Epidemiology of panic disorder and subthreshold panic symptoms in the Greek general population

Panic disorder (PD) is a common anxiety disorder with severe social and health consequences in the lives of individuals who suffer from it. General population studies that attempt to measure the prevalence of this disorder across the world suggest that a 1.7% to 4.7 % of adults and adolescents suffer from Panic Disorder. In Greece, research analyzing the abovementioned matters is limited, and previous studies were put forward in small samples. The aim of the present study was to describe the prevalence and sociodemographic associations of panic disorder (PD) and related subthreshold panic symptoms in the general population of Greece and to appraise the comorbidity, use of services and impact on quality of life of these syndromes. This was a secondary analysis of the 2009-2010 psychiatric morbidity survey carried out in a representative sample of the Greek general population (4894 participants living in private households, 18-70 years, response rate 54%). Psychiatric disorders were assessed with the computerized version of the revised Clinical Interview Schedule (CIS-R). Quality of life was assessed with the EuroQoL EQ-5D generic instrument. The utilization of health services was examined by making relevant questions. Finally, direct questions were used to assess sociodemographic and socioeconomic factors According to our findings, 1.87% of the participants (95% confidence interval [CI]: 1.50-2.26%) met criteria for PD and 1.61% met criteria for subclinical PD (95% CI: 1.26-1.96%). There was a clear female preponderance for both PD (p=0.001) and Sub-PD (p=0.01). In addition, 3.48% of the participants reported having experienced panic attacks during the past week (95% confidence interval [CI]: 2.98-4.01%). PD or subclinical PD was independently associated with a limited number of sociodemographic and socioeconomic variables especially after the adjusted analysis. Both panic related conditions involved significant reductions in quality of life and elevated utilization of health services for both medical and psychological reasons in comparison to healthy participants. In conclusion, PD and subclinical panic symptoms were common in the general Greek population with substantial comorbidity and impaired quality of life. The observed use of the general and psychological health services among adults with panic symptoms and its temporal and economic consequences calls for more efficient diagnostic and treatment policies.

Panic disorder and subthreshold panic in the UK general population: Epidemiology, comorbidity and functional limitation

Objective

The epidemiology of panic disorder has not been investigated in the past in the UK using a nationally representative sample of the population. The aim of the present paper was to examine the epidemiology, comorbidity and functional impairment of subthreshold panic and panic disorder with or without agoraphobia.

Method

We used data from the 2000 Office for National Statistics Psychiatric Morbidity survey (N = 8580). Panic disorder and agoraphobia were assessed with the Revised Clinical Interview Schedule (CIS-R).

Result

The prevalence of panic disorder with or without agoraphobia was 1.70% (95% confidence interval: 1.41–2.03%). Subthreshold panic was more common. Economic inactivity was consistently associated with all syndromes. The comorbidity pattern of the panic syndromes and the associated functional impairment show that panic-related conditions are important public health problems, even in subthreshold status.

Conclusions

The findings show that efforts to reduce the disability associated with psychiatric disorders should include detection and management of panic disorder.

Factor analysis and normative scores of Alcohol Use Disorders Identification Test (AUDIT) in a representative sample of the general population of Greece

The most widely used screening instrument for alcohol use disorders (AUD) is the Alcohol Use Disorders Identification Test (AUDIT) which, although initially developed for use in primary care, is increasingly used in general population studies. Previous studies that have assessed the screening properties and the factorial structure of AUDIT were mostly based on clinical samples and did not take into consideration the possible differences in AUDIT factorial properties between subgroups according to age, sex and mental health status. Aim of the current study was to explore the distribution of AUDIT and AUDIT-Consumption (AUDIT-C) scores and the factorial structure of AUDIT in subgroups of participants according to sex, age and the presence of mental health disorder. Descriptive statistics and Exploratory/Confirmatory Factor Analysis of AUDIT were extracted in a general population representative sample of 4,894 Greek participants. Different cut-offs are suggested in order to screen 10% of the population with the highest severity of AUD into the aforementioned subgroups. Generally, a cut-off between 10-12 at AUDIT score is suggested for screening the 10% with the highest severity of alcohol use problems in subgroups of frequent alcohol consumers (e.g. younger males) and a cut-off between 4-5 would screen the 5% with the highest severity of alcohol use problems in subgroups of low alcohol-consumers (e.g. older women). A cut-off of 3 in AUDIT-C score is suggested for screening 25% of individuals with the heaviest alcohol consumption. The traditional three-factor model does not explain better the factorial structure of AUDIT compared to the 2-factors model. The AUDIT is a reliable instrument for assessing AUD and heavy alcohol consumption in the Greek general population. Age, sex and the presence of mental health disorders should be taken into consideration when selecting cut-offs for screening purposes in non-clinical samples.

Assessing depression in Greek dementia patients: Which scale to use?

Depression in dementia is known to deteriorate patients' cognitive function and Quality of Life and to increase the burden of care. Although detecting depression in dementia is crucial, there is no gold standard for its screening and diagnosis. We examined the psychometric properties of 3 different scales in detecting depression in dementia. Results will be useful as community services for dementia in the country are developing and the need for reliable detection of depression in dementia patients is urgent. Our sample consisted of 136 Greek dementia patients who consulted a memory clinic. For the diagnosis of depression, DSM-IV criteria for major depression and 3 different depression measures were used: a self-assessment scale (Geriatric Depression Scale; GDS), a caregiver assessment scale (Neuropsychiatric Inventory-Depression; NPI-D) and a clinician rated scale (Cornell Scale for Depression in Dementia; CSDD). For the evaluation of the screening performance of the three depression scales receiver operating characteristic curve (ROC) analysis was applied. The DSMIV criteria served as the gold standard method for the diagnosis of major depression. CSDD showed the best psychometric properties for the diagnosis of depression in dementia. The ROC curve analysis revealed that among the three measures, the CSDD had the wider AUC (0.919), second in the width of the AUC was the GDS (0.871), and last was the NPI-D (0.812). The prevalence of depression ranged from 18.4% according to DSM-IV criteria to 42.6% using the NPI-D. Using the GDS (cut off point: 7/8) and the CSDD (cut off point: 6/7), depression was present in 26.9% and 33.1% of the patients, respectively. Correlations between scales used were significant (r from 0.432 to 0.660; p<0.001). Caregivers tend to report more depressive symptoms in dementia compared to patients' and clinicians' ratings. CSDD should be used in specialized centers, but GDS may be an alternative in patients able to complete the assessment. The need to establish valid criteria for the diagnosis of depression in dementia is urgent.

Changes in the cytokine profile in first episode, drug-naïve patients with psychosis after short-term antipsychotic treatment

Introduction

An increasing body of evidence suggests that antipsychotic medication can cause immunological changes that could be attributed to the amelioration of psychotic symptoms or the metabolic side effects of the drugs. So far, the results of the studies remain controversial.

Objective

Our aim was to compare the levels of interleukin (IL) IL-2, IL-6 and transforming growth factor-β2 (TGF-β2) in drug-naïve, first-episode patients with psychosis before and after six weeks of antipsychotic medication.

Methods

Thirty-nine first episode patients with psychosis were enrolled in the study. Serum levels of IL-2, IL-6 and TGF-β2 were measured by enzyme linked immunosorbent assay (ELISA) before and six weeks after the initiation of antipsychotic medication. In addition, clinical psychopathology was assessed using Positive and Negative Syndrome Scale (PANSS) before and after treatment.

Results

Serum levels of IL-2 were significantly higher in the study group six weeks after the initiation of antipsychotic treatment (P < 0.001) while TGF-β2 levels were decreased (P < 0.001) and IL-6 levels were slightly reduced (P < 0.004).

Conclusion

The changes in cytokine levels may be attributed to the action of antipsychotic medication and the remission of psychopathology. The reduction in TGF-β2 levels is observed in all patients and with all antipsychotic medications used. TGF-β2 may be a marker of clinical efficacy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Symptoms of generalized anxiety disorder but not panic disorder at age 15 years increase the risk of depression at 18 years in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort study

BACKGROUND

Generalized anxiety disorder (GAD) and panic disorder (PD) differ in their biology and co-morbidities. We hypothesized that GAD but not PD symptoms at the age of 15 years are associated with depression diagnosis at 18 years.

METHOD

Using longitudinal data from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort we examined relationships of GAD and PD symptoms (measured by the Development and Well-Being Assessment) at 15 years with depression at 18 years (by the Clinical Interview Schedule - Revised) using logistic regression. We excluded adolescents already depressed at 15 years and adjusted for social class, maternal education, birth order, gender, alcohol intake and smoking. We repeated these analyses following multiple imputation for missing data.

RESULTS

In the sample with complete data (n = 2835), high and moderate GAD symptoms in adolescents not depressed at 15 years were associated with increased risk of depression at 18 years both in unadjusted analyses and adjusting for PD symptoms at 15 years and the above potential confounders. The adjusted odds ratio (OR) for depression at 18 years in adolescents with high relative to low GAD scores was 5.2 [95% confidence interval (CI) 3.0-9.1, overall p < 0.0001]. There were no associations between PD symptoms and depression at 18 years in any model (high relative to low PD scores, adjusted OR = 1.3, 95% CI 0.3-4.8, overall p = 0.737). Missing data imputation strengthened the relationship of GAD symptoms with depression (high relative to low GAD scores, OR = 6.2, 95% CI 3.9-9.9) but those for PD became weaker.

CONCLUSIONS

Symptoms of GAD but not PD at 15 years are associated with depression at 18 years. Clinicians should be aware that adolescents with GAD symptoms may develop depression.

The burden of caring for patients with dementia and its predictors

Dementia not only affects patients but also care providers. The assessment of Caregivers' Burden (CB) has grown exponentially in the dementia field, as studies have shown that it is higher in dementia than in other diseases. Dementia care in Greece is different compared to other developed countries, as most of the patients receive care at home from family members. The aim of the present study was to examine the level of burden in Greek caregivers who live in Athens, and its association with patient and caregiver factors. This was a cross-sectional study of 161 primary caregivers of dementia patients living in the community and attending a secondary clinic. CB was assessed with the Zarit Burden Interview (ZBI) and caregivers' depression with the Center for Epidemiological Studies Depression Scale (CES-D). Clinical characteristics of the patients were also assessed using validated scales (cognitive status, functional ability, neuropsychiatric symptoms). In order to find predictors of caregiver Burden, we conducted a 3-step hierarchical regression analysis. Most patients were suffering from Alzheimer's Dementia (n=101; 62.73%) and had moderate and severe dementia according to the MMSE score (mean MMSE=11.50), with patients being unable to perform 2 basic activities of daily living on average. 45 patients (27.95%) had depression according to the CSDD; only 5 patients didn't have any behavioral problem in the NPI, while patients had more than 5 behavioral problems on average. Caregivers were involved in their role for 3.6 years on average and the mean weekly caregiving time was more than 70 hours. Nearly half (n=80; 49.06%) of the 161 caregivers demonstrated high CB (ZBI>40) and nearly one fourth had depression according to the CES-D scale. All blocks of variables entered into the regression model independently predicted caregiver burden's variance (demographics, clinical factors and caregiving characteristics). Lower caregiver's age, high behavioral symptoms of dementia patients and caregivers' depression were found to be independently associated with CB. The final regression model explained 47.2% of the variance in CB. Dementia causes a great burden in caregivers. CB is a complex issue that is associated with several patients and caregivers' factors. The level of CB should be assessed in everyday dementia clinical practice.

[Mini Mental State Examination (MMSE): determination of cutoff scores according to age and educational level]

For the last 38 years, Mini Mental State Examination (MMSE) has been widely used as a dementia screening measure in everyday clinical practice as well as in both cohort and cross-sectional studies. Its validity and reliability for the Greek population has explicitly been documented. However, the effect of age and education on the subject's performance makes it necessary to reckon them in the estimation of the "cutoff score". The purpose of this study is to estimate the prevalence of dementia in Greek population and determine the "cutoff score" by age and education-corrected norms. Cross sectional study of 630 patients older than 55 years, who live independently in Ilion and Helioupolis Municipalities was conducted, 27.3% of the subjects tested in the study were diagnosed with memory disorder according to their MMSE scores and the validation for the Greek population. The effect of age and education to the subjects' performance was statistically significant (p=.000). The use of standard "cutoff score" was not proved to be useful for the personalized interpretation of the results, as documented by the fact that older individuals with lower education had a poorer performance relatively to younger, highly educated subjects. Comparatively to the group age of 55-60 years, the odds ratio after the age of 75 years varies from 2.58 to 4.91. Regarding the variable factor of education, the odds ratio for the first degree education graduates decreases from 1.43 to 3.19 for the third degree education graduates in comparison with the group of illiterates. In conclusion, the use of the "cutoff score" algorithm and the simultaneous estimation of age and education effect on MMSE score may prove useful for the proper evaluation of MMSE performance. According to the age and education of examine candidates in the community and the primary care, we propose the use of the 25th percentile as a more useful cutoff score in order to decrease the false positive results.

Estimated verbal IQ and the odds of problem gambling: a population-based study

BACKGROUND

The neurocognitive deficits and other correlates of problem gambling are also observable in individuals with lower cognitive abilities, suggesting that a low IQ may be a determinant of problem gambling. There has been very little research into this possibility. This study aimed to investigate the characteristics associated with problem gambling in a large population-based study in England, with a particular focus on IQ.

METHOD

The Adult Psychiatric Morbidity Survey (APMS) 2007 comprised detailed interviews with 7403 individuals living in private households in England. Problem gambling was ascertained using a questionnaire based on DSM-IV criteria. Verbal IQ was estimated using the National Adult Reading Test (NART). Confounders included socio-economic and demographic factors, common mental disorders, impulsivity, smoking, and hazardous drug and alcohol use.

RESULTS

More than two-thirds of the population reported engaging in some form of gambling in the previous year, but problem gambling was rare [prevalence 0.7%, 95% confidence interval (CI) 0.5-1.0]. The odds of problem gambling doubled with each standard deviation drop in estimated verbal IQ [adjusted odds ratio (OR) 2.1, 95% CI 1.3-3.4, p = 0.003], after adjusting for other characteristics associated with problem gambling including age, sex, socio-economic factors, drug and alcohol dependence, smoking, impulsivity and common mental disorders. There was no strong relationship observed between IQ and non-problem gambling.

CONCLUSIONS

People with lower IQs may be at a higher risk of problem gambling. Further work is required to replicate and study the mechanisms behind these findings, and may aid the understanding of problem gambling and inform preventative measures and interventions.

Evaluation of dangerousness of Greek mental patients

There is a diachronic interest on the evaluation of the risk of violence by mental patients.Difficulties that have been underlined concern the definition of the term dangerousness and the different methods of approaching it. Accurate risk assessments are particularly important for psychiatric patients, with history of violence, in indoor care. The accuracy of predictions can better determine the patients designated as "at risk" for violence and avoid false designations. The aim of this study was to investigate the probability of patients, from several psychiatric units, to become violent after their discharge and over the next three years. We also investigate the predictive validity and accuracy of the HCR-20 in relation to post-discharge outcomes. Two hundred ninety five (295) psychiatric patients, from several psychiatric units, were assessed with the HCR-20, PCL: SV and GAF scales at discharge (using case file data, interviews with the patients and the clinicians of the units, and also information from the collateral informants) and were monitored for violent episodes over the following three years. The study was conducted in two phases: 1st phase: During the last week before discharge. 2nd phase: Every six months, over the following three years. Both the HCR-20 and PCL: SV scales and their subscales are significant predictors of readmission, suicide attempts and violent behavior. The GAF scale had a low positive correlation with the HCR-20 scale. A number of other variables such as duration of hospitalization, previous violent acts, diagnosis, gender, marital status, socioeconomic status, number of previous hospitalizations, were statistically related with failure of re-integration in the community. The results provide a strong evidence base that the HCR-20 is a good predictor of violent behavior in psychiatric patients, following their discharge from psychiatric wards in Greece, and hence can be used by clinicians in routine clinical practice.

Sleep disturbances and depressive symptoms: an investigation of their longitudinal association in a representative sample of the UK general population

BACKGROUND

It has been argued that sleep disturbances are a risk factor for depression but previous longitudinal studies have had limitations and not addressed alternative explanations. The aim of this study was to examine the longitudinal association between sleep disturbances and depressive symptoms in a nationally representative sample.

METHOD

Data from the 18-month follow-up of the UK National Psychiatric Morbidity survey were used (n = 2406). Sleep disturbances, depressive and other psychiatric symptoms (fatigue, concentration problems, irritability, anxiety and pain symptoms) were assessed using the Revised Clinical Interview Schedule (CIS-R). The bidirectional association between symptoms was investigated with logistic regression analyses and path analysis.

RESULTS

Sleep disturbances and depressive symptoms were correlated with each other cross-sectionally (r = 0.52, p < 0.001). In the longitudinal analysis, sleep disturbances at baseline did not predict depressive symptoms at follow-up [odds ratio (OR) 1.27, 95% confidence interval (CI) 0.51-3.19] and the same was observed for the reciprocal association (OR 0.87, 95% CI 0.56-1.35). In the path analysis, the reciprocal model did not have a better fit compared to the simpler first-order model without cross-lagged paths. The path from sleep disturbances at baseline to depressive symptoms at follow-up had a minimal contribution to the explained variance of the latter (<1%).

CONCLUSIONS

Previous studies may have overestimated the importance of sleep disturbances as an independent risk factor of depression. The strong cross-sectional association is compatible with sleep disturbances being either a prodromal or a residual symptom of depression and this may have implications for recognition and treatment of depression.

Feeling life is not worth living: A cross sectional study of Greek adolescents

Introduction

Thoughts of feeling life is not worth living could be the initial stage of a continuum that might end in a suicide.

Objectives

Psychiatric morbidity is quite prevalent among adolescents and has been associated with suicidal ideation.

Aims

Our aim was to test the association between thoughts that life is not worth living and psychiatric morbidity in a sample of Greek adolescents.

Methods

A two-phase cross sectional study of 5614 adolescents aged 16–18 years old attending 25 senior high schools in Greece. A stratified random sample of 2431 subjects was selected for a detailed interview at the second phase. Psychiatric morbidity and thoughts of life is not worth living were assessed with the revised Clinical Interview Schedule (CIS-R). Odds ratios adjusted for age and sex were computed for the association between such thoughts and CIS-R scores.

Results

3,72% of the adolescents (girls:5,11%, boys:2,36%, p < 0.001) reported thoughts of feeling life is not worth living in the week before interview. Psychiatric morbidity correlated significantly with those thoughts (OR = 1.16, 95% Confidence Intervals: 1.14–1.19). The level of psychiatric morbidity was strongly associated with such thoughts with higher levels of distress showing a greater association (Table 1).

[Table 1]

Conclusions

Policies aiming at preventing the overall burden of psychiatric disease in adolescence may reduce the frequency of thoughts that life is not worth living, which could eventually lead to a decrease in completed suicides.

One-year outcome of unexplained fatigue syndromes in primary care: results from an international study

BACKGROUND

Outcome studies of chronic fatigue, neurasthenia and other unexplained fatigue syndromes are few and have been carried out in developed Western countries. This paper aimed to study the outcome of unexplained fatigue syndromes in an international primary care sample and to identify risk factors for persistence.

METHOD

We used data from the WHO collaborative study of psychological problems in general health care, in which 3201 primary care attenders from 14 countries were followed-up for 12 months. The assessment included a modified version of the Composite International Diagnostic Interview.

RESULTS

Unexplained fatigue persisted in one-fifth to one-third of the subjects depending on the definition of fatigue. From the factors studied only severity of fatigue and psychiatric morbidity at baseline were associated with persistence 12 months later. Outcome did not differ between countries of different stages of economic development.

CONCLUSIONS

The prognosis of fatigue syndromes in international primary care is relatively good. The study underlines the importance of psychological factors in influencing short-term prognosis.

Clarifying the relationship between unexplained chronic fatigue and psychiatric morbidity: results from a community survey in Great Britain

The study examined the associations between several sociodemographic and psychosocial variables and unexplained chronic fatigue in the community before and after adjustment for psychiatric morbidity and determined the prevalence of fatigue and rate of disability resulting from fatigue in the general population. The study is a secondary analysis of 1993 data from a household survey of psychiatric morbidity conducted by the Office for Population Censuses and Surveys in Great Britain. The survey included 12,730 subjects age 16-64 years. Unexplained chronic fatigue was used as the dependent variable in a logistic regression analysis, with various sociodemographic and psychosocial variables and psychiatric morbidity as the independent variables. Psychiatric morbidity was assessed by using the Revised Clinical Interview Schedule. Fatigue was measured by using the fatigue section of the Revised Clinical Interview Schedule. A total of 10,108 subjects agreed to cooperate (79.4% participation rate). The prevalence of unexplained chronic fatigue was 9%. Subjects with psychiatric morbidity had higher rates of fatigue. Adjustment for psychiatric morbidity had a minor effect on the associations between sociodemographic factors and chronic fatigue. After adjustment, older subjects, women, and couples with children had higher rates of fatigue. Single subjects, widowed subjects, adults living with parents, and economically inactive subjects had lower rates of fatigue. Fatigue was associated with considerable disability, but the association between fatigue and psychiatric morbidity explained most of this disability. Unexplained chronic fatigue is a common condition, strongly associated with psychiatric morbidity. The close relationship between fatigue and psychiatric morbidity should not obscure the possibility of differences as well as similarities in their aetiologies.

Epidemiology in community psychiatric research: common uses and methodological issues

OBJECTIVE

Epidemiological principles underpin much medical research particularly that concerned with the planning and evaluation of health services, including research in community and social psychiatry. The aim of this paper is to review some of the common uses of epidemiology in community psychiatric research and to discuss some methodological issues that arise frequently in epidemiological research in community settings.

METHODS

This is a review of the relevant literature and of the work currently in progress in the department of psychological medicine of the university of Wales College of Medicine.

RESULTS

Among the many uses of epidemiology in health care, four are especially relevant in community psychiatric settings: the assessment of the mental health needs of the population (four approaches are described: the collection of routine data, surveys of existing patients, surveys of the general population and statistical modelling), the identification of risk factors of disease, the contribution to prevention and the assessment of the clinical effectiveness of health care interventions. The most important methodological issues include causal inference which in epidemiology takes the form of explaining the association between an exposure and disease (chance, bias, confounding, reverse causality and causality), the issue of confounding and how to adjust for it and issues arising in the context of specific study designs.

CONCLUSION

Epidemiology has become a set of methods used to investigate a wide range of clinical questions. Population based research is an essential part of clinical research but epidemiological knowledge is also needed by clinicians in order to critically appraise and interpret the scientific literature.

Clarifying the relationship between unexplained chronic fatigue and psychiatric morbidity: results from a community survey in Great Britain

OBJECTIVE

The study examined the associations between several sociodemographic and psychosocial variables and unexplained chronic fatigue in the community before and after adjustment for psychiatric morbidity and determined the prevalence of fatigue and rate of disability resulting from fatigue in the general population.

METHOD

The study is a secondary analysis of 1993 data from a household survey of psychiatric morbidity conducted by the Office for Population Censuses and Surveys in Great Britain. The survey included 12,730 subjects age 16-64 years. Unexplained chronic fatigue was used as the dependent variable in a logistic regression analysis, with various sociodemographic and psychosocial variables and psychiatric morbidity as the independent variables. Psychiatric morbidity was assessed by using the Revised Clinical Interview Schedule. Fatigue was measured by using the fatigue section of the Revised Clinical Interview Schedule.

RESULTS

A total of 10,108 subjects agreed to cooperate (79.4% participation rate). The prevalence of unexplained chronic fatigue was 9%. Subjects with psychiatric morbidity had higher rates of fatigue. Adjustment for psychiatric morbidity had a minor effect on the associations between sociodemographic factors and chronic fatigue. After adjustment, older subjects, women, and couples with children had higher rates of fatigue. Single subjects, widowed subjects, adults living with parents, and economically inactive subjects had lower rates of fatigue. Fatigue was associated with considerable disability, but most of this disability was explained by the association between fatigue and psychiatric morbidity.

CONCLUSIONS

Unexplained chronic fatigue is a common condition, strongly associated with psychiatric morbidity. The close relationship between fatigue and psychiatric morbidity should not obscure the possibility of differences as well as similarities in their etiologies.