Problematic substance use, depressive symptoms, and gender in primary care

Association between depressive symptoms and all-cause mortality in Chilean adult population: prospective results from two national health surveys

PURPOSE

Depression is a prevalent disorder with effects beyond mental health. A positive association with mortality has been mostly reported, however, evidence comes from a few high-income countries. This study aims to assess the association between depressive symptoms and all-cause mortality in the Chilean population and assess a potential secular effect in this association.

METHODS

This prospective study used data from the Chilean National Health Survey (CNHS). Data from 3151 and 3749 participants from the 2003 and 2010 CNHS, respectively, were linked to mortality register data. Cox survival analysis was performed. The main exposure was depressive symptoms, measured with CIDI-SF (cut-off ≥ 5), and the outcome all-cause mortality. The study period was limited to 8.5 years to allow for the same length of follow-up.

RESULTS

10% and 8.5% of participants from the 2003 and 2010 cohort died during the follow-up. Adjusting for age and sex, those with depressive symptoms had 1.58 (95% CI 1.18-2.13) and 1.65 (95% CI 1.14-2.12) times the risk to die than those without symptoms in the 2003 and 2010 cohort, respectively. In models adjusted for demographic, socioeconomic, behavioural variables and comorbidities, participants with depressive symptoms had 1.42 (95% CI 1.05-1.92) and 1.46 (95% CI 1.07-- 1.99) times the risk to die compared to those without symptoms in the 2003 and 2010 cohort, respectively.

CONCLUSION

Chilean adults with depressive symptoms are at higher risk of all-cause mortality compared to those without symptoms. The effect size was similar regardless of the economic development of the country.

'I Was Present but I Was Absent': Perceptions and Experiences of the Non-Medical Use of Prescription or over the Counter Medication among Employed South African Women

BACKGROUND

The need for workplace substance use prevention programmes globally and in South Africa is driven by the growing problem of substance use and the associated burden on the health and welfare of employees, their families and organizations. Substance use, which include the non-medical use of medications (both prescription and over-the counter), remains widespread and is a major cause of mortality and a risk factor for non-communicable diseases (NCDs).

METHOD

Twenty in-depth semi-structured qualitative interviews were conducted with employed women in treatment or shortly out of treatment for the non-medically indicated use of over the counter or/and prescription medications (NMIU). These interviews were conducted face-to face with women residing in the Western and Eastern Cape provinces of South Africa. Thematic analysis using NVIVO was used to analyse data collected.

RESULTS

The findings from this study suggest that previous use of legal or illegal substances and challenging life experiences underpin pathways to the non-medical use of over-the-counter and prescription medications among employed women. Factors found to contribute to misuse relate to a lack of understanding on risks, and health professional prescribing practices, while mitigators to harmful use were related to increased awareness and understanding harmful practices, the need for improved access and referral to specialist treatment as well as prevention programmes for women.

CONCLUSION

With the improved understanding of the issues surrounding the NMIU of over-the-counter and prescription medications among employed women, the need for interventions to prevent misuse and inadvertently dependency is highlighted.

Study of Sex Differences in Unmedicated Patients With Major Depressive Disorder by Using Resting State Brain Functional Magnetic Resonance Imaging

Some important clinical characteristics of major depressive disorder (MDD) differ between sexes. We explored abnormal spontaneous neuronal activity in MDD patients using the amplitude of low-frequency fluctuation (ALFF) and its relationship to clinical manifestations in male and female patients, to seek the neural mechanisms underlying sex-related differences in depression. Twenty-five male MDD patients, 36 female MDD patients, and 25 male and 36 female matched healthy controls (HC) were included. The ALFF difference was investigated among four groups, and partial correlation analysis was used to explore a possible clinical relevance. The main effect results of sex difference were located in the bilateral caudate nucleus and posterior cingulate gyrus. Post hoc comparisons found that the male MDD patients showed decreased ALFF in the bilateral caudate nucleus and posterior cingulate gyrus when compared with female MDD patients/female HCs, and female MDD patients showed increased ALFF in the bilateral caudate nucleus and posterior cingulate gyrus when compared with male HCs. The average ALFF of the right caudate nucleus was positively correlated with illness duration in female MDD patients. Our results suggest that the sex-specific abnormal brain activity might be a potential pathomechanism of different symptoms in male and female MDD patients.

"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial

BACKGROUND

Depression and harmful alcohol use are two of the top five leading causes of years of life lost to disability in high-income countries. Integrated treatment targeting both at the same time is often considered more complicated and difficult and, therefore, more expensive. Consequently, integrated internet-based interventions could be a valuable addition to traditional care.

METHODS

A three-arm randomized controlled trial was conducted comparing the effectiveness of (1) an integrated, minimal-guidance, adherence-focused self-help intervention designed to reduce both alcohol use and depression symptoms (AFGE-AD); (2) a similar intervention designed to reduce alcohol use only (AFGE-AO), and (3) internet access as usual (IAU) as a control condition, in at least moderately depressed alcohol misusers from February 2016-March 2020. We recruited 689 alcohol misusers (51.6 % males, mean age = 42.8 years) with at least moderate depression symptoms not otherwise in treatment from the general population. Six months after baseline, 288 subjects (41.8 %) were reachable for the final assessment.

RESULTS

All interventions yielded reduced alcohol-use after six months (AFGE-AD: -16.6; AFGE-AO: -19.8; IAU: -13.2). Those who undertook active-interventions reported significantly fewer standard drinks than controls (AFGE-AD: p = .048, d=0.10; AFGE-AO: p = .004, d=0.20). The two active-intervention groups also reported significantly less severe depression symptoms than controls (AFGE-AD: p = .006, d=0.41; AFGE-AO: p = .008, d=0.43). Testing revealed noninferiority between the two interventions.

CONCLUSIONS

This study documented sustained effectiveness of the first integrated, fully internet-based self-help intervention developed for the reduction of both alcohol use and depression symptoms in at least moderately depressed adult alcohol misusers recruited from the general population.

Depression Screening Rates and Symptom Severity by Alcohol Use Among Primary Care Adult Patients

BACKGROUND

Hazardous alcohol use with depression may exacerbate health conditions and complicate medical care. We examined the rate of depression screening by alcohol use severity among primary care patients screened for hazardous alcohol use and, among those screened, examined patterns of significant depressive symptoms.

METHODS

Using cross-sectional data from primary care patients (n = 2,894,906), we examined past-90-day alcohol use (number of typical drinking days/week and typical number of drinks consumed daily); depression screening rates (using the Patient Health Questionnaire 9 [PHQ-9]); and symptom severity, demographics, and prevalence of selected psychiatric diagnoses.

RESULTS

Within 30 days of routine, in-clinic alcohol use screening by medical assistants, 2.4% (n = 68,686) of patients also completed a PHQ-9; these patients were more likely to be female, younger, white, Medicaid insured, and to have a nondepressive psychiatric diagnosis and a lower Charlson comorbidity score. Abstainers and moderate drinkers (1 to 7 drinks/week or 1 to 4 drinks/week for women and individuals >65 years or for men ≤65 years, respectively) were less likely than hazardous drinkers (exceeding weekly limits) to complete the PHQ-9 or to have significant depressive symptoms (PHQ-9 score ≥10). Nonwhite patients with higher Charlson comorbidity scores were more likely to endorse significant depressive symptoms.

CONCLUSIONS

Only a small fraction of patients in this cohort were screened for depression. Nonwhite patients and those with higher comorbidity burden were more likely to report depression but less likely to be screened. These discrepancies between depression-screening rates and significant depressive symptoms suggest that screening for depression should be enhanced in these at-risk groups.

How Much Do Mental Health and Substance Use/Addiction Affect Use of General Medical Services? Extent of Use, Reason for Use, and Associated Costs

OBJECTIVE

To measure service use and costs associated with health care for patients with mental health (MH) and substance use/addiction (SA) problems.

METHODS

A 5-year cross-sectional study (2007-2012) of administrative health care data was conducted (average annual sample size = 123,235 adults aged >18 years who had a valid Ontario health care number and used at least 1 service during the year; 55% female). We assessed average annual use of primary care, emergency departments and hospitals, and overall health care costs for patients identified as having MH only, SA only, co-occurring MH and SA problems (MH+SA), and no MH and/or SA (MH/SA) problems. Total visits/admissions and total non-MH/SA visits (i.e., excluding MH/SA visits) were regressed separately on MH, SA, and MH+SA cases compared to non-MH/SA cases using the 2011-2012 sample ( N = 123,331), controlling for age and sex.

RESULTS

Compared to non-MH/SA patients, MH/SA patients were significantly ( P < 0.001) more likely to visit primary care physicians (1.82 times as many visits for MH-only patients, 4.24 for SA, and 5.59 for MH+SA), use emergency departments (odds, 1.53 [MH], 3.79 [SA], 5.94 [MH+SA]), and be hospitalized (odds, 1.59 [MH], 4.10 [SA], 7.82 [MH+SA]). MH/SA patients were also significantly more likely than non-MH/SA patients to have non-MH/SA-related visits and accounted for 20% of the sample but over 30% of health care costs.

CONCLUSIONS

MH and SA are core issues for all health care settings. MH/SA patients use more services overall and for non-MH/SA issues, with especially high use and costs for MH+SA patients.

A randomized clinical trial of Motivational Interviewing to reduce alcohol and drug use among patients with depression

OBJECTIVE

This study examined the efficacy of Motivational Interviewing (MI) to reduce hazardous drinking and drug use among adults in treatment for depression.

METHOD

Randomized controlled trial based in a large outpatient psychiatry program in an integrated health care system in Northern California. The sample consisted of 307 participants ages 18 and over who reported hazardous drinking, drug use (primarily cannabis) or misuse of prescription drugs in the prior 30 days, and who scored ≥5 on the Patient Health Questionnaire (PHQ-9). Participants were randomized to receive either 3 sessions of MI (1 in person and 2 by phone) or printed literature about alcohol and drug use risks (control), as an adjunct to usual outpatient depression care. Measures included alcohol and drug use in the prior 30 days and PHQ-9 depression symptoms. Participants completed baseline in-person interviews and telephone follow-up interviews at 3 and 6 months (96 and 98% of the baseline sample, respectively). Electronic health records were used to measure usual care.

RESULTS

At 6 months, MI was more effective than control in reducing rate of cannabis use (p = .037); and hazardous drinking (≥4 drinks in a day for women, ≥5 drinks in a day for men; p = .060). In logistic regression, assignment to MI predicted lower cannabis use at 6 months (p = .016) after controlling for covariates. Depression improved in both conditions.

CONCLUSIONS

MI can be an effective intervention for cannabis use and hazardous drinking among patients with depression. (PsycINFO Database Record

Masculine Traits and Depressive Symptoms in Older and Younger Men and Women

Evidence suggests that men who strongly endorse masculine traits display an atypical presentation of depression, including more externalizing symptoms (e.g., anger or substance use), but fewer typical, internalizing symptoms (e.g., depressed mood or crying). This phenomenon has not been adequately explored in older adults or women. The current study used the externalizing subscale of the Masculine Depression Scale in older and younger men and women to detect atypical symptoms. It was predicted that individuals who more strongly endorsed masculine traits would have higher scores on the measure of externalizing symptoms relative to a measure of typical depressive symptoms Center for Epidemiologic Studies-Depression Scale. It was anticipated that results would differ by age-group but not by gender. Multigroup path analysis was used to test the hypothesis. The hypothesized path model, in which endorsement of masculine traits was associated with lower scores on the Center for Epidemiologic Studies-Depression Scale and with scores on the externalizing, but not internalizing, factor of the Masculine Depression Scale, fit the data well. Results differed significantly by age-group and gender. Masculine individuals reported lower levels of typical depressive symptoms relative to externalizing symptoms, but further research is needed within age- and gender groups. Results are consistent with the gendered responding framework and suggest that current assessment tools, which tend to focus on internalizing symptoms of depression, may not detect depression in individuals who endorse masculine traits.

Gender differences in a cohort of major depressive patients: further evidence for the male depression syndrome hypothesis

BACKGROUND

Previous studies have shown that major depressive patients may differ in several features according to gender, but the existence of a specific male depressive syndrome remains controversial.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 125 (27.7%) were of male gender, whereas 317 (72.3%) were female, after exclusion of bipolar I patients.

RESULTS

Compared to women, men were more often married, had more associated mixed features, with more bipolar disorder NOS, more hyperthymic temperaments, and less depressive temperaments. Women had an earlier age at onset of depression, more depressive episodes and suicide attempts. A higher family loading was shown in men for bipolar disorder, alcohol use disorder, impulse control disorders and suicide, whereas their family loading for major depressive disorder was lower. Men displayed more comorbidities with alcohol use, impulse control, and cardiovascular disorders, with lower comorbidities with eating, anxiety and endocrine/metabolic disorders. The following independent variables were associated with male gender: hyperthymic temperament (+), alcohol use disorder (+), impulse control disorders (+), and depressive temperament (-).

LIMITATIONS

The retrospective design and the lack of specific tools to assess the male depressive syndrome.

CONCLUSION

Study findings may lend support to the male depression syndrome concept and draw attention to the role of hyperthymic temperament, soft bipolarity as well as comorbidities as determinants of this syndrome. The latter could help recognize an entity which is probably underdiagnosed, but conveys a high risk of suicide and cardiovascular morbidity.

Brain grey matter abnormalities in medication-free patients with major depressive disorder: a meta-analysis

BACKGROUND

Because cerebral morphological abnormalities in major depressive disorder (MDD) may be modulated by antidepressant treatment, inclusion of medicated patients may have biased previous meta-analyses of voxel-based morphometry (VBM) studies. A meta-analysis of VBM studies on medication-free MDD patients should be able to distinguish the morphological features of the disease itself from those of treatment.

METHOD

A systematic search was conducted for the relevant studies. Effect-size signed differential mapping was applied to analyse the grey matter differences between all medication-free MDD patients and healthy controls. Meta-regression was used to explore the effects of demographics and clinical characteristics.

RESULTS

A total of 14 datasets comprising 400 medication-free MDD patients and 424 healthy controls met the inclusion criteria. The pooled meta-analysis and subgroup meta-analyses showed robustly reduced grey matter in prefrontal and limbic regions in MDD. Increased right thalamus volume was only seen in first-episode medication-naive patients, and increased grey matter in the bilateral anterior cingulate cortex only in medication wash-out patients. In meta-regression analyses the percentage of female patients in each study was negatively correlated with reduced grey matter in the right hippocampus.

CONCLUSIONS

By excluding interference from medication effects, the present study identified grey matter reduction in the prefrontal-limbic network in MDD. The subgroup meta-analysis results suggest that an increased right thalamus volume might be a trait directly related to MDD, while an increased anterior cingulate cortex volume might be an effect of medication. The meta-regression results perhaps reveal the structural underpinning of the sex differences in epidemiological and clinical aspects of MDD.

Problematic substance use in urban adolescents: role of intrauterine exposures to cocaine and marijuana and post-natal environment

BACKGROUND

Linkages between intrauterine exposures to cocaine and marijuana and adolescents' problematic substance use have not been fully delineated.

METHODS

Prospective longitudinal study with assessors unaware of intrauterine exposure history followed 157 urban participants from birth until late adolescence. Level of intrauterine exposures was identified by mother's report and infant's meconium. Problematic substance use, identified by the Voice Diagnostic Interview Schedule for Children (V-DISC) or the Audio Computer Assisted Self-Interview (ACASI) and urine assay, was a composite encompassing DSM-IV indication of tolerance, abuse, and dependence on alcohol, marijuana, and tobacco and any use of cocaine, glue, or opiates.

RESULTS

Twenty percent (32/157) of the sample experienced problematic substance use by age 18 years, of whom the majority (22/157) acknowledged abuse, tolerance or dependence on marijuana with or without other substances. Structural equation models examining direct and indirect pathways linking a Cox survival model for early substance initiation to a logistic regression models found effects of post-natal factors including childhood exposure to violence and household substance use, early youth substance initiation, and ongoing youth violence exposure contributing to adolescent problematic substance use.

CONCLUSION

We did not identify direct relationships between intrauterine cocaine or marijuana exposure and problematic substance use, but did find potentially modifiable post-natal risk factors also noted to be associated with problematic substance use in the general population including earlier substance initiation, exposure to violence and to household substance use.

Advising depression patients to reduce alcohol and drug use: factors associated with provider intervention in outpatient psychiatry

BACKGROUND AND OBJECTIVES

Mental health clinicians have an important opportunity to help depression patients reduce co-occurring alcohol and drug use. This study examined demographic and clinical patient characteristics and service factors associated with receiving a recommendation to reduce alcohol and drug use from providers in a university-based outpatient psychiatry clinic.

METHODS

The sample consisted of 97 participants ages 18 and older who reported hazardous drinking (≥3 drinks/occasion), illegal drug use (primarily cannabis) or misuse of prescription drugs, and who scored ≥15 on the Beck Depression Inventory-II (BDI-II). Participants were interviewed at intake and 6 months.

RESULTS

At 6-month telephone interview, 30% of participants reported that a clinic provider had recommended that they reduce alcohol or drug use. In logistic regression, factors associated with receiving advice to reduce use included greater number of drinks consumed in the 30 days prior to intake (p = .035); and greater depression severity on the BDI-II (p = .096) and hazardous drinking at 6 months (p = .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

While participants with greater alcohol intake and depression symptom severity were more likely to receive advice to reduce use, the low overall rate of recommendation to reduce use highlights the need to improve alcohol and drug use intervention among depression patients, and potentially to address alcohol and drug training and treatment implementation issues among mental health providers.

Sex differences of gray matter morphology in cortico-limbic-striatal neural system in major depressive disorder

Sex differences are observed in both epidemiological and clinical aspects of major depressive disorder (MDD). The cortico-limbic-striatal neural system, including the prefrontal cortex, amygdala, hippocampus, and striatum, have shown sexually dimorphic morphological features and have been implicated in the dysfunctional regulation of mood and emotion in MDD. In this study, we utilized a whole-brain, voxel-based approach to examine sex differences in the regional distribution of gray matter (GM) morphological abnormalities in medication-naïve participants with MDD. Participants included 29 medication-naïve individuals with MDD (16 females and 13 males) and 33 healthy controls (HC) (17 females and 16 males). Gray matter morphology of the cortico-limbic-striatal neural system was examined using voxel-based morphometry analyzes of high-resolution structural magnetic resonance imaging scans. The main effect of diagnosis and interaction effect of diagnosis by sex on GM morphology were statistically significant (p < 0.05, corrected) in the left ventral prefrontal cortex, right amygdala, right hippocampus and bilateral caudate when comparing the MDD and HC groups. Posthoc analyzes showed that females with MDD had significant GM decreases in limbic regions (p < 0.05, corrected), compared to female HC; while males with MDD demonstrated significant GM reduction in striatal regions, (p < 0.05, corrected), compared to HC males. The observed sex-related patterns of abnormalities within the cortico-limbic-strial neural system, such as predominant prefrontal-limbic abnormalities in MDD females vs. predominant prefrontal-striatal abnormalities in MDD males, suggest differences in neural circuitry that may mediate sex differences in the clinical presentation of MDD and potential targets for sex-differentiated treatment of the disorder.

Role of severity and gender in the association between late-life depression and all-cause mortality

BACKGROUND

Mortality associated with depression may be influenced by severity of depression and gender. We investigated the differential impacts on all-cause mortality of late-life depression by the type of depression (major depressive disorder, MDD; minor depressive disorder, MnDD; subsyndromal depression, SSD) and gender after adjusting comorbid conditions in the randomly sampled elderly.

METHODS

One thousand community-dwelling elderly individuals were enrolled. Standardized face-to-face clinical interviews, neurological examination, and physical examination were conducted to diagnose depressive disorders and comorbid cognitive disorders. Depressive disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria and SSD to study-specific operational criteria. Five-year survivals were compared between groups using Cox proportional hazards models.

RESULTS

By the end of 2010, 174 subjects (17.4%) died. Depressive disorder (p = 0.001) and its interaction term with gender (p < 0.001) were significant in predicting five-year survival. MDD was an independent risk factor for mortality in men (hazard ratio = 3.65, 95% confidence interval = 1.67-7.96) whereas MnDD and SSD were not when other risk factors were adjusted.

CONCLUSIONS

MDD may directly confer the risk of mortality in elderly men whereas non-major depression may be just an indicator of increased mortality in both genders.

Motivational interviewing to reduce hazardous drinking and drug use among depression patients

This randomized study examined the efficacy of motivational interviewing (MI) to reduce substance use among adults with depression in outpatient psychiatry. The sample consisted of 104 participants ages 18 and over who reported hazardous drinking (three drinks or more per occasion), illegal drug use or misuse of prescription drugs in the prior 30 days, and who scored ≥ 15 on the Beck Depression Inventory-II (BDI-II). Participants were randomized to receive either three sessions of MI or printed literature about alcohol and drug use risks, as an adjunct to usual outpatient depression care, and completed telephone follow-up interviews at 3 and 6 months (93 and 99% of the baseline sample, respectively). Among participants reporting any hazardous drinking at baseline (n=73), MI-treated participants were less likely than controls to report hazardous drinking at 3 months (60.0 vs. 81.8%, p=.043). MI is a promising intervention to reduce hazardous drinking among depression patients.

Can patterns of alcohol use disorder in young adulthood help explain gender differences in depression?

OBJECTIVE

To test whether gender differences in the prevalence of major depressive disorder differ by longitudinal patterns of alcohol use disorder symptoms.

METHOD

Data are from a prospective longitudinal study examining a broad range of mental health and substance use problems. A gender-balanced sample of 808 participants was interviewed at ages 21, 24, 27, and 30. The sample was divided into subgroups corresponding to longitudinal patterns of alcohol use disorder derived from latent class growth analysis.

RESULTS

Four patterns of alcohol use disorder symptoms were identified: A "low disorder symptom" group, a "decreaser" group, an "increaser" group, and a "chronic disorder symptom" group. Rates of depression were significantly higher for females only among those with a pattern of chronic or decreasing alcohol disorder symptoms.

CONCLUSIONS

Elevated rates of depression among females in young adulthood may depend on patterns of co-occurring alcohol disorder symptoms. Practitioners should pay particular attention to signs of chronic alcohol use disorders and associated risks for depression among young adult women.

Factors Influencing Risk of Premature Mortality in Community Cases of Depression: A Meta-Analytic Review

Background. Depressive disorders are associated with substantial risk of premature mortality. A number of factors may contribute to reported risk estimates, making it difficult to determine actual risk of excess mortality in community cases of depression. The aim of this study is to conduct a systematic review and meta-analysis of excess mortality in population-based studies of clinically defined depression. Methods. Population-based studies reporting all-cause mortality associated with a clinically defined depressive disorder were included in the systematic review. Estimates of relative risk for excess mortality in population-representative cases of clinical depressive disorders were extracted. A meta-analysis was conducted using Stata to pool estimates of excess mortality and identify sources of heterogeneity within the data. Results. Twenty-one studies reporting risk of excess mortality in clinical depression were identified. A significantly higher risk of mortality was found for major depression (RR 1.92 95% CI 1.65–2.23), but no significant difference was found for dysthymia (RR 1.37 95% CI 0.93–2.00). Relative risk of excess mortality was not significantly different following the adjustment of reported risk estimates. Conclusion. A mortality gradient was identified with increasing severity of clinical depression. Recognition of depressive symptoms in general practice and appropriate referral for evidence-based treatment may help improve outcomes, particularly in patients with comorbid physical disorders.

Preventing prescription drug misuse: field test of the SmartRx Web program

Purpose of the project was to test a Web-based program designed to prevent prescription drug misuse. Study sample consisted of 346 working women randomized into either an experimental or wait-list control condition. Analysis of covariance and logistic regression were used to compare responses. Women receiving the intervention had greater knowledge of drug facts and greater self-efficacy in medication adherence and ability to manage problems with medications compared with controls. Women receiving the intervention also had reduced symptoms reported on the CAGE for prescription medications. Findings suggest that multimedia Web-based programs can be a beneficial addition to substance misuse prevention services. The study's limitations are noted.

The association between intimate partner violence, alcohol and depression in family practice

Background

Depressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored.

Methods

This paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiological Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner.

Results

23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95%CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level.

Conclusions

Strategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care.

Initiation of Primary Care-Mental Health Integration programs in the VA Health System: associations with psychiatric diagnoses in primary care

BACKGROUND

Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program.

OBJECTIVES

To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment.

RESEARCH DESIGN

Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white.

CONCLUSIONS

Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

Does gender matter? A vignette study of general practitioners' management skills in handling patients with alcohol-related problems

AIMS

The aims of this study were to analyse the perceptions of female and male primary care physicians (PCPs) of alcohol problems in male and female patients, their recommendations to reduce or abstain from alcohol, their referrals to treatment and their views of safe levels of drinking for male and female patients. These factors were related to the physicians' own alcohol consumption.

METHODS

A slightly adjusted version of the WHO Collaborative Study Questionnaire for General Practitioners was posted to all PCPs (n = 132) in the district of Skaraborg, Sweden, of whom 68 PCPs responded. In the questionnaire, the PCPs' perceptions of two patient vignettes were analysed.

RESULTS

Both the gender of the patients in the vignettes and of the PCPs influenced the advice and the referrals that the patients received: 83% of male excessive drinkers and 47% of female excessive drinkers were recommended to cut down on drinking. In 50% of cases, the male excessive drinker was not referred, compared with 25% for the female excessive drinker. This was statistically significant only for excessive drinkers. The odds ratio for referral to any treatment was 0.33 (CI = 0.12-0.93) for the male excessive drinker compared with the female excessive drinker. The male PCP referred the excessive drinker less often to any treatment than did the female PCP, odds ratio 0.26 (CI = 0.08-0.90). The upper limit of alcohol consumption before the PCPs would advise the patient to cut down was significantly higher for PCPs with the AUDIT-C score >or= 3. The limit was 146 g/week for male patients and 103 g/week for female patients. Corresponding figures for PCP with the AUDIT-C score <or= 2 were 89 and 68 g/week.

CONCLUSION

Male patients were less likely to be advised to stop drinking altogether than female patients and were less likely to be referred, according to this vignette study. Taking into account that male patients have a higher prevalence of alcohol problems, this may be of considerable importance for men's health outcomes. Implications of these findings are the need to increase awareness of male excessive drinking and that gendered perceptions might bias alcohol management recommendations.

Profiling risk of fear of an intimate partner among men and women

OBJECTIVE

Fear of a partner, a component of intimate partner violence (IPV), can be used in clinical IPV assessment. This study examines correlates of fear in a population-based, urban sample to inform a gender-specific health care response to IPV.

METHODS

This study used pooled data on 9687 men and 13,903 women collected in 2002, 2004 and 2005 through three random-digit-dial surveys of New York City adults. Bivariate and multivariable analyses were used to examine associations between fear and sociodemographic and health-related factors.

RESULTS

There was no significant difference in age-adjusted prevalence of reported fear of a partner between women (2.7%) and men (2.2%). In multivariable analysis, fear was correlated with being female, younger age, divorced or separated marital status, poor self-reported health status, and multiple sex partners. The most striking gender difference was in the stronger association with multiple sex partners among women (adjusted Odds Ratio [aOR]=6.2; p<0.01). Binge drinking was correlated with fear only among low-income adults (aOR=2.8; p<0.01).

CONCLUSION

IPV is a health concern for both men and women, and a risk profile for fear can guide IPV assessment in health care. Physicians should consider multiple sex partners in women and alcohol misuse in low-income patients as potential markers for IPV.

Gender sensitivity among general practitioners: results of a training programme

BACKGROUND

Gender differences contribute to patients' health and illness. However in current healthcare practices attention to gender differences is still underdeveloped. Recognizing these differences and taking them into account can improve the quality of care. In this study we aimed to investigate whether GPs' gender sensitivity can be stimulated by a training programme. The focus was on three diseases: angina pectoris, depression and urinary incontinence.

METHODS

This study had a quantitative, explorative and descriptive design. By means of a training programme 18 GPs were trained to focus on gender-sensitive recommendations for the three diseases. With standardised registration forms, data were collected during a 6-month period. During the registration period, the GPs were visited by the study team to discuss the process of data collection.

RESULTS

The GPs filled in registration forms for 100 patients: 39 with angina pectoris (31 women and 8 men), 40 with depression (26 women and 14 men), and 21 with urinary incontinence (20 women and 1 man). The results show that gender sensitivity can be stimulated among trained professionals. The combination of the training programme, clear and practical recommendations, daily discussion of relevant cases between the GP couples, feedback and support during registration by the study team probably contributed to the outcome.

CONCLUSION

GPs' gender sensitivity was stimulated by the training programme and the supporting visits. Ideally, structural attention could be realised by embedding gender issues in existing organisational structures of general practices.

Alcohol consumption and the use of antidepressants

BACKGROUND

The purpose of the present study is to explore the relation between use of antidepressants and level of alcohol consumption among depressed and nondepressed men and women.

METHODS

Random-digit dialling and computer-assisted telephone interviewing were used to survey a sample of 14,063 Canadian residents, aged 18-76 years. The survey included measures of quantity and frequency of drinking, the World Health Organization's Composite International Diagnostic Interview measure of depression, and a question as to whether respondents had used antidepressants during the past year.

RESULTS

Overall, depressed respondents drank more alcohol than did nondepressed respondents. This was not true, however, for depressed men who used antidepressants; they consumed a mean of 414 drinks during the preceding year, versus 579 drinks for depressed men who did not use antidepressants and 436 for nondepressed men. For women, the positive relation between depression and heavier alcohol consumption held true regardless of their use of antidepressants: 264 drinks during the preceding year for depressed women who used antidepressants; 235, for depressed women who did not use antidepressants; and 179, for nondepressed women.

INTERPRETATION

Results of this cross-sectional study are consistent with a possible beneficial effect of antidepressant use upon drinking by depressed men. Further research is needed, however, to assess whether this finding results from drug effects or some other factor, and to ascertain why the effect was found among men but not women.

The BRENDA model: integrating psychosocial treatment and pharmacotherapy for the treatment of alcohol use disorders

While the U.S. Food and Drug Administration has approved several medications for the treatment of alcohol-related problems, their use has not gained wide acceptance in the United States. Typically, patients with alcohol use disorders are only referred to psychosocial support (e.g., Alcoholics Anonymous). However, the use of pharmacotherapy may complement psychosocial treatments, as evidence shows that pharmacotherapy can improve treatment outcomes. The effectiveness of pharmacotherapy depends on patient compliance with taking the medication and the context in which the medication is administered. BRENDA is a psychosocial program designed specifically to be used by many types of healthcare providers, including primary care clinicians. Designed to enhance medication and treatment compliance, BRENDA is an ideal approach for use in conjunction with pharmacotherapy. The BRENDA approach has 6 components: 1) a biopsychosocial evaluation; 2) a report of findings from the evaluation given to the patient; 3) empathy; 4) addressing patient needs; 5) providing direct advice; and 6) assessing patient reaction to advice and adjusting the treatment plan as needed. This paper describes these components and discusses how the empirical support for each component is linked to the enhancement of medication compliance and the improvement of treatment outcomes.

Gender differences in depression: findings from the STAR*D study

BACKGROUND

Epidemiologic research consistently reports gender differences in the rates and course of major depressive disorder (MDD). The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) multicenter trial provides a unique opportunity to explore gender differences in outpatients with nonpsychotic MDD.

METHODS

This sample included the first 1500 outpatients with MDD who enrolled in STAR*D. Nearly two-thirds of the sample (62.8%) were women. Baseline sociodemographic factors, comorbidities, and illness characteristics were analyzed by gender.

RESULTS

Women (62.8% of the sample) had a younger age at onset of the first major depressive episode. They commonly reported concurrent symptoms consistent with anxiety disorders, somatoform disorder, and bulimia as well as atypical symptoms. Alcohol and drug abuses were more common in men.

LIMITATIONS

This report is a subpopulation of the entire STAR*D sample. These exploratory analyses aimed to identify potential gender differences for further hypothesis testing.

CONCLUSIONS

The gender-specific rate of MDD in this study population is proportional to rates found in community samples with a 1.7:1 prevalence of MDD in women vs. men which argues against increased treatment seeking in women.

Increased mortality in depressive disorders: a review

Several factors have been proposed to explain the relationship between excess mortality and depressive disorders. These include mechanisms such as increased suicide rates, hazardous health behavior (smoking, alcohol use, unhealthy eating), psychologic reactions to developing a medical illness, biological dysregulations (hyperactivity of the hypothalamic pituitary adrenal, neuro-immune dysregulation, sympathoadrenergic dysregulation), and noncompliance with medical treatment. The evidence supporting the role of each of these mechanisms in excess mortality varies considerably. The causal direction in most of the mechanisms is not clear. It is possible that the explanatory factors, such as smoking, compliance, or biological mechanisms, cause depression, or that depression causes these factors, or that both are explained by a third, underlying factor. We will summarize the evidence supporting these mechanisms, and propose options for possible interventions aimed at reducing the increased risk of dying.

Binge drinking and health-related quality of life: do popular perceptions match reality?

BACKGROUND

Popular culture (movies, television shows, advertising) often portrays drinking to the point of intoxication as either humorous or associated with enjoyable social activities that enhance quality of life. This study examined the association between binge drinking (consuming five or more alcoholic drinks on one occasion) and health-related quality of life (HRQOL) among U.S. adults.

METHODS

Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of adults aged >/=18 years conducted in all states. This survey included questions about alcohol consumption and HRQOL.

RESULTS

In 2001, 52% of U.S. adults were current drinkers (one or more drinks in the past 30 days). Of current drinkers, 11% were frequent binge drinkers (three or more episodes in past month) and 14% were infrequent binge drinkers (one to two episodes in past month). After adjusting for confounding factors, frequent binge drinkers were more likely than non-binge drinkers to experience >/=14 unhealthy days (physical or mental) in the past month (adjusted odds ratio [AOR]=1.39, 95% confidence interval [CI]=1.24-1.56), primarily because they had more mentally unhealthy days than non-binge drinkers (AOR=1.52, 95% CI=1.32-1.75).

CONCLUSIONS

Frequent binge drinking is associated with significantly worse HRQOL and mental distress, including stress, depression, and emotional problems. Effective interventions to prevent binge drinking should be widely adopted and may help improve quality of life.

Requiring a one-week addiction treatment experience in a six-week psychiatry clerkship: effects on attitudes toward substance-abusing patients

BACKGROUND

Medical education shapes students' attitudes toward substance-abusing patients, often in negative ways. Curricular interventions to foster more positive attitudes toward such patients and their treatment can have lasting effects on clinical practice. The nature and duration of such interventions, however, requires clarification.

PURPOSE

To test the hypothesis that spending 1 week of a 6-week psychiatry clerkship on an addication treatment site would improve attitudes toward substance-abusing patients without reducing the clerkship's benefits on attitudes toward, and knowledge about, psychiatry patients.

METHOD

Using the Medical Condition Regard Scale, preclerkship and postclerkship attitudes toward patients with alcoholism, major depression, and emphysema (a control condition) were examined in 3rd-year medical students following the conversion of 1 of the clerkship's weeks to an addiction treatment site assignment. Psychiatric knowledge was assessed by comparing scores on the Psychiatry Subject examination before and after the change.

RESULTS

Mean regard scores increased significantly for patients with alcoholism and for patients with major depression but did not change for patients with emphysema. Subject examination scores before and after the curriculum change were not significantly different.

CONCLUSIONS

Spending 1 week of a 6-week psychiatry clerkship on an addiction treatment site increased regard for patients with alcoholism without adversely affecting measures of attitudes toward, and knowledge about, psychiatric patients.