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

Assessing depression in patients with chronic pain: a comparison of three rating scales

BACKGROUND

Considerable evidence has suggested depression is significantly more prevalent in patients with chronic pain. A number of studies exclusively based on Western samples have evaluated the effectiveness of depression rating scales in assessing depression in the chronic pain context. The objective of this cross-sectional study was to compare within a Chinese chronic pain sample three depression rating scales commonly used in identifying depression.

METHODS

A total of 366 Chinese patients with chronic pain attending either an orthopedic specialist clinic (n=185) or a multidisciplinary pain clinic (n=181) in Hong Kong completed a structured interview using CIS-R and two depression rating scales, the Beck Depression Inventory (BDI standard and short form) and the Center for Epidemiological Studies-Depression (CES-D). Patient scores on the BDI and CES-D were then assessed against their responses on the CIS-R to determine their effectiveness.

RESULTS

The prevalence of depression was 20.2% and 57.8% in the Orthopedics and Pain Clinic sample respectively. Results of ROC analyses showed that all the three measures performed well at predicting depression with AUC ≥ 0.89 and high sensitivity and specificity.

CONCLUSIONS

Our findings suggest that the three depression measures assessed have good predictive validity in the Chinese chronic pain context, and they could be used as screening or diagnostic measures of depression in Chinese chronic pain patients. The decision of using a specific measure and a specific cutoff score should be based on study aim and setting.

[Subjective relaxing effect of a hospital's rooftop forest on elderly patients requiring care]

OBJECTIVES

To clarify the relaxing effects of a 5-min stay in a hospital's rooftop forest on elderly patients requiring care.

METHODS

This was a within-subject, cross-sectional study. The participants were 30 elderly female patients requiring help in walking, aged 81.2±6.4 (mean±SD). A simplified emotional 7-point rating scale from -3 to 3 for 5 pairs of emotions, which was derived from the two-question Whooley Depression Screen, was used as a subjective indicator. The experimental areas were the rooftop forest that covered an area of 122 m(2) on the rooftop of a four-story health service facility and an outdoor car park area (as the control area). The participants were instructed to sit still in a wheelchair and view the scenery for 5 min in each experimental area and were then assessed. Data from the participants during exposure to the rooftop forest were compared with those during exposure to the control area. First, 15 participants moved to the rooftop forest from the preroom, and the other 15 moved to the outdoor car park area, and then they moved to the other site to eliminate any order effect.

RESULTS

In the rooftop forest, the mean scores of the simplified emotional rating were 1.70 (1.17 for control) for "hopeful", 1.70 (1.17) for "interest in doing things", 1.53 (1.10) for "enjoyment", 1.67 (1.17) for "calm", and 2.03 (1.30) for "secure". The scores were all significantly higher than those in the control (p<0.01).

CONCLUSION

It was demonstrated that a visit to the rooftop forest induced a significant subjective relaxing effect in elderly female patients requiring care.

Accuracy and prognostic value of American Heart Association: recommended depression screening in patients with coronary heart disease: data from the Heart and Soul Study

BACKGROUND- In 2008, the American Heart Association (AHA) recommended a 2-step screening method, consisting of the 2-item Patient Health Questionnaire (PHQ-2) followed by the 9-item Patient Health Questionnaire (PHQ-9), for identifying depression in cardiovascular patients. The accuracy and prognostic value of this screening method have not been evaluated. METHODS AND RESULTS- We administered the 2-step AHA-recommended screening algorithm to 1024 patients with stable coronary heart disease and calculated sensitivity and specificity against a gold standard interview for major depressive disorder. Subsequent cardiovascular events (myocardial infarction, stroke, transient ischemic attack, heart failure, or death) were determined during a mean of 6.27 ± 2.11 years of follow-up. The AHA-recommended screening method had high specificity (0.91; 95% confidence interval, 0.89 to 0.93) but low sensitivity (0.52; 95% confidence interval, 0.46 to 0.59) for a diagnosis of major depressive disorder. Participants who screened positive on the AHA depression protocol had a 55% greater risk of events than those who screened negative (age-adjusted hazard ratio, 1.55; 95% confidence interval, 1.21 to 1.97; P=0.0005). After adjustment for age, sex, body mass index, history of myocardial infarction, hypertension, diabetes, heart failure, and high-density lipoprotein levels, screening positive remained associated with a 41% greater rate of cardiovascular events (hazard ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P=0.008). CONCLUSIONS- Among outpatients with stable coronary heart disease, the AHA-recommended depression screening protocol is highly specific for depression and identifies patients at risk for adverse cardiovascular outcomes.

A national survey of GP and nurse attitudes and beliefs towards depression after myocardial infarction

AIM

To investigate primary care practitioner's attitudes to depression after myocardial infarction.

BACKGROUND

Depression after myocardial infarction affects almost half of all patients and has a considerable negative effect on recovery. Despite the increased prevalence of depression in this population, it is often not recognised or treated.

DESIGN

Survey.

METHOD

A total of 813 (106 general practitioners and 707 nurses) practitioners responded. Our questionnaire developed for this project by the authors in collaboration with a group of ten cardiovascular nurse specialists contained 27 items that were summated into five subscales.

RESULTS

Primary care practitioners underestimated the prevalence of depression in the post-myocardial infarction population. General acknowledgement of the negative impact that depression can have was reported by the majority of participants. Diagnosing depression was perceived as complex by both groups but significantly more so by nurses. General practitioners were significantly more positive about their understanding of the signs and symptoms of depression and in using depression-screening tools. We observed that training seems to have a significant effect on reported practice. Practitioners who reported that they had recent training in the management of depression were significantly more accurate in their estimate of how common depression was in this population.

CONCLUSION

Depression may be underdiagnosed in this population because primary care practitioners, especially nurses, are not aware of how common the disorder is and lack competence in diagnosis. There is merit in developing and testing a brief training intervention to ensure competence in depression screening and treatment in post-myocardial infarction patients.

RELEVANCE TO CLINICAL PRACTICE

Diagnosing depression in post-myocardial infarction patients is perceived by nurses as complex but training in the management of depression is seen as helping practice.

Usefulness of a single-item measure of depression to predict mortality: the GAZEL prospective cohort study

BACKGROUND

It remains unknown whether short measures of depression perform as well as long measures in predicting adverse outcomes such as mortality. The present study aims to examine the predictive value of a single-item measure of depression for mortality.

METHODS

A total of 14,185 participants of the GAZEL cohort completed the 20-item Center-for-Epidemiologic-Studies-Depression (CES-D) scale in 1996. One of these items (I felt depressed) was used as a single-item measure of depression. All-cause mortality data were available until 30 September 2009, a mean follow-up period of 12.7 years with a total of 650 deaths.

RESULTS

In Cox regression model adjusted for baseline socio-demographic characteristics, a one-unit increase in the single-item score (range 0-3) was associated with a 25% higher risk of all-cause mortality (95% CI: 13-37%, P<0.001). Further adjustment for health-related behaviours and physical chronic diseases reduced this risk by 36% and 8%, respectively. After adjustment for all these variables, every one-unit increase in the single-item score predicted a 15% increased risk of death (95% CI: 5-27%, P<0.01). There is also an evidence of a dose-reponse relationship between reponse scores on the single-item measure of depression and mortality.

CONCLUSION

This study shows that a single-item measure of depression is associated with an increased risk of death. Given its simplicity and ease of administration, a very simple single-item measure of depression might be useful for identifying middle-aged adults at risk for elevated depressive symptoms in large epidemiological studies and clinical settings.

Project HEAL: peer education leads to weight loss in Harlem

BACKGROUND

Obesity and diabetes are epidemic in the predominantly minority Harlem community. To address them, a coalition of community and academic leaders tested the effectiveness of a peer-led weight loss course.

METHODS

The coalition developed Project HEAL: Healthy Eating, Active Lifestyles through extensive collaboration with community members and experts in nutrition, exercise, and peer education. We piloted the course in a local church and assessed its impact through pre and post course weights, self-reported behaviors and quality of life.

RESULTS

Twenty-six overweight and obese African American adults lost a mean of 4.4 pounds at 10 weeks, 8.4 pounds at 22 weeks, and 9.8 pounds at 1 year. Participants reported decreased fat consumption and sedentary hours, and improved health related quality of life.

CONCLUSIONS

A peer-led, community-based course can lead to weight loss and behavior change. The minority communities most affected by obesity and diabetes may benefit from this low-cost, culturally appropriate intervention.

Depression screening for patients with epilepsy in a primary care setting using the Patient Health Questionnaire-2 and the Neurological Disorders Depression Inventory for Epilepsy

Depression among people with a diagnosis of epilepsy is under-recognized. General practitioner (GP) screening for depression using a new scale developed specifically for patients with epilepsy, the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), has not before been reported. The aims were to examine the process of GP screening for depression in patients with epilepsy employing the widely used Patient Health Questionnaire-2 (PHQ-2) and the NDDI-E; to determine the impact of screening on GP-recognized depression; and to ascertain depression predictors. Patients were screened via their GPs. A subset of participants underwent clinical interview to assess screener accuracy. Use of either instrument almost doubled the proportion of GP-recognized depression. Ninety-four percent of those interviewed found screening acceptable. More recent and frequent seizures predicted screening positive. The results suggest that screening for depression in patients with epilepsy via GPs improves detection of depression and is acceptable to interviewed patients.

Identifying depressed older adults in primary care: a secondary analysis of a multisite randomized controlled trial

OBJECTIVE

To determine whether a subset of depressive symptoms could be identified to facilitate diagnosis of depression in older adults in primary care.

METHOD

Secondary analysis was conducted on 898 participants aged 60 years or older with major depressive disorder and/or dysthymic disorder (according to DSM-IV criteria) who participated in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study, a multisite, randomized trial of collaborative care for depression (recruitment from July 1999 to August 2001). Linear regression was used to identify a core subset of depressive symptoms associated with decreased social, physical, and mental functioning. The sensitivity and specificity, adjusting for selection bias, were evaluated for these symptoms. The sensitivity and specificity of a second subset of 4 depressive symptoms previously validated in a midlife sample was also evaluated.

RESULTS

Psychomotor changes, fatigue, and suicidal ideation were associated with decreased functioning and served as the core set of symptoms. Adjusting for selection bias, the sensitivity of these 3 symptoms was 0.012 and specificity 0.994. The sensitivity of the 4 symptoms previously validated in a midlife sample was 0.019 and specificity was 0.997.

CONCLUSION

We identified 3 depression symptoms that were highly specific for major depressive disorder in older adults. However, these symptoms and a previously identified subset were too insensitive for accurate diagnosis. Therefore, we recommend a full assessment of DSM-IV depression criteria for accurate diagnosis.

Watering flowers in the rain: The elusive nature of executive dysfunction in HIV

Individuals infected with human immunodeficiency virus (HIV) frequently experience both neurocognitive and psychiatric dysfunction. Apathy is a prominent neuropsychiatric symptom associated with HIV and is related to neurologic dysfunction. In contrast, depression is independent of neurocognitive impairment in HIV. This case report illustrates the importance of behavioral observations from family members of HIV-positive (HIV+) individuals as a valuable source of information. These behavioral observations can be particularly important in rural resource-limited settings, where cognitive testing is often limited to standardized mental status examinations.

Feasibility study of short-term effects of chiropractic manipulation on older adults with impaired balance

OBJECTIVE

The purpose of this study was to collect preliminary information on the effects of chiropractic spinal manipulation on reducing risk of falls in older adults with impaired balance, as assessed by the Berg Balance Scale (BBS). This information is necessary to develop a line of investigation into the role of chiropractic care on reduction of fall risk in this population.

METHODS

Randomized, 2-group pretest/posttest design feasibility study with a target sample size of 10 (5 per group), conducted within the outpatient health center of a chiropractic college. Inclusion criteria were as follows: aged 60 years or older, able to stand on one leg <5 seconds, and able to attend all sessions. Patients were assigned to chiropractic care (CMT) or supervised exercise (EX) and scheduled for 2 visits per week for 8 weeks.

RESULTS

A total of 26 people responded to recruitment; and 11 were enrolled: 6 in the CMT and 5 in the EX group. Two patients dropped out at the baseline visit when they were assigned to the EX group. One CMT patient dropped out in the seventh week because of a fall at home resulting in a leg fracture. All remaining patients were compliant with treatment protocols. Five of 6 CMT patients and 4 of 5 EX patients had baseline BBS scores <45, indicating increased risk of falls. At visit 16, 2 CMT and 1 of the 3 remaining EX patients had BBS scores <45. One mild and transient adverse event was noted.

CONCLUSION

Further investigation of the possible role of chiropractic care in reducing fall risk in this population appears feasible.

Screening for depression with a brief questionnaire in a primary care setting: validation of the two questions with help question (Malay version)

OBJECTIVE

To determine the diagnostic accuracy of the two questions with help question (TQWHQ) in the Malay language. The two questions are case-finding questions on depression, and a question on whether help is needed was added to increase the specificity of the two questions.

METHOD

This cross sectional validation study was conducted in a government funded primary care clinic in Malaysia. The participants included 146 consecutive women patients receiving no psychotropic drugs and who were Malay speakers. The main outcome measures were sensitivity, specificity, and likelihood ratios of the two questions and help question.

RESULTS

The two questions showed a sensitivity of 99% (95% confidence interval 88% to 99.9%) and a specificity of 70% (62% to 78%), respectively. The likelihood ratio for a positive test was 3.3 (2.5 to 4.5) and the likelihood ratio for a negative test was 0.01 (0.00 to 0.57). The addition of the help question to the two questions increased the specificity to 95% (89% to 98%).

CONCLUSION

The two qeustions on depression detected most cases of depression in this study. The questions have the advantage of brevity. The addition of the help question increased the specificity of the two questions. Based on these findings, the TQWHQ can be strongly recommended for detection of depression in government primary care clnics in Malaysia. Translation did not apear to affect the validity of the TQWHQ.

Efficacy of a brief screening tool to identify medical students in distress

PURPOSE

To determine whether the Medical Student Well-Being Index (MSWBI) can serve as a brief assessment tool to identify medical students in severe psychological distress.

METHOD

The authors used data from 2,248 medical students at seven U.S. medical schools who responded to a 2007 survey to explore the accuracy of the MSWBI in identifying medical students with three outcomes: low mental quality of life (QOL; defined by having a Medical Outcomes Study Short-Form Health Survey mental component summary score ≥1/2 standard deviation below that of the age- and gender-matched population norm), suicidal ideation, or serious thoughts of dropping out. The authors confirmed their analyses using data from a separate sample of 2,682 students evaluated in 2009.

RESULTS

Students with low mental QOL, suicidal ideation, or serious thoughts of dropping out were more likely to endorse each individual MSWBI item and a greater number of total items than were students without such distress (all P < .001). The likelihood ratio for low mental QOL among students with MSWBI scores <4 was 0.47 as compared with 4.79 for those with scores ≥4. At an MSWBI threshold score of ≥4, the MSWBI's sensitivity and specificity for identifying students with low mental QOL or recent suicidal ideation/serious thoughts of dropping out were both ≥90%. On multivariable logistic regression, all MSWBI items were independently associated with at least one outcome.

CONCLUSIONS

The MSWBI is a useful brief screening tool to help identify students with severe distress.

Depressive symptoms predict long-term mortality after liver transplantation

OBJECTIVE

Depressive symptoms are common after liver transplantation (LT). We studied whether depressive symptoms affect long-term survival after LT.

METHODS

In a prospective cohort study, 134 liver transplant patients were assessed for depressive symptoms using the Beck Depression Inventory-short form (BDI), focusing on the 3 months post-LT score and on the score change from the waiting list period. They were followed up for long-term survival. The median duration of the follow-up period was 43 months post-LT. None of the 134 patients was lost to follow-up for survival.

RESULTS

A total of 33.6% of the LT patients had mild to moderate depressive symptoms 3 months post-LT. Eighteen (13.4%) patients died during the follow-up. Using Cox proportional hazards analysis, depressive symptoms were significantly associated with mortality (hazard ratio [HR] 1.22, 95% confidence interval (CI) 1.07-1.40, P<.003), one more point in the BDI score being associated with a 17% increase in mortality risk. Other predictive factors of mortality were older age and hepatitis C virus with recurrence 3 months post-LT. Similarly, an increase in depressive symptoms between the waiting list and 3 months post-LT periods predicted mortality (HR 1.18, 95% CI 1.01-1.38, P=.03), especially for patients without depressive symptoms on waiting list (HR 1.56, 95% CI 1.16-2.12, P=.004).

CONCLUSION

Depressive symptoms after LT and an increase in depressive symptoms between the waiting list and post-LT are associated with an increased risk of long-term mortality. Interventions that could reduce depressive symptoms could potentially decrease long-term mortality after LT.

Integrating treatment for mental and physical disorders and substance misuse in Indigenous primary care settings

OBJECTIVE

Australian Indigenous peoples in remote and rural settings continue to have limited access to treatment for mental illness. Comorbid disorders complicate presentations in primary care where Indigenous youths and perinatal women are at particular risk. Despite this high comorbidity there are few examples of successful models of integrated treatment. This paper outlines these challenges and provides recommendations for practice that derive from recent developments in the Northern Territory.

CONCLUSIONS

There is a strong need to develop evidence for the effectiveness of integrated and culturally informed individual and service level interventions. We describe the Best practice in Early intervention Assessment and Treatment of depression and substance misuse study which seeks to address this need.

Quick and easy self-rating of Generalized Anxiety Disorder: validity of the Dutch web-based GAD-7, GAD-2 and GAD-SI

Screening of Generalized Anxiety Disorder (GAD), which is often undetected and untreated, could be improved by quick and easy web-based data collection. This paper aims to validate the web-based self-rated 7-item GAD-7, its shortened 2-item GAD-2 and a single item from the GAD-7 scale (GAD-SI) to screen for GAD. Of a total of 502 subjects aged 18-80 who rated the web-based GAD-7, Center for Epidemiological Studies Depression scale (CES-D) and Hospital Anxiety and Depression Scale (HADS), 157 (31%) subjects had a WHO Composite International Diagnostic Interview for DSM-IV-disorders by telephone. The GAD-7 had good reliability. Subjects with a GAD-diagnosis had significantly higher means on GAD-2, GAD-SI and GAD-7 than subjects without a GAD-diagnosis. The AUC (Area Under the Curve) of the GAD-SI and GAD-2 was accurate and not significantly different to the GAD-7 AUC. The web-based GAD-SI, GAD-2 and GAD-7 are reliable, valid tools to quickly screen for GAD in busy mental health settings and clinical research. More research is needed to validate the GAD-SI 'Do you have trouble relaxing' to see if its screening properties approach those of the GAD-7.

Expert opinion on detecting and treating depression in palliative care: A Delphi study

BACKGROUND

There is a dearth of data regarding the optimal method of detecting and treating depression in palliative care. This study applied the Delphi method to evaluate expert opinion on choice of screening tool, choice of antidepressant and choice of psychological therapy. The aim was to inform the development of best practice recommendations for the European Palliative Care Research Collaborative clinical practice guideline on managing depression in palliative care.

METHODS

18 members of an international, multi-professional expert group completed a structured questionnaire in two rounds, rating their agreement with proposed items on a scale from 0-10 and annotating with additional comments. The median and range were calculated to give a statistical average of the experts' ratings.

RESULTS

There was contention regarding the benefits of screening, with 'routine informal asking' (median 8.5 (0-10)) rated more highly than formal screening tools such as the Hospital Anxiety and Depression Scale (median 7.0 (1-10). Mirtazapine (median 9 (7-10) and citalopram (median 9 (5-10) were the considered the best choice of antidepressant and cognitive behavioural therapy (median 9.0 (3-10) the best choice of psychological therapy.

CONCLUSIONS

The range of expert ratings was broad, indicating discordance in the views of experts. Direct comparative data from randomised controlled trials are needed to strengthen the evidence-base and achieve clarity on how best to detect and treat depression in this setting.

Factor structure and concurrent/convergent validity of the modified somatic perception questionnaire and pain beliefs instrument

OBJECTIVE

Our goal was to create a parsimonious combination of the Modified Somatic Perception Questionnaire (MSPQ) and the Pain Beliefs Screening Instrument (PBSI) through factorial structural analysis and to investigate the associations of the new scale (if unique) to disability, health condition, and quality of life report in patients with neck and low back pain scheduled for spine fusion surgery.

METHODS

Factor analysis was used to refine all items within the 2 scales to 4 distinct factors: (1) somatic complaints of the head/neck, (2) somatic complaints of the gastrointestinal symptom, (3) pain beliefs and fear, and (4) self perception of serious problems. Each factor was assessed for concurrent validity with other well-established tools including the Deyo comorbidity index, the Short Form (SF)-36 mental and physical component subscales, and the Oswestry and Neck Disability Indices (ODI/NDI).

RESULTS

The PBSI was fairly to moderately correlated with assessment tools of quality of life (SF-36) and disability assessment (ODI/NDI). Some of the items in the factor 1 from the MSPQ were slightly associated with the Deyo comorbidity index but not with the ODI/NDI.

CONCLUSIONS

The items from the MSPQ failed to associate with measures of quality of life and disability and thus may provide only marginal value when assessing the multidimensional aspects associated with neck and low back pain. The PBSI has moderate correlation with disability assessments. Neither tool was found to strongly correlate with disability measures or with SF-36 scales (mental and physical component subscales). Additional tools may be needed to further identify the dimensions associated with chronic pain patients.

Disseminating a smoking cessation intervention to childhood and young adult cancer survivors: baseline characteristics and study design of the partnership for health-2 study

BACKGROUND

Partnership for Health-2 (PFH-2) is a web-based version of Partnership for Health, an evidence-based smoking cessation intervention for childhood cancer survivors. This paper describes the PFH-2 intervention and baseline data collection.

METHODS

374 childhood and young adult cancer survivors were recruited from five cancer centers and participated in the baseline assessment. At baseline, participants completed measures of their smoking behavior, self-efficacy and stage of change for quitting smoking as well as psychological and environmental factors that could impact their smoking behavior.

RESULTS

At baseline, 93% of survivors smoked in the past seven days; however, 89% smoked a pack or less during this period. Forty-seven percent were nicotine dependent, and 55% had made at least one quit attempt in the previous year. Twenty-two percent of survivors were in contemplation for quitting smoking; of those 45% were somewhat or very confident that they could quit within six months. Sixty-three percent were in preparation for quitting smoking; however, they had relatively low levels of confidence that they could quit smoking in the next month. In multivariate analyses, stage of change, self-efficacy, social support for smoking cessation, smoking policy at work and home, fear of cancer recurrence, perceived vulnerability, depression, BMI, and contact with the healthcare system were associated with survivors' smoking behavior.

DISCUSSIONS/CONCLUSIONS

A large proportion of the sample was nicotine dependent, yet motivated to quit. Individual- interpersonal- and environmental-level factors were associated with survivors' smoking behavior. Smoking is particularly dangerous for childhood and young adult cancer survivors. This population may benefit from a smoking cessation intervention designed to build self-efficacy and address other known predictors of smoking behavior.

Predictors of response to physical therapy intervention in patients with primary hip osteoarthritis

BACKGROUND

Few studies have investigated or identified common clinical tests and measures as being associated with progression of hip osteoarthritis (OA); fewer still are longitudinal studies exploring prognostic variables associated with long-term outcome following physical therapy treatment.

OBJECTIVE

The purpose of this study was to determine a set of prognostic factors that maximize the accuracy of identifying patients with hip osteoarthritis (OA) likely to demonstrate a favorable response to physical therapy intervention.

DESIGN

This was a prognostic study.

METHODS

Ninety-one patients with a clinical diagnosis of hip OA were analyzed to determine which clinical measures, when clustered together, were most predictive of a favorable response to physical therapy intervention. Responders were determined based on OMERACT-OARSI response criteria, which included percent and absolute changes in pain, function, and global rating of change over 1 year. These data served as the reference standard for determining the predictive validity of baseline clinical examination variables. Using multivariate regression analyses and calculations for sensitivity, specificity, and positive and negative likelihood ratios, a cluster was identified.

RESULTS

Five baseline variables (unilateral hip pain, age of ≤58 years, pain of ≥6/10 on a numeric pain rating scale, 40-m self-paced walk test time of ≤25.9 seconds, and duration of symptoms of ≤1 year) were retained in the final model. Failure to exhibit a condition of 1 of the 5 predictor variables decreased the posttest probability of responding favorably to physical therapy intervention from 32% to <1% (negative likelihood ratio=0.00, 95% confidence interval=0.00-0.70). Having at least 2 out of 5 predictor variables at baseline increased the posttest probability of success with physical therapy intervention from 32% to 65% (positive likelihood ratio=3.99, 95% confidence interval=2.66-4.48), and having 3 or more of 5 predictor variables increased the posttest probability of success to 99% or higher. A comparison with a control group that did not receive physical therapy further substantiated the cluster.

LIMITATIONS

The small sample size and the number of variables entered into the logistic regression model may have resulted in spurious findings. This study must be validated in replication studies before it can be considered for use in clinical practice.

CONCLUSIONS

This study completed the first step in the development of a preliminary cluster of baseline variables that identify patients with hip OA as positive responders to physical therapy intervention.

Using patient-centred consultation when screening for depression in elderly patients: a comparative pilot study

OBJECTIVE

Using validated screening instruments to detect depressive symptoms in the elderly has been recommended. The aim of this study was to compare a patient-centred consultation model with the PRIME-MD screening questionnaire, using the MADRS-S as reference for detecting depressive symptoms in an elderly primary care population.

DESIGN

Comparative study.

SETTING

Primary care, Sweden.

SUBJECTS

During an 11-month period 302 consecutive patients aged 60 and over attending a primary care centre were screened with the PRIME-MD and the Montgomery-Asberg Depression Rating Scale-Self-rated version (MADRS-S) instrument. The results were unknown to the GPs who used a structured, patient-centred consultation model comprising seven open-ended "key questions".

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated for the PRIME-MD screening questionnaire and the patient-centred consultation model using MADRS-S as reference for possible depression at two cut-off levels with 15% prevalence. Results. Sensitivity was lower for the consultation model than the PRIME-MD screening questionnaire: 78% and 98%, respectively. The GPs failed to identify every fifth patient using the lower cut-off (MADRS-S≥13) but the number of required diagnostic interviews decreased by almost 50%: 85 versus 162, respectively. PPV was 43% and 28%, respectively. Both instruments showed high sensitivity (93%) using the higher cut-off (MADRS-S≥20) and had high NPV: 95% and 99%, respectively.

CONCLUSIONS

The findings suggest that the consultation screening procedure might be as useful in everyday practice as the PRIME-MD screening questionnaire. Both screening procedures may also be useful for ruling out depressive symptoms.

Changes in depressive symptoms over 0-9 months postpartum

OBJECTIVE

To investigate mothers' changes in prevalence of postpartum depression (PPD) symptoms over 0-9 months postpartum and determine which symptoms best distinguish depressed from nondepressed women.

METHODS

This was a prospective study of English-literate mothers of newborns, recruited from four family medicine clinics and three pediatric clinics. Mothers completed surveys at 0-1, 2, 4, 6, and 9 months postpartum, and surveys included demographic characteristics, a two-question depression screen, the 9-Item Patient Health Questionnaire (PHQ-9), and other health and work characteristics.

RESULTS

There were 506 participants (33% response rate), and 112 (22.1%) had a positive PHQ-9 (score ≥10) at some time within the first 9 months after delivery. The proportion of women with a positive PHQ-9 was greatest at 0-1 month (12.5%), then fell to between 5.0% and 7.1% at 2-6 months, and rose again to 10.2% at 9 months postpartum. Most of the PHQ-9 symptoms differentiated well between depressed and nondepressed women; items that were less discriminating were abnormal sleep, abnormal appetite/eating, and fatigue. Assessment of possible predictors of a change from negative to positive PHQ-9 between 6 and 9 months postpartum revealed only one significant predictor: prior history of depression.

CONCLUSIONS

Depressive symptoms in this sample were most frequent at 0-1 month and 9 months postpartum. Most PHQ-9 items differentiated well between depressed and nondepressed mothers; these findings support the use of the PHQ-9 for PPD screening. Future research is needed to confirm our observed secondary peak in depressive symptoms at 9 months postpartum and to investigate possible causes.

Disability in activities of daily living, depression, and quality of life among older medical ICU survivors: a prospective cohort study

Background

Accurate measurement of quality of life in older ICU survivors is difficult but critical for understanding the long-term impact of our treatments. Activities of daily living (ADLs) are important components of functional status and more easily measured than quality of life (QOL). We sought to determine the cross-sectional associations between disability in ADLs and QOL as measured by version one of the Short Form 12-item Health Survey (SF-12) at both one month and one year post-ICU discharge.

Methods

Data was prospectively collected on 309 patients over age 60 admitted to the Yale-New Haven Hospital Medical ICU between 2002 and 2004. Among survivors an assessment of ADL's and QOL was performed at one month and one-year post-ICU discharge. The SF-12 was scored using the version one norm based scoring with 1990 population norms. Multivariable regression was used to adjust the association between ADLs and QOL for important covariates.

Results

Our analysis of SF-12 data from 110 patients at one month post-ICU discharge showed that depression and ADL disability were associated with decreased QOL. Our model accounted for 17% of variability in SF12 physical scores (PCS) and 20% of variability in SF12 mental scores (MCS). The mean PCS of 37 was significantly lower than the population mean whereas the mean MCS score of 51 was similar to the population mean. At one year mean PCS scores improved and ADL disability was no longer significantly associated with QOL. Mortality was 17% (53 patients) at ICU discharge, 26% (79 patients) at hospital discharge, 33% (105 patients) at one month post ICU admission, and was 45% (138 patients) at one year post ICU discharge.

Conclusions

In our population of older ICU survivors, disability in ADLs was associated with reduced QOL as measured by the SF-12 at one month but not at one year. Although better markers of QOL in ICU survivors are needed, ADLs are a readily observable outcome. In the meantime, clinicians must try to offer realistic estimates of prognosis based on available data and resources are needed to assist ICU survivors with impaired ADLs who wish to maintain their independence. More aggressive diagnosis and treatment of depression in this population should also be explored as an intervention to improve quality of life.

Stages of change for the component behaviors of advance care planning

OBJECTIVES

To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP.

DESIGN

Observational cohort study.

SETTING

Community.

PARTICIPANTS

Persons aged 65 and older recruited from physician offices and a senior center.

MEASUREMENTS

Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues.

RESULTS

Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life.

CONCLUSION

Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.

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

BACKGROUND

Because of the quick development and widespread use of mobile phones, and their vast effect on communication and interactions, it is important to study possible negative health effects of mobile phone exposure. The overall aim of this study was to investigate whether there are associations between psychosocial aspects of mobile phone use and mental health symptoms in a prospective cohort of young adults.

METHODS

The study group consisted of young adults 20-24 years old (n = 4156), who responded to a questionnaire at baseline and 1-year follow-up. Mobile phone exposure variables included frequency of use, but also more qualitative variables: demands on availability, perceived stressfulness of accessibility, being awakened at night by the mobile phone, and personal overuse of the mobile phone. Mental health outcomes included current stress, sleep disorders, and symptoms of depression. Prevalence ratios (PRs) were calculated for cross-sectional and prospective associations between exposure variables and mental health outcomes for men and women separately.

RESULTS

There were cross-sectional associations between high compared to low mobile phone use and stress, sleep disturbances, and symptoms of depression for the men and women. When excluding respondents reporting mental health symptoms at baseline, high mobile phone use was associated with sleep disturbances and symptoms of depression for the men and symptoms of depression for the women at 1-year follow-up. All qualitative variables had cross-sectional associations with mental health outcomes. In prospective analysis, overuse was associated with stress and sleep disturbances for women, and high accessibility stress was associated with stress, sleep disturbances, and symptoms of depression for both men and women.

CONCLUSIONS

High frequency of mobile phone use at baseline was a risk factor for mental health outcomes at 1-year follow-up among the young adults. The risk for reporting mental health symptoms at follow-up was greatest among those who had perceived accessibility via mobile phones to be stressful. Public health prevention strategies focusing on attitudes could include information and advice, helping young adults to set limits for their own and others' accessibility.

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

Background

Because of the quick development and widespread use of mobile phones, and their vast effect on communication and interactions, it is important to study possible negative health effects of mobile phone exposure. The overall aim of this study was to investigate whether there are associations between psychosocial aspects of mobile phone use and mental health symptoms in a prospective cohort of young adults.

Methods

The study group consisted of young adults 20-24 years old (n = 4156), who responded to a questionnaire at baseline and 1-year follow-up. Mobile phone exposure variables included frequency of use, but also more qualitative variables: demands on availability, perceived stressfulness of accessibility, being awakened at night by the mobile phone, and personal overuse of the mobile phone. Mental health outcomes included current stress, sleep disorders, and symptoms of depression. Prevalence ratios (PRs) were calculated for cross-sectional and prospective associations between exposure variables and mental health outcomes for men and women separately.

Results

There were cross-sectional associations between high compared to low mobile phone use and stress, sleep disturbances, and symptoms of depression for the men and women. When excluding respondents reporting mental health symptoms at baseline, high mobile phone use was associated with sleep disturbances and symptoms of depression for the men and symptoms of depression for the women at 1-year follow-up. All qualitative variables had cross-sectional associations with mental health outcomes. In prospective analysis, overuse was associated with stress and sleep disturbances for women, and high accessibility stress was associated with stress, sleep disturbances, and symptoms of depression for both men and women.

Conclusions

High frequency of mobile phone use at baseline was a risk factor for mental health outcomes at 1-year follow-up among the young adults. The risk for reporting mental health symptoms at follow-up was greatest among those who had perceived accessibility via mobile phones to be stressful. Public health prevention strategies focusing on attitudes could include information and advice, helping young adults to set limits for their own and others' accessibility.

Depressed mood in the working population: associations with work schedules and working hours

The impact of working time arrangements (WTA) on health has been studied extensively. Still, little is known about the interrelation between work schedules, working hours, and depressed mood. For work schedules, the underlying assumptions regarding depressed mood refer to a disturbance of social and biological rhythms, whereas for working hours, the assumptions relate to workload and work capacity. Conversely, depressed mood may urge an employee to adjust his/her work schedule and/or number of working hours/week (h/wk). The aim of this study was to assess the association between work schedule and working hours with depressed mood. Using baseline data from the Maastricht Cohort Study, depressed mood in day work was compared with depressed mood in different shiftwork schedules (n = 8843). Within day work, several categories of working h/wk were studied in association with depressed mood (n = 7217). The association between depressed mood and several aspects of overtime was assessed separately. Depressed mood was measured with a dichotomous item: "Did you feel down every day over the last two weeks?" Separate logistic regression analyses were conducted for men and women, with adjustments for potential confounders. The odds ratio (OR) for depressed mood was greater for men involved in shiftwork than for men only involved in day work (three-shift OR = 2.05 [95% confidence interval, CI 1.52-2.77]; five-shift OR = 1.34 [95% CI 1.00-1.80]; irregular-shift OR = 1.79 [95% CI 1.27-2.53]). In female employees, five-shift work was associated with a higher prevalence of depressed mood (OR = 5.96 [95% CI 2.83-12.56]). Regarding the number of working h/wk, men working <26 h/wk had a higher prevalence of depressed mood than men working 36-40 h/wk (OR = 2.73 [95% CI 1.35-5.52]). After conducting trend analyses, a significant decreasing trend was found in men, whereas an increasing trend was found in women working a high number of hours. Furthermore, a dose-response relationship was present in men regarding the number of overtime h/wk. This study showed that different work schedules and working hours are associated with depressed mood. Shiftwork was related to a higher prevalence of depressed mood than day work. The association was more pronounced for male employees. Regarding the number of working h/wk, male and female employees showed an opposite trend in depressed mood. Because of the possibility of a healthy worker effect and the possibility of a reciprocal relationship between WTA and depressed mood, the reported relation might be underestimated. This study has illustrated that occupational physicians, who deal with depressed mood among workers, should carefully consider the impact of WTA.

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

Ease of screening for depression and delirium in patients enrolled in inpatient hospice care

BACKGROUND

Major depression and delirium are prevalent, underrecognized, and undertreated in hospice and palliative care settings. Furthermore, they are both associated with significant morbidity and mortality.

OBJECTIVE

A screening study of patients receiving inpatient hospice care was conducted in order to determine the ease of screening for depression and delirium in patients with advanced, life-threatening illnesses by hospice social workers and nurses, respectively.

METHODS

A two-question depression screening tool was administered to 20 consecutive patients on admission to a hospice general inpatient care center by social work staff during their initial assessment. A delirium-screening tool was administered daily to 22 consecutive patients admitted to the ICC daily by nursing staff. Screening results were collected, as were patient and staff feelings about the burden of the screening process.

RESULTS

Of the 20 patients screened on admission for depression by social work, 70% (14/20) screened positive. Of the 22 patients screened daily for delirium by nursing, 64% (14/22) screened positive at least once during their admission. Screening for both conditions was considered relatively easy to accomplish by the hospice staff. There were no significant associations between a positive screen of depression or delirium and patient gender, age, ethnicity, terminal diagnosis, or marital status.

DISCUSSION

These results support the notion that depression and delirium are very common in hospice inpatients, and that screening for both is relatively easy and practical for hospice clinicians to conduct.

Depression and suicide ideation among students accessing campus health care

Depression and suicide are of increasing concern on college campuses. This article presents data from the College Health Intervention Projects on the frequency of depression and suicide ideation among 1,622 college students who accessed primary care services in 4 university clinics in the Midwest, Northwest, and Canada. Students completed the Beck Depression Inventory and other measures related to exercise patterns, alcohol use, sensation seeking, and violence. The frequency of depression was similar for men (25%) and women (26%). Thought of suicide was higher for men (13%) than women (10%). Tobacco use, emotional abuse, and unwanted sexual encounters were all associated with screening positive for depression. "Days of exercise per week" was inversely associated with screening positive for depression. Because the majority of students access campus-based student health centers, medical providers can serve a key role in early identification and intervention. With every 4th student reporting symptoms of depression and every 10th student having suicidal thoughts, such interventions are needed.

Lack of association between resident doctors' well-being and medical knowledge

OBJECTIVES

Resident doctors' (residents) well-being impacts on the medical care they provide. Despite the high prevalence of resident doctors' distress, the relationship between their well-being and the specific competencies defined by the Accreditation Council for Graduate Medical Education is poorly understood. We evaluated the association of resident well-being with medical knowledge as assessed on both a standardised test of general medical knowledge and at the end of web-based courses on a series of focused topics.

METHODS

We conducted a repeated cross-sectional study of associations between well-being and medical knowledge scores over time for internal medicine residents from July 2004 to June 2007. Well-being measures included linear analogue self-assessment (LASA) scales measuring quality of life (including overall quality of life, mental, physical and emotional well-being, and fatigue), the Medical Outcome Study Eight-Item Short Form Health Survey (SF-8) assessment of mental and physical well-being, the Maslach Burnout Inventory and the PRIME-MD two-item depression screen. We also measured empathy using the perspective taking and empathic concern subscales of the Interpersonal Reactivity Index. Medical knowledge measures included scores on web-based learning module post-tests and scores on the national Internal Medicine In-Training Examination (IM-ITE). As data for each association were available for at least 126 residents, this study was powered to detect a small-to-moderate effect size of 0.3 standard deviations.

RESULTS

No statistically significant associations were observed between well-being and either web-based learning module post-test score or IM-ITE score. Parameter estimates of the association of well-being variables with knowledge scores were uniformly small. For all well-being metrics, meaningful differences were associated with knowledge score difference estimates of < 1 percentage point.

CONCLUSIONS

Resident well-being appears to have limited association with competence in medical knowledge as assessed following web-based courses on specific topics or using standardised general medical examinations.

Screening depression aging services clients

OBJECTIVES

To establish the psychometric characteristics of the Patient Heath Questionnaire (PHQ) (PHQ-2, -9, and their sequential administration) in older adults who use community-based, social service care management.

DESIGN

Comparison of screening tools with criterion standard diagnostic interview.

SETTING

A community-based aging services agency.

PARTICIPANTS

Three hundred seventy-eight adults aged 60 years or older undergoing in-home aging services care management assessments.

MEASUREMENTS

Subjects were administered the PHQ-9 and Structured Clinical Interview for DSM-IV-TR- fourth edition. The authors examined the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and receiver operating characteristic (ROC) curve for the PHQ-2 and PHQ-9 separately, and for a two-stage screening process that used each in sequence (the PHQ-2/9).

RESULTS

Using a cut score of 3, the sensitivity of the PHQ-2 was 0.80 and the specificity was 0.78. The area under the ROC curve (AUC) for the PHQ-2 was 0.87. Using a cut score of 10, the sensitivity and specificity of the PHQ-9 were 0.82 and 0.87. The AUC was 0.91. The sensitivity and specificity of the two-stage PHQ-2/9 were 0.81 and 0.89, respectively, and the AUC was 0.91.

CONCLUSIONS

The greater specificity of the PHQ-9 is an advantage over the PHQ-2 in aging service settings in which false-positive tests have potentially high cost. The PHQ-2/9 performed equally well as the PHQ-9, but would be more efficient for the agency to administer. Combined with an appropriate referral system to healthcare providers, use of the PHQ-2/9 sequence by aging services personnel can efficiently assist in reducing the burden of late-life depression.

Documented combat-related mental health problems in military noncombatants

Although combat-related posttraumatic stress disorder (PTSD) has been documented for military combatants, little is known about PTSD in noncombatants. Active-duty U.S. Air Force noncombatants (N = 5,367) completed a Post-Deployment Health Assessment upon return from combat zones in Iraq (n = 4,408) or a noncombat zone in Qatar (n = 959). Those deployed to Iraq were significantly more likely to report exposure to someone who was wounded or killed (20.8% vs. 6.3%), feeling in great danger of being killed at some point during deployment (18.9% vs. 3.5%), symptoms of PTSD (4.1% vs. 0.7%), and symptoms of major depression (9.9% vs. 5.4%). These findings suggest that deployment to a war zone is associated with increased mental health problems, even for noncombatants.

Burden in caregivers of older adults with advanced illness

OBJECTIVES

To examine caregiver burden over time in caregivers of patients with advanced chronic disease.

DESIGN

Observational cohort with interviews over 12 months.

SETTING

Community.

PARTICIPANTS

Caregivers of 179 community-living persons aged 60 and older with advanced cancer, heart failure (HF), or chronic obstructive pulmonary disease (COPD).

MEASUREMENTS

Caregiver burden was assessed using a short-form of the Zarit Burden Inventory to measure psychosocial distress.

RESULTS

At baseline, the median caregiver burden was 5 (interquartile range (IQR) 1-11), which indicates that the caregiver endorsed having at least two of 10 distressing concerns at least some of the time. Only 10% reported no burden. Although scores increased modestly over time, the association between time and burden was not significant in longitudinal multivariable analysis. High burden was associated with caregiver need for more help with daily tasks (odds ratio (OR)=23.13, 95% confidence interval (CI)=5.94-90.06) and desire for greater communication with the patient (OR=2.53, 95% CI=1.16-5.53). The longitudinal multivariable analysis did not yield evidence of associations between burden and patient sociodemographic or health characteristics.

CONCLUSION

Caregiver burden was common in caregivers of patients with cancer, HF, and COPD. High burden was associated with the caregiver's report of need for greater help with daily tasks but not with objective measures of the patient's need for assistance, such as symptoms or functional status, suggesting that burden may be a measure of the caregiver's ability to adapt to the caregiving role.

Characteristics in patients with headache in an outpatient clinic in Japan

BACKGROUND

Little is known about the prevalence of primary and secondary headache in clinics in Japan. The aim of this study is to characterize patients with headache in an outpatient unit where primary care physicians are working in Japan.

METHODS

Consecutive outpatients who newly visited the Department of General Medicine, Asahikawa Medical College Hospital, Asahikawa, Japan between April 2005 and March 2009 were analyzed. Each parameter such as age, sex or diagnosis was investigated.

RESULTS

Out of 4693 patients, 418 patients visited to our department because of headache. Primary headache was found in 167 patients (39.9%). The rate of tension-type headache (TTH) (30.8%) was highest, followed by migraine (9.1%). Approximately 3 times higher rate of migraine was observed in female patients when compared with male patients. In female patients, migraine was observed more frequently in younger patients. On the other hands, TTH was observed in almost all aged patients in males and females, and the rate of TTH peaks between the ages of 40 and 49 years in both sex. The present study also demonstrated that 8.4% of patients who chiefly complained of headache had been diagnosed as depression while 1.7% of remained patients had been diagnosed as depression, indicating 5-times higher rate of depression in patients with headache.

CONCLUSION

All these results suggest that primary headache, especially TTH, is highly observed and depression should be considered in patients with headache in an outpatient clinic where primary care physicians are working in Japan.

A novel emergency medical services-based program to identify and assist older adults in a rural community

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.

Health-Led Interventions in the Early Years to Enhance Infant and Maternal Mental Health: A Review of Reviews

BACKGROUND

  Increasing recognition of the importance of maternal mental health and early parenting in optimising the later mental health of the child has given rise to new ways of working during the perinatal period.

AIMS

  The objective of this review is to identify effective health-led interventions to support parents, parenting and the parent-infant relationship during the perinatal period,¹ and beyond.

METHOD

  A systematic search of key electronic databases was undertaken to identify secondary and primary sources of data addressing the research question. Twenty-four reviews addressed the effectiveness of interventions delivered during the postnatal period in promoting closeness and sensitive parenting, infant sensory and perceptual capabilities, and positive parenting, and in addressing infant regulatory problems, maternal mental health problems, and parent-infant relationship problems.

CONCLUSIONS

  A number of methods of working are recommended as part of a model of progressive-universalism beginning ante-natally and continuing through the first two post-natal years, and beyond. The implications for universal, targeted and specialist healthcare services are explored, alongside the role and contribution of CAMHS practitioners.