Choosing not to undergo predictive genetic testing for hereditary colorectal cancer syndromes: expanding our understanding of decliners and declining.

While medical research continues to investigate the genetic basis of cancer, and personalised prevention gains momentum, little research has been conducted with the individuals who decline predictive genetic testing for cancer. We recruited individuals who had been offered genetic testing for Lynch syndrome or bi-allelic MUTYH mutations due to their participation in a large, population-based, Australia-wide colorectal cancer study. Thirty-three individuals in mutation-carrying families, unaffected by cancer, who had actively or passively declined testing at one of four decision-making points, took part in a qualitative interview about their decision. Data analysis revealed a typology of 'decliners': (1) uninformed about genetic testing; (2) a weak intention to undergo genetic testing; (3) conditionally declining; and (4) unconditionally declining testing. In this population we found substantial barriers to achieving the benefits promised by predictive genetic testing; a lack of knowledge of the availability of genetic testing; a lack of trust in genetic test information; a desire to see a stronger benefit from genetic testing before proceeding; and a sense that there may be more negative than positive outcomes from genetic testing. These discourses must be addressed if medical research on the genetic basis of cancer continues to be funded, and personalised prevention of cancer continues to be recommended by experts.

Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia.

BACKGROUND: Previous research showed an increase in Australian suicide rates during the Global Financial Crisis (GFC). There has been no research investigating whether suicide rates by occupational class changed during the GFC. The aim of this study was to investigate whether the GFC-associated increase in suicide rates in employed Australians may have masked changes by occupational class. METHODS: Negative binomial regression models were used to investigate Rate Ratios (RRs) in suicide by occupational class. Years of the GFC (2007, 2008, 2009) were compared to the baseline years 2001-2006. RESULTS: There were widening disparities between a number of the lower class occupations and the highest class occupations during the years 2007, 2008, and 2009 for males, but less evidence of differences for females. CONCLUSIONS: Occupational disparities in suicide rates widened over the GFC period. There is a need for programs to be responsive to economic downturns, and to prioritise the occupational groups most affected.

Suicide by occupational skill level in the Australian construction industry: data from 2001 to 2010.

OBJECTIVE: This study examines variation in suicide deaths by occupational skill level within the construction industry and changes in the rate of suicide over time. METHODS: Suicide deaths were extracted from a national coronial database and occupations were coded. Adjusted suicide rates over the period 2001 to 2010 were calculated and incidence-rate ratios (IRRs) used to compare the overall burden of suicide in the lowest skilled group (machine operators and labourers) against skilled tradespersons in the construction industry. RESULTS: Those employed as labourers or machine operators had an adjusted rate of 18 per 100,000 persons (95%CI 14-22) and those employed in skilled trades had an adjusted rate of 13 per 100,000 (95%CI 11-15) over the period 2001 to 2010. Compared to skilled trades, the lower skilled group had significantly elevated suicide at several time points over the period 2001 to 2010. The most observable difference in IRRs were in the years 2002 and 2007. CONCLUSIONS: Low-skilled workers in the construction industry had elevated rates of suicide compared to skilled trades workers. IMPLICATIONS: These workers should be targeted by prevention efforts.

Perceived versus predicted risks of colorectal cancer and self-reported colonoscopies by members of mismatch repair gene mutation-carrying families who have declined genetic testing.

People carrying germline mutations in mismatch repair genes are at high risk of colorectal cancer (CRC), yet about half of people from mutation-carrying families decline genetic counselling and/or testing to identify mutation status. We studied the association of quantitative measures of risk perception, risk prediction and self-reported screening colonoscopy in this elusive yet high-risk group. The sample of 26 participants (mean age 43.1 years, 14 women) in the Australasian Colorectal Cancer Family Registry were relatives of mutation carriers; had not been diagnosed with any cancer at the time of recruitment and had declined an invitation to attend genetic counselling and/or testing. A structured elicitation protocol captured perceived CRC risk over the next 10 years. Self-reported colonoscopy screening was elicited during a 45-minute semi-structured interview. Predicted 10-year CRC risk based on age, gender, known mutation status and family history was calculated using "MMRpro." Mean perceived 10-year risk of CRC was 31 % [95 % CI 21, 40], compared with mean predicted risk of 4 % [2, 7] (p < 0.001); this was independent of age and sex (p = 0.9). Among those reporting any medical advice and any screening colonoscopy (n = 18), those with higher risk perception had less frequent colonoscopy (Pearson's r = 0.49 [0.02, 0.79]). People who decline genetic testing for CRC susceptibility mutations perceive themselves to be at substantially higher risk than they really are. Those with high perceived risk do not undertake screening colonoscopy more often than those who perceive themselves to be at average risk.

Life events, first depression onset and the serotonin transporter gene.

BACKGROUND: A relationship between the serotonin transporter gene, adverse events and onset of major depression has been reported. AIMS: To replicate a gene x environment interaction in a cohort with longitudinal data for life events, experience of depression, parental bonding and neuroticism. METHOD: At the 25-year follow-up, genomic DNA was obtained from 127 cohort members (mean age 48 years) to determine the genotype of the serotonin transporter gene-linked promoter region (5-HTTLPR). Associations were investigated between the 5-HTTLPR genotype, positive and adverse life events and the gene x environment interaction, and also between the 5-HTTLPR genotype and risk factors for depression. RESULTS: No relationship was found between 5-HTTLPR genotype and either risk factors for depression or positive life events. Adverse life events had a significantly greater impact on the onset of depression for individuals with the s/s genotype. CONCLUSIONS: The 5-HTTLPR genotype is a significant predictor of onset of major depression following multiple adverse events. This is one of the more robust findings concerning specific biological risk factors for depression.

Smoking cessation and depression: current knowledge and future directions.

This paper reviews the literature on comorbid smoking and depression. Current models used to explain this co-occurrence are examined, as are treatment options (both psychological and pharmacological). This paper surmises that treatment planning should consider factors that potentially confound treatment efficacy, including the nature of the depressive illness and the patient's smoking profile. Although there is limited research examining the benefits of a stepped-care framework, a tiered treatment format appears to work well, assisting those who require minimal treatment, as well as those who prolonged difficulties. Further research examining a stepped-care framework for smokers at risk of depression is required, as is appropriate training for health practitioners using this model. Further directions for research and practice are also discussed.

Great expectations: factors influencing patient expectations and doctors recommendations at a Mood Disorders Unit.

BACKGROUND: Literature about expectations and management of depression within community samples reflects attitudes of people who have generally not received treatment. We examined the factors influencing treatment expectations and psychiatrists' treatment recommendations for patients referred to a mood disorders unit with identified episodes of major depression. METHODS: Prior to attending a mood disorders unit, 182 men and women who met DSM-III-R or DSM-IV criteria for current major depression provided data on sociodemographic details, history of medical and psychiatric illness and expectations of treatment. Psychiatrists' treatment recommendations to the referring clinician were assessed to determine whether the patients' initial expectations were met. RESULTS: Data analyses revealed three factors relating to patients' expectations: "enhanced coping", "providing fresh ideas for the referring doctor" and "providing fresh ideas to self". Patients' expectations were influenced by sociodemographic and illness-related characteristics. In particular, young female patients typically expected to receive strategies to enhance coping, while those with lifetime anxiety expected less active involvement on their part. Some clinicians' recommendations were dependent upon depression type and patient factors. Women and those with a history of anxiety disorders received more education and recommendations for relationship counselling and support groups. LIMITATIONS: The study design did not allow determination of the impact of patients' expectations on the psychiatrists' recommendations. CONCLUSIONS: Individual and illness characteristics are important predictors of treatment expectations prior to specialist care. It appears that doctors take these factors into account with implications for patients' satisfaction with the type of care recommended.

The stability of the Parental Bonding Instrument over a 20-year period.

BACKGROUND: The Parental Bonding Instrument (PBI) measures the perception of being parented to the age of 16 years. Low scores on the care dimension and high scores on the overprotection dimension are considered to be risk factors of depression. While the PBI has been shown to be a reliable and valid instrument, the stability of the PBI over extended periods (taking into account individual characteristics and life experience) needs to be demonstrated. METHOD: The PBI was measured in a non-clinical cohort on four waves between 1978 and 1998, along with a series of self-report measures including state depression and neuroticism. Differences in PBI change over time were examined by gender, lifetime major depression diagnosis, and life event variables, as well as by scores on neuroticism and state depression. RESULTS: Acceptable retest coefficients on PBI scores over the 20-year study were found for the cohort. No differences were found in PBI scores over time on the variables examined, including sex and depression measures. CONCLUSIONS: The results indicate long-term stability of the PBI over time. The influences of mood state and life experience appear to have little effect on the stability of the perception of parenting as measured by the PBI. The present study increases confidence in the PBI as a valid measure of perceived parenting over extended time periods.

A review of HIV prevention among young injecting drug users: A guide for researchers.

Young people aged 15-24 years account for fifty percent of all new AIDS cases worldwide. Moreover, half of all new HIV infections are associated with injection drug use. The average age for initiation into injecting drug use is 20 years of age. This paper investigates whether HIV prevention programs have reduced risk behaviours in young people.

Grey lungs and blue moods: smoking cessation in the context of lifetime depression history.

OBJECTIVE: To present an overview of the relationship between depression and cigarette smoking and to provide recommendations for clinicians who wish to help patients with a history of depression to stop smoking. METHOD: English language journal articles published in the last 15 years on clinical material related to depression history, smoking cessation and related health issues were collected via MEDLINE, PsycINFO and Cochrane Library database searches. RESULTS: Nicotine dependence is associated with increased rates of depression prior to and after taking up smoking as well as increased rates of suicidal ideation. Depression history is associated with increased rates of nicotine dependence, problems with smoking cessation and depression after cessation. While nicotine replacement and counselling are effective for smoking cessation, standard smoking cessation strategies may not pay sufficient attention to the needs of smokers with a depression history. Some antidepressants (bupropion and nortriptyline) are particularly effective for those with a lifetime depression history as they appear to assist with dysphoria during withdrawal and prevent relapse. Psychological and lifestyle strategies, such as motivational interviewing, relaxation exercises and mood charts, assist in mood regulation over and above the standard smoking cessation treatments for smokers with a depression history, who require more attention to relapse of depression and smoking after quitting. CONCLUSIONS: There is a complex and circular relationship between depression, smoking and medical illness that complicates smoking cessation in those who have a history of depression. Depression-history smokers require a multimodal approach to assist with mood regulation and nicotine withdrawal. Further research is required to identify effective strategies to reduce smoking in this context.