Association of sleep characteristics with suicidal ideation and suicide attempt among adults aged 50 and older with depressive symptoms in low- and middle-income countries.

OBJECTIVES: Investigate the association of sleep characteristics with suicidal ideation and suicide attempt among middle-aged and older adults with depressive symptoms in five low- and middle-income countries (LMICs). DESIGN: Cross-sectional. SETTING: China, Ghana, India, Russia, and South Africa. PARTICIPANTS: Adults aged ≥50 years with depressive symptoms from the World Health Organization (WHO) Study on Global AGEing and Adult Health (n=2,040). MEASUREMENTS: Predictors were self-reported average sleep duration for the past 2 nights (<7 hours (shorter), 7 to <9 hours (reference), ≥9 hours (longer)), sleep quality for the past 2 nights (moderate/good/very good [both nights], poor/very poor [≥1 night]), past-month insomnia symptoms (none/mild, moderate, severe/extreme), and past-day daytime sleepiness. Outcomes were past-year suicidal ideation and suicide attempt. Analyses were adjusted for age, sex, household wealth, marital status, self-rated health, cognitive performance, number of depressive symptoms, and country of residence. RESULTS: Participants with poor/very poor sleep quality ≥1 night had greater odds of suicidal ideation (vs. moderate/good/very good sleep quality both nights). Participants with moderate and severe/extreme insomnia symptoms had greater odds of suicidal ideation and suicide attempt (vs. none/mild insomnia symptoms). In moderation analyses, greater insomnia symptoms were associated with higher odds of suicidal ideation among women only and those aged 60-60 years and ≥80 years only. CONCLUSIONS: Among middle-aged and older adults with depressive symptoms in LMICs, sleep characteristics are markers of-and potential contributors to-suicidal ideation and suicide attempt, and there was evidence of moderation by age and sex. Interventions aimed at preventing suicide-related outcomes in these populations should consider the role of sleep.

Pain severity as a mediator of the association between depressive symptoms and physical performance in knee osteoarthritis.

OBJECTIVE: Depressive symptoms in knee osteoarthritis (OA) are associated with increased pain severity and declines in physical performance. This study examined whether pain severity mediates the association between depressive symptoms and physical performance in persons with radiographic knee OA. METHOD: Three years of annual data from participants (n = 1,463) with radiographic knee OA in the Osteoarthritis Initiative (OAI) were analyzed. Depressive symptoms were measured using the Center for Epidemiological Studies Depression (CES-D) scale. Pain severity was evaluated with the Western Ontario and McMaster Universities Arthritis Index. Physical performance was assessed via standardized gait speed. Marginal structural models were used to assess the direct (unmediated) effects of depressive symptoms on physical performance and indirect (mediated) effects through pain severity. RESULTS: Direct and indirect effects for a difference in CES-D score of 0-1 were -0.0051 (95% confidence intervals (CI): -0.0053, -0.0049) and -0.0016 (95% CI: -0.0024, -0.0007) standard deviations in gait speed, respectively. Higher depressive symptom severity exhibited diminishing, incremental, direct and indirect effects and for a difference in CES-D score of 15-16 were -0.0045 (95% CI: -0.0047, -0.0042) and -0.0009 (95% CI: -0.0014, -0.0004) standard deviations in gait speed, respectively. Therefore, the magnitude of the mediated, indirect effect, was never larger than 24%. CONCLUSION: Pain severity mediated approximately one-fifth of the association between depressive symptoms and physical performance in persons with radiographic knee OA, and the diminishing incremental effects may explain why unimodal treatment strategies with a single disease target are often ineffective in depressed OA patients.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers.

Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

[Intratumoral versus subareolar injection in breast cancer sentinel lymph node biopsy. A case report]. / Inyección intratumoral versus subareolar en el diagnóstico de la biopsia del ganglio centinela, en el carcinoma de mama. A propósito de un caso.

The use of deep (intratumoral, peritumoral) and superficial (subdermal, subareolar) administration is recognized as valid in sentinel lymph node biopsy for breast cancer. Herein, we are presenting a clinical case in which a personalized methodology was a determining factor in axillary staging. Initially, the radiotracer was injected intratumorally guided by ultrasound. The ultrasound scan identified a previously unknown axillary lymphadenopathy, with focal cortical thickening, this being a non-specific ultrasound finding, but with possibility of biopsy. The lymphoscintigraphy did not show uptake in the mentioned node, hence, a second subareolar dose was administered. On this occasion, the lymphoscintigraphy detected drainage to the sentinel node, which was the only one positive for micrometastases.

Cost-effective analysis of genotyping using oral cells in the geriatric population.

We evaluated the cost-effectiveness of using buccal swab brushes in comparison with blood samples for obtaining DNA for large epidemiological studies of the elderly population. The data reported here are from the third phase of the Integral Study of Depression among the Elderly in Mexico City's Mexican Institute of Social Security, conducted in 2007. The total cost of the two procedures was determined. The measurement of effectiveness was the quality and quantity of DNA measured in ng/µL and the use of this DNA for the determination of apolipoprotein E (APO E) polymorphism by PCR. Similar rates of amplification were obtained with the two techniques. The cost of the buccal swab brushes, including sample collection and DNA extraction, was US$16.63, compared to the cost per blood sample of US$23.35. Using the buccal swab, the savings was US$6.72 per patient (P < 0.05). The effectiveness was similar. Quantity and quality of DNA obtained were similar for the oral and blood procedures, demonstrating that the swab brush technique offers a feasible alternative for large-scale epidemiological studies.

The link between depressive symptoms, negative cognitive bias and memory complaints in older adults.

OBJECTIVES: We sought to examine the relationship between depressive symptoms and subjective memory problems. We hypothesized that the relationship between depressive symptoms and poor subjective memory functioning is mediated by negative cognitive bias that is associated with hopelessness, a wish to die and low self-esteem. METHODS: Complete data were available for 299 older adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate, completed a baseline in-home assessment. Subjective memory functioning and psychological status was assessed with commonly used, validated standard questionnaires. RESULTS: In regression models that included terms for age, gender and cognitive measures, depressive symptoms were significantly inversely associated with the global self-assessment of memory (beta=-0.019; p=0.006). When components of negative cognitive bias were included in the model (hopelessness, low self-esteem, a wish to die), the relationship of depressive symptoms with subjective memory problems was attenuated, consistent with mediation. CONCLUSIONS: Our results suggest that assessment and successful interventions for memory complaints in non-demented older adults need to account for negative cognitive bias as well as depressive symptoms. Longitudinal research is needed to confirm our findings before a mediator relationship can be presumed.

Personal characteristics associated with consistency of recall of depressed or anhedonic mood in the 13-year follow-up of the Baltimore Epidemiologic Catchment Area survey.

OBJECTIVE: Our study addressed two primary questions: (1) How reliable is long-term recall of lifetime history of episodes of depressed mood? (2) What characteristics are associated with consistent recall of this history? METHOD: Psychiatric symptoms were assessed in a population-based longitudinal survey of 1498 persons twice, in 1981 and 1994. Respondents whose reports of history of depressed affect were discordant after a 13-year follow-up interval were compared with those whose reports were concordant. RESULTS: Absence of a reported history of episode of depressed mood was more consistently recalled than presence of such an episode. The kappa of reported lifetime history of episode of depressed mood was 0.32. Several personal characteristics predicted consistency of recall. CONCLUSION: If assessment of past episodes of depressed mood is used as guide for identifying cases at risk for depression, account must be taken of the personal factors that might influence recall.

Linking depressive symptoms and functional disability in late life.

We hypothesized that the relationship of depressive symptoms to functional disability might be mediated by cognitive processes such as memory and problem-solving. The study sample consisted of 147 community-dwelling older adults (mean age = 74.0 years, SD = 5.9). In regression models that included terms for age, gender, and years of education, depressive symptoms were significantly inversely associated with two performance-based measures of functioning: everyday problems test (beta = -0.15, p = 0.04) and observed tasks of daily living (beta = -0.14, p = 0.02). When memory and problem-solving ability were added to the model, the relationship of depressive symptoms with function was attenuated. A structural equation model based on our conceptual framework revealed that both memory and problem-solving abilities were important mediators in the relationship of depressive symptoms and functional disability. The results suggest that intervention studies intended to limit functional disability secondary to depression among older adults may need to consider the effect of depression on cognition.

The association of gynecological symptoms with psychological distress in women of reproductive age: a survey from gynecology clinics in Beirut, Lebanon.

To date there has been no previous research into a possible association between psychological distress and gynecologic symptoms in the Arab world. We hypothesized that psychological distress would be associated with specific gynecologic complaints as well as with psychosocial factors. We conducted a cross-sectional study of women attending gynecology clinics in Beirut, Lebanon. The study sample consisted of 355 women aged 18 to 49 years who were seeking healthcare from gynecologists affiliated with two general teaching hospitals in Beirut. Psychological distress was assessed using the General Health Questionnaire (GHQ). Gynecologic complaints were assessed by asking women about presenting gynecologic symptoms. Women who visited the gynecologists for specific complaints, for post-surgical follow-up, or for insertion of coils or other services were more likely to be distressed than women who were attending for a general checkup (chi 2 = 9.466, p = 0.024). About 50% of women who reported abdominal pain or breast pain also reported significant psychological distress. Only bleeding and infertility were not significantly associated with psychological distress. It is concluded that a high proportion of women who attend gynecology clinics with specific complaints report psychological distress. Our findings highlight the importance of considering the psychological component of gynecological morbidity.

Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland.

BACKGROUND: Utilizing a prospectively designed community sample, we set out to estimate the rate of newly-incident suicidal ideation and attempts (non-fatal suicide behaviour) in a community sample, to evaluate antecedent sociodemographic characteristics and psychiatric disorders, and to assess use of mental health services in relation to non-fatal suicide behaviour. METHOD: Prospectively-gathered data was utilized from 3481 continuing participants in the 13-year follow-up of the Baltimore sample of the NIMH Epidemiologic Catchment Area survey interviewed in 1981, 1982 and 1993/6. RESULTS: The incidence of suicide attempts was estimated at 148.8 per 100,000 person-years and ideation at 419.9 per 100,000 person-years. Persons in the youngest age group, in the lowest socioeconomic status, and previously married persons were at increased risk for non-fatal suicide behaviour during the follow-up interval. Persons who reported suicidal ideation at baseline were more likely to report having attempted suicide at follow-up (RR = 6.09, 95% CI 2.58-14.36). Psychiatric disorders, especially depression and substance abuse, were associated with new-onset of non-fatal suicidal behaviour. While persons who reported newly-incident suicidal behaviour were more likely to report use of mental health services, few said that suicidal ideation or attempts were the reason for the visits. CONCLUSIONS: Suicidal ideation is a common and important antecedent to suicide attempts and deserves more attention in community and general medical settings.

Epidemiology of unexplained fatigue and major depression in the community: the Baltimore ECA follow-up, 1981-1994.

BACKGROUND: Fatigue is a common, non-specific, subjective symptom associated with several medical and psychiatric illnesses. The purpose of this investigation was to explore further the epidemiology of unexplained fatigue in the general population and the relationship between fatigue and depression. METHODS: The design was a prospective population-based study. Subjects included community-dwelling adults who were participants of the Baltimore sample of the Epidemiologic Catchment Area Program in 1981 and who were reinterviewed 13 years later. Lay interviewers using the Diagnostic Interview Schedule interviewed subjects. RESULTS: Number of somatization symptoms and history of a dysphoric episode at baseline were the two strongest predictors of both new onset of fatigue as well as recurrent/chronic fatigue over the 13-year follow-up interval. In addition, individuals who reported a history of unexplained fatigue at baseline as well as during the follow-up, were at markedly increased risk for new onset major depression as compared to those who never reported such fatigue, (RR = 28.4, 95% CI) (11.7, 68.0). Similarly, respondents who developed new fatigue or had remitted fatigue after 1981 were also at increased risk for developing major depression. CONCLUSIONS: Somatization was the strongest predictor of both new and chronic fatigue with unknown cause. In addition, fatigue was both predictive and a consequence of the depression syndrome.

The systematic assessment of depressed elderly primary care patients.

Studies of the primary care treatment of depressed elderly patients are constrained by limited time and space and by subject burden. Research assessments must balance these constraints with the need for obtaining clinically meaningful information. Due to the wide-ranging impact of depression, assessments should also focus on suicidality, hopelessness, substance abuse, anxiety, cognitive functioning, medical comorbidity, functional disability, social support, personality, service use and satisfaction with services. This paper describes considerations concerning the assessment selection process for primary care studies, using the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study as an example. Strategies are discussed for ensuring that data are complete, valid and reliable.

A factor analysis of the fagerstrom tolerance questionnaire.

A factor analysis of 1309 Fagerstrom Tolerance Questionnaires (FTQ) was performed with LISCOMP software, which utilizes tetrachoric correlations to account for the dichotomous responses of the FTQ. Three factors with eigenvalues greater than 1.0 were obtained, accounting for 56.6% of the variance. Factor 1 was loaded by questions "How soon on waking do you smoke your first cigarette?," "Do you find it difficult to refrain from smoking in places it is forbidden?," "How many cigarettes a day do you smoke?," and "Do you smoke if you are so ill that you are in bed most of the day?" Factor 2 was loaded by questions "Which cigarette would you hate to give up?" and "Do you smoke more during the morning than during the rest of the day?" Factor 3 was loaded exclusively by question "What brand do you smoke?" The question "Do you inhale always, sometimes, or never?" loaded exclusively on a fourth factor, however its eigenvalue did not reach significance. Support is provided for the modification of the eight-item FTQ to the six-item Fagerstrom Test for Nicotine Dependence (FTND). Based on the wording of the questions that loaded on each factor, we propose that Factor 2 assesses the degree of urgency to initiate smoking after overnight abstinence and that Factor 1 reflects the persistence of smoking during waking hours.

occupational physical activity and the development of impaired mobility: the 12-year follow-up of the Baltimore Epidemiologic Catchment Area sample.

OBJECTIVE: To examine the association between occupational physical activity and self-reported disability. DESIGN: Population-based case control analysis of a longitudinal population-based study in east Baltimore. Eligible participants were aged 18 to 29 yr in 1981, had complete information on occupation in 1981, no disability with tasks related to the domain of mobility in 1981, and complete information on mobility function in 1993 (n = 174). Occupations were divided into low, moderate, and high metabolic equivalents based on job category in 1981. The main outcome measure was disability defined by self-report of difficulty in one or more of five exercise mobility tasks in 1993. RESULTS: Of 174 eligible participants, 45 (26%) reported the onset of disability at follow-up in 1993. A crude odds ratio of 0.25 (95% confidence interval, 0.06, 0.82) was found for the association of moderate compared with low occupational physical activity and the risk of incident disability in mobility tasks. After adjustments to control for possible confounders, moderate job metabolic activity (1.8-2.9 Mets) was independently protective against disability in this cohort (odds ratio = 0.25; 95% confidence interval = 0.083, 0.783). CONCLUSION: In this cohort of people aged 18 to 29 yr, a moderate amount of occupational physical activity was protective against disability in mobility tasks.

Education bias in the mini-mental state examination.

Education is correlated with cognitive status assessment. Concern for test bias has led to questions of equivalent construct validity across education groups. Following the work of previous researchers, we submitted Mini-Mental State Examination (MMSE) responses to external validation analyses. Subjects were older participants in the Epidemiologic Catchment Area study (age 50-98). Little evidence for test bias against those with low education was found. The correlation of MMSE scores and age was equivalent across high- and low-education groups (-.29 vs. -.27, p = .48), as was the correlation of MMSE scores and activities of daily living (ADL) functioning (-.23 vs. -.27, p = .42). The MMSE displayed significantly higher internal consistency reliability in the low-education group (.75 vs. .72, p = .04). The MMSE did not predict functional decline over 1 year or mortality over 13 years differently by level of educational attainment. Evidence for sex bias was found. The MMSE was more highly correlated with age among women than among men (-.28 vs. -.21, p < .001). The MMSE was more highly correlated with ADL impairment among women than among men (-.30 vs. -.17, p = .01). The MMSE predicted mortality differently according to participant sex (p = .053). The lack of evidence for bias provides little support to proposals to adjust MMSE scores according to level of education.

Major depression and cancer: the 13-year follow-up of the Baltimore epidemiologic catchment area sample (United States).

OBJECTIVE: The relationship between depression and development of cancer is not well understood, with some studies finding a significant but small increase in risk for cancer among persons with depression. No studies have employed standardized interviews keyed to the diagnostic criteria for Major Depression. Our objective was to evaluate the relationship between Major Depression at baseline and new onset of cancer at follow-up. METHOD: The study was based on a population-based 13-year follow-up survey of community-dwelling adults living in East Baltimore in 1981. After excluding 372 persons with a history of cancer or those whom reported their health as poor at the baseline interview, 3109 adults remained. Information on baseline depression status and cancer at follow-up was available for 2017 persons. A diagnosis of cancer was ascertained at follow-up through interview of survivors and from death certificates. RESULTS: There were 203 new cases of cancer among 2017 persons at risk. Neither Major Depression (relative risk (RR) = 1.0, 95% confidence interval (CI) 0.5-2.1) nor dysphoric episode (RR = 1.3, 95% CI 0.9-1.9) were significantly associated with increased risk of cancer at follow-up. However, among women with Major Depression, the risk of breast cancer was increased (adjusted RR = 3.8, 95% CI 1.0-14.2). CONCLUSIONS: We found no overall association of depression with cancer. However, among women, Major Depression (but not dysphoric episode alone) was associated with the onset of breast cancer.