Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study

BACKGROUND

Population-based studies of the prevalence of all functional gastrointestinal disorders (FGID) using the Rome II criteria are lacking. It is also not certain whether subjects who meet the Rome II criteria for an FGID are different in terms of demographic and psychological characteristics from those subjects meeting exclusively the more restrictive Rome I criteria.

AIM

To determine whether using the more restrictive Rome I criteria would result in a more biologically determined group of FGID than when the Rome II is applied.

METHODS

Subjects included individuals aged 18 years and older (n = 1,225) from the Penrith population who were initially surveyed with the Penrith District Health Survey in 1997. Subjects were sent a self-report questionnaire that contained items on gastrointestinal symptoms applying the Rome II criteria. Subjects were also assessed on psychological and personality factors and on physical and mental functioning.

RESULTS

A total of 36.1% (n = 275) of respondents was diagnosed with an FGID according to Rome II criteria. The five most prevalent FGID were functional heartburn (10.4%), irritable bowel syndrome (8.9%), functional incontinence (7.6%), proctalgia fugax (6.5%) and functional chest pain (5.1%). Subjects meeting Rome II only criteria for FGID scored significantly higher on measures of psychological caseness and emotionality than Rome I only subjects, and these were independently associated with meeting Rome I only versus Rome II only criteria for FGID.

CONCLUSION

The Rome II criteria FGID are common and do not appear to identify a vastly different group of FGID sufferers compared with the earlier Rome I criteria.

Risk factors for postnatal depression: a review and risk factors in Australian populations

Postnatal depression affects up to 15% of women in the six months following childbirth. Risk factors for this disorder are predominantly psychosocial. An overview of sociodemographic, early life experiences, external environment, internal environment and obstetric and infant variables are presented in the introduction. Two studies that recruited women shortly after they had given birth and followed up to six months postpartum are used to demonstrate the salience of such risk factors. The importance of clarifying risk factors to postnatal depression are discussed especially in relation to improving our understanding of the mechanisms of postnatal depression, how they may assist in developing preventative strategies and how they can help in planning treatment.

Predictors of conventional and alternative health care seeking for irritable bowel syndrome and functional dyspepsia

BACKGROUND

The drivers of conventional and, especially, alternative health care use for irritable bowel syndrome and functional dyspepsia are not clear.

AIM

To determine the predictors of conventional and alternative health care use for irritable bowel syndrome and functional dyspepsia.

METHODS

Two hundred and seven subjects with irritable bowel syndrome or functional dyspepsia, identified from a previous population survey, were included in the study. Individuals with irritable bowel syndrome/functional dyspepsia were defined as consulters (n = 103) if they had visited their doctor for gastrointestinal symptoms more than once in the past year. Controls (n = 100) did not report having any abdominal pain. Subjects were given structured interviews to assess the Diagnostic and Statistical Manual - version IV (DSM-IV) and International Classification of Disorders - version 10 (ICD-10) psychiatric diagnosis for anxiety, depression, somatization or any psychiatric diagnosis, aspects of health care use and symptom factors.

RESULTS

About one-half (n = 103, 49.8%) of community subjects with irritable bowel syndrome/functional dyspepsia had sought conventional care for gastrointestinal symptoms in the past 12 months. Lifetime rates for alternative health care use for gastrointestinal symptoms were 20.8% (n = 43). Independent predictors of conventional health care use were more frequent abdominal pain, greater interference of gastrointestinal symptoms with work and activities and a greater satisfaction with the physician-patient relationship. Being female independently predicted alternative health care use.

CONCLUSIONS

Psychological morbidity did not predict conventional or alternative health care use for gastrointestinal symptoms. Other factors were more important.

Predictors of health care seeking for irritable bowel syndrome and nonulcer dyspepsia: a critical review of the literature on symptom and psychosocial factors

OBJECTIVES

Health care use is a costly outcome of the irritable bowel syndrome (IBS) and nonulcer dyspepsia (NUD), but the predictors of this behavior remain poorly defined. We aimed to systematically review the literature to determine which symptoms and psychosocial factors drive health care seeking in these disorders.

METHODS

A broad based MEDLINE and Current Contents search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.

RESULTS

The literature suggests that symptom severity is an important factor, but only explains a small proportion of the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have been found to characterize those that seek help versus those that do not. The role of other psychosocial factors such as social support, coping style and knowledge about illness are as yet undetermined.

CONCLUSIONS

A model for health care seeking for IBS and NUD, with an emphasis on psychosocial factors is presented, but remains to be tested.

Obstetric risk factors for postnatal depression in urban and rural community samples

OBJECTIVE

The objective of this study was to examine obstetric risk factors for postnatal depression in an urban and rural community sample, with concurrent consideration of personality, psychiatric history and recent life events.

METHODS

This was a prospective study with women planning to give birth in one of the four participating hospitals recruited antenatally. Obstetric information was obtained from the New South Wales Midwives Data Collection, completed shortly after delivery. Personality, psychiatric history and life-events information were obtained from a questionnaire, administered within 1 week postpartum. Depression status was assessed at 8 weeks postpartum using the Edinburgh Postnatal Depression Scale.

RESULTS

Complete data were obtained from 490 women. Several non-obstetric risk factors for the development of postnatal depression at 8 weeks postpartum were reported including: sociodemographic (up to technical college level education, rented housing, receiving a pension/benefit), personality (those who described themselves as either nervy, shy/selfconscious, obsessional, angry or a worrier), psychiatric history (familial history of mental illness, personal history of depression or anxiety or a history of depression in the participant's mother) and recent life-events (major health problem, arguments with partner and friends/relatives). None of the obstetric variables were significantly associated with increased risk for postnatal depression, but several showed marginally significant increases (multiparous women, antepartum haemorrhage, forceps and caesarean section deliveries).

CONCLUSIONS

The results emphasize the importance of psychosocial risk factors for postnatal depression and suggest that most obstetric factors during pregnancy and birth do not significantly increase risk for this depression. Early identification of potential risk for postnatal depression should include assessment of sociodemography, personality, psychiatric history and recent life events, as well as past and present obstetric factors.

Irritable bowel syndrome according to varying diagnostic criteria: are the new Rome II criteria unnecessarily restrictive for research and practice?

OBJECTIVES

It has been suggested that the variation in the prevalence of irritable bowel syndrome (IBS) may be due to the application of different diagnostic criteria. New criteria for IBS have been proposed (Rome II). It is unknown whether persons meeting different criteria for IBS have similar psychological and symptom features. The aim of this study was to measure the prevalence of IBS according to Manning and Rome definitions of IBS and to evaluate the clinical and psychological differences between diagnostic categories.

METHODS

A total of 4500 randomly selected subjects, with equal numbers of male and female subjects aged > or = 18 yr and representative of the Australian population, took part in this study. Subjects were mailed a questionnaire (response rate, 72%). Characteristics measured were gastrointestinal symptoms over the past 12 months, neuroticism and extroversion (Eysenck Personality Questionnaire), anxiety and depression (Delusions-Symptoms-States Inventory), mental and physical functioning (SF-12), and somatic distress (Sphere).

RESULTS

The prevalence for IBS according to Manning, Rome I, and Rome II was 13.6% (95% confidence interval [CI] = 3.5-5.1%), 4.4% (CI 6.0-7.8%), and 6.9% (CI 12.3-14.8%), respectively [corrected]. Only 12 persons with Rome I did not also meet Rome II criteria; 196 persons with Manning criteria did not meet Rome II cut-offs. Having IBS regardless of which criteria were used was significantly associated with psychological morbidity, but psychological factors were not important in discriminating between diagnostic categories. However, pain and bowel habit severity independently discriminated between diagnostic groups.

CONCLUSIONS

IBS is a relatively common disorder in the community. The new Rome II criteria may be unnecessarily restrictive in practice.

The impact of functional gastrointestinal disorders on quality of life

OBJECTIVE

The impact of functional gastrointestinal disorders (FGIDs) on quality of life is unknown. We aimed to evaluate whether FGIDs impair quality of life in terms of mental and physical functioning in patients and nonpatients.

METHODS

A random sample of 4500 subjects, representative of the Australian population, were mailed a questionnaire on gastrointestinal symptoms in the past 12 months. Quality of life was assessed using the valid SF-12, in which the lower the scores, the greater the impairment of quality of life. The response rate was 72%.

RESULTS

Among those fulfilling Rome I criteria for a diagnosis of a FGID (n = 1006) versus those not having a FGID (n = 1904) (healthy controls), there was a significant association with impaired mental (43.9 vs. 48.1) and physical (47.7 vs. 51.6) functioning. Mental functioning (43.3 vs. 44.9) and physical functioning (46.0 vs. 50.5) was significantly more impaired in patients versus nonpatients with a FGID. Furthermore, nonpatients with a FGID had more impaired mental and physical functioning than healthy controls.

CONCLUSION

FGIDs impair quality of life, particularly in those that consult for health care.

Evidence of a genetic contribution to functional bowel disorder

OBJECTIVE

Anecdotally, functional bowel disorders (FBD) such as the irritable bowel syndrome appears to cluster in some families, but no studies have investigated the heritability of FBD. We aimed to investigate the influence of heritable factors in FBD.

METHODS

Same sex twin pairs enrolled in the Australian Twin Registry completed a structured interview that included questions related to symptoms consistent with FBD: abdominal pain, diarrhea, constipation, excessive gas or bloating, and nausea. Reasons for the occurrence of each symptom, including their physicians' diagnoses, were recorded. Lisrel 7.16 software was used to fit genetic models following standard procedures.

RESULTS

Of the 686 individual twins from same-sex pairs, 33 (4.8%) had one or more symptoms diagnosed by a medical practitioner as functional bowel disorder. Complete data on this symptom scale was available for 186 monozygotic and 157 same sex dizygotic twin pairs. A model in which 56.9% (95% CI: 40.6-75.9%) of the variance was attributed to additive genetic variance, with the remaining 43.1% attributed to the individual's unique environment, closely fitted the data (chi2=0.01, df=4, p=1.0).

CONCLUSION

Our results suggest that a substantial proportion of the liability for FBD may be under genetic control. Whether this liability is related to the disorder itself or to other potential predisposing factors requires clarification.

Is the association between irritable bowel syndrome and abuse explained by neuroticism? A population based study

BACKGROUND

In outpatients and the community, an association between abuse (particularly sexual abuse) and irritable bowel syndrome (IBS) has been observed, but whether there is a causal link continues to be disputed.

AIMS

To test the hypothesis that psychological factors explain the apparent association between abuse and IBS.

METHODS

A sample of residents of Penrith (a Sydney suburb sociodemographically similar to the Australian population) selected randomly from the electoral rolls (that by law include the entire population of age 18 years and above) was mailed a validated self report questionnaire. Measured were gastrointestinal (GI) symptoms including the Rome criteria for IBS, abuse (including the standardised Drossman questions), neuroticism (Eysenck Personality Questionnaire), and psychological morbidity (General Health Questionnaire).

RESULTS

The response rate was 64% (n = 730); 12% fulfilled the Rome criteria for IBS. Overall abuse in childhood (odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.29 to 3.15) but not adulthood (OR = 1.39, 95% CI 0.88 to 2.19) was associated with IBS univariately. Neuroticism and psychological morbidity were also univariately associated with abuse in childhood, abuse in adulthood and IBS, respectively. However, by logistic regression, abuse in childhood was not associated with IBS after controlling for age, gender, and psychological factors (OR = 1.34, 95% CI 0.83 to 2.17). The results were not altered by restricting the analyses to more severe forms of abuse, and were not explained by interactions between abuse and psychological variables.

CONCLUSION

There is an association between abuse and IBS in the community, but this may be explained in part by other psychological factors. Based on a path analysis, we postulate that abuse may induce the expression of neuroticism that in turn leads to IBS.

Early discharge and risk for postnatal depression

OBJECTIVE

To determine whether early discharge (< 72 hours) after childbirth increased the risk for women developing postnatal depression.

DESIGN

Prospective cohort design consisting of an initial interview, and six-weekly assessments for 24 weeks using a self-report questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Women discharged within 72 hours were compared with the remaining women.

SETTING

Tertiary referral hospital in western Sydney, New South Wales, 1993.

PARTICIPANTS

All 749 women delivering over a three-month period were recruited. Of the 522 participants, 425 women completed the study.

MAIN OUTCOME MEASURES

Women scoring > 13 on the EPDS on two or more occasions were considered potential "cases" of postnatal depression. The diagnosis was confirmed using the Structured Clinical Interview for DSM-III-R disorders (SCID).

RESULTS

Of the 153 women (36%) discharged early, 22 women (14.4%) developed postnatal depression over the study period compared with 20 of the 272 women (7.4%) who had standard length of stay. Women who were discharged within 72 hours had a significantly increased risk for developing postnatal depression (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.07-4.21). This risk persisted when other sociodemographic, obstetric and psychosocial risk factors were controlled for in a logistic regression analysis (OR, 3.06; 95% CI, 1.22-7.69).

CONCLUSION

Women planning early discharge after childbirth should be carefully assessed before discharge and follow-up should be rigorous. The potential to develop postnatal depression should be considered in all women choosing early discharge from hospital.

Predictors of health care seeking for irritable bowel syndrome: a population based study

BACKGROUND

It has been suggested that psychological factors rather than symptoms drive subjects with irritable bowel syndrome (IBS) to seek medical care, but this issue has not been tackled in a population based study.

AIM

To identify whether psychological factors or abuse explain health care seeking for IBS.

METHODS

A sample of residents of Penrith (a Sydney suburb representative of the Australian population) selected randomly from the electoral rolls (that by law include the entire population > or = 18 years) was mailed a validated self-report questionnaire. Measured were gastrointestinal symptoms including the Manning (and Rome) criteria for IBS, health care seeking, neuroticism (Eysenck Personality Questionnaire), psychological morbidity (General Health Questionnaire: GHQ) and sexual, physical and emotional abuse (including the standardised Drossman questions).

RESULTS

Among 730 subjects, 96 (13%, 95% confidence interval (CI) 11-16%) had IBS by the Manning criteria. Of those with IBS, 73% (95% CI 63-81%) had sought medical care for abdominal pain or discomfort. Only increasing pain severity (odds ratio (OR) = 2.10, 95% CI 1.11-3.95) and duration of pain (OR = 1.53, 95% CI 1.10-2.13) were independently associated with seeking health care for IBS. Pain severity was also predictive of recent care seeking (OR = 1.74, 95% CI 1.12-1.96). Neuroticism, psychological morbidity and abuse history were not significant predictors.

CONCLUSION

Psychological factors do not seem to explain health care seeking among community subjects with IBS.

Cucumber mosaic virus RNA 5 is a mixed population derived from the conserved 3'-terminal regions of genomic RNAs 2 and 3

Analysis of encapsidated RNA from the Q strain of CMV (Q-CMV) has indicated the presence of a discreet population of molecules of approximately 300 nt termed RNA 5 (Peden, K.W.C., and Symons, R.H., Virology 53,487-492, 1973.). Q-CMV RNA 5 was isolated and the 5'-end sequence was determined by direct RNA sequencing. This sequence corresponded to the exact beginning of the imperfectly conserved 3'-terminal region of genomic RNAs 1, 2, and 3. A probe generated from RNA 3 consisting of the last 130 nt of this region hybridised to RNA 5. Oligonucleotides containing sequences from the 5'- and 3'-ends of the conserved region were used to generate RNA 5 cDNA clones by RT-PCR on gel-purified RNA 5. Sequencing of these clones and primer extension analysis of transcripts (derived from the cDNA clones) and purified RNA 5 indicated that RNA 5 consists of the conserved 3'-terminal region of genomic RNAs 2 and 3.

RNA 4 sequences from cucumber mosaic virus subgroups I and II

The complete sequences of RNA 4 from cucumber mosaic virus (CMV) strains Ny (subgroup I) and Sn (subgroup II) have been determined and compared to all other known complete CMV RNA 4 sequences. The identification of a unique EcoRI site, present only in subgroup-II RNA 4 sequences, provides the basis for a simple method of classifying CMV isolates.

Initial validation of a bowel symptom questionnaire and measurement of chronic gastrointestinal symptoms in Australians

BACKGROUND

Chronic gastrointestinal (GI) symptoms are believed to be common in the general population, but Australian data are lacking. A valid instrument is required to assess GI symptoms adequately and determine their prevalence in the community.

AIMS

To test the feasibility, reliability and concurrent validity of a self-report Bowel Symptom Questionnaire (BSQ) as a measure of GI symptoms, and obtain preliminary data on the prevalence of symptoms in an Australian population-based sample.

METHODS

Outpatients (n = 63), volunteers (n = 163) and a random sample (n = 99) of the Penrith population, Sydney, completed the BSQ. Feasibility was evaluated in 264 subjects. Reliability was measured by a test-retest procedure (n = 43), while concurrent validity was documented by comparing self-report data with an independent interview (n = 20). The response rate in the population mail survey was 68%. Prevalence data on bowel symptoms in the community sample (n = 99) were age and gender standardised to the Australian population.

RESULTS

The majority of subjects found the BSQ easy to complete (97%) and understand (97%); 90% completed the questionnaire in half an hour or less. Reliability (median kappa 0.70, interquartile range 0.20) and concurrent validity (median kappa 0.79, interquartile range 0.26) of GI symptoms were both very acceptable. The internal consistency of all GI symptom scales was good (Cronbach's Alpha range 0.51-0.74). The prevalence of the irritable bowel syndrome (defined as abdominal pain and disturbed defaecation based on two or more of the Manning criteria) was 17.2% (95% CI: 10-25%).

CONCLUSIONS

The BSQ was well accepted and easy to understand; it provided reliable and valid data on GI symptoms and should prove useful in large scale epidemiological studies in Australia.

A brave new world in managing depression--or is it?

In recent years new pharmacological agents have become available for the treatment of depression encouraging many to opt for the biochemical theory as the cause of depression. This article looks at the pros and cons and whether there is still a place for non pharmacological interventions in the treatment of depression.

Increased risk of postnatal depression after emergency caesarean section

OBJECTIVE

To examine whether women having an emergency caesarean section are at increased risk of developing postnatal depression at one, three and six months postpartum.

DESIGN

Participants were part of a larger study examining the relationship between personality dysfunction and postnatal depression. All women were recruited at an antenatal clinic in the first trimester of their pregnancy. These women were followed up at one, three and six months postpartum to identify cases of postnatal depression, defined by the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

Data were collected from 188 women, who were divided into three groups by method of delivery: 21 women had an emergency caesarean section, 49 had a forceps delivery and 118 had a spontaneous vaginal delivery. Comparison of the groups indicated a significant difference at three months postpartum only. Women having an emergency caesarean section had significantly higher EPDS scores than women who had forceps or spontaneous vaginal delivery (9.15 +/- 6.18 v. 5.05 +/- 3.81 v. 5.79 +/- 4.47; F(2,143) = 4.2, P less than 0.02). Analysis of postnatal depression at three months indicated that women in the emergency caesarean section group had a relative risk of 6.82 (95% confidence interval, 2.85-16.15) compared with women in the other groups.

CONCLUSIONS

When compared with women having spontaneous vaginal or forceps deliveries, women having an emergency caesarean section had more than six times the risk of developing postnatal depression three months postpartum. Special attention to this group appears warranted.

6-Sulphatoxy melatonin in melancholia

The daytime and nighttime levels of 6-sulphatoxy melatonin, a metabolite of melatonin, were measured in eight melancholic patients. Three patients did not show a marked nocturnal increase in 6-sulphatoxy melatonin excretion. The author discusses the relationship between melatonin and melancholia.