Case-finding instruments for depression. Two questions are as good as many

Utility of a brief screening tool to identify physicians in distress

BACKGROUND

Despite a high prevalence of distress, few physicians seek help. Earlier identification of physicians in distress has been hampered by the lack of a brief screening instrument to assess the common forms of distress.

OBJECTIVE

To evaluate the ability of the seven-item Physician Well-Being Index (PWBI) to i) stratify physician well-being in several important dimensions (mental quality of life [QOL], fatigue, suicidal ideation); and ii) identify physicians whose degree of distress may negatively impact their practice (career satisfaction, intent to leave current position, medical errors).

DESIGN

Cross-sectional study.

PARTICIPANTS

National sample of 6,994 U.S. physicians.

MAIN MEASURES

PWBI, Mental QOL, fatigue, suicidal ideation, career satisfaction,and clinical practice measures.

KEY RESULTS

Physicians with low mental QOL, high fatigue, or recent (< 12 months) suicidal ideation were more likely to endorse each of the seven PWBI items and a greater number of total items (all P < 0 .001). Assuming a prevalence of 19 %, the PWBI could reduce the post-test probability of a physician having low mental QOL to < 1 % or raise it to > 75 %. The likelihood ratio for low mental QOL among physicians with PWBI scores ≥ 4 was 3.85 in comparison to 0.33 for those with scores < 4. At a threshold score of >4, the PWBI's specificity for identifying physicians with low mental QOL, high fatigue, or recent suicidal ideation were 85.8 %. PWBI score also stratified physicians' career satisfaction, reported intent to leave current practice, and self-reported medical errors.

CONCLUSIONS

The seven-item PWBI appears to be a useful screening index to identify physicians with distress in a variety of dimensions and whose degree of distress may negatively impact their practice.

Diagnosis and treatment of depression following routine screening in patients with coronary heart disease or diabetes: a database cohort study

BACKGROUND

Depression is common in chronic illness and screening for depression has been widely recommended. There have been no large studies of screening for depression in routine care for patients with chronic illness.

METHOD

We performed a retrospective cohort study to examine the timing of new depression diagnosis or treatment in relation to annual screening for depression in patients with coronary heart disease (CHD) or diabetes. We examined a database derived from 1.3 million patients registered with general practices in Scotland for the year commencing 1 April 2007. Eligible patients had either CHD or diabetes, were screened for depression during the year and either received a new diagnosis of depression or commenced a new course of antidepressant (excluding those commonly used to treat diabetic neuropathy). Analysis was by the self-controlled case-series method with the outcome measure being the relative incidence (RI) in the period 1-28 days after screening compared to other times.

RESULTS

A total of 67358 patients were screened for depression and 2269 received a new diagnosis or commenced treatment. For the period after screening, the RI was 3.03 [95% confidence interval (CI) 2.44-3.78] for diagnosis and 1.78 (95% CI 1.54-2.05) for treatment. The number needed to screen was 976 (95% CI 886-1104) for a new diagnosis and 687 (95% CI 586-853) for new antidepressant treatment.

CONCLUSIONS

Systematic screening for depression in patients with chronic disease in primary care results in a significant but small increase in new diagnosis and treatment in the following 4 weeks.

A pilot study to investigate adherence to long-acting opioids among patients with advanced lung cancer

BACKGROUND

Uncontrolled pain remains prevalent in patients with advanced cancer and has been associated with worse quality of life and greater health care utilization. Poor adherence to analgesics may represent a modifiable barrier to pain management.

OBJECTIVE

This pilot study aimed to establish feasibility/utility of evaluating self-reported adherence to long-acting (LA) opioids in patients with advanced lung cancer, and to explore rates and correlates of adherence.

METHODS

Consecutive patients attending an ambulatory thoracic oncology clinic with a diagnosis of advanced lung cancer and a current LA opioid regimen were approached to complete a brief questionnaire during their clinic visit. Participants reported LA opioid adherence during the past 4 weeks (0%-100%) and knowledge of their LA opioid regimen, and completed the Patient Health Questionnaire-2 (PHQ-2) depression screen. Demographic and clinical information were confirmed via electronic health record review.

RESULTS

Fifty-four eligible patients were approached to reach our target sample (n=50; enrollment=92.6%). Self-reported adherence to LA opioids was 85.4% (standard deviation [SD]=21.0). Twenty-eight percent reported a frequency of medication use that did not match the prescribed daily frequency. Lower adherence was associated with inaccurate frequency (p=0.004), positive depression screen (p=0.005), and older age (p=0.04).

CONCLUSIONS

Our results demonstrate the feasibility of integrating self-report assessments of LA opioid adherence into a thoracic oncology clinic. Patients reported high adherence, but more than one-quarter did not accurately report the prescribed frequency of daily doses. Understanding of LA opioid regimens may be a critical indicator of adherence in patients with advanced cancer.

Design of the DISCovery project: tailored work-oriented interventions to improve employee health, well-being, and performance-related outcomes in hospital care

Background

It is well-known that health care workers in today’s general hospitals have to deal with high levels of job demands, which could have negative effects on their health, well-being, and job performance. A way to reduce job-related stress reactions and to optimize positive work-related outcomes is to raise the level of specific job resources and opportunities to recover from work. However, the question remains how to translate the optimization of the balance between job demands, job resources, and recovery opportunities into effective workplace interventions. The aim of the DISCovery project is to develop and implement tailored work-oriented interventions to improve health, well-being, and performance of health care personnel.

Methods/Design

A quasi-experimental field study with a non-equivalent control group pretest-posttest design will be conducted in a top general hospital. Four existing organizational departments will provide both an intervention and a comparison group. Two types of research methods are used: (1) a longitudinal web-based survey study, and (2) a longitudinal daily diary study. After base-line measures of both methods, existing and yet to be developed interventions will be implemented within the experimental groups. Follow-up measurements will be taken one and two years after the base-line measures to analyze short-term and long-term effects of the interventions. Additionally, a process evaluation and a cost-effectiveness analysis will be carried out.

Discussion

The DISCovery project fulfills a strong need for theory-driven and scientifically well-performed research on job stress and performance interventions. It will provide insight into (1) how a balance between job demands, job resources, and recovery from work can be optimized, (2) the short-term and long-term effects of tailored work-oriented effects, and (3) indicators for successful or unsuccessful implementation of interventions.

Treatment of depression in individuals living with HIV/AIDS

BACKGROUND

Depression is common in patients with HIV/AIDS, and can have an impact on quality of life, as well as various health outcomes. This study was designed to observe the efficacy of standard treatment of depression in human immunodeficiency virus (HIV) (+) individuals in an urban psychiatric clinic.

METHODS

This study consisted of a retrospective chart review of patients presenting for psychiatric services between January 1, 2008 and December 31, 2010. A total of 211 charts were examined for factors including diagnosis given at initial visit, health status, sociodemographic factors and comorbid illnesses, as well as treatment plan prescribed; of these, 132 patients were determined to be depressed at the initial evaluation (Beck Depression Inventory (BDI> 13) and to return for at least one follow-up visit.

RESULTS

Of the 132 depressed patients, 48 (36.4%) reached remission (BDI <13) at some point at follow-up, and an additional 12 (50.7%) achieved response (decrease in BDI of 50%). Remission correlated with having disability income and having a viral load that was not detectable.

CONCLUSIONS

Depression is common in HIV/AIDS, and is important to treat. Furthermore, individuals with depression and HIV/AIDS respond at rates similar to what is seen in other depressed populations.

Maternal low- and high-depressive symptoms and safety concerns for low-income preschool children

OBJECTIVES

Our objective was to examine the relationship between low- and high-level depressive symptoms in mothers' and children's risks in the areas of home and car safety, monitoring, and exposure to violence.

METHODS

Participants included 978 mothers of preschool-age children who were interviewed about their home environment and screened for maternal depression.

RESULTS

Whereas only 5.7% scored at high depressive levels on the screen, another 21.3% scored at low depressive levels. Logistic regression analyses controlling for demographics revealed that children were significantly more likely to experience home safety risks in 6 of 7 areas when mothers reported either low or high levels of depressive symptoms.

CONCLUSIONS

Results suggest that children whose mothers experience even low-level depressive symptoms are at increased risk for safety problems in the home environment, pointing to the need for screening and interventions to reduce the risk of injury.

Psychotropic medications, including short acting benzodiazepines, strongly increase the frequency of falls in elderly

OBJECTIVES

Falls in the elderly are common and often serious. The aim of this study was to examine the association between the use of different classes of psychotropic medications, especially short acting benzodiazepines, and the frequency of falling in elderly. Study design This retrospective cohort study was performed with patients who visited the day clinic of the department of geriatric medicine of the University Medical Center Utrecht in the Netherlands between 1 January 2011 and 1 April 2012. Measurements Frequencies of falling in the past year and medication use were recorded. Logistic regression analysis was performed to assess the relationship between the frequency of falling in the past year and the use of psychotropic medications.

RESULTS

During this period 404 patients were included and 238 (58.9%) of them had experienced one or more falls in the past year. After multivariate adjustment, frequent falls remained significantly associated with exposure to psychotropic medications (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.17-3.28), antipsychotics (OR 3.62; 95% CI 1.27-10.33), hypnotics and anxiolytics (OR 1.81; 95% CI 1.05-3.11), short-acting benzodiazepines or Z-drugs (OR 1.94; 95% CI 1.10-3.42) and antidepressants (OR 2.35; 95% CI 1.33-4.16).

CONCLUSIONS

This study confirms that taking psychotropic medication, including short-acting benzodiazepines, strongly increases the frequency of falls in elderly. This relation should be explicitly recognized by doctors prescribing for older people, and by older people themselves. If possible such medication should be avoided for elderly patients especially with other risk factors for falling.

Association of intern and resident burnout with self-reported medical errors

Background

Burnout is a common problem for interns and residents. It may be related to medical error, but little is known about this relationship. The purpose of this study was to determine the association between burnout and perceived medical errors among interns and residents.

Methods

The study group consisted of interns and residents working in a university hospital in Busan. Data were provided by 86 (58.5%) of 147 interns and residents. They completed a questionnaire including self-assessment of medical errors, a linear analog self-assessment of overall quality of life (QOL), fatigue, the Epworth Sleepiness Scale (ESS) score, the Maslach Burnout Inventory, and a validated depression screening tool.

Results

According to univariate logistic regression analyses, there was an association between perceived medical errors and fatigue (odds ratio [OR], 1.37 per unit increase; 95% confidence interval [CI], 1.12 to 1.69; P < 0.003) and ESS scores (OR, 1.13 per unit increase; 95% CI, 1.03 to 1.23; P < 0.009). Perceived medical errors were also associated with burnout (ORs per 1-unit change; emotional exhaustion OR, 1.07; 95% CI, 1.02 to 1.13; P < 0.005; depersonalization OR, 1.11; 95% CI, 1.02 to 1.21; P < 0.013), a negative depression screen (OR, 0.29; 95% CI, 0.11 to 0.76; P < 0.013), and overall QOL (OR, 0.80; 95% CI, 0.70 to 0.98; P < 0.033). In multivariate logistic regression analyses, an association was identified between perceived medical errors and emotional exhaustion (OR, 1.06; 95% CI, 1.00 to 1.11; P < 0.046) when adjusted for ESS, and depersonalization (OR, 1.01; 95% CI, 1.01 to 1.19; P < 0.04) when adjusted for fatigue.

Conclusion

Higher levels of burnout among interns and residents were associated with perceived medical errors.

An exploration of violence, mental health and substance abuse in post-conflict Guatemala

Guatemala's 36-year civil war officially ended in December 1996 after some 200,000 deaths and one million refugees. Despite the ceasefire, Guatemala continues to be a violent country with one of the highest homicide rates in the world. We investigated potential associations between violence, mental health, and substance abuse in post-conflict Guatemala using a community-based survey of 86 respondents living in urban and rural Guatemala. Overall, 17.4% of our respondents had at least one, direct violent experience during the civil war. In the post-conflict period, 90.7% of respondents reported being afraid that they might be hurt by violence, 40.7% screened positive for depression, 50.0% screened positive for PTSD, and 23.3% screened positive for alcohol dependence. Potential associations between prior violent experiences during the war and indicators of PTSD and aspects of alcohol dependence were found in regression-adjusted models (p < 0.05). Certain associations between prior civil war experiences, aspects of PTSD and alcohol dependence in this cohort are remarkable, raising concerns for the health and safety of the largely indigenous populations we studied. Higher than expected rates of depression, PTSD, and substance abuse in our cohort may be related to the ongoing violence, injury and fear that have persisted since the end of the civil war. These, in turn, have implications for the growing medical and surgical resources needed to address the continuing traumatic and post-traumatic complications in the post-conflict era. Limitations of the current study are discussed. These findings are useful in beginning to understand the downstream effects of the Guatemalan civil war, although a much larger, randomly sampled survey is now needed.

Description of a psychosocial assessment instrument and risk criteria to support social work recommendations for kidney transplant candidates

Developing uniform criteria and a risk assessment clinical intervention plan to identify, assess, and assign psychosocial risk levels may help guide transplant social workers' interventions and justify their listing recommendation. This article describes a kidney pre-transplant psychosocial assessment instrument that is supported by psychosocial risk criteria and a risk assessment clinical intervention plan.

The New York PTSD risk score for assessment of psychological trauma: male and female versions

We previously developed a new posttraumatic stress disorder (PTSD) screening instrument-the New York PTSD Risk Score (NYPRS). Since research suggests different PTSD risk factors and outcomes for men and women, in the current study we assessed the suitability of male and female versions of this screening instrument among 3298 adults exposed to traumatic events. Using diagnostic test methods, including receiver operating characteristic (ROC) curve and bootstrap techniques, we examined different prediction domains, including core PTSD symptoms, trauma exposures, sleep disturbances, depression symptoms, and other measures to assess PTSD prediction models for men and women. While the original NYPRS worked well in predicting PTSD, significant interaction was detected by gender, suggesting that separate models are warranted for men and women. Model comparisons suggested that while the overall results appeared robust, prediction results differed by gender. For example, for women, core PTSD symptoms contributed more to the prediction score than for men. For men, depression symptoms, sleep disturbance, and trauma exposure contributed more to the prediction score. Men also had higher cut-off scores for PTSD compared to women. There were other gender-specific differences as well. The NYPRS is a screener that appears to be effective in predicting PTSD status among at-risk populations. However, consistent with other medical research, this instrument appears to require male and female versions to be the most effective.

The impact of common mental disorders on work ability in mentally and physically demanding construction work

PURPOSE

To gain insight into (1) the prevalence and incidence of common mental disorders (CMD) and low work ability among bricklayers and construction supervisors; (2) the impact of CMD on current work ability and work ability 1 year later and (3) the added value of job-specific questions about work ability for detecting signs of low work ability.

METHODS

We randomly selected 750 bricklayers and 750 supervisors. This sample was surveyed by means of a baseline questionnaire and a follow-up questionnaire 1 year later. Work ability was measured with the first three questions of the Work Ability Index and job-specific questions. Self-reported CMD were measured with instruments designed to detect a high need for recovery after work, distress and depression. We used univariate logistic regression to analyse the presence or absence of CMD as independent variable.

RESULTS

The prevalence and incidence of CMD among 199 bricklayers and 224 supervisors was 22 %/10 % and 32 %/15 %, respectively. The prevalence of low general work ability was comparable for both occupations (5 %). CMD were associated with low current work ability and low work ability at follow-up (ORs 4.3-22.4), but not with a reduction in work ability 1 year later. Questions on job-specific work ability resulted in more indications of low work ability among both occupations than did questions on general work ability.

CONCLUSIONS

Regardless of occupation, workers who report CMD at baseline have a high likelihood of current low work ability and low work ability 1 year later.

Maternal obesity is the new challenge; a qualitative study of health professionals' views towards suitable care for pregnant women with a Body Mass Index (BMI) ≥ 30 kg/m²

BACKGROUND

An increase in the number of women with maternal obesity (Body Mass Index [BMI] ≥30 kg/m2) has had a huge impact on the delivery of maternity services. As part of a programme of feasibility work to design an antenatal lifestyle programme for women with a BMI ≥30 kg/m2, the current study explored health professionals' experiences of caring for women with a BMI ≥30 kg/m2 and their views of the proposed lifestyle programme.

METHOD

Semi-structured interviews with 30 health professionals (including midwives, sonographers, anaesthetists and obstetricians) were conducted and analysed using thematic analysis. Recruitment occurred in two areas in the North West of England in early 2011.

RESULTS

Three themes were evident. Firstly, obesity was seen as a conversation stopper; obesity can be a challenge to discuss. Secondly, obesity was seen as a maternity issue; obesity has a direct impact on maternity care and therefore intervention is needed. Finally, the long-term impact of maternal obesity intervention; lifestyle advice in pregnancy has the potential to break the cyclic obesity relationship. The health professionals believed that antenatal lifestyle advice can play a key role in addressing the public health issue of obesity as pregnancy is a time of increased motivation for women with a BMI ≥30 kg/m2.

CONCLUSIONS

Maternal obesity is a challenge and details of the training content required for health professionals to feel confident to approach the issue of maternal obesity with women are presented. Support for the antenatal lifestyle programme for women with a BMI ≥30 kg/m2 highlights the need for further exploration of the impact of interventions on health promotion.

Asthma medication adherence: the role of God and other health locus of control factors

BACKGROUND

Medication adherence is an important determinant of disease outcomes, yet medication use on average tends to be low among patients with chronic conditions, including asthma. Although several predictors of non-adherence have been assessed, more research is needed on patients' beliefs about God and how these relate to medication use.

OBJECTIVE

To examine the relationship between perceptions about "God's" role in health and other locus of control factors with inhaled corticosteroid (ICS) adherence among asthma patients.

METHODS

Participants were from a clinical trial to improve ICS adherence and were 5-56 years old, had a diagnosis of asthma, and were receiving ICS medication. Baseline adherence was estimated from electronic prescription and pharmacy fill records. Patients were considered to be adherent if ICS use was ≥80% of prescribed. A baseline survey with the Multidimensional Health Locus of Control scale was used to assess five sources (God, doctors, other people, chance, and internal).

RESULTS

Medication adherence was low (36%). Patients' who had a stronger belief that God determined asthma control were less likely to be adherent (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.70-0.96). This relationship was stronger among African American (OR 0.68, 95% CI0.47-0.99) compared to white patients (OR 0.89, 95% CI 0.75-1.04), and among adults (OR 0.81, 95% CI 0.69-0.96) compared to children (OR 0.84, 95% CI 0.58-1.22).

CONCLUSION

Patients' belief in God's control of health appears to be a factor in asthma controller use, and therefore should be considered in physician-patient discussions concerning course of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00459368.

A feasibility study of a telephone-supported self-care intervention for depression among adults with a comorbid chronic physical illness in primary care

Objective We assessed the feasibility and acceptability to patients of a telephone-supported self-care intervention for depression among adults aged 40 years or over with one of six targeted chronic physical illnesses and comorbid depressive symptoms in family practice settings. Methods An open, uncontrolled trial (feasibility study) was conducted among patients treated in Montreal family practices. Eligible patients were aged 40 years or over, had one or more of the targeted chronic physical illnesses for at least 6 months (arthritis, hypertension, diabetes, heart disease, asthma and chronic obstructive pulmonary disease) and were evaluated as having at least mild depressive symptoms (a score of ≥ 5 on the 9-item Patient Health Questionnaire, PHQ-9). Participants received a package of six self-care tools (information booklet, video, Internet programme, action plan, workbook and mood-monitoring tool) with telephone support by a lay coach for up to 6 months. Results In total, 63 eligible patients provided written consent and completed the baseline interview; 57 (90%) and 55 (87%) patients completed 2-month and 6-month follow-up interviews, respectively. The mean number of telephone calls made by coaches to participants was 10.5 (SD 4.0), and the average length of these calls was 10.6 minutes. At the 6-month follow-up, 83.6% of the participants reported that one or more of the tools were helpful. Clinically significant improvements were seen in depressive symptoms (as assessed by the PHQ-9) at 6 months, with an effect size of 0.88 (95% CI, 0.55, 1.14). Conclusion A telephone-supported self-care intervention for depression was feasible, was acceptable to patients, and was associated with a significant 6-month improvement in depressive symptoms. A randomised trial of this intervention is justified.

Validation of the Whooley questions and the Beck Depression Inventory in older adults

OBJECTIVE

To analyse the psychometric properties of the Whooley questions and the 21-item Beck Depression Inventory (BDI-21) in older adults with depression and chronic health problems.

DESIGN

A population-based study.

SETTING

Community.

SUBJECTS

474 adults, aged 72-73 years, living in the city of Oulu, Finland.

MAIN OUTCOME MEASURES

The screening parameters of the Whooley questions and the BDI-21 for detecting major depression.

RESULTS

The prevalence of major depression according to the DSM-IV was 5.3% (single or recurrent episode) obtained by the Mini Neuropsychiatric Interview (MINI). The BDI-21 was best able to identify a current episode of major depression with a cut-off point of 11. The sensitivity and specificity of this cut-off point were 88.0% (95% confidence interval (95% CI) 68.8-97.5) and 81.7% (95% CI 77.8-85.2), respectively. The area under the receiver operating characteristics (ROC) curve was 0.89 (95% CI 0.83-0.96). The two Whooley screening questions had a sensitivity of 62.5% (95% CI 40.6-81.2) and either screening question plus the help question had a sensitivity of 66.7% (44.7-84.4).

CONCLUSIONS

The Beck Depression Inventory is a valid instrument for the diagnosis of depression in older adults. As a screening measure, the optimal cut-off score should be 11 or higher. Our results indicate that the sensitivity of the Whooley questions is not high enough to be used as a screening scale among the elderly.

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part I: Risk Factors, Screening, Suicide Risk Diagnosis and Assessment in Patients with a Depression Diagnosis]

INTRODUCTION

Depression is an important cause of morbidity and disability in the world; however, it is under-diagnosed at all care levels.

OBJECTIVE

The purpose here is to present recommendations based on the evidence gathered to answer a series of clinical questions concerning risk factors, screening, suicide risk diagnosis and evaluation in patients undergoing a depressive episode and recurrent depressive disorder. Emphasis has been made upon the approach used at the primary care level so as to grant adult diagnosed patients the health care guidelines based on the best and more updated evidence available thus achieving minimum quality standards.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from guides NICE90 and CANMAT were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 1-22 corresponding to screening, suicide risk and depression diagnosis were presented. The corresponding degree of recommendation is included.

Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents

OBJECTIVE

To evaluate the effect of resident physicians' distress on their personal safety.

PARTICIPANTS AND METHODS

We conducted a prospective, longitudinal cohort study of internal medicine residents at Mayo Clinic in Rochester, Minnesota. Participants completed surveys quarterly from July 1, 2007, through July 31, 2011, during their training period. Frequency of self-reported blood and body fluid (BBF) exposures and motor vehicle incidents was recorded. Associations of validated measures of quality of life, burnout, symptoms of depression, fatigue, and sleepiness with a subsequently reported BBF exposure or motor vehicle incident were determined using generalized estimating equations for repeated measures.

RESULTS

Data were provided by 340 of 384 eligible residents (88.5%). Of the 301 participants providing BBF exposure data, 23 (7.6%) reported having at least 1 BBF exposure during the study period. Motor vehicle incidents were reported by 168 of 300 respondents (56.0%), including 34 (11.3%) reporting a motor vehicle crash and 130 (43.3%) reporting a near-miss motor vehicle crash. Other than the low personal accomplishment domain of burnout, distress and fatigue at one time point exhibited no statistically significant associations with BBF exposure in the subsequent 3 months. However, diminished quality of life, burnout, positive screening for depression, fatigue, and sleepiness were each associated with statistically significantly increased odds of reporting a motor vehicle incident in the subsequent 3 months.

CONCLUSION

Exposures to BBF are relatively uncommon among internal medicine residents in current training environments. Motor vehicle incidents, however, remain common. Our results confirm the importance of fatigue and sleepiness to resident safety concerns. In addition, higher levels of distress may be contributory factors to motor vehicle crashes and other related incidents. Interventions designed to address both fatigue and distress may be needed to optimally promote patient and resident safety.

Clinical usefulness of the two-question assessment tool for depressive symptoms in Japanese patients with chronic obstructive pulmonary disease

PURPOSE

Depressive symptoms are highly prevalent in patients with chronic obstructive pulmonary disease (COPD) and have been associated with poor outcomes. Developing a concise questionnaire to measure depressive symptoms in COPD patients is needed in outpatient settings. We evaluated the clinical usefulness of a concise two-question instrument to assess depressive symptoms in patients with COPD.

METHODS

The study was conducted as a cross-sectional analysis in patients with COPD. All patients completed a self-reported questionnaire consisting of the two-question instrument, as well as a shortened version of the Center for Epidemiologic Studies Depression Scale (CESD-10) to measure depressive symptoms. Performance of the two-question instrument was evaluated using the results for CESD-10 as standard. We also measured patients' health-related quality of life using the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) to determine whether the instrument was related to SF-8.

RESULTS

Sensitivity of the two-question instrument in the detection of depressive symptoms was 73.3 % (95 % confidence interval [CI] 51-95.7), specificity was 73 % (95 % CI 58.7-87.3), and area under the receiver operating characteristics curve was 0.73 (95 % CI 0.59-0.87). When study patients were divided into two groups with a cutoff of 1 point on the two-question instrument, scores for all subscales of the SF-8 except "bodily pain" were significantly lower in patients with than without depressive symptoms.

CONCLUSIONS

This concise two-question instrument is useful as assessment of depressive symptom in patients with COPD in busy outpatient settings.

Prevalence and associated risk factors for postpartum depression in women attending a tertiary hospital, Delhi, India

BACKGROUND

Maternal mental health is a largely ignored issue in the Indian population. Considering the high prevalence of postpartum depression, mental health assessment and screening of high-risk cases should be a part of routine antenatal care.

AIM

To study the prevalence of women at risk for peripartum depression using Edinburgh Postnatal Depression Scale (EPDS) score in a tertiary teaching hospital in New Delhi, and to study the associated risk factors in the Indian population.

METHOD

Five hundred and six (506) peripartum women were interviewed using a structured questionnaire, which included sociodemographic details like socioeconomic status, family structure, relationship with husband and mother-in-law, past obstetric history and gender of children, any history of previous psychiatric illness and outcome of current pregnancy in terms of mode of delivery, gender of newborn and neonatal complications. EPDS scoring was done using a Hindi translated version. Data were analysed using Epi Info version 3.32.

RESULTS

Thirty one (6%) out of 506 women scored ≥ 10 on the EPDS. Birth of female child, nuclear family structure and poor marital relationship were found to have a statistically significant correlation with peripartum depression.

CONCLUSION

The 6% prevalence of women at risk of peripartum depression in our study, which is similar to other such studies, is significant and hence maternal mental health assessment should be made a part of routine antenatal and postnatal care.

Self-perception of glycemic control among Japanese type 2 diabetic patients: accuracy of patient perception and characteristics of patients with misperception

Aims

Some diabetic patients, despite reporting a good perception of their glycemic control, actually show poor control and this misperception might well hinder successful diabetes management. This study aimed to assess patients' self‐perception of glycemic control and to clarify factors associated with misperception of glycemic control status.

Methods

Baseline data from a hospital‐based prospective cohort of 519 type 2 diabetic patients were analyzed. Self‐perception of glycemic control and other items, including sociodemographic factors and blood test data, were determined from a self‐administered questionnaire and medical records. Factors associated with misperception were examined by age group (elderly [aged ≥ 65 years] vs non‐elderly [aged < 65 years]) using multiple logistic regression analysis.

Results

Among poorly controlled patients, misperception was higher in the elderly (glycated hemoglobin [HbA_1c] 7.4–8.3, 55.1%; HbA_1c >8.4, 44.8%) than in the non‐elderly (HbA_1c 7.4–8.3, 20.0%; HbA_1c >8.4, 18.9%). The factors significantly associated with misperception were as follows: high lifestyle regimen adherence in both age groups (non‐elderly group odds ratio [OR] 5.23; elderly group OR 5.15, respectively); high family support (OR = 7.32), failure to achieve blood pressure control (OR = 6.94) and having diabetic complications (OR = 0.06) among the non‐elderly; and long duration of diabetes (OR = 4.06) among the elderly.

Conclusions

For better management of diabetes, physicians should pay attention to the patient characteristics associated with misperception among uncontrolled diabetic patients, particularly among those who are elderly.

Computer use and stress, sleep disturbances, and symptoms of depression among young adults--a prospective cohort study

BACKGROUND

We have previously studied prospective associations between computer use and mental health symptoms in a selected young adult population. The purpose of this study was to investigate if high computer use is a prospective risk factor for developing mental health symptoms in a population-based sample of young adults.

METHODS

The study group was a cohort of young adults (n = 4163), 20-24 years old, who responded to a questionnaire at baseline and 1-year follow-up. Exposure variables included time spent on computer use (CU) in general, email/chat use, computer gaming, CU without breaks, and CU at night causing lost sleep. Mental health outcomes included perceived stress, sleep disturbances, symptoms of depression, and reduced performance due to stress, depressed mood, or tiredness. Prevalence ratios (PRs) were calculated for prospective associations between exposure variables at baseline and mental health outcomes (new cases) at 1-year follow-up for the men and women separately.

RESULTS

Both high and medium computer use compared to low computer use at baseline were associated with sleep disturbances in the men at follow-up. High email/chat use was negatively associated with perceived stress, but positively associated with reported sleep disturbances for the men. For the women, high email/chat use was (positively) associated with several mental health outcomes, while medium computer gaming was associated with symptoms of depression, and CU without breaks with most mental health outcomes. CU causing lost sleep was associated with mental health outcomes for both men and women.

CONCLUSIONS

Time spent on general computer use was prospectively associated with sleep disturbances and reduced performance for the men. For the women, using the computer without breaks was a risk factor for several mental health outcomes. Some associations were enhanced in interaction with mobile phone use. Using the computer at night and consequently losing sleep was associated with most mental health outcomes for both men and women. Further studies should focus on mechanisms relating information and communication technology (ICT) use to sleep disturbances.

Depression in multiple sclerosis: a review of assessment and treatment approaches in adult and pediatric populations

Multiple sclerosis is a chronic demyelinating disease affecting one million people worldwide, with a significant burden of psychiatric comorbidity. Depression is the commonest psychiatric manifestation but still remains largely underdiagnosed and undertreated. The present work reviews current knowledge on diagnosis, assessment, and somatic and psychotherapeutic treatment interventions for depression in adult and pediatric populations of patients with multiple sclerosis.

Prevalence of DSM-IV major depression among U.S. military personnel: meta-analysis and simulation

A meta-analysis of 25 epidemiological studies estimated the prevalence of recent Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) major depression (MD) among U.S. military personnel. Best estimates of recent prevalence (standard error) were 12.0% (1.2) among currently deployed, 13.1% (1.8) among previously deployed, and 5.7% (1.2) among never deployed. Consistent correlates of prevalence were being female, enlisted, young (ages 17-25), unmarried, and having less than a college education. Simulation of data from a national general population survey was used to estimate expected lifetime prevalence of MD among respondents with the sociodemographic profile and none of the enlistment exclusions of Army personnel. In this Simulated sample, 16.2% (3.1) of respondents had lifetime MD and 69.7% (8.5) of first onsets occurred before expected age of enlistment. Numerous methodological problems limit the results of the meta-analysis and simulation. The article closes with a discussion of recommendations for correcting these problems in future surveillance and operational stress studies.

Identifying social risk via a clinical social history embedded in the electronic health record

Although the link between social determinants and health outcomes is well established, the social history remains poorly integrated into clinical care processes. This study's purpose was to determine social risk documentation rates among newborns using a new electronic template. A retrospective review of 639 well-infant visits was performed. The authors determined documentation rates for a standardized social history embedded in the clinic electronic health record. Social history completion rates and prevalence of risks were identified. More than 80% of clinicians documented asking at least 1 of 7 questions (mean = 4.5, SD = 2.9). The most commonly asked question was about "making ends meet," and the least common was about personal safety (79% vs 57%, P < .01). Nearly 30% of caregivers reported at least 1 risk, 11% at least 2 risks. An electronic health record-embedded social history led to documented screening in more than 80% of visits, identifying 30% as having at least 1 social risk.

Meta-analysis of screening and case finding tools for depression in cancer: evidence based recommendations for clinical practice on behalf of the Depression in Cancer Care consensus group

BACKGROUND

To examine the validity of screening and case-finding tools used in the identification of depression as defined by an ICD10/DSM-IV criterion standard.

METHODS

We identified 63 studies involving 19 tools (in 33 publications) designed to help clinicians identify depression in cancer settings. We used a standardized rating system. We excluded 11 tools without at least two independent studies, leaving 8 tools for comparison.

RESULTS

Across all cancer stages there were 56 diagnostic validity studies (n=10,009). For case-finding, one stem question, two stem questions and the BDI-II all had level 2 evidence (2a, 2b and 2c respectively) and given their better acceptability we gave the stem questions a grade B recommendation. For screening, two stem questions had level 1b evidence (with high acceptability) and the BDI-II had level 2c evidence. For every 100 people screened in advanced cancer, the two questions would accurately detect 18 cases, while missing only 1 and correctly reassure 74 with 7 falsely identified. For every 100 people screened in non-palliative settings the BDI-II would accurately detect 17 cases, missing 2 and correctly re-assure 70, with 11 falsely identified as cases. The main cautions are the reliance on DSM-IV definitions of major depression, the large number of small studies and the paucity of data for many tools in specific settings.

CONCLUSIONS

Although no single tool could be offered unqualified support, several tools are likely to improve upon unassisted clinical recognition. In clinical practice, all tools should form part of an integrated approach involving further follow-up, clinical assessment and evidence based therapy.

Standard operational procedures for low sexual desire in men

INTRODUCTION

Low sexual desire in men is a condition that has received little attention; nevertheless it occurs with high frequency. Clinicians are in need of clear guidelines to address this problem.

AIM

To develop standardized operational procedures to be implemented with men presenting low sexual desire/interest (LSD/I).

METHODS

Review of relevant evidence-based literature and published guidelines, integrated with expert opinion.

MAIN OUTCOME

Operational procedures for LSD/I that are recommended for clinical practice with various degrees of support from published evidence.

RESULTS

A new classification scheme is proposed; LSD/I is proposed as an umbrella term for which hypoactive sexual desire disorder (HSDD) is only a subtype. The following standard operational procedures are described: (i) Detection of LSD/I: screening for LSD/I, screening for LSD/I in patients with other sexual dysfunctions; (ii) Diagnosis and assessment of etiology: diagnostic criteria for LSD/I, assessment of depression status, assessment of relationship status, assessment of endocrinologic status, diagnostic criteria for HSDD in men; (iii)

TREATMENT

treatment of LSD/I secondary to low testosterone, treatment of LSD/I secondary to elevated prolactin, treatment of LSD/I secondary to other endocrinologic disorders, treatment of LSD/I secondary to depressive illness and or anxiety disorders, treatment of LSD/I secondary to relationship conflict and treatment of HSDD. A diagnostic and treatment algorithm is presented.

CONCLUSIONS

LSD/I is a common condition that should be identified in patients; it is recommended that this condition be actively investigated by the clinician. Once the diagnosis of LSD/I in men is confirmed, a thorough search for possible causes needs to include both biological and psychological causes. TREATMENT should be etiologically oriented.

[Depression in Patients with Age-Related Macular Degeneration]

Age-related macular degeneration is a cause for disability in the elderly since it greatly affects their quality of life and increases depression likelihood. This article discusses the negative effect depression has on patients with age-related macular degeneration and summarizes the interventions available for decreasing their depression index.

Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: a systematic review and meta-analysis

To date, few systematic reviews of observational studies have been conducted to comprehensively evaluate the co-morbidity of intimate partner violence (IPV) and specific depression outcomes in women. In this systematic review and meta-analysis, we summarize the extant literature and estimate the magnitude of the association between IPV and key depressive outcomes (elevated depressive symptoms, diagnosed major depressive disorder and postpartum depression). PubMed (January 1, 1980-December 31, 2010) searches of English-language observational studies were conducted. Most of the selected 37 studies had cross-sectional population-based designs, focused on elevated depressive symptoms and were conducted in the United States. Most studies suggested moderate or strong positive associations between IPV and depression. Our meta-analysis suggested two to three-fold increased risk of major depressive disorder and 1.5-2-fold increased risk of elevated depressive symptoms and postpartum depression among women exposed to intimate partner violence relative to non-exposed women. A sizable proportion (9%-28%) of major depressive disorder, elevated depressive symptoms, and postpartum depression can be attributed to lifetime exposure to IPV. In an effort to reduce the burden of depression, continued research is recommended for evaluating IPV preventive strategies.

Study protocol for the Fukushima Health Management Survey

BACKGROUND

The accidents that occurred at the Fukushima Daiichi Nuclear Power Plant after the Great East Japan Earthquake on 11 March 2011 have resulted in long-term, ongoing anxiety among the residents of Fukushima, Japan. Soon after the disaster, Fukushima Prefecture launched the Fukushima Health Management Survey to investigate long-term low-dose radiation exposure caused by the accident. Fukushima Medical University took the lead in planning and implementing this survey. The primary purposes of this survey are to monitor the long-term health of residents, promote their future well-being, and confirm whether long-term low-dose radiation exposure has health effects. This report describes the rationale and implementation of the Fukushima Health Management Survey.

METHODS

This cohort study enrolled all people living in Fukushima Prefecture after the earthquake and comprises a basic survey and 4 detailed surveys. The basic survey is to estimate levels of external radiation exposure among all 2.05 million residents. It should be noted that internal radiation levels were estimated by Fukushima Prefecture using whole-body counters. The detailed surveys comprise a thyroid ultrasound examination for all Fukushima children aged 18 years or younger, a comprehensive health check for all residents from the evacuation zones, an assessment of mental health and lifestyles of all residents from the evacuation zones, and recording of all pregnancies and births among all women in the prefecture who were pregnant on 11 March. All data have been entered into a database and will be used to support the residents and analyze the health effects of radiation.

CONCLUSIONS

The low response rate (<30%) to the basic survey complicates the estimation of health effects. There have been no cases of malignancy to date among 38 114 children who received thyroid ultrasound examinations. The importance of mental health care was revealed by the mental health and lifestyle survey and the pregnancy and birth survey. This long-term large-scale epidemiologic study is expected to provide valuable data in the investigation of the health effects of low-dose radiation and disaster-related stress.

Primary care evaluation of mental disorders (PRIME-MD) screening for minor depressive disorder in primary care

OBJECTIVE

Individuals visiting a primary care practice were screened to determine the prevalence of depressive disorders. The DSM-IV-TR research criteria for minor depressive disorder were used to standardize a definition for subthreshold symptoms.

METHOD

Outpatients waiting to see their physicians at 3 community family medicine sites were invited to complete a demographic survey and the Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD PQ). Those who screened positive for depression on the PRIME-MD PQ were administered both the PRIME-MD Clinician Evaluation Guide (CEG) mood module and the Hamilton Depression Rating Scale (HDRS) by telephone. Data were collected over a 2-year period (1996-1998).

RESULTS

1,752 individuals completed the PRIME-MD PQ with 478 (27.3%) scoring positive for depression. Of these 478 patients, 321 received telephone follow-up using the PRIME-MD CEG mood module and the HDRS. PRIME-MD diagnoses were major depressive disorder (n = 85, 26.5%), dysthymia (n = 31, 9.6%), minor depressive disorder (n = 51, 15.9%), and no depression diagnosis (n = 154, 48.0%). The mean HDRS scores by diagnosis were major depressive disorder (20.3), dysthymia (12.9), minor depressive disorder (11.7), and no depression diagnosis (5.8). Post hoc analyses using Dunnett's C test indicated differences between each of the 4 groups at P ≤ .05, with the exception that dysthymia and minor depressive disorder were not significantly different.

CONCLUSIONS

Minor depressive disorder was more prevalent than dysthymia and had similar symptom severity to dysthymia as measured by the HDRS. More research using standardized definitions and longitudinal studies is needed to clarify the natural course and treatment indications for minor depressive disorder.

Prevalence of depressive symptoms and associated factors in elderly primary care patients: a descriptive study

BACKGROUND

Depressive symptoms are common in older adults. A majority will be seen in primary care. The aim was to study the prevalence of and to explore factors associated with depressive symptoms in elderly primary care patients.

METHOD

In consecutive patients aged 60 years and older attending a Swedish primary care center between February and December of 2003, depressive symptoms were identified as ≥ 13 points on the Montgomery-Asberg Depression Rating Scale-Self-Rated version (MADRS-S). Somatic symptoms measured according to PRIME-MD, age, socioeconomic status, gender, somatic diagnoses, and medication were analyzed in relation to presence of depressive symptoms.

RESULTS

Forty-six of 302 patients (15%) rated themselves in the depressed range. There were no differences between depressed and nondepressed patients concerning socioeconomic status, other illnesses, or medication except for use of sedatives/hypnotics being more common (OR = 2.7, 95% CI = 1.3 to 5.6) in depressed patients. Patients in the group scoring ≥ 13 on the MADRS-S were more likely to have become widowed during the last year (OR = 6.0, 95% CI = 1.7 to 20.8) or to have indicated significant life events (OR = 4.3, 95% CI = 2.0 to 9.0), but were less likely to report having leisure time activities (OR = 0.2, 95% CI = 0.08 to 0.41) or perception of good health (OR = 0.1, 95% CI = 0.05 to 0.3). Patients being treated for depression did not have increased depression scores (OR = 1.4, 95% CI = 0.66 to 3.1).

CONCLUSION

In a group of unselected primary care elderly patients, the prevalence of depressive symptoms was high. Use of sedatives/hypnotics was remarkably common in patients with depressive symptoms. Patients with ongoing treatment of depression did not have increased depression scores, indicating the good prognosis for treated depression in the elderly.

Association of depression and antidepressant use with mortality in a large cohort of patients with nondialysis-dependent CKD

BACKGROUND AND OBJECTIVES

Depression is common and is associated with higher mortality in patients with ESRD or CKD (stage 5). Less information is available on earlier stages of CKD. This study aimed to determine the prevalence of depression and any association with all-cause mortality in patients with varying severity of nondialysis-dependent CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This is a retrospective study of a national cohort of 598,153 US veterans with nondialysis-dependent CKD stages 1-5 followed for a median of 4.7 years in the US Department of Veterans Affairs Health System. Diagnosis of depression was established as a result of systematic screening and administration of antidepressants. Association of depression with all-cause mortality overall and stratified by CKD stages were examined with the Kaplan-Meier method and in Cox models.

RESULTS

There were 179,441 patients (30%) with a diagnosis of depression. Over median follow-up of 4.7 years, depression was associated with significantly higher age-adjusted mortality overall (hazard ratio, 1.55; 95% confidence interval, 1.54-1.57; P<0.001). Sequential adjustments for sociodemographic characteristics and especially for comorbid conditions attenuated this association, which nevertheless remained significant (hazard ratio, 1.25; 95% confidence interval, 1.23-1.26).

CONCLUSIONS

In this large cohort of predominantly elderly male patients with CKD, prevalence of depression and antidepressant use is high (30%) and is associated with significantly higher all-cause mortality independent of comorbid conditions.

The importance of full-time work for urban adults' mental and physical health

Unemployment and underemployment have adverse mental and physical health consequences, such as increased stress and depression. Health damaging behaviors like unhealthy eating, smoking, and alcohol use may be used to cope, contributing to chronic disease risk. In this adverse economic climate, it is vital to understand the health implications of unemployment and underemployment as well as underlying mechanisms. A randomized household survey of adults in six low resource communities was conducted in New Haven, Connecticut in 2009, yielding a sample of 1205 (73% participation) racially diverse adults (61% Black, 20% Latino, 12% White) ages 18-65 (61% women). We used ANOVA to test group differences and structural equation modeling to test mediation. 14.5% were unemployed and looking for work, 18.4% worked part-time, 38.2% worked full-time. Those employed full-time reported the least damaging psychological factors and health behaviors: lowest levels of stress and depression, most healthy and least unhealthy eating, most physical activity, and lowest levels of smoking and drinking. Those employed part-time fell in the middle, and those unemployed fell on the unhealthy end of all psychological and behavioral factors. Stress significantly mediated the associations of full-time employment with frequency of unhealthy eating and physical activity, and amount of cigarette smoking and alcohol consumption. Depression significantly mediated the association of full-time employment with frequency of healthy eating. Compared to <10% nationwide, rates of unemployment in this sample were high. Both those unemployed and employed part-time reported adverse health behaviors as compared to those employed full-time, partially mediated by heightened stress and depression. It is vital for the health and well-being of the nation to increase not simply employment, but specifically full-time employment. Provision of mental health services to those unemployed and underemployed should be a priority to promote healthier lifestyles and prevent costly future chronic disease.

The association of maternal mental health with prenatal smoking cessation and postpartum relapse in a population-based sample

To examine the association between mental health factors with smoking cessation during pregnancy and postpartum relapse. We used data from 1,416 women who participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey in 2004-2006 and reported smoking immediately prior to pregnancy. Maternal mood during pregnancy, stressful life events and postpartum depression were the mental health variables. We used multivariate logistic regression to examine the association between these variables and two outcomes, smoking cessation during pregnancy and postpartum relapse. Stressful life events was associated with smoking cessation in multivariate regression models, however maternal mood was not. Smoking cessation was also associated with pre-conception smoking intensity, maternal education, and income. Maternal mood, stressful life events and postpartum depression were not associated with relapse in multivariate regression models. Breastfeeding at the time of the survey was the strongest correlate of relapse, with women who breast fed 60% less likely to resume smoking during the postpartum. Post-hoc analysis suggests that mental health variables may interact with other mitigating factors to influence smoking behavior during pregnancy. Mental health variables may be important to successful prenatal smoking cessation. Further research with larger sample sizes is needed to explore the possibility of interactive relationships between mental health variables and other co-factors on prenatal smoking cessation and postpartum relapse.

The inconsistent mediating effects of psychosocial work characteristics on the education-health relationship

This study examined the relationship between psychosocial work characteristics and educational disparities in health. Informed by the evidence on the relationship between work pressure and higher education, we suggested reframing the distribution of psychosocial work characteristics in the context of education. We differentiated psychosocial work resources from demands and hypothesized that the inconsistent mediation effects of psychosocial resources and demands are associated with educational status. Using data from the 2008 National Study of Changing Workforce (NSCW), we found that psychosocial work resources and demands had inconsistent mediating effects on the education-health relationship. Higher educated employees were more likely to report autonomy, challenge and schedule control, but they were also more likely to experience overtime hours, job overload and work-family conflict. Work resources appeared to protect higher-educated workers from stress and health problems while work demands put them at risk of less favorable health outcomes. In addition we found that the 'costs' of psychosocial work demands were stronger among women, particularly those who were highly educated, suggesting that highly educated women did not reap the full health benefit of high educational attainment. Our findings illustrate that the observed positive associations between education and health mask important heterogeneity in the effects of psychosocial work characteristics. We discuss the implications of this study for health and family-based work policies.

Utility of self-reported sleep disturbances as a marker for major depressive disorder (MDD): findings from the World Mental Health Japan Survey 2002-2006

Although major depressive disorder (MDD) is a serious common disease, many depressive patients seek primary care with complaints of sleep disturbances that remain undiagnosed. The purpose of this study was to investigate the utility of self-reported sleep disturbances as a marker for MDD. This study investigated the association between 12-month prevalence of self-reported sleep disturbances and MDD using data from a cross-sectional survey in Japan. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the area under the receiver operating characteristic curve (AUC) of self-reported sleep disturbances as a marker for MDD were 58.9%, 73.4%, 6.9%, 98.1%, and 0.66, respectively. Self-reported sleep disturbances showed highest utility for the youngest group. Among four types of sleep disturbances, the problem of daytime sleepiness was most useful as a marker for MDD. Combined with at least moderate role impairment, self-reported sleep disturbances became more informative with higher specificity (99.6%) and PPV (80.0%) as a marker for MDD. Self-reported sleep disturbances cannot be a marker for MDD in isolation. Comorbid role impairment increases the probability of MDD. Clinicians should be cautious in assessments of young people who have sleep disturbances. Daytime sleepiness should be included among the questions asked when inquiring about sleep disturbances.

Recognizing and treating peripartum depression

BACKGROUND

In this article, we review current data on the prevalence of, risk factors for, and treatment of peripartum depression.

METHOD

Pertinent publications were retrieved by searches in Medline and the Cochrane Library using the key words "peri/pre/post", "partum/partal/natal", "maternal/motherhood/pregnancy", and "depression/affective disorder".

RESULTS

Depression is the most common peripartal disease: The prevalence of depressive disorders is 18.4% during pregnancy and 19.2% in the puerperium. Prepartum depression is associated with preterm birth, low birth weight, and an abnormal fetal heart rate. In the long run, children of depressed mothers have been found to have impaired cognitive and emotional abilities. Risk factors for peripartal depression include prior depression, poor social support, poor quality of intimate relationship, and negative live events. Peripartum depression can be treated effectively with psychotherapy or drug therapy. Current data support the use of antidepressants during pregnancy and breastfeeding. In many places, pregnancy counseling centers offer low-threshold psychosocial assistance. Nonetheless, no more than 20% of the affected women are identified, even though rapid screening would be possible with instruments such as the Edinburgh Postnatal Depression Scale (EPDS) and the two Whooley questions.

CONCLUSION

Peripartum depression is both common and treatable. Screening for depression should become a routine part of both prepartum care by gynecologists and postpartum care by midwives. This will only be possible, however, with expanded availability of ambulatory and inpatient psychotherapy and psychiatric care for the affected women and their children.

Analysis of decisions made in meta-analyses of depression screening and the risk of confirmation bias: a case study

BACKGROUND

Depression is common in primary care and clinicians are encouraged to screen their patients. Meta-analyses have evaluated the effectiveness of screening, but two author groups consistently reached completely opposite conclusions.

METHODS

We identified five systematic reviews on depression screening conducted between 2001 and 2009, three by Gilbody and colleagues and two by the United States Preventive Task Force. The two author groups consistently reached completely opposite conclusions. We analyzed two contemporaneous systematic reviews, applying a stepwise approach to unravel their methods. Decision points were identified, and discrepancies between systematic reviews authors' justification of choices made were recorded.

RESULTS

Two systematic reviews each addressing three research questions included 26 randomized controlled trials with different combinations in each review. For the outcome depression screening resulting in treatment, both reviews undertook meta-analyses of imperfectly overlapping studies. Two in particular, pooled each by only one of the reviews, influenced the recommendations in opposite directions. Justification for inclusion or exclusion of studies was obtuse.

CONCLUSION

Systematic reviews may be less objective than assumed. Based on this analysis of two meta-analyses we hypothesise that strongly held prior beliefs (confirmation bias) may have influenced inclusion and exclusion criteria of studies, and their interpretation. Authors should be required to declare a priori any strongly held prior beliefs within their hypotheses, before embarking on systematic reviews.

How patients understand depression associated with chronic physical disease--a systematic review

BACKGROUND

Clinicians are encouraged to screen people with chronic physical illness for depression. Screening alone may not improve outcomes, especially if the process is incompatible with patient beliefs. The aim of this research is to understand people's beliefs about depression, particularly in the presence of chronic physical disease.

METHODS

A mixed method systematic review involving a thematic analysis of qualitative studies and quantitative studies of beliefs held by people with current depressive symptoms. MEDLINE, EMBASE, PSYCHINFO, CINAHL, BIOSIS, Web of Science, The Cochrane Library, UKCRN portfolio, National Research Register Archive, Clinicaltrials.gov and OpenSIGLE were searched from database inception to 31st December 2010. A narrative synthesis of qualitative and quantitative data, based initially upon illness representations and extended to include other themes not compatible with that framework.

RESULTS

A range of clinically relevant beliefs was identified from 65 studies including the difficulty in labeling depression, complex causal factors instead of the biological model, the roles of different treatments and negative views about the consequences of depression. We found other important themes less related to ideas about illness: the existence of a self-sustaining 'depression spiral'; depression as an existential state; the ambiguous status of suicidal thinking; and the role of stigma and blame in depression.

CONCLUSIONS

Approaches to detection of depression in physical illness need to be receptive to the range of beliefs held by patients. Patient beliefs have implications for engagement with depression screening.