Perceived helpfulness of treatment for generalized anxiety disorder:a World Mental Health Surveys report

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment.METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment.RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness.CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.</p

The epidemiology of drug use disorders cross-nationally:Findings from the WHO's World Mental Health Surveys

BACKGROUND: Illicit drug use and associated disease burden are estimated to have increased over the past few decades, but large gaps remain in our knowledge of the extent of use of these drugs, and especially the extent of problem or dependent use, hampering confident cross-national comparisons. The World Mental Health (WMH) Surveys Initiative involves a standardised method for assessing mental and substance use disorders via structured diagnostic interviews in representative community samples of adults. We conducted cross-national comparisons of the prevalence and correlates of drug use disorders (DUDs) in countries of varied economic, social and cultural nature.METHODS AND FINDINGS: DSM-IV DUDs were assessed in 27 WMH surveys in 25 countries. Across surveys, the prevalence of lifetime DUD was 3.5%, 0.7% in the past year. Lifetime DUD prevalence increased with country income: 0.9% in low/lower-middle income countries, 2.5% in upper-middle income countries, 4.8% in high-income countries. Significant differences in 12-month prevalence of DUDs were found across country in income groups in the entire cohort, but not when limited to users. DUDs were more common among men than women and younger than older respondents. Among those with a DUD and at least one other mental disorder, onset of the DUD was usually preceded by the 'other' mental disorder.CONCLUSIONS: Substantial cross-national differences in DUD prevalence were found, reflecting myriad social, environmental, legal and other influences. Nonetheless, patterns of course and correlates of DUDs were strikingly consistent. These findings provide foundational data on country-level comparisons of DUDs.</p

Unipolar Depression and the Progression of Coronary Artery Disease:Toward an Integrative Model

Background: Despite extensive research on the relationship between depression and coronary artery disease (CAD) after an acute coronary syndrome (ACS), causal interpretations are still difficult. This uncertainty has led to much confusion regarding screening and treatment for depression in CAD patients. Method: A critical and conceptual analysis of the pertinent literature, which elaborates the implications of the heterogeneity in symptom pattern, etiology, and course of depression in CAD patients. Results: We propose an integrative dynamic model of the depression-CAD relationship. The model rests on three core hypotheses: (1) Depression in CAD patients consists of mixtures of two types of depression, denoted as 'cognitive/affective' and 'somatic' depression, each having a somewhat characteristic symptom expression and etiology. (2) Effects of depression on CAD depend on the type and duration of depression. The dynamic aspect of the model indicates that post-ACS depression shifts, when it persists, from a marker of the severity (somatic type) and meaning (cognitive/affective type) of the ACS to a largely indirect causal factor in the progression of CAD. (3) The most plausible pathways mediating the effects of persistent/recurrent depression, irrespective of type, on cardiac prognosis are behavioral and act by making depressed CAD patients more susceptible to other CAD risks. The model offers testable predictions and explanations for a variety of apparently unrelated or inconsistent findings. Conclusion: The proposed model may have potential for integrating findings regarding the depression-CAD relationship, contributing to the clarification of discords on screening and treatment of depression, and guiding future research. Copyright (C) 2011 S. Karger AG, Base

Prevention of major depression in complex medically ill patients: preliminary results from a randomized, controlled trial

Background: Depression is highly prevalent in patients with physical illness and is associated with a diminished quality of life and poorer medical outcomes. Objective: The authors evaluated whether a multifaceted intervention conducted by a psychiatric consultation-liaison nurse could reduce the incidence of major depression in rheumatology inpatients and diabetes outpatients with a high level of case complexity. Method: Of 247 randomized patients, the authors identified 100 patients with a high level of case complexity at baseline and without major depression (65 rheumatology and 35 diabetes patients). Patients were randomized to usual care (N = 53) or to a nurse-led intervention (N = 47). Main outcomes were the incidence of major depression and severity of depressive symptoms during a 1-year follow-up, based on quarterly assessments with standardized psychiatric interviews. Results: The incidence of major depression was 63% in usual-care patients and 36% in the intervention group. Effects of intervention on depressive symptoms were observed in outpatients with diabetes but not in rheumatology inpatients. Conclusion: These preliminary results based on subgroup analysis suggest that a multifaceted nurse-led intervention may prevent the occurrence of major depression in complex medically ill patients and reduce depressive symptoms in diabetes outpatients. (Psychosomatics 2009; 50: 227-233)

Why would associations between cardiometabolic risk factors and depressive symptoms be linear?

In medical science, researchers mostly use the linear model to determine associations among variables, while in reality many associations are likely to be non-linear. Recent advances have shown that associations may be regarded as parts of complex, dynamic systems for which the linear model does not yield valid results. Using as an example the interdepencies between organisms in a small ecosystem, we present the work of Sugihara et al. in Science 2012, 338:496-500 who developed an alternative non-parametric method to determine the true associations among variables in a complex dynamic system. In this context, we discuss the work of Jani et al. recently published in BMC Cardiovascular Disorders, describing a non-linear, J-shaped curve between a series of cardiometabolic risk factors and depression. Although the exact meaning of these findings may not yet be clear, they represent a first step in a different way of thinking about the relationships among medical variables, namely going beyond the linear model

The presence of a depressive episode predicts lower return to work rate after myocardial infarction

AbstractContextNo studies have evaluated whether the presence of a depressive episode is associated with an increased risk of not returning to work following myocardial infarction (MI).ObjectivesTo examine the prospective associations between depressive episode and anxiety disorders with return to work (RTW) after MI at 3 and 12 months based on International Classification of Diseases, 10th Revision.DesignProspective cohort study.SettingFour hospitals in the North of The Netherlands.ParticipantsFrom a sample of patients hospitalized for MI (n=487), we selected those who had a paid job at the time of the MI (N=200).Main exposure measuresPresence of a depressive episode and presence of any anxiety disorder during the first 3 months post-MI.Main outcome measuresRTW at 12 months post-MI.ResultsOf the patients with work prior to MI, 75% had returned to work at 12 months. The presence of a depressive episode during the first 3 months (prevalence: 19.4%) was a significant predictor of no RTW at 12 months post-MI, also after controlling for confounders [odds ratio (OR) 3.48; 95% confidence interval (CI): 1.45–8.37]. The presence of an anxiety disorder (prevalence: 11.9%) had a borderline significant association with no RTW as well. This association remained after controlling for confounders (OR 2.90; 95% CI: 1.00–6.38) but diminished when controlling for depression.ConclusionsThe presence of a depressive episode was associated with an increased risk of no RTW in MI patients. The association between anxiety and risk of no RTW could in part be explained by the presence of depression. Further studies may address the possibility of countering the effect of depression by effective treatment

Onset and Recurrence of Depression as Predictors of Cardiovascular Prognosis in Depressed Acute Coronary Syndrome Patients:A Systematic Review

Background: Depression after acute coronary syndrome (ACS) is associated with worse cardiac outcomes. This systematic review evaluated whether depressed ACS patients are at differential risk depending on the recurrence and timing of onset of depressive episodes. Methods: MEDLINE, EMBASE and PsycINFO were searched from inception to 11 April 2009. Additionally, reference lists and recent tables of contents of 34 selected journals were manually searched. Eligible studies evaluated cardiovascular outcomes for subgroups of ACS patients with depression or depressive symptoms according to recurrence or onset. Results: Six studies were included that reported outcomes for subgroups of ACS patients with first-ever versus recurrent depression. Four of these reported also outcomes for post-ACS onset versus pre-ACS onset depression, and incident versus nonincident depression. Worse outcomes (odds ratio &gt;1.4) were reported for ACS patients with first-ever depression in 3 of 6 studies (1 study p &lt;0.05), for patients with post-ACS onset depression in 3 of 4 studies (1 study p &lt;0.05, but better outcomes in one study) and for patients with incident depression in 2 of 4 studies (no studies p &lt;0.05). Conclusions: Although it is still suggested that ACS patients with first and new-onset depression are at particularly increased risk of worse prognosis, the inconsistent results from the studies included in this systematic review show that there is no consistent evidence to support such statements. Copyright (C) 2011 S. Karger AG, Basel</p

Childhood trauma and bullying-victimization as an explanation for differences in mental disorders by sexual orientation

Sexual minority individuals are more likely to have mental disorders, including mood, anxiety, and substance use disorders, compared to heterosexual individuals. Whether experiencing trauma or bullying-victimization during childhood explains these differences is currently unclear. We used a psychiatric epidemiological general population-based study to assess whether childhood trauma severity and bullying-victimization before age 16 explains the difference by sexual attraction in mental disorders. Data from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2; N = 6392) were used to examine (1) whether same/both-sex attraction and predominantly other-sex attraction is linked to self-reports of childhood trauma (types and severity) and bullying-victimization, and (2) whether these experiences explain differences between these groups in lifetime and 12-month prevalence of DSM-IV disorders assessed by the Composite International Diagnostic Interview 3.0. Same/both-sex attracted individuals reported a higher childhood trauma severity score compared to exclusively other-sex attracted individuals (B = 0.93, SE = 0.20, p < .001), and were more likely to report bullying-victimization (OR = 2.51 95%CI[1.68, 3.74]). DSM-IV disorders were more prevalent among same/both-sex attracted individuals than among exclusively other-sex attracted individuals (ORs ranged from 1.57 to 4.68). There were no differences in DSM-IV disorders for predominantly other-sex attracted individuals. Childhood trauma severity explained between 9.0% and 57.0% of significant indirect associations between same/both-sex attraction and DSM-IV disorders. Sexual minority individuals experience more types of, and more severe childhood trauma, and are more likely to experience bullying-victimization. These negative experiences partly explained disparities in mental disorders