Is depression associated with pathways to care and diagnosis delay in people with tuberculosis in Ethiopia?

BACKGROUND

Co-morbid depression is common in people with tuberculosis (TB). Symptoms of depression (low energy, impaired concentration, decreased motivation and hopelessness) may affect help-seeking; however, this impact has not been studied so far. The objectives of this study were to assess the impact of co-morbid depression on diagnostic delay, pathways to care, and to identify if it mediates other factors associated with diagnostic delay.

METHODS

We analyzed cross-sectional data collected from 592 adults with newly diagnosed TB. We assessed probable depression using Patient Health Questionnaire, nine items (PHQ-9) at a cut-off 10. Data on diagnosis delay, pathways to TB care, socio-demographic variables, stigma, types of TB, substance use, co-morbid chronic illnesses, and perception about TB were assessed using a structured questionnaire. Generalized structural equation modelling was used to analyze the data.

RESULTS

A total of 313 (52.9%) participants had probable depression. Pathway to TB care was direct for 512 (86.5%) of the participants and indirect for 80 (13.5%) of them. The median diagnosis delay was 12.0 weeks. Depression did not have a statistically significant association with pathways to TB care (β = -0.45; 95% CI-1.85 to 0.96) or diagnostic delay [adjusted odds ratio (AOR) = 0.90; 0.77-1.06]. Indirect pathway to TB care was positively associated with diagnosis delay (AOR = 2.72; 95% CI 1.25-5.91).

CONCLUSIONS

People with TB who had co-morbid probable depression visited the modern health care as directly as and as soon as those without co-morbid depression. How socio-demographic factors influence pathways to care and diagnosis delay require qualitative exploration.

Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study

AIM

There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.

METHODS

In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.

RESULTS

Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.

CONCLUSIONS

An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.

Food insecurity among people with severe mental disorder in a rural Ethiopian setting: a comparative, population-based study

AIM

In low-income African countries, ensuring food security for all segments of the population is a high priority. Mental illness is associated consistently with poverty, but there is little evidence regarding the association with food insecurity. The aim of this study was to compare the levels of food insecurity in people with severe mental disorders (SMD) with the general population in a rural African setting with a high burden of food insecurity.

METHOD

Households of 292 community-ascertained people with a specialist-confirmed diagnosis of SMD (including schizophrenia and bipolar disorder) were compared with 284 households without a person with SMD in a rural district in south Ethiopia. At the time of the study, no mental health services were available within the district. Food insecurity was measured using a validated version of the Household Food Insecurity Access Scale. Disability was measured using the World Health Organisation Disability Assessment Schedule 2.0.

RESULT

Severe household food insecurity was reported by 32.5% of people with SMD and 15.9% of respondents from comparison households: adjusted odds ratio 2.82 (95% confidence interval 1.62 to 4.91). Higher annual income was associated independently with lower odds of severe food insecurity. When total disability scores were added into the model, the association between SMD and food insecurity became non-significant, indicating a possible mediating role of disability.

CONCLUSION

Efforts to alleviate food insecurity need to target people with SMD as a vulnerable group. Addressing the disabling effects of SMD would also be expected to reduce food insecurity. Access to mental health care integrated into primary care is being expanded in this district as part of the Programme for Improving Mental health carE (PRIME). The impact of treatment on disability and food insecurity will be evaluated.

Factors influencing women in physical activity programs in Malaysia

The majority of research on factors associated with women participation in physical activity (PA) has been in developed countries with limited research in developing countries. Few women in Malaysia are active at the recommended levels for health, and activity rates are less than developed countries. Little research has focused specially on physically active Malaysian women and the factors that contribute to them becoming and staying active in PA programs. This lack of knowledge hinders the tailored development and implementation of PA programs to meet their needs. The aim of this study was to identify the factors of participation in PA programs for Malaysian women. The social-ecological model was used to investigate and theme the factors. Focus group discussion was conducted with participants in six PA programs targeted specifically to women. Thirty-seven women were involved in the focus group discussion, with ages ranging from 19 to 82 years. Inductive and deductive content analysis was conducted from verbatim transcripts using NVivo. Inductive content analysis allowed raw data and second-order themes to emerge. Findings revealed social support structures, tailored programs for women, and location were key contributors that encouraged women to participate in these programs. The similarity in contributors between women in non-western and western countries signifies a prime opportunity for bi-lateral relationships to be formed to enable the enhancement of program development relevant to different ethnicities and cultures within or across countries.

'Restoring the person's life': a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia

AIMS

In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia.

METHODS

The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework.

RESULTS

Three main themes were identified. (1) Focused on 'Restoring the person's life', including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting.

CONCLUSIONS

Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.

Adapting the Bayley Scales of infant and toddler development in Ethiopia: evaluation of reliability and validity

BACKGROUND

There is a need for valid and reliable observational measures of early child development in low-income and middle-income country settings.

METHODS

The aims of the study were to adapt the Bayley Scales of Infant Development (Bayley III) for a rural Ethiopian setting and evaluate reliability and validity. The study was carried out between January 2008 and January 2009 in the Butajira demographic surveillance site, south central Ethiopia. The Bayley III was adapted to be socioculturally appropriate for a rural Ethiopian context. Nurses and high school graduates were trained in administration of the measure for 10 days. Inter-rater reliability was evaluated (n = 60). Content, construct and convergent validity was then examined on a population-based cohort of children at the ages of 30 (n = 440) and 42 months (n = 456). Mokken scale analysis was used to determine the scalability of items in unidimensional, hierarchical sub-scales. The mean score was compared by age of child and by stunting status (less than -2 z scores below the standard height-for-age).

RESULTS

The intra-class correlations between raters were above 0.90 for all sub-scales of the child development measure. Some scale items were not contextually relevant and showed poor scalability. However, the majority of items scaled onto the existing sub-scales of the international measure to form adequate-to-strong hierarchical scales with good internal consistency (Cronbach's α above 0.70 except for gross motor and expressive language sub-scales). Item-scale coefficients were good. The mean score of all sub-scales was significantly higher in the older group of children (33.02 higher total score; P < 0.001) and in the children who were stunted (total Bayley score 2.58 (95% confidence interval 0.07 to 5.10) points lower at 30 months and 3.87 (1.94 to 5.81) points lower at 42 months.

CONCLUSIONS

An adapted version of an international, observational measure of child development was found to be reliable, valid and feasible in a rural Ethiopian setting.

Exposure to Helicobacter pylori infection in early childhood and the risk of allergic disease and atopic sensitization: a longitudinal birth cohort study

Background

An inverse relation between Helicobacter pylori infection and allergic disease has been reported by a range of independent epidemiological studies, but evidence from longitudinal studies is scarce.

Objective

We have investigated the effects of H. pylori infection on the incidence and prevalence of allergic diseases and sensitization in a low-income birth cohort.

Methods

In 2005/2006, a population-based birth cohort was established in Butajira, Ethiopia, and the 1006 singleton babies born were followed up at ages 1, 3, and 5. Symptoms of allergic disease were collected using the ISAAC questionnaire, allergen skin tests performed, and stool samples analysed for H. pylori antigen and geohelminths. Multiple logistic regression was used to determine the independent effects of H. pylori measured at age 3 on the incidence of each outcome between ages 3 and 5 years (in those without the outcome at age 3), controlling for potential confounders, and to additionally assess cross-sectional associations.

Results

A total of 863 children were followed up to age 5. H. pylori infection was found in 25% of the children at both ages 3 and 5, in 21% at age 5 but not 3, and in 17% at age 3 but not at age 5. H. pylori infection at age 3 was significantly associated with a decreased risk of incident eczema between ages 3 and 5 (adjusted OR, 95% CI, 0.31; 0.10–0.94, P = 0.02). Cross-sectionally at age 5, H. pylori infection was inversely associated with skin sensitization (adjusted OR, 95% CI, 0.26; 0.07–0.92, P = 0.02).

Conclusion and clinical relevance

These findings provide further evidence to suggest that early-life exposure to H. pylori may play a protective role in the development of allergy.

Prevalence and risk factors of wheeze and eczema in 1-year-old children: the Butajira birth cohort, Ethiopia

BACKGROUND

The rising global prevalence of asthma and other allergic conditions has been linked to potential aetiological factors influencing the developing immune system.

OBJECTIVE

To investigate the prevalence and associated risk factors for wheeze and eczema in 1-year-old children in a birth cohort from Butajira, Ethiopia.

METHODS

In 2005/6, a population-based cohort of 1065 pregnant women was established. At 1 year of age, data on wheeze and eczema in the children were collected from the mother via an interview-administered questionnaire, along with numerous demographic and lifestyle factors. A stool sample was also obtained from the child for geohelminth analysis.

RESULTS

The prevalence of wheeze was 11.5% (103/899) and eczema 8.6% (77/899). Independent predictors of wheeze were maternal allergic history [adjusted OR (AOR)=3.00, 95% CI 1.23-7.36], paternal allergic history (AOR=2.59, 95% CI 1.08-6.25), increasing household size (P for trend=0.023; AOR=3.54, 95% CI 1.31-9.56 for 7+ vs. 1-3 individuals) and paracetamol use by the child (overall P<0.001; AOR 11.04, 95% CI 4.30-28.31 for 4+ tablets in past month vs. never). Factors independently associated with eczema were maternal allergic history (AOR=3.68, 95% CI 1.54-8.77), household size (overall P=0.035; AOR=0.45, 95% CI 0.23-0.87 for 4-6 individuals relative to 1-3) and place of sleeping (overall P<0.001; AOR=0.29, 95% CI 0.10-0.82 for floor vs. bed/platform).

CONCLUSION

These findings support the hypothesis that eczema in early life in these children is a manifestation of allergy, while wheezing is probably due to infection as well as allergy.

Rabies in a puppy imported from India to the USA, March 2007

In March 2007, a puppy that was recently imported from India into the United States was found to be positive for rabies by the Alaska Department of Health and Social Services. This case report highlights several important public health issues. First, recognizing that humans and animals are part of a global community with frequent travel and translocation, the risks of disease introduction, particularly with sub-clinical or incubating animals, are real and present. Animal-importation regulations, policies and practices are intended to minimize these risks and should be routinely evaluated and updated as needed in response to occurrences such as detailed in this communication. Second, veterinarians play key roles in safeguarding the public's health with regard to monitoring the movement of animals and diagnosing zoonoses. Third, investigating rabies cases that involve multiple jurisdictions are labour-intensive and require significant resources to ensure that all potentially exposed persons are identified and receive the appropriate rabies post-exposure prophylaxis.

A single-institution validation of the AJCC staging system for stage IV melanoma

8517

Background: We sought to validate the AJCC staging system for stage IV melanoma in a contemporary, prospective, single- institution cohort and explore additional clinical factors that may influence prognosis. Methods: A prospective institutional database identified 1319 patients with stage IV melanoma. To minimize tertiary center referral bias, only patients seen prior to a stage IV diagnosis were included (n=687). Variables were dichotomized: lactate dehydrogenase (LDH) (=200, >200), number of metastases (1, >1), and number of involved organs (1, >1). Kaplan-Meier curves were generated and Cox regression was used to identify factors independently predictive of survival. Results: Demographics are provided in the table . The median age at diagnosis of stage IV was 55 years (range 16–94) and the median disease free interval (DFI) was 12 months (0–181). The overall median survival was 10 months (5–21) with a median follow-up for survivors of 31 months (9–68); 569 deaths were observed. Cox regression analysis ( table ) identified younger age at stage IV diagnosis, a longer DFI, and a normal LDH to be predictive of improved survival. Patients with either distant skin/subcutaneous/nodal or pulmonary disease experienced prolonged survival when compared to patients with metastases to other visceral sites. Survival was improved in patients with a single metastatic site at diagnosis of stage IV. Gender, antecedent stage, and number of involved organs were not associated with outcome. Conclusions: In this single institution cohort of patients with stage IV melanoma, poorer survival in patients with non-pulmonary visceral metastases and/or abnormal LDH levels as described by the AJCC staging system was confirmed. Additionally, the number of metastases at the time of diagnosis of stage IV was the most powerful predictor of poorer survival and may be a variable to consider in future staging systems.

No significant financial relationships to disclose.

[Table: see text]

Prevalence of hepatitis B and C infection in a methadone clinic population: implications for hepatitis B vaccination

AIMS

To examine the HBV and HCV markers of injecting drug users on methadone maintenance, and the feasibility of vaccination at the drug clinic.

METHODS

Systematic serological testing of patients for hepatitis B and C was undertaken, and free hepatitis B vaccination was offered via arranged clinic appointments.

RESULTS

Hepatitis B serology was obtained in 163 of the 220 clinic patients. 85 (52.1%) patients had evidence of hepatitis B exposure, and 3 (1.8%), of previous vaccination. Positive hepatitis B markers were associated with increasing age (p=0.004), and the duration of injecting prior to treatment (p=0.008). Hepatitis B and C serology was obtained for 153 patients, with 76 (49.7%) having evidence of dual exposure. 164 (84.1%) of 195 patients were positive for antibody to hepatitis C. Completion of the vaccine course was lower than anticipated (36.5% of HBV negative patients).

CONCLUSIONS

The high rates of hepatitis B exposure in injecting drug users on methadone treatment confirm the need for hepatitis B vaccination, particularly in view of their endemic hepatitis C infection. Monitoring of this group for the development of chronic liver disease and hepatocellular carcinoma is recommended. Routine cost-free vaccination of patients on entering drug treatment, using a rapid vaccination schedule, may improve compliance.

GAD65 and insulin B chain peptide (9-23) are not primary autoantigens in the type 1 diabetes syndrome of the BB rat

To investigate whether GAD65 whole molecule, GAD65 p35 or insulin B chain peptide (amino acids 9-23) play an essential role in the pathogenesis of type 1 diabetes in the BioBreeding (BB) rat, we gave serial injections of GAD65, p35 or insulin B chain (9-23) to six groups of BB/Worcester rats. The individual antigens were administered either intrathymically on day 2 and intraperitoneally in MF 59-0 adjuvant 5 times during the first 5 weeks, or by intranasal instillation once neonatally and 5 days/week for the following 6 weeks. Control groups were injected with vehicle only. Age of onset of diabetes and degree of insulitis were not different between controls and antigen-treated rats. Rats that received GAD65 intrathymically and intraperitoneally developed high GAD65-antibody titers without altering diabetes development. In GAD65-treated animals, serum antibodies recognized epitopes at 3 sites on GAD65 in diabetic animals but only at 1 site in non-diabetic animals. GAD65-injected animals also showed a significant reduction of IFN-gamma mRNA expression in the thymus. This study provides evidence against the hypothesis that GAD65 and insulin B chain peptide (9-23) are primary diabetogenic autoantigens in BB rats because immunizations with these antigens and GAD65-induced immune deviation did not alter the development of diabetes.

Capillariasis in the trachea of a raccoon

Cross-sections of nematodes were seen in histologic sections of trachea from a raccoon (Procyon lotor) collected in Virginia (USA); they occupied epithelium and contained unembryonated, bioperculated eggs characteristic of the genus Capillaria (= Eucoleus). A mild inflammatory cell infiltrate in the lamina propria subjacent to the nematode was the only apparent host response. This is the first report of capillariasis in the trachea of raccoons.

Improved survival in stage III melanoma patients with GM2 antibodies: a randomized trial of adjuvant vaccination with GM2 ganglioside

PURPOSE

To perform a double-blind randomized trial with American Joint Commission on Cancer (AJCC) stage III melanoma patients for the following reasons: (1) to confirm our previous finding that patients with antibodies against the melanoma differentiation antigen GM2 have an improved prognosis, and (2) to demonstrate clinical benefit from GM2 antibody induction.

PATIENTS AND METHODS

One hundred twenty-two patients with AJCC stage III melanoma who were free of disease after surgery were randomized: 58 to receive treatment with the GM2/BCG vaccine, and 64 to receive treatment with bacille Calmette-Guèrin (BCG) alone. All patients were pretreated with low-dose cyclophosphamide (Cy).

RESULTS

GM2 antibody was detected in 50 of 58 patients treated with GM2/BCG and seven of 64 patients treated with BCG alone. With a minimum follow-up period of 51 months, there was a highly significant increase in the disease-free interval (P = .004) and a 17% increase in overall survival (P = .02) in these 57 antibody-positive patients, confirming our earlier experience. Exclusion of all patients with preexisting GM2 antibodies (one in the GM2/BCG group and five in the BCG group) from statistical analysis resulted in a 23% increase in disease-free interval (P = .02) and a 14% increase in overall survival (P = .15) at 51 months for patients treated with the GM2/BCG vaccine. However, when all patients in the two treatment groups were compared as randomized, these increases were 18% for disease-free interval and 11% for survival in the GM2/BCG treatment group, with neither result showing statistical significance.

CONCLUSION

(1) Vaccination with GM2/BCG induced immunoglobulin M (IgM) antibodies in most patients. (2) GM2 antibody production was associated with a prolonged disease-free interval and survival. (3) Comparison of the two arms of this trial as randomized fails to show a statistically significant improvement in disease-free interval or survival for patients treated with GM2/BCG vaccines.

In vivo expression of inducible nitric oxide synthase in experimentally induced neurologic diseases

The purpose of this study was to investigate the induction of inducible nitric oxide synthase (iNOS) mRNA in the brain tissue of rats and mice under the following experimental conditions: in rats infected with borna disease virus and rabies virus, in mice infected with herpes simplex virus, and in rats after the induction of experimental allergic encephalitis. The results showed that iNOS mRNA, normally nondetectable in the brain, was present in animals after viral infection or after induction of experimental allergic encephalitis. The induction of iNOS mRNA coincided with the severity of clinical signs and in some cases with the presence of inflammatory cells in the brain. The results indicate that nitric oxide produced by cells induced by iNOS may be the toxic factor accounting for cell damage and this may open the door to approaches to the study of the pathogenesis of neurological diseases.

Prerequisites for oral immunization of free-ranging raccoons (Procyon lotor) with a recombinant rabies virus vaccine: study site ecology and bait system development

A model baiting system suitable for the delivery of an oral rabies vaccine to free-ranging raccoons (Procyon lotor) was developed and tested on barrier islands in South Carolina (USA). Features of barrier island physiography and ecology were studied relative to selective bait deployment and site biosecurity. Capture-mark-recapture data were obtained from 228 raccoons. Raccoon density estimates, using a modified census assessment technique, were one raccoon per 1.8 to 2.7 ha. Mean (+/- SE) and range home area estimates of radio-collared raccoons were 84 (+/- 15.6) ha (27 to 176 ha) by a minimum convex polygon method and 138 (+/- 22.8) ha (43 to 241 ha), by a harmonic mean transformation method. Habitat utilization determinations of radio-collared raccoons were conducted to identify study areas to potentially maximize selectivity of bait towards raccoons and to reduce the absolute number of baits deployed. Island raccoons showed a habitat preference for maritime forest, maritime shrub and marsh areas. Additionally, there was no evidence of inter-island or mainland exchange of ear-tagged or radio-collared raccoons. A disease and mortality survey was conducted to identify baseline pathology and incidental lesions in the target raccoon population, prior to actual vaccination initiation. Thirty-eight percent of 30 clinically suspect raccoons sampled had intracytoplasmic eosinophilic inclusions diagnostic of canine distemper; no other lesions suggestive of viral etiologies were found. Serological surveys for raccoon poxvirus and rabies virus antibodies were negative. Antibody titers to canine adenovirus 1 and 2 indicated a moderate level of exposure (approximately 10 to 16%) in the raccoon population. Overall, 93 to 100% of placebo baits were consistently disturbed by 7 days post-bait deployment, and bait acceptance rates by raccoons ranged from 49 to 85%, by using a modular systems approach to select the optimum combination of bait attractant, biomarker, matrix, density, and distribution. These results suggest that a large proportion (up to 85%) of a free-ranging island raccoon population can be selectively and safely targeted, marked and monitored utilizing a proposed oral bait delivery system for recombinant or other rabies vaccines.

Signs of REM prior to the first REM period in prepubertal children

In a previous publication, prepubertal depressives were found not to exhibit a shortened REM period latency during active illness when compared with pathological and normal control groups. It was hypothesized that this might be due to a nonselective inhibition of REM sleep by slow-wave sleep (SWS), which is quite intense among prepubertal children, especially during the first 2 h of the sleep period. A number of polysomnographic signs normally associated with REM sleep were observed to occur periodically, prior to the beginning of the first REM period. It was thought that these signs might be indicative of "minor escapes" of REM sleep activity from the inhibitory influence of SWS. It was further hypothesized that differences among the experimental groups in the occurrence (timing and amount per minute) of these signs support the idea of an inhibitory effect of SWS on REM; and thus offer an explanation for the apparent dissociation between the depressive disorder among prepubertal children and a shortened REM period latency. The hypotheses were not supported by the results presented here indicating that the above dissociation is probably not due to inhibitory mechanisms of SWS on REM sleep.

Growth hormone secretion in prepubertal children with major depression. IV. Sleep-related plasma concentrations in a drug-free, fully recovered clinical state

Prepubertal children with major depressive disorder have shown increased growth hormone (GH) secretion during sleep while in a depressive episode. When restudied in a fully recovered state (for at least three months) and drug free (for at least one month), their increased GH secretory pattern during sleep had not changed. Illness-recovery correlations using area under the curve for GH secretion during sleep were highly significant, whereas paired comparisons showed no significant differences. In addition, children who had recovered from major depressive episodes secreted significantly more GH during sleep than did nondepressed neurotic and normal children. No significant differences in delta-sleep were found in the depressed group between ill and recovered states nor among those who had recovered from major depressive episodes or controls. It is concluded that increased GH secretion during sleep is independent of depressive episodes, remains unaltered after full recovery, and may be a true marker of trait for major depressive disorder in prepuberty.

Growth hormone secretion in prepubertal children with major depression. II. Sleep-related plasma concentrations during a depressive episode

Plasma growth hormone (GH) concentrations were determined every 20 minutes during sleep in 71 prepubertal children: 22 had endogenous major depressive disorder, 20 had nonendogenous major depressive disorder, 21 had nondepressed neurotic disorders, and eight were normal. Both depressive groups secreted significantly more GH during sleep than did controls. Measures included maximal GH plasma peak and area under the curve (AUC) during the total sleep period, during the first three hours after sleep onset, and during the first five hours after sleep onset. An AUC cutoff of 2,000 ng X min/mL identified positively half the prepubertal children with major depression; with a specificity of 78% (v neurotics) and 100% (v normal children). Increased GH secretion during sleep may be a marker of illness, a past episode, or trait for prepubertal major depression regardless of endogenicity.

Spindle characteristics in prepubertal major depressives during an episode and after sustained recovery: a controlled study

In a previous publication, this group reported a dissociation between multiple sleep complaints and polysomnographic abnormalities in prepubertal major depressive children. Spindle activity has been thought by some to be a correlate of restorative sleep. On this basis, it was hypothesized that prepubertal depressives might exhibit differences in sleep spindle characteristics when compared with normal and psychiatric control groups, and with their former state during sustained recovery in a drug-free state. Further, it was thought that clinical complaints of disrupted sleep might be related to differences in spindle characteristics. Spindle frequency (Hz) was the only significant finding among the groups, but it was not specific to depressive disorder, since all psychiatric groups presented higher frequencies than did normal children. As expected, significant differences across halves of the sleep period time (SPT) were also found for the number of spindles, frequency (Hz), duration (ms), spindle density (rate), and the amount of stage 2 sleep (min). The presence or absence of sleep complaints had no bearing on spindle characteristics, thus indicating a lack of apparent relationship between the two. Upon recovery the depressives exhibited no changes across clinical state, and a cross-sectional comparison of the recovered data with the original control data gave results essentially identical to the first (active illness) comparisons. It is suggested that high spindle frequency may be a nonspecific correlate of emotional disorders in prepuberty, which, at least in depressives, does not change with clinical state.

Sleep architecture and REM sleep measures in prepubertal children with attention deficit disorder with hyperactivity

A 2-night polysomnographic study of 9 rigorously assessed prepubertal children who fit Diagnostic Statistical Manual-III criteria for attention deficit disorder with hyperactivity (ADDH) and a contrast group of 11 control children is reported. Despite the fact that 57% of the ADDH group were reported to experience restless sleep on structured parental rating forms, they did not show any sleep architecture abnormalities on polysomnographic recordings when compared with the normals at baseline other than decreased rapid eye movement (REM) activity. Seven of the ADDH boys were restudied after 6 months of continuous methylphenidate therapy (mean daily dose of 34.4 +/- 14.0 mg or 1.4 +/- 0.7 mg/kg). Across and within (pre-post) group comparisons showed that methylphenidate therapy was associated with delayed sleep onset, lengthened sleep, and changes in certain REM sleep variables.

Sleep architecture and REM sleep measures in prepubertal major depressives. Studies during recovery from the depressive episode in a drug-free state

The sleep of 28 fully recovered, drug-free, prepubertal patients with major depressive disorder was recorded for three consecutive nights in the laboratory. Recovered depressives had significantly shorter first rapid eye movement period (REMP) latencies and a higher number of REMPs compared with themselves when depressed and with nondepressed neurotic and normal children. In addition, most sleep continuity measures improved considerably on recovery. We suggest that a short first REMP latency may be a marker of past episode or of trait in prepubertal major depressives.

Sleep architecture and REM sleep measures in prepubertal children with major depression: a controlled study

We performed a three-night polysomnographic study of 54 rigorously assessed, drug free, prepubertal children who fit unmodified Research Diagnostic Criteria for major depressive disorder, and two groups of nondepressed controls (25 with emotional disorders and 11 who were normal). The groups did not differ polysomnographically, even though a high proportion of depressives and neurotics reported sleep disturbance in structured interviews. Sleep stage data do not appear to differentiate children with prepubertal major depressive disorders from nondepressed neurotic or normal children. Other psychobiologic findings in prepubertal depressives together with marked age effects on polysomnographic correlates of adult major depressive disorders suggest the hypothesis that polysomnographic abnormalities in adult major depressives are secondary to an interaction between depression and age.