Social capital in relation to depression, musculoskeletal pain, and psychosomatic symptoms: a cross-sectional study of a large population-based cohort of Swedish adolescents

<p>Abstract</p> <p>Background</p> <p>Social capital has lately received much attention in health research. The present study investigated whether two measures of subjective social capital were related to psychosomatic symptoms, musculoskeletal pain, and depression in a large population of Swedish adolescents.</p> <p>Methods</p> <p>A total of 7757 13-18 year old students anonymously completed the Survey of Adolescent Life in Vestmanland 2008 which included questions on sociodemographic background, neighbourhood social capital, general social trust, and ill health.</p> <p>Results</p> <p>Low neighbourhood social capital and low general social trust were associated with higher rates of psychosomatic symptoms, musculoskeletal pain, and depression. Individuals with low general social trust had more than three times increased odds of being depressed, three times increased odds of having many psychosomatic symptoms, and double the odds of having many symptoms of musculoskeletal pain.</p> <p>Conclusions</p> <p>The findings make an important contribution to the social capital - health debate by demonstrating relations between social capital factors and self-reported ill health in a young population.</p

Recovery from dysthymia and panic disorder : Options and obstacles

p>Dysthymia, a depressive disorder with usually an insidious, early onset (before age 21), and panic disorder are psychiatric disorders with a major impact on public health due to their high frequency of recurrence, persistent course and superimposed major depressions. This thesis aimed to improve knowledge of factors that help or hinder recovery from such disorders in ordinary outpatient psychiatric settings. A focus was how various understandings of illness may affect recognition, treatment and outcome. The thesis consists of a study that examined the validity of a self-report instrument for DSM-IV personality disorders, the DIP-Q, in different clinical samples (Paper I), and a prospective 9-year longitudinal study of patients with dysthymia and panic disorder that combined quantitative and qualitative methods (Papers II & III). Paper II presented the long-term outcome, stability of change and impact of comorbid personality disorders. For the investigation of lifetime course and treatments, a modification of the NIMH Life-Charting Methodology was used. Paper III examined the phenomenon of recovery by analysing in-depth interviews with qualitative content analysis. A theory-testing and explorative multiple-case study used developmental cognitive theory as framework to examine barriers to recognition and treatment for patients with early-onset dysthymia (Paper IV). Personality disorders (PD) evaluated by DIP-Q discriminated between different clinical samples and healthy controls, and the self-assessed PD had independent strong associations to depression and belonging to a sample of psychotherapy applicants. In paper II, diagnostic assessments showed low recovery rates; about 50 % had improved, of whom 25 % had recovered. Life-charting and case records indicated that undertreatment contributed to poor outcome. Comorbid PD was a negative prognostic factor and patients with panic disorder had deteriorated compared to the 2-year outcome. Based on the qualitative analysis in Paper III, a general model for recovery from dysthymia and panic disorder is suggested, involving: (1) understanding self and mechanisms of illness, (2) enhanced flexibility of thinking, (3) change from avoidance coping to approach coping, and that a helpful relationship to the health care provider is a vehicle for this change. Patients with dysthymia and panic disorder described specific helpful relationships to therapists ( as a parent vs. as a coach ) and central areas for change (self-acceptance and resolution of relational problems vs. identifying and handling feelings), indicating necessity of distinguishing early onset dysthymia from secondary depressions. The common main obstacle was difficulty in negotiating treatments. Non-remitted with PD had problems expressing needs, which may explain why comorbid PD is a negative prognostic factor. Paper IV showed that barriers to treatment of dysthymia could be explained by misunderstandings as patients mainly expressed illness with a complexity of concrete, perceptually bound language structures and providers focused mainly on a single aspect. Other barriers were patients core pattern of concealing due to fear of rejection and distrust, providers attitudes, access problems and providers lack of follow-up. To achieve higher recovery rates and reduce inequalities in attaining care, comorbid PD need to be assessed and addressed in ordinary psychiatric practice. Early-onset dysthymia needs to be recognised and distinguished from secondary depressions, e.g. by noting cognitive core symptoms and routinely examining age of onset. To enhance collaboration and communication, means of shared understanding and treatment planning are suggested, such as combining diagnostic assessments with attention to patients perceptually bound understanding of illness, goals and treatment preferences, as well as systematic follow-up including re-evaluations. Life-charting may be a tool

Helpful and hindering factors for remission in dysthymia and panic disorder at 9-year follow-up: A mixed methods study

Abstract Background A better understanding is needed of factors behind the long-term outcome of dysthymic and panic disorders. Combining patients' perceptions of factors that help and hind remission with objective assessments of outcome may give greater insight into mechanisms for maintaining recovery. Methods Twenty-three dysthymic and 15 panic disorder patients participated in a 9-year follow-up investigation of a naturalistic study with psychotherapy and antidepressants. Degree of remission was determined by reassessments with SCID-I & II interviews, self-reported symptoms and life-charting (aided by case records). Qualitative content analysis of in-depth interviews with all 38 patients was done to examine the phenomenon of enduring remission by exploring: 1) perceived helpful and hindering factors, 2) factors common to and specific for the diagnostic groups, 3) convergence between patients' subjective views on remission with objective diagnostic assessments. Results About 50% of the patients were in full or partial remission. Subjective and objective views on degree of remission generally converged, and remission was perceived as receiving 'Tools to handle life'. Common helpful factors were self-understanding, enhanced flexibility of thinking, and antidepressant medication, as well as confidence in the therapist and social support. The perceived main obstacle was difficulty in negotiating treatments. Remitted had overcome the obstacles, whereas many non-remitted had problems expressing their needs. Patients with dysthymia and panic disorder described specific helpful relationships with the therapist: 'As a parent' versus 'As a coach', and specific central areas for change: self-acceptance and resolution of relational problems versus awareness and handling of feelings. Conclusion A general model for recovery from dysthymic and panic disorders is proposed, involving: 1) understanding self and illness mechanisms, 2) enhanced flexibility of thinking, and 3) change from avoidance coping to approach coping; and recognising that a vehicle for this change is a helpful relationship to the health care provider. The perceived needs of specific treatment ingredients suggest that it is essential to differentiate between early-onset dysthymia and secondary depressions. The perceived access problems will be further investigated.</p

Predicting Outcome in Internet-Based Cognitive Behaviour Therapy for Major Depression: A Large Cohort Study of Adult Patients in Routine Psychiatric Care.

Although the effectiveness of therapist-guided internet-based cognitive behaviour therapy (ICBT) for treating depression has been well documented, knowledge of outcome predictors and risk factors associated with lower treatment response is limited, especially when the treatment has been conducted within a naturalistic clinical setting. Identification of such factors is important for clinicians when making treatment recommendations.Data from a large cohort (N = 1738) of adult outpatients having been treated with ICBT for depression at an outpatient psychiatric clinic were analysed. A multilevel modelling approach was used to identify patient and treatment variables associated with the speed of recovery during treatment using weekly measurements of the Montgomery Åsberg Depression Rating Scale Self-Rated (MADRS-S).Adhering to the treatment, perceiving it as credible and working full-time emerged as predictors of a faster pace of recovery and were also associated with a lower level of depression at the end of treatment. Higher pre-treatment depression and sleep problems were associated with a greater improvement rate, but predicted higher depression after treatment. Having a history of psychotropic medication was associated with both slower improvement and higher post-treatment depression.Perceived credibility of ICBT is a strong predictor of treatment response. Assessing patient beliefs and expectations may be a useful aid for clinicians when identifying those who are more or less likely to benefit from ICBT. Helping patients improve expectations prior to treatment may be an important goal for clinicians during the initial assessment phase

Psychometric evaluation of the Swedish self-rated 36-item version of WHODAS 2.0 for use in psychiatric populations - using classical test theory.

Aim The aim of this study was to evaluate the reliability and validity of the Swedish version of the self-rated 36-item WHODAS 2.0 in patients from Swedish psychiatric outpatient settings, using classical test theory. Methods The 36-item WHODAS 2.0, together with the Sheehan Disability Scale (SDS), was filled in by a sample of 780 participating psychiatric patients: 512 (65.6%) women, 263 (33.7%) men, and 5 (0.6%) who did not report any sex. Results The internal consistency, measured by Cronbach’s alpha, for the different domains of functioning were between 0.70 and 0.94, and interpreted as good. The confirmatory factor analysis (CFA) revealed two levels: the first level consisted of a general disability factor, while the second level consisted of the six domains of the scale, respectively. The model had borderline fit. There was a significant correlation between WHODAS 2.0 36-item and SDS (n = 395). The WHODAS 2.0 differed significantly between diagnostic groups. Conclusion The present study demonstrates that the Swedish self-rated 36-item version of WHODAS 2.0, within a psychiatric outpatient population, showed good reliability and convergent validity. We conclude that the self-rated 36-item Swedish version of WHODAS 2.0 can be used for valid interpretations of disability in patients with psychiatric health conditions

Evidence for validity of the Swedish self-rated 36-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in patients with mental disorders : a multi-centre cross-sectional study using Rasch analysis

Background The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a generic instrument for the assessment of functioning in six domains, resulting in a total health-related disability score. The aim of this study was to investigate the psychometric properties of the Swedish-language version of the self-rated 36-item version in psychiatric outpatients with various common psychiatric diagnoses using Rasch analysis. A secondary aim was to explore the correlation between two methods of calculating overall scores to guide clinical practice: the WHODAS simple (summative) model and the WHODAS complex (weighted) model. Methods Cross-sectional data from 780 Swedish patients with various mental disorders were evaluated by Rasch analysis according to the partial credit model. Bivariate Pearson correlations between the two methods of calculating overall scores were explored. Results Of the 36 items, 97% (35 items) were within the recommended range of infit mean square; only item D4.5 (Sexual activities) indicated misfit (infit mean square 1.54 logits). Rating scale analysis showed a short distance between severity levels and disordered thresholds. The two methods of calculating overall scores were highly correlated (0.89-0.99). Conclusions The self-administered WHODAS 2.0 fulfilled several aspects of validity according to Rasch analysis and has the potential to be a useful tool for the assessment of functioning in psychiatric outpatients. The internal structure of the instrument was satisfactorily valid and reliable at the level of the total score but demonstrated problems at the domain level. We suggest rephrasing the item Sexual activities and revising the rating scale categories. The WHODAS simple model is easier to use in clinical practice and our results indicate that it can differentiate function among patients with moderate psychiatric disability, whereas Rasch scaled scores are psychometrically more precise even at low disability levels. Further investigations of different scoring models are warranted

Return on investment of internet delivered exposure therapy for irritable bowel syndrome : a randomized controlled trial

Background: Irritable bowel syndrome (IBS) is a debilitating and costly disorder. Cognitive behavior therapy (CBT) is effective in the treatment of IBS, both when delivered over the internet and in face-to-face settings. CBT consists of different components and little is known about their relative importance. We have in an earlier study showed that inclusion of exposure in the CBT for IBS makes it even more effective. In the present study we wanted to evaluate the economic effects for society of inclusion vs exclusion of exposure in an internet delivered CBT for IBS. Methods: We used data from a previous study with 309 participants with IBS. Participants were randomized to internet delivered CBT with (ICBT) or without exposure (ICBT-WE). We compared direct and indirect costs at baseline, after treatment, and 6 months after treatment (primary endpoint; 6MFU). Data was also collected on symptom severity and time spent by therapists and participants. The relative Incremental Cost Effectiveness Ratio (ICER) was calculated for the two treatment conditions and the return on investment (ROI). Results: Results showed that ICBT cost $213.5 (20$300. At a willingness to pay for a case of clinically significant improvement in IBS symptoms of $0, there was an 84$1 invested in ICBT rather than ICBT-WE, the return would be $5.64 six months after treatment. Analyses of post-treatment data showed a similar pattern although cost-savings were smaller. Conclusions: Including exposure in Cognitive Behavior Treatment for IBS is more cost-effective from a societal perspective than not including it, even though it may demand more therapist and patient time in the short term.Funding Agencies|Karolinska InstituteKarolinska Institutet; Region Vastra Gotaland, Sweden</p

Effect of sleep problems on change in depression.

<p>Effect of sleep problems on change in depression.</p