the results need to be interpreted cautiously because of the imitated range of disease severity for inclusion. This trial was registered with the Iranian Registry of Clinical Trials (www.irct.ir; No. IRCT20090117001556N132).

Efficacy and safety of sulforaphane for treatment of mild to moderate depression in patients with history of cardiac interventions: A randomized, double-blind, placebo-controlled clinical trial

AIM

Depression has been recognized as one of the disorders associated with cardiac interventions such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In the present study, we evaluated the efficacy and safety of sulforaphane in treatment of depression induced by cardiac interventions.

METHODS

After initial screening, 66 patients with previous history of at least one cardiac intervention and current mild to moderate depression were randomly assigned to two parallel groups receiving either sulforaphane (n = 33) or placebo (n = 33) for six successive weeks. Efficacy was assessed using the Hamilton Rating Scale for Depression (HAM-D) at baseline and week 2, 4, and 6. Safety of the treatments was checked during the trial period.

RESULTS

Sixty participants completed the clinical trial (n = 30 in each group). Baseline demographic and clinical parameters were all similar among groups. Repeated measures analysis indicated that the sulforaphane group exhibited greater improvement in HAM-D scores throughout the trial (P < 0.001). Response to treatment (≥50% reduction in the HAM-D score) rate was higher in the sulforaphane group at trial endpoint (30% vs 6.67%, P = 0.042). Remission (HAM-D score ≤ 7) rate was also higher in the sulforaphane group; however, the difference was not significant (23.33% vs 3.33%, P = 0.052). Finally, no significant difference was observed between the two groups in terms of frequency of side effects.

CONCLUSIONS

Sulforaphane could safely improve depressive symptoms induced by cardiac interventions. Further clinical trials with larger sample sizes and longer follow-up periods are warranted to confirm our results.

Atomoxetine as an adjunct to nonpharmacological treatments for preventing vasovagal attacks in patients with recurrent vasovagal syncope: A pilot randomized-controlled trial

BACKGROUND

Despite the reduced quality of life in patients with recurrent vasovagal syncope (VVS), pharmacologic treatment options remain limited. Studies indicate that norepinephrine reuptake inhibition reduces tilt-induced syncope/pre-syncope. This study aimed to evaluate the effects of atomoxetine on syncopal/pre-syncopal episodes in patients with recurrent VVS.

METHODS

In a placebo-controlled trial, we randomized patients with newly diagnosed VVS who experienced ≥3 syncopal episodes in the past three months to receive either atomoxetine (20 mg daily for two weeks followed by 40 mg daily for two weeks) or placebo. The primary endpoint was the combined number of syncopal and pre-syncopal episodes.

RESULTS

Among 843 patients initially screened, 46 were randomized (N = 23 in each group) and reevaluated at one and three months. Compared to placebo, atomoxetine significantly reduced the primary endpoint after three months (P < 0.001). In the atomoxetine arm, the median time to first pre-syncopal episode was 55 days (95% confidence interval (CI): 41.21-68.79), while this was 27 days (95% CI: 14.48-39.52) for the placebo group (P < 0.001). In a subgroup analysis of patients with systolic blood pressure < 110 mmHg, atomoxetine reduced the primary endpoint, and the number of syncopal and pre-syncopal episodes after one and three months. In this subgroup, the median time to first pre-syncopal attack was 56 days in the atomoxetine group as opposed to 9 days in the placebo group.

CONCLUSIONS

In this pilot study, the promising effects of atomoxetine in reducing syncopal/pre-syncopal episodes in recurrent VVS, especially with low blood pressure phenotype, warrant the conduction of future randomized trials.

Health Care Professionals' Perception of Stress During COVID-19 Pandemic in Iran: A Qualitative Study

BACKGROUND

The health care professionals have a unique role in controlling the pandemic of COVID-19 and decreasing its mortality and morbidity. The burden of care and psychological impact of working in this circumstance can be unfavorable for many caregivers. In this qualitative study, the health care professionals' perception of stress during COVID-19 pandemic in Iran was assessed and several implications were proposed.

MATERIALS AND METHODS

The participants were selected among staff who were providing medical services to patients with COVID-19 infection at the largest teaching hospital in Iran. Quota sampling was used to include physicians, nurses, and other paramedics. The grounded theory was selected to develop interview questions. Moreover, the thematic approach was applied to analyze the data content and data analysis was performed based on open and axial coding following the implementation of codes in MAQDA software.

RESULTS

A wide range of psychological reactions including anxiety, feelings of guilt, depression, and anger were detected in the staff. Uncertainty accompanied by the pandemic of COVID-19 and shortcomings in preparation for crisis management were recognized as the two main sources of stress among health care professionals.

CONCLUSION

Based on the findings of the study, it is important to identify and evaluate the mental health needs of healthcare professionals. To reduce stress among health staff at COVID-19 care centers, it seems that the optimal strategy is simultaneous improvement in equipment and crisis management.

Atomoxetine in patients with recurrent vasovagal syncope for preventing vasovagal attacks and improvement of depression and anxiety: a randomized double-blind placebo-controlled clinical trial

Background

Studies showed that sibutramine or reboxetine reduced head-up tilt (HUT)-induced syncope and pre-syncope by 78%. Furthermore, in an open-label series of highly symptomatic patients with vasovagal syncope (VVS), sibutramine reduced frequency of vasovagal spells. In a recent proof of principle study, atomoxetine reduced number of HUT-induced syncopal episodes by about 50% compared to placebo.

Purpose

In this study, we aimed to evaluate the effectiveness of atomoxetine on preventing recurrence of syncopal and pre-syncopal episodes in patients with recurrent VVS after three months of follow-up. Moreover, we determined whether it can improve patients' anxiety and depression.

Methods

In this double-blind placebo-controlled randomized clinical trial, we screened 843 patients with VVS. Patients with 10 &lt; age &lt; 70 years who had ≥3 syncopal episodes in the past three months were included. Eventually, 46 patients were randomized to receive atomoxetine (20 mg daily for two weeks followed by 40 mg daily for two weeks, N=23) or placebo (for four weeks, N=23). The primary endpoint was the number of syncopal and pre-syncopal episodes at one and three months and was analyzed by the repeated measures analysis of variance. Secondary endpoints were decrements of depression and anxiety measured by the Hospital Anxiety and Depression Scale after three months and were analyzed by the Mann-Whitney U test.

Results

The primary endpoint was lower after three months in the atomoxetine arm (2.3±1.3 vs 4.3±1.7), with a significant between-subjects effect by atomoxetine versus placebo (P&lt;0.001). This observation was primarily due to the reduction of pre-syncopal episodes rather than syncopal episodes (P&lt;0.001 vs P=0.944, respectively, Table). In contrast with placebo, atomoxetine significantly improved anxiety (P=0.048 vs P=0.352) and depression (P=0.001 vs P=0.206) after three months; nonetheless, anxiety and depression scores of the patients were not different across the groups after three months (P&gt;0.05, Figure).

Conclusions

In patients with VVS, atomoxetine significantly reduced the recurrence of a composite of syncopal and pre-syncopal episodes, and remarkably improved anxiety and depression at three months.

Anxiety and Depression of the Patients

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences

Depression and Anxiety among Iranian Medical Students during COVID-19 Pandemic

Objective: COVID-19 has spread throughout the world and has become a global pandemic. This situation can cause psychological distress among people, especially health care workers.

This study aimed to determine depression and anxiety levels among Iranian medical students during the COVID-19 pandemic.

Method: In this cross sectional study, we designed an online survey of Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) questionnaires. The survey link was sent to 500 medical clerks and interns studying at Tehran University of Medical Sciences (TUMS).

Results: A total of 64.6% of the students completed the survey. The prevalence of mild to severe anxiety and depression among them was 38.1% and 27.6%, respectively. Anxiety and changes in sleep patterns were the most common symptoms. Higher levels of anxiety were related to female gender, lower grade point average (GPA), and experience of COVID-19 symptoms. Students with lower GPA and prior experience of COVID-19 symptoms were more likely to feel depressed.

Conclusion: Depression and anxiety did not significantly differ among Iranian medical students before and after the COVID-19 outbreak. Somatic symptoms of depression are more common during this pandemic and need particular attention in future similar situations. A higher GPA is related to lower anxiety and depression among medical students.

Association between Illness Perception and Emotional Status in Iranian Patients after Heart Transplantation

Background: Heart transplantation is a major procedure which imposes high emotional stress on patients. Illness perception (IP) is a psychological issue which affects psychological adjustment after transplantation. This study aimed to investigate the association between IP and emotional status in Iranian post-heart transplantation patients. Methods: The present cross-sectional study, conducted between 2018 and 2019 in Imam Khomeini Hospital, Tehran, Iran, recruited 121 post-heart transplantation patients. IP was measured using the Brief Illness Perception Questionnaire (B-IPQ), and emotional status was measured using the Hospital Anxiety and Depression Scale. The association between IP and depression/anxiety was assessed. Results: Men comprised 80.2% of the study population. The mean age of the participants was 43.9±12.95 years. Definite caseness for depression and anxiety was reported in 11.6% and 18.2% of the participants, respectively. The median score of IP was 55. The association between anxiety and IP in total IP and the 3 dimensions of IP was statically significant (P=0.015, P=0.018, P=0.002, and P=0.023 for the cognition, emotion, and understanding dimensions and the total IPQ, respectively). Additionally, the association between depression and IP was significant (P=0.001, P=0.029, and P=0.002 for the cognition and emotion dimensions and the total IPQ, correspondingly, except for the understanding dimension). Furthermore, lower levels of anxiety in the patients showed a greater impact on IP than did depression. Conclusion: There was a significant association between IP and depression and anxiety in our study population. Therefore, the diagnosis and management of anxiety and depression in heart transplantation patients may improve IP. The cross-sectional design of the present study precluded an investigation of the causality between IP and emotional status.

Association between Illness Perception and Emotional Status in Iranian Patients after Heart Transplantation

Background: Heart transplantation is a major procedure which imposes high emotional stress on patients. Illness perception (IP) is a psychological issue which affects psychological adjustment after transplantation. This study aimed to investigate the association between IP and emotional status in Iranian post-heart transplantation patients. Methods: The present cross-sectional study, conducted between 2018 and 2019 in Imam Khomeini Hospital, Tehran, Iran, recruited 121 post-heart transplantation patients. IP was measured using the Brief Illness Perception Questionnaire (B-IPQ), and emotional status was measured using the Hospital Anxiety and Depression Scale. The association between IP and depression/anxiety was assessed. Results: Men comprised 80.2% of the study population. The mean age of the participants was 43.9±12.95 years. Definite caseness for depression and anxiety was reported in 11.6% and 18.2% of the participants, respectively. The median score of IP was 55. The association between anxiety and IP in total IP and the 3 dimensions of IP was statically significant (P=0.015, P=0.018, P=0.002, and P=0.023 for the cognition, emotion, and understanding dimensions and the total IPQ, respectively). Additionally, the association between depression and IP was significant (P=0.001, P=0.029, and P=0.002 for the cognition and emotion dimensions and the total IPQ, correspondingly, except for the understanding dimension). Furthermore, lower levels of anxiety in the patients showed a greater impact on IP than did depression. Conclusion: There was a significant association between IP and depression and anxiety in our study population. Therefore, the diagnosis and management of anxiety and depression in heart transplantation patients may improve IP. The cross-sectional design of the present study precluded an investigation of the causality between IP and emotional status.

Effect of Showing Angiograms to Patients After Elective Percutaneous Coronary Intervention on Anxiety and Illness Perception: A Randomized, Blinded, Controlled Clinical Trial

BACKGROUND

As an invasive modality, a coronary angioplasty may cause a great deal of anxiety in patients and affect their mental health and general well-being. Accordingly, we sought to assess whether showing patients the video of their elective percutaneous coronary intervention (angiogram) could affect their illness perception and anxiety level.

MATERIALS AND METHODS

In this randomized clinical trial, the patients undergoing angioplasty, were randomly divided into two groups of 30 patients. Angiograms were shown only to the intervention group postprocedurally. A checklist comprising demographic data and clinical presentations as well as the Beck anxiety questionnaire and the Brief Illness Perception Questionnaire (BIPQ) was completed for each patient immediately after the intervention and one month later. The differences in the patients' anxiety level and illness perception were analyzed.

RESULTS

In the intervention group, the mean anxiety score before and after watching the angiograms was 34.26 ± 8.1 and 24.4 ± 8.56, respectively. While in the control group, the score before and after angioplasty was 34.46 ± 9.34 and 26.6 ± 9.44, respectively. Thus, watching angiograms led to a significant decrease in the anxiety score in the intervention group, whereas there was no such difference in the control group. There was also a considerable difference in the anxiety score between the two groups. Further, there was a significant decrease in the BIPQ score of the intervention group after watching the angioplasty videos.

CONCLUSION

Educating cardiovascular patients about diagnostic and therapeutic procedures may confer such good outcomes as alleviated anxiety, enhanced satisfaction, and ultimately, fewer anxiety-related complications.

Assessment and detection of depression in patients with coronary artery disease: validation of the Persian version of the PHQ-9

Background: Depression is a common comorbidity in patients with coronary artery disease (CAD), which often remains undetected and untreated. Objective: This study aimed to examine the psychometric properties of the Depression Module of the Patient Health Questionnaire (PHQ-9) on a sample of cardiac patients in Iran. Method: The Persian version of the PHQ-9 was developed and administered to 150 patients with CAD, admitted to a tertiary hospital in Tehran, Iran. The major depression module of the International Neuropsychiatric Interview (MINI) was used as the gold standard for the diagnosis of depression. Results: The Persian PHQ-9 demonstrated acceptable internal consistency, with Cronbach's alpha coefficient of 0.80. The optimal cut-off score of ≥7 showed a sensitivity of 76, specificity of 78, and the area under curve of 0.82. Conclusion: The Persian PHQ-9 has acceptable psychometric properties to screen for and detect a current depressive episode in patients with CAD, with recommended cut-off score of ≥7.

Association between illness perception and health-related quality of life in patients with preexisting premature coronary artery disease

OBJECTIVES

Illness perception in younger age differs from that in older age. We aimed to examine the association between illness perception and health-related quality of life (HRQoL) in patients with premature coronary artery disease (CAD).

METHODS

In a cross-sectional design, between November 2016 and September 2017, a total of 779 adults (52.5% female) with premature CAD (diagnosed in men aged ≤ 45 y and women aged ≤ 55 y) completed the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Brief Illness Perception, and the Short-Form Health Survey 36 questionnaires in an outpatient clinic 8 years after the diagnosis.

RESULTS

The patients were treated with coronary artery bypass graft surgery (24.6%), percutaneous coronary intervention (39.5%), and medical treatment (35.8%). The cognitive, emotional, and comprehension aspects of illness perception had significant associations with both physical and mental health in univariable analysis (all Ps < 0.001). After adjustments for potential confounding factors, higher cognitive perception was independently associated with greater physical health [OR = 4.13, Confidence interval (CI): 3.53-4.72] and mental health (OR = 3.17, CI: 2.57-3.77). Additionally, emotional perception was also directly associated with higher physical (OR = 1.62, CI: 1.17-2.06) and mental (OR = 1.52, CI: 1.07-1.96) health; all Ps < 0.001.

CONCLUSIONS

Of the 3 different aspects of illness perception, cognitive perception appeared to have the greatest influence on HRQoL, either physical or mental health. Further studies are needed to investigate whether cognitive interventions can improve HRQoL in premature CAD patients and, thus, their outcome.

Does oral administration of ketamine accelerate response to treatment in major depressive disorder? Results of a double-blind controlled trial

BACKGROUND

Major depressive disorder (MDD) exerts a high health and financial burden on society. The conventional pharmacotherapies for MDD are partially effective and the response to medication often starts with some delay. There are recent reports of antidepressant effects for oral ketamine.

METHODS

We employed a double-blind controlled trial to examine the time course of the therapeutic effect of ketamine when combined with the conventional administration of sertraline. A total of 81 patients participated in the study and were scored with the Hamilton Depression Rating Scale (HDRS) at baseline and at 2, 4 and 6 weeks after the start of the trial RESULTS: General linear model repeated measures demonstrated significant effect for time × treatment interaction on the HDRS scores, with significant difference at all time points post treatment. Early improvement was significantly greater in the ketamine group (85.4%) compared to the placebo group (42.5%). We did not observe any side effects for ketamine administration.

LIMITATIONS

Our follow up was limited to 6 weeks post initiation of treatment and cannot reveal the potential long-term adverse effects of oral ketamine and the sustainability of its benefit.

CONCLUSION

Altogether, our results suggest that oral ketamine may be considered as suitable adjuvant to sertraline in relieving depressive symptoms.

Saffron (Crocus sativus) versus duloxetine for treatment of patients with fibromyalgia: A randomized double-blind clinical trial

OBJECTIVE

Saffron was found efficient and safe in treatment of neuropsychiatric disorders, in particular depression. We compared the efficacy of saffron with duloxetine in treatment of patients with fibromyalgia.

MATERIALS AND METHODS

In this double-blind parallel-group clinical trial, outpatients with fibromyalgia were randomized to receive either saffron 15 mg or duloxetine 30 mg starting with 1 capsule per day in the first week followed by 2 capsules per day from week 2 until the end of week 8. Participants were men and women aged 18-60 years diagnosed with fibromyalgia based on the American College of Rheumatology 2010 criteria who also had a pain score≥40 based on visual analogue scale. Participants were excluded in case they had rheumatologic diseases, inflammatory/infectious/autoimmune arthritis, comorbid neuropsychiatric disorders except depressive disorders, pain due to traumatic injuries, drug history of duloxetine or saffron use, current use of psychoactive medications, recent use of muscle relaxants, steroids, opioid analgesics, benzodiazepines, anti-epileptics, or injective analgesics. Primary outcomes included differences in mean score changes from baseline to endpoint between the treatment arms for Hamilton Rating Scale for Depression, Fibromyalgia Impact Questionnaire, and Brief Pain Inventory.

RESULTS

Socio-demographic characteristics and baseline scores were similarly distributed between the two treatment arms (2n=46). No significant difference was detected for any of the scales neither in terms of score changes from baseline to endpoint between the two treatment arms (Mean score changes: -4.26 to 2.37; p-values: 0.182-0.900) nor in terms of timetreatment interactions (p-values: 0.209-0.964).

CONCLUSIONS

Saffron and duloxetine demonstrated comparable efficacy in treatment of fibromyalgia symptoms.

Effects of Saffron on Cognition, Anxiety, and Depression in Patients Undergoing Coronary Artery Bypass Grafting: A Randomized Double-Blind Placebo-Controlled Trial

OBJECTIVES

Cognitive decline, depression, and anxiety are among the major concerns in patients undergoing coronary artery bypass grafting (CABG). Crocus sativus L. (saffron) seems to be a promising candidate for treatment of these conditions.

DESIGN

In this 12-week, randomized, double-blind, placebo-controlled clinical trial, men and women with on-pump CABG, who had Wechsler Memory Scale (WMS) score >70 and age <70 years, received either saffron capsules (15 mg/twice daily) or placebo. Patients were excluded if they had history of treatment with saffron or acetylcholinesterase inhibitors, comorbid neuropsychiatric disorders, serious medical conditions other than cardiovascular diseases, and hypersensitivity to herbal compounds. The primary outcome was defined as the difference in mean total score changes for WMS-Revised from the baseline to week 12 between the saffron and placebo groups. Secondary outcomes included difference in mean score changes from baseline to endpoint between the two treatment groups for Mini Mental Status Examination and subscales of Hospital Anxiety and Depression Scale ( www.irct.ir ; IRCT201408071556N63).

RESULTS

No significant difference was detected in primary or secondary outcomes between the saffron and placebo groups. Also, no significant time × treatment interaction effect was found for any of the scales.

CONCLUSIONS

The results of this trial do not support the hypothesis of potential benefits of saffron in treatment of CABG-related neuropsychiatric conditions.

A Survey on Mental Health Status of Adult Population Aged 15 and above in the Province of Chaharmahal and Bakhtiari, Iran

INTRODUCTION

This research aims to determine the mental health status of population aged 15 and over in the province of Chaharmahal and Bakhtiari in 2015.

METHODS

The statistical population of this cross-sectional field survey consisted of residents of urban and rural areas of Chaharmahal and Bakhtiari in Iran. An estimated sample size of 1200 people was chosen using systematic random cluster sampling. The access was provided by the contribution of Geographical Post Office of Shahre Kord, Farsan and Farrokhshar cities. The General Health Questionnaire-28 (GHQ-28) was used as the screening tool for mental disorders. The analysis of data in the current study was carried out using the SPSS-18 software.

RESULTS

Using GHQ traditional scoring method, the results showed that 24.9% of the subjects were at risk of mental disorders (26.8% of females and 23% of males). Urban areas (27.1%) were more at risk of mental disorders compared with rural residents (19.1%). Anxiety and somatization symptoms were more frequent than depression and social dysfunction among respondents. The obtained data revealed that the prevalence of mental disorders increased with age. The results also indicated that mental disorders were more common in certain subgroups, in particular females, people aged 65 years and above, the divorced and widowed, illiterate and unemployed adults.

CONCLUSION

Our findings suggest that one fourth of the participants are at risk of developing mental disorders. Although the prevalence of these disorders has decreased from 39.1% to 24.9% between 1999 and 2015, it is still of great importance to further promote mental health policies and advocate psychological welfare of those suffering from mental disorders along with their re-empowerment.

Psychological Features of Takotsubo Cardiomyopathy: Report of Four Cases

Takotsubo or stress-induced cardiomyopathy is a cardiomyopathy in which the patient has a sudden onset, reversible left ventricular systolic dysfunction without any significant coronary artery disease. Four women, who were at a mean age of 64 years and suffered from chest pain exacerbated by emotional stress, were admitted as cases of acute coronary syndrome and were completely evaluated through precise history taking, physical examination, and ECG. Coronary angiography or coronary multidetector computed tomography was used to exclude significant coronary artery disease. In these patients with confirmed Takotsubo cardiomyopathy, in addition to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) criteria, a 71-item form of the Minnesota Multiphasic Personality Inventory (MMPI)-Mini-Mult-was employed for psychological assessment. The main common elevated scale was hypochondriasis. Individuals with high scores on this scale are obsessed with themselves, especially in regard to their body, and often use their disease symptoms in order to manipulate others. They are mainly passive aggressive, critical, and demanding, which stems from their lack of effective verbal abilities as a means of communication, specifically when it comes to anger or hostility expression. To the best of our knowledge, there is no available study evaluating patients with Takotsubo cardiomyopathy using the Mini-Mult questionnaire for psychological assessment.

Factors Associated with Depressive Symptoms in Young Adults with Coronary Artery Disease: Tehran Heart Center's Premature Coronary Atherosclerosis Cohort (THC-PAC) Study

Objective: Depressed coronary artery disease (CAD) patients may experience a poorer prognosis than non-depressed patients. The aim of this study was to find the associated factors for depressive symptoms in young adults with CAD. Method: This was a cross-sectional study within Tehran Heart Center's Premature Coronary Atherosclerosis Cohort (THC-PAC) study. Young adult CAD patients (men ≤ 45 year-old and women ≤ 55 year-old) were visited from March 2013 to February 2014. Demographic, clinical and laboratory data were collected and all patients were asked to fill in the Beck Depression Inventory II. Informed consent was obtained from all participants. A logistic regression model was used to find multiple associated factors of depressive symptoms. Results: Seven hundred seventy patients (mean ±SD age: 45.34 ±5.75 y, men: 47.7%) were visited. The point prevalence of depressive symptoms was 46.9% in women and 30.2% in men (p < 0.001). Logistic regressions model revealed that the most important associated factors for depressive symptoms in the male premature CAD patients were opium usage (OR: 2.4, 95% CI: 1.33-4.43), major adverse cardiac events (MACE) (OR: 2.2, 95% CI: 1.17-3.93), initial coronary artery bypass grafting (CABG) treatment (OR: 2.1, 95% CI: 1.07-4.06), positive family history for CAD (OR: 1.8, 95% CI: 1.11-3.01) and cigarette smoking (OR: 1.7, 95% CI: 0.97-2.98). Hypertension showed a protective role in this group of patients (OR = 0.5, CI = 0.29-0.92). In the female patients, hypertension (OR = 1.5, CI = 0.96-2.22) and body mass index (BMI) (OR = 1.1, CI = 1.02-1.10) were associated with depressive symptoms. Conclusion: In premature CAD male patients, opium usage, MACE, initial CABG treatment, positive family history for CAD and cigarette smoking were associated with depressive symptoms; and hypertension and BMI were associated with depressive symptoms in women.

Factors Associated with Anxiety in Premature Coronary Artery Disease Patients: THC-PAC Study

Anxiety may negatively affect the course of coronary artery disease (CAD). The aim of this study was to assess which factors are associated with anxiety in young adults with CAD. A cohort of individuals with premature coronary artery disease was formed between 2004-2011, as the Tehran Heart Center's Premature Coronary Atherosclerosis Cohort (THC-PAC) study. Patients (men≤45-year-old, and women≤55-year-old) were visited between March 2013 and February 2014. All participants were examined, and their demographic, clinical, and laboratory data were collected. Then, all participants filled in the Beck Anxiety Inventory. Logistic regression models were used to identifying factors related to anxiety in both sexes. During the study, 708 patients (mean [SD] age: 45.3 [5.8] y, men:48.2%) were visited. Anxiety was present in 53.0% of participants (66.0% of women and 39.0% of men). The logistic regressions model showed that the associated factors for anxiety in men were opium usage (OR=1.89, 95% CI: 1.09-3.27), positive family history (OR=1.49, 95% CI:0.94-2.35), and creatinine serum level (OR=1.17, 95% CI:1.05-1.303); and in women were major adverse cardiac events (MACE) during follow-up (OR=2.30, 95% CI:1.25-4.23), hypertension (OR=1.71, 95% CI:1.07-2.73) and the duration of CAD (OR=0.99, 95% CI:0.98-1.00). In premature CAD patients, the determinants of anxiety seem to be different in each sex. Opium usage, positive family history of CAD, and creatinine serum levels in men, and MACE, hypertension, and duration of CAD in women appear the relevant factors in this regard.

Simvastatin versus atorvastatin for improving mild to moderate depression in post-coronary artery bypass graft patients: A double-blind, placebo-controlled, randomized trial

BACKGROUND

A decreased risk of developing depression has been reported among statin users. Aside from their lipid-lowering effects, statins are considered immunomodulatory agents and have protective effects against oxidative stress and inflammation which are well known for their association with depression. The aim of the present study was to compare the probable antidepressant effects of simvastatin and atorvastatin among post-coronary artery bypass graft (CABG) surgery patients with high and low potentials for blood-brain-barrier penetration, respectively.

METHOD

Forty-six outpatients who had undergone CABG in the last 6 months and suffered from mild to moderate depression participated in a parallel, double-blind, placebo-controlled trial, and were randomized to undergo 6 weeks of treatment with either simvastatin (20mg/day) or atorvastatin (20mg/day). Participants were evaluated using Hamilton depression rating scale (HDRS) at baseline and weeks 3 and 6. The primary outcome was to evaluate the efficacy of simvastatin in improving the depressive symptoms.

RESULT

General linear model repeated measures demonstrated significant effect for time×treatment interaction on the HDRS scores [F (1.62, 71.06)=3.41, P=0.048]. There was no significant difference between the treatment groups regarding the adverse events. No one experienced serious adverse event.

LIMITATION

The limitations of the present study were its small sample size and the short-term follow-up period.

CONCLUSION

Treatment with simvastatin seems to be well tolerated with superior antidepressant effects compared to atorvastatin in post-CABG patients. Long-term outcomes of this practice and its probable influence on other psychological aspects are yet to be investigated in future studies.

TRIAL REGISTRATION

Iranian registry of clinical trials (http://www.irct.ir): IRCT201410271556N68.

Evaluating the Potential Effect of Melatonin on the post-Cardiac Surgery Sleep Disorder

BACKGROUND

Postoperative neurological injuries, including cognitive dysfunction, sleep disorder, delirium, and anxiety, are the important consequences of coronary artery bypass graft surgery (CABG). Evidence has shown that postoperative sleep disturbance is partly due to disturbed melatonin secretion in the perioperative period. The aim of this study was to evaluate the effect of melatonin on postoperative sleep disorder in patients undergoing CABG.

METHOD

One hundred forty-five elective CABG patients participated in a randomized double-blind study during the preoperative period. The patients were randomized to receive either 3 mg of melatonin or 10 mg of Oxazepam one hour before sleep time. Each group received the medication from 3 days before surgery until the time of discharge. Sleep quality was evaluated using the Groningen Sleep Quality Score (GSQS), and the incidence of delirium was evaluated by nursing records. Sleep quality and anxiety scores were compared before and after surgery through the Wilcoxon signed-rank test. The analysis of covariance (ANCOVA) and independent t-test were used to compare the sleep and anxiety scores between the groups. P values ≤ 0.05 were considered statistically significant.

RESULTS

Totally, 137 patients at a mean age of 60 years completed the study (76% male). The analysis of the data showed that sleep was significantly disturbed after surgery in both groups. The patients in the Oxazepam group demonstrated significantly higher disturbance in their mean postoperative GSQS score than did their counterparts in the melatonin group (p value < 0.001). A smaller proportion of the participants experienced delirium in the melatonin group (0.06%) than in the Oxazepam group (0.12%); however, this difference was not statistically significant.

CONCLUSION

The result of the present study revealed that melatonin improved sleep in post-cardiac surgery patients more than what was observed with Oxazepam. Therefore, melatonin may be considered an effective alternative for Benzodiazepines in the management of postoperative sleep disorder.

Association between Perioperative Parameters and Cognitive Impairment in Post-Cardiac Surgery Patients

BACKGROUND

Postoperative cognitive dysfunction (POCD) has been an important complication of cardiac surgery over the years. Neurocognitive dysfunction can affect quality of life and lead to social, functional, emotional, and financial problems in the patient's life. To reduce POCD, we sought to identify the association between cognitive dysfunction and perioperative factors in patients undergoing cardiac surgery.

METHODS

One hundred one patients aged between 45 and 75 years undergoing elective cardiac surgery were enrolled in this study. All the surgeries were performed on-pump by the same medical team. A brief Wechsler Memory Test (WMT) was administered before surgery, 3 to 5 days after the surgery, and 3 months after discharge. All related perioperative parameters were collected in order to study the effect of these parameters on the postoperative WMT scores and WMT score change.

RESULTS

The study population consisted of 101 patients, comprising 14 (13.8%) females and 87 (86.2%) males aged between 45 and 75 years. In univariate analysis, the baseline WMT score, serum levels of lactate dehydrogenase and T3, cross-clamp time, and preexistence of chronic obstructive pulmonary disease showed significant effects on the postoperative WMT score (p value < 0.05), whereas only the baseline WMT score and chronic obstructive pulmonary disease showed strong effects on the postoperative WMT score in the multiple regression model. In addition, the multiple regression model demonstrated a significant association between the baseline WMT score, serum creatinine level, and nitrate administration and the WMT score change.

CONCLUSION

Our study showed that preexisting chronic obstructive pulmonary disease and preoperative high serum creatinine levels negatively affected cognitive function after surgery. In addition, there was a strong relationship between the patients' basic cognition and POCD. Preoperative nitrate administration led to a significant improvement in POCD. It is also concluded that the preoperative administration of specific medicines like nitrates can reduce neurological complications after cardiac surgery.

Introducing the Tehran Heart Center's Premature Coronary Atherosclerosis Cohort: THC-PAC Study

BACKGROUND

Data on premature coronary artery disease (CAD) are scarce. The Tehran Heart Center's Premature Coronary Atherosclerosis Cohort Study (THC-PAC) is the first study of its kind in the Middle East to assess major adverse cardiac events (MACE) in young CAD patients.

METHODS

The cohort consists of CAD patients, males ≤ 45 years old and females ≤ 55 years old. The participants are residents of Tehran or its suburbs and underwent coronary angiography between June 2004 and July 2011. A 10-year follow-up, via either clinical visits or telephone calls at least once a year, was commenced in August 2012. The end point is considered MACE, encompassing death, myocardial infarction, stroke, new coronary involvement, percutaneous coronary intervention, and coronary artery bypass grafting.

RESULTS

The cohort comprises 1232 eligible patients (613 [49.8%] males) at a mean age of 45.1 years (SD = 5.8). High frequencies of conventional risk factors, including hyperlipidemia (884 [71.8%]), hypertension (575 [46.7%]), positive family history (539 [43.8%]), cigarette smoking (479 [38.8%]), and diabetes mellitus (390 [31.7%]), were seen in the participants. The mean body mass index (BMI) of the enrolled patients was high (29.2 ± 4.8 kg/m(2)), and 532 (43.3%) and 440 (35.8%) of them were overweight and obese, respectively. The females' BMI was higher (30.4 ± 5.3 vs. 28.0 ± 3.9 kg/m2; P < 0.001) and they had a greater mean abdominal circumference (99.9 ± 13.5 vs. 98.1 ± 9.3 cm; P = 0.035). Between August 2012 and August 2013, follow-up was successful in 1173 (95.2%) patients (median follow-up duration = 55.3 months, 95%CI: 53.5-57.0 months).

CONCLUSION

Our younger patients with CAD had a high frequency of risk factors compared to the same-age general population and all-age CAD patients, which may predispose them to higher incidence of recurrent MACE.

A randomized, double-blind, clinical trial comparing the efficacy and safety of Crocus sativus L. with fluoxetine for improving mild to moderate depression in post percutaneous coronary intervention patients

OBJECTIVE

A significant correlation exists between coronary artery diseases and depression. The aim of this trial was to compare the efficacy and safety of saffron versus fluoxetine in improving depressive symptoms of patients who were suffering from depression after performing percutaneous coronary intervention (PCI).

METHODS

In this randomized double-blind parallel-group study, 40 patients with a diagnosis of mild to moderate depression who had undergone PCI in the last six months were randomized to receive either fluoexetine (40mg/day) or saffron (30mg/day) capsule for six weeks. Participants were evaluated by Hamilton depression rating scale (HDRS) at weeks 3 and 6 and the adverse events were systemically recorded.

RESULTS

By the study endpoint, no significant difference was detected between two groups in reduction of HDRS scores (P=0.62). Remission and response rates were not significantly different as well (P=1.00 and P=0.67; respectively). There was no significant difference between two groups in the frequency of adverse events during this trial.

LIMITATIONS

Relatively small sample size and short observational period were the major limitations of this study.

CONCLUSION

Short-term therapy with saffron capsules showed the same antidepressant efficacy compared with fluoxetine in patients with a prior history of PCI who were suffering from depression.

An atypical suicide attempt: self-inflicted intra-cardiac injury with sewing needle

Atypical cases of suicide are less likely to be seen in general hospitals, nonetheless require further investigation into the precipitating factors as well as proper follow-up. This paper illustrates a 61-year-old woman with major depressive disorder who experienced auditory hallucinations during delirious periods of taking low-dose benzodiazepines, who referred to the hospital with a sewing needle stuck in her chest wall. The needle was successfully removed. Psychiatric problems are often underdiagnosed, therefore undertreated in general hospitals. Thus close monitoring of the patients during the hospitalization and after discharge is crucial.

Beliefs about parental authority, parenting styles, and parent-adolescent conflict among Iranian mothers of middle adolescents

Associations among parenting styles, parental authority beliefs, and adolescent—parent conflict were examined in 426 mothers of middle adolescents from 3 cities in Iran. Consistent with past research, mothers judged parental authority as less legitimate for personal than for conventional or prudential issues. Poorer, less educated mothers were more authoritarian in their parenting, and more authoritarian and less authoritative parenting and poorer maternal mental health were uniquely associated with more frequent and more intense conflicts. Conflicts were more frequent among mothers who evaluated parental authority as less legitimate for prudential issues and more legitimate for personal issues, particularly among mothers of boys. Despite broad variation in mothers’ education and social class, conflicts reflected concerns about drawing boundaries between mothers’ legitimate authority and adolescents’ personal jurisdiction.