Suicidality in primary care patients who present with sadness and anhedonia: a prospective European study.

BACKGROUND: Sadness and anhedonia (loss of interest in activities) are central symptoms of major depression. However, not all people with these symptoms meet diagnostic criteria for major depression. We aimed to assess the importance of suicidality in the outcomes for primary care patients who present with sadness and anhedonia. METHOD: Cohort study of 2,599 unselected primary care attenders in six European countries followed up at 6 and 12 months. RESULTS: 1) In patients with sadness and/or anhedonia who were not depressed at entry to the study, suicide plans (OR = 3.05; 95 % CI = 1.50-6.24; p = 0.0022) and suicide attempts (OR = 9.08; 95 % CI = 2.57-32.03; p = 0.0006) were significant predictors of developing new onset depression at 6 or 12 months. 2) In patients with sadness and/or anhedonia who met CIDI criteria for major depression at entry, suicidal ideation (OR = 2.93; 95 % CI = 1.70-5.07; p = 0.0001), suicide plans (OR = 3.70; 95 % CI = 2.08-6.57; p < 0.0001), and suicide attempts (OR = 3.33; 95 % CI = 1.47-7.54; p = 0.0040) were significant predictors of persistent depression at 6 or 12 months. CONCLUSIONS: Three questions on suicidality could help primary care professionals to assess such patients more closely without necessarily establishing whether they meet criteria for major depression.

Chronic gastritis.

Prevalence of chronic gastritis has markedly declined in developed populations during the past decades. However, chronic gastritis is still one of the most common serious pandemic infections with such severe killing sequelae as peptic ulcer or gastric cancer. Globally, on average, even more than half of people may have a chronic gastritis at present. Helicobacter pylori infection in childhood is the main cause of chronic gastritis, which microbial origin is the key for the understanding of the bizarre epidemiology and course of the disease. A life-long and aggressive inflammation in gastritis results in destruction (atrophic gastritis) of stomach mucosa with time (years and decades). The progressive worsening of atrophic gastritis results subsequently in dysfunctions of stomach mucosa. Atrophic gastritis will finally end up in a permanently acid-free stomach in the most extreme cases. Severe atrophic gastritis and acid-free stomach are the highest independent risk conditions for gastric cancer known so far. In addition to the risks of malignancy and peptic ulcer, acid-free stomach and severe forms of atrophic gastritis may associate with failures in absorption of essential vitamins, like vitamin B12, micronutrients (like iron, calcium, magnesium and zinc), diet and medicines.

[Development of an algorithm to predict the incidence of major depression among primary care consultants]. / Desarrollo y validación de un algoritmo para predecir riesgo de depresión en consultantes de atención primaria en Chile.

BACKGROUND: The reduction of major depression incidence is a public health challenge. AIM: To develop an algorithm to estimate the risk of occurrence of major depression in patients attending primary health centers (PHC). MATERIAL AND METHODS: Prospective cohort study of a random sample of 2832 patients attending PHC centers in Concepción, Chile, with evaluations at baseline, six and twelve months. Thirty nine known risk factors for depression were measured to build a model, using a logistic regression. The algorithm was developed in 2,133 patients not depressed at baseline and compared with risk algorithms developed in a sample of 5,216 European primary care attenders. The main outcome was the incidence of major depression in the follow-up period. RESULTS: The cumulative incidence of depression during the 12 months follow up in Chile was 12%. Eight variables were identified. Four corresponded to the patient (gender, age, depression background and educational level) and four to patients' current situation (physical and mental health, satisfaction with their situation at home and satisfaction with the relationship with their partner). The C-Index, used to assess the discriminating power of the final model, was 0.746 (95% confidence intervals (CI = 0,707-0,785), slightly lower than the equation obtained in European (0.790 95% CI = 0.767-0.813) and Spanish attenders (0.82; 95% CI = 0.79-0.84). CONCLUSIONS: Four of the factors identified in the risk algorithm are not modifiable. The other two factors are directly associated with the primary support network (family and partner). This risk algorithm for the incidence of major depression provides a tool that can guide efforts towards design, implementation and evaluation of effectiveness of interventions to prevent major depression.

Desarrollo y validación de un algoritmo para predecir riesgo de depresión en consultantes de atención primaria en Chile / Development of an algorithm to predict the incidence of major depression among primary care consultants

Background: The reduction of major depression incidence is a public health challenge. Aim: To develop an algorithm to estimate the risk of occurrence of major depression in patients attending primary health centers (PHC). Material and Methods: Prospective cohort study of a random sample of 2832 patients attending PHC centers in Concepción, Chile, with evaluations at baseline, six and twelve months. Thirty nine known risk factors for depression were measured to build a model, using a logistic regression. The algorithm was developed in 2,133 patients not depressed at baseline and compared with risk algorithms developed in a sample of 5,216 European primary care attenders. The main outcome was the incidence of major depression in the follow-up period. Results: The cumulative incidence of depression during the 12 months follow up in Chile was 12%. Eight variables were identified. Four corresponded to the patient (gender, age, depression background and educational level) and four to patients' current situation (physical and mental health, satisfaction with their situation at home and satisfaction with the relationship with their partner). The C-Index, used to assess the discriminating power of the final model, was 0.746 (95% confidence intervals (CI = 0,707-0,785), slightly lower than the equation obtained in European (0.790 95% CI = 0.767-0.813) and Spanish attenders (0.82; 95% CI = 0.79-0.84). Conclusions: Four of the factors identified in the risk algorithm are not modifiable. The other two factors are directly associated with the primary support network (family and partner). This risk algorithm for the incidence of major depression provides a tool that can guide efforts towards design, implementation and evaluation of effectiveness of interventions to prevent major depression.

Patients' experience with cancer care: a qualitative study in family practice.

BACKGROUND: Continuity is an important aspect of cancer care that is often a challenge owing to the movement of patients between family practice, cancer clinics, and hospitals. OBJECTIVES: To investigate the experiences of cancer patients in relation to continuity of care. METHODS: A qualitative study was conducted in a family practice setting. Semi-structured interviews were used for data collection. 10 cancer patients with a wide variation in their disease duration and experiences with medical care were interviewed. Open questions were used to encourage patients to express their personal experiences with cancer care. The interviews were recorded, transcribed and analysed by three researchers using thematic analysis. RESULTS: Cancer patients experienced a lack of information concerning cancer and its treatment. They also perceived that the cancer treatment made them suffer. In the patients' opinion, the family doctor has a limited role in cancer care. However, the patients felt that the family doctor should be aware of their health. The patients' satisfaction with the oncologist's care was high. They considered that their role in cancer care was to mediate an exchange of information between the oncologist and the family doctor. CONCLUSION: Cancer patients experience continuity of care in several ways: continuity in cancer care should be implemented by co-ordinating activities, such as regular check-ups, a clear timeframe and provision of adequate information. In addition, communication between the primary and secondary sector could be improved.

Physical activity and exercise counselling: a cross-sectional study of family practice patients in Estonia.

BACKGROUND: Low levels of physical activity are common in developed countries. Therefore, regular exercise counselling in family practice is potentially important. AIMS: To assess the physical activity of consecutive patients in family practice settings and to find out whether patients seek advice from their family doctors (FDs) regarding physical activity. METHODS: The study group was made up of consecutive patients aged 18 to 75 years from five family practices across Estonia. Every patient completed a questionnaire to assess physical activity and exercise counselling. The patient's level of physical activity in metabolic units per week (MET, min/week) was calculated on the basis of the International Physical Activity Questionnaire (IPAQ). Questions about counselling for physical activity and lifestyle were also included. RESULTS: The total number of patients was 239. According to the IPAQ, 47% of the patients showed high (MET ≥ 3001), 41% moderate (MET = 601-3000) and 12% low (MET leq 600) physical activity during the previous seven days. Higher physical activity was observed in patients living in rural rather than urban areas (P = 0.025) and in patients who did not suffer from a chronic disease (P = 0.044). Twenty-three percent of participants reported having sought their FD's advice on physical activity and 34% reported that they had received counselling for physical activity. CONCLUSIONS: Physical activity levels in consecutive family practice patients were high in Estonia: 88% of patients reported a moderate or high level of physical activity. In patients' opinions, FDs mostly counsel elderly and obese patients and those with chronic diseases. By contrast, the overall frequency of counselling for physical activity was low.

Differential impact of risk factors for women and men on the risk of major depressive disorder.

PURPOSE: Our aim is to examine which risk factors have a greater impact in women than in men on the risk of major depressive disorder (MDD) and whether factors differ between a possible recurrent MDD and a first onset of MDD. METHODS: Prospective cohort study of general practice attendees in seven countries, who were followed up at 6 and 12 months (predictD). Absolute risk differences (interaction contrast) across sex for onset of DSM-IV MDD after 6 or 12 months of follow-up were estimated for 35 risk factors from 7101 participants without MDD at baseline. RESULTS: A total of 599 participants (80% female) had an onset of MDD at 6 or 12 months. Most risk factors had a greater impact in women than in men on the risk of MDD and were not restricted to a specific class of risk factors. After we stratified for a history of depressive symptoms, we found that the impact of risk factors across sex was generally stronger on possible recurrent MDD than on a first onset of MDD. CONCLUSIONS: Our findings may partly account for the observed difference in incidence of MDD between men and women.

A 10-year serological follow-up of celiac disease in an Estonian population.

BACKGROUND: Celiac disease (CD) is induced by wheat gluten and related prolamines. Its prevalence may be underestimated in many geographic regions and populations, and has recently increased in several countries. In 1998 and 1999, a random sample of Estonian schoolchildren was screened with IgA-type tissue transglutaminase antibodies (IgA-tTG) for CD. The results revealed a CD prevalence of 0.34%, which is lower compared with many other European countries. OBJECTIVE: We rescreened the same population for CD using IgA-tTG after a 10-year interval. MATERIALS AND METHODS: A total of 891 patients from the initial sample were rescreened using the IgA-tTG assay for a participation rate of 76.8% (median age, 24.3 years). As in the initial study, the IgA-tTG results were evaluated by ImmunoCAP EliA Celikey using an IgG-tTG and deamidated gliadin antibody assay for IgA-deficient cases. RESULTS: No new cases of CD were found in this follow-up study. Of note, 75% of patients with initial IgA-tTG-positive results and biopsy-proven CD remained seropositive. One patient with a negative seroconversion at the time of rescreening followed a strict gluten-free diet during the follow-up years. CONCLUSION: In a 10-year follow-up period, no new cases of CD were found in this Estonian population of school-children and young adults. Therefore, we presume no increase in CD during the last decade among this age group in Estonia. Additional studies are needed to determine whether similar results would be obtained in other age groups, because of differences in the CD prevalence between Estonian and other European populations.

Recent life events pose greatest risk for onset of major depressive disorder during mid-life.

BACKGROUND: The authors examined an additive model for the association of life events and age with onset of major depressive disorder (MDD) and whether the combination of life events and age posed greater risk than the sum of their independent effects. METHODS: Data were used from a prospective cohort study of 10,045 general practice attendees (PredictD). We included those without MDD at baseline (N=8293). We examined age divided into tertiles and into 10 year groups. Life events were assessed at baseline using the List of Threatening Life Experiences Questionnaire and categorized according to type. Main outcome measure was onset of DSM-IV MDD at 6 or 12 months of follow-up. The authors calculated Relative Excess Risks due to Interaction (RERI). RESULTS: 6910 persons (83.3%) had a complete follow-up, of whom 589 (8.5%) had an onset of MDD (166 younger, 254 middle aged and 169 older). The combined effect of personal problems (RERI=1.30; 95% CI 0.29 to 2.32), events in family or friends (RERI=1.23; 95% CI 0.28 to 2.19), or problems with law (RERI=1.57; 95% CI 0.33 to 2.82) and middle age was larger than the sum of individual effects. LIMITATIONS: Lower response to recruitment in the UK and the Netherlands. CONCLUSIONS: Recent life events carry the largest risk of onset of MDD in mid-life. Understanding the different vulnerability to life events according to age may help to indicate groups at a particular risk and assist in preventive strategies.

Development and validation of a risk model for prediction of hazardous alcohol consumption in general practice attendees: the predictAL study.

BACKGROUND: Little is known about the risk of progression to hazardous alcohol use in people currently drinking at safe limits. We aimed to develop a prediction model (predictAL) for the development of hazardous drinking in safe drinkers. METHODS: A prospective cohort study of adult general practice attendees in six European countries and Chile followed up over 6 months. We recruited 10,045 attendees between April 2003 to February 2005. 6193 European and 2462 Chilean attendees recorded AUDIT scores below 8 in men and 5 in women at recruitment and were used in modelling risk. 38 risk factors were measured to construct a risk model for the development of hazardous drinking using stepwise logistic regression. The model was corrected for over fitting and tested in an external population. The main outcome was hazardous drinking defined by an AUDIT score ≥8 in men and ≥5 in women. RESULTS: 69.0% of attendees were recruited, of whom 89.5% participated again after six months. The risk factors in the final predictAL model were sex, age, country, baseline AUDIT score, panic syndrome and lifetime alcohol problem. The predictAL model's average c-index across all six European countries was 0.839 (95% CI 0.805, 0.873). The Hedge's g effect size for the difference in log odds of predicted probability between safe drinkers in Europe who subsequently developed hazardous alcohol use and those who did not was 1.38 (95% CI 1.25, 1.51). External validation of the algorithm in Chilean safe drinkers resulted in a c-index of 0.781 (95% CI 0.717, 0.846) and Hedge's g of 0.68 (95% CI 0.57, 0.78). CONCLUSIONS: The predictAL risk model for development of hazardous consumption in safe drinkers compares favourably with risk algorithms for disorders in other medical settings and can be a useful first step in prevention of alcohol misuse.

Factors associated with recurrent depression: a prospective study in family practice.

BACKGROUND: Depression has a high rate of recurrence. Finding the variables that predict which patients are at higher risk of experiencing a recurrent episode of depression would benefit an individual patient. OBJECTIVE: To determine the factors associated with recurrent depression >12 months. METHODS: Consecutive patients (N = 1094), aged 18-75 years, were recruited from 23 family practices across Estonia. The patients were followed up at 6- and 12-month intervals as suggested in the PredictD study. Depression was assessed using the Composite International Diagnostic Interview. Each participant filled in a questionnaire to assess their risk factors for depression. RESULTS: Major depression was diagnosed in 13% of the patients. Twenty-eight per cent of the depressed patients had a recurrent episode of depression 12 months later. The odds of having recurrent depression were significantly higher for patients who had a history of drug abuse, odds ratio (OR) 7.48 [95% confidence interval (CI) = 1.42-39.43), for patients who had experienced discrimination, OR 2.92 (95% CI = 1.05-8.11) and for patients with a history of childhood abuse, OR 1.58 (95% CI = 1.05-2.38). CONCLUSIONS: One-third of the patients developed recurrent depression. Drug abuse, discrimination and childhood abuse predicted recurrent depression. These factors should be taken into consideration by family doctors when managing patients with depression.

Physical activity of Estonian family doctors and their counselling for a healthy lifestyle: a cross-sectional study.

BACKGROUND: Physical activity offers major health benefits and counselling for it should be integrated into the medical consultation. Based on the literature, the personal health behaviour of the physician (including physical activity) is associated with his/her approach to counselling patients. Our hypothesis is that family doctors (FD) in Estonia are physically active and their recommendation to counsel patients with chronic diseases to use physical activity is high. The study was also interested in how FDs value physical activity among other important determinants of a healthy lifestyle, e.g. nutrition, non-consumption of alcohol, and non-smoking. METHODS: Physicians on the electronic list were contacted by e-mail and sent a questionnaire. The first part assessed physical activity by the International Physical Activity Questionnaire (IPAQ) short form. Self-reported physical activity during one week was calculated as total physical activity in minutes per week (MET min/week). The second part of the questionnaire included questions about the counselling of patients with chronic disease concerning their physical activity and a healthy lifestyle. The study focused on female FDs because 95% of the FDs in Estonia are women and to avoid bias related to gender. RESULTS: 198 female FDs completed the questionnaire. 92% reported that they exercised over the past 7 days to a moderate or high level of physical activity. Analysis revealed no statistically significant relationship between the level of physical activity and general characteristics (age, living area, body mass index [BMI], time spent sitting). FDs reported that patients with heart problems, diabetes, and obesity seek their advice on physical activity more often than patients with depression. Over 94% of the FDs claimed that they counsel their patients with chronic diseases about exercising. According to the FDs' reports, the most important topic in counselling patients for a healthy lifestyle was physical activity. CONCLUSION: This study showed that female FDs are physically active. The level of physical activity is not related to their age, BMI, living area, or time spent sitting. Also, FDs reported that promotion of physical activity is part of their everyday work.

Comparison of risk factors for the onset and maintenance of depression.

BACKGROUND: Factors associated with depression are usually identified from cross-sectional studies. AIMS: We explore the relative roles of onset and recovery in determining these associations. METHOD: Hazard ratios for onset and recovery were estimated for 39 risk factors from a cohort study of 10,045 general practice attendees whose depression status was assessed at baseline, 6 and 12 months. RESULTS: Risk factors have a stronger relative effect on the rate of onset than recovery. The strongest risk factors for both onset and maintenance of depression tend to be time-dependent. With the exception of female gender the strength of a risk factor's effect on onset is highly predictive of its impact on recovery. CONCLUSIONS: Preventive measures will achieve a greater reduction in the prevalence of depression than measures designed to eliminate risk factors post onset. The strength of time-dependent risk factors suggests that it is more productive to focus on proximal rather than distal factors.

Subjective disease perception and symptoms of depression in relation to healthcare-seeking behaviour in patients with rosacea.

Many patients with rosacea do not seek medical care. The aim of this study was to find predictors for healthcare-seeking behaviour among patients with rosacea. The study subjects were 70 consecutive patients attending a dermatologist (seekers) and 56 subjects with rosacea symptoms selected randomly from among the working population (non-seekers). All subjects completed an Estonian Mood Scale questionnaire, a screening instrument for depressive symptoms, and evaluated their subjective disease perception on a visual analogue scale (VAS). Multivariate analysis showed that the independent predictors for healthcare-seeking behaviour were VAS scores >5 and the presence of advanced forms of rosacea. Higher mean VAS scores were not related to severity of rosacea, but were associated with the presence of depressive symptoms among seekers. In conclusion, healthcare-seeking behaviour is associated with higher subjective disease perception. The presence of depressive symptoms is not related to severity of the disease, but to the subjective disease perception of rosacea patients.

Patients with depressive disorder, their co-morbidity, visiting rate and disability in relation to self-evaluation of physical and mental health: a cross-sectional study in family practice.

BACKGROUND: High prevalence of depression among primary care patients has increased the need for more research in this field. The objectives of our study were to analyse how depressed patients evaluate their health; which co-morbid diseases are associated with depression; how depression influences the patients' consultation rate in family practice (FP); how disability is associated with depression; and how depression influences the patients' working ability. METHODS: A cross-sectional study, part of the PREDICT study. The study group was formed of 1094 consecutive patients from 23 FPs across Estonia, aged 18-75 years, attending a FP to consult the family doctor (FD). Occurrence of major depression during six months was estimated using the Depression Section of the Composite International Diagnostic Interview. The medical records of all patients were analysed concerning co-morbid diseases, number of visits to the FD, and disability. Every patient filled in questionnaires to assess health-related risk factors for depression, and the SF-12 Health Survey to assess functioning and the perception of health. RESULTS: Depression was found in 230 (21%) of the patients. Depressed patients reported less accomplishment owing to emotional problems (OR 1.80; 95% CI 1.18-2.72), being less careful as usual (OR 1.81; 95% CI 1.26-2.60), and having pain that extremely interfered with their normal work (OR 2.50; 95% CI 1.33-4.70) in comparison with non-depressed patients. Also depressed patients were more days on sick-leave (OR 1.00; 95% CI 1.00-1.01) than non-depressed patients. However, analysis of the medical records did not indicate that depressed patients consulted the FD more or had more co-morbid diagnoses than the non-depressed patients. CONCLUSION: Depressed patients may have low self-reported functioning due to emotional problems, pain, and their working ability may have decreased; however, the patients of both groups have an equal number of co-morbid diagnoses and their consultation rate is similar.

Physical activity of depressed patients and their motivation to exercise: Nordic Walking in family practice.

The objectives of this study were to find out how motivated depressed patients are to exercise regularly, to measure the physical activity of depressed patients and to find out how regular Nordic Walking affects the mood and physical fitness of depressed patients. A cross-sectional study was carried out. Three years after the Prediction of Primary Episodes of Depression in Primary Medical Care study, telephone calls were made to 178 patients who had had depression during that study. We enquired whether and why they would be interested in starting regular Nordic Walking three times a week, at least 30 min at a time, for 24 weeks. Furthermore, there were questions about the patients' earlier physical activity. The Composite International Diagnostic Interview was used to assess depression. To measure physical fitness, we used an outdoor 2 km walking test. Altogether, 106 patients were interviewed, 48 (45%) of them were depressed and 58 (55%) were nondepressed. Of the depressed patients, 16, and of the nondepressed patients, five, started the training programme. During the past 2 years, 12 of the patients had not had any regular physical activity. One-fourth of the depressed patients completed the study. Mean fitness index was 21.99+/-20.38 at week 0 and 38.72+/-26.12 at week 24. The feedback of the patients and their families to the programme was positive. Depressed patients in family practice were physically inactive. About one-third of the depressed patients were motivated to start regular physical activity. Nordic Walking increased the patients' physical activity and improved their mood.

Development and validation of an international risk prediction algorithm for episodes of major depression in general practice attendees: the PredictD study.

CONTEXT: Strategies for prevention of depression are hindered by lack of evidence about the combined predictive effect of known risk factors. OBJECTIVES: To develop a risk algorithm for onset of major depression. DESIGN: Cohort of adult general practice attendees followed up at 6 and 12 months. We measured 39 known risk factors to construct a risk model for onset of major depression using stepwise logistic regression. We corrected the model for overfitting and tested it in an external population. SETTING: General practices in 6 European countries and in Chile. PARTICIPANTS: In Europe and Chile, 10 045 attendees were recruited April 2003 to February 2005. The algorithm was developed in 5216 European attendees who were not depressed at recruitment and had follow-up data on depression status. It was tested in 1732 patients in Chile who were not depressed at recruitment. Main Outcome Measure DSM-IV major depression. RESULTS: Sixty-six percent of people approached participated, of whom 89.5% participated again at 6 months and 85.9%, at 12 months. Nine of the 10 factors in the risk algorithm were age, sex, educational level achieved, results of lifetime screen for depression, family history of psychological difficulties, physical health and mental health subscale scores on the Short Form 12, unsupported difficulties in paid or unpaid work, and experiences of discrimination. Country was the tenth factor. The algorithm's average C index across countries was 0.790 (95% confidence interval [CI], 0.767-0.813). Effect size for difference in predicted log odds of depression between European attendees who became depressed and those who did not was 1.28 (95% CI, 1.17-1.40). Application of the algorithm in Chilean attendees resulted in a C index of 0.710 (95% CI, 0.670-0.749). CONCLUSION: This first risk algorithm for onset of major depression functions as well as similar risk algorithms for cardiovascular events and may be useful in prevention of depression.