Mediators of the association between depression and role functioning.

OBJECTIVE: While the adverse effect of Major Depressive Episode on role functioning is well established, the exact pathways remain unclear. METHOD: Data from The European Study of the Epidemiology of Mental Disorders, a cross-sectional survey including 21 425 adults from six European countries, were used to assess 12-month depression (Composite International Diagnostic Interview), activity limitations and role functioning in the past 30 days (Disability Assessment Schedule). An a priori model based on the World Health Organization's International Classification of Functioning, Disability and Health was designed and a structural equation model for categorical and ordinal data was used (MPlus) to estimate the extent to which six limitations mediated the association between depression and role functioning. RESULTS: The unadjusted association between depression and role functioning was strong (0.43; SE = 0.04). In the best-fitting model, only concentration and attention problems and embarrassment mediated a significant amount of association (direct effect dropped to 0.17; SE = 0.10, which was no longer significant). CONCLUSIONS: Targeting cognition and embarrassment in treatment could help reduce depression-associated role disfunctioning.

Psychometric properties of the World Health Organization Disability Assessment Schedule used in the European Study of the Epidemiology of Mental Disorders.

This study assessed the factor structure, internal consistency, and discriminatory validity of the World Health Organization Disability Assessment Schedule (WHODAS) version used in the European Study of the Epidemiology of Mental Disorders (ESEMeD). In total 8796 adults were assessed using the ESEMeD WHODAS (22 severity and 8 frequency items). An Exploratory Factor Analysis (EFA) with promax rotation was done with a random 50%. The other half was used for confirmatory factor analysis (CFA) comparing models (a) suggested by EFA; (b) hypothesized a priori; and (c) reduced with four items. A CFA model with covariates was conducted in the whole sample to assess invariance across Mediterranean (Spain, France and Italy) and non-Mediterranean (Belgium, Germany and the Netherlands) countries. Cronbach's alphas and discriminatory validity were also examined. EFA identified seven factors (explained variance: 80%). The reduced model (six factors, four frequency items excluded) presented the best fit [Confirmatory Fit Index (CFI) = 0.992, Tucker-Lewis Index (TLI) = 0.996, Root Mean Square Error of Approximation (RMSEA) = 0.024]. The second-order factor structure also fitted well (CFI = 0.987, TLI = 0.991, RMSEA = 0.036). Measurement non-invariance was found for Embarrassment. Cronbach's alphas ranged from 0.84 for Participation to 0.93 for Mobility. Preliminary data suggest acceptable discriminatory validity. Thus, the ESEMeD WHODAS may well be a valuable shortened version of the WHODAS-II, but future users should reconsider the filter questions.

Assessment of severity of hand eczema: discrepancies between patient- and physician-rated scores.

BACKGROUND: In clinical practice or trials on hand eczema the severity of this disease can be 'measured' in different ways: by means of a physician-rated clinical severity score, a patient-rated clinical severity score or by an indicator of the burden of disease. We assume that the patient-rated severity score corresponds more with the (change in) burden of disease than with the physician-rated severity score. OBJECTIVES: To demonstrate how physicians and patients differ in their assessment of the severity of hand eczema as seen in a physician-rated severity score, patient-rated severity score and a burden of disease questionnaire. METHODS: We used data from an open-label randomized controlled trial which was set up in two university hospital dermatology departments in the Netherlands, specializing in hand eczema. One hundred and fifty-eight patients with moderate to severe chronic hand eczema were included. The main outcome measures were the physician-rated severity score, based on five visible aspects of hand eczema (desquamation, erythema, vesicles, infiltration, fissures), the patient-rated severity score (a self-rating scale), a burden of disease questionnaire (the Dermatology Life Quality Index, DLQI) and the correlations between these parameters, both at inclusion and over time. RESULTS: Only desquamation and infiltration were significantly correlated with patient-rated severity score. Patient-rated severity score correlated with seven of 10 DLQI items, but it did not correlate with the items regarding influence on clothes worn, impairment of sporting activities, and problems associated with treatment of the skin. The majority of patients showed improvement in all parameters after treatment. However, the improvement in patient-rated severity score was not clearly correlated with changes in physician-rated severity score. Except for DLQI item 1 (itch, soreness, pain, stinging), none of the changes in burden of disease was correlated with changes in patient-rated severity score. For each DLQI item, change over time correlated weakly with decreases in several, but not all, components of the physician-rated severity score. CONCLUSIONS: Disease severity can be expressed by different scores; these scores are not clearly correlated, and measure different aspects. Patient satisfaction is not guaranteed when treatment is focused solely on the visible aspects of hand eczema. Instead, burden of disease has a greater impact.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q).

OBJECTIVE: To evaluate the psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q) in patients with atrial fibrillation. DESIGN: A prospective study of the patients who underwent DC electrical cardioversion. SETTING: Clinics of cardiology and thoracic surgery of the University Hospital in Groningen, the Netherlands. MAIN OUTCOME MEASURES: The disease-specific MLHF-Q and generic measures of quality of life were administered. The sensitivity to change over time was tested with effect sizes (ES). Internal consistency of MLHF-Q scales was estimated with Cronbach's alpha. To evaluate the construct validity multitrait-multimethod analysis was applied. The 'known group validity' was evaluated by the comparison of mean scores and effect sizes between two groups of the New York Heart Association (NYHA) classification (NYHA I versus II-III). Stability of MLHF-Q scales was estimated in a subgroup of patients who remained stable. Perfect congruence analysis and factor analysis were applied to confirm the a priori determined structure. RESULTS: Cronbach's alpha was > or = 0.80 of the MLHF-Q scales. Perfect congruence analysis (PCA) showed that the results resemble quite well the a priori assumed factor structure. Multitrait-multimethod analysis showed convergent validity coefficients ranging from 0.59 to 0.73 (physical impairment dimension) and 0.39 to 0.69 (emotional dimension). The magnitude of change can be interpreted as medium (ES = 0.50). The results of a 'test-retest' analysis in a stable group can be valued as satisfactory for the MLHF-Q scales (Pearson's r > 0.60). The physical dimension and the overall score of the MLHF-Q discriminated significantly between the NYHA I and II-III groups (p < 0.001) with large effect sizes (ES > 1.0).

Factors related to successful job reintegration of people with a lower limb amputation.

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.

Recovery of physical function after limb injuries in independent older people living at home.

OBJECTIVES: to describe changes in physical functioning after fall-related injuries to the limbs in independently living older people. DESIGN: prospective cohort study, including a pre-injury assessment and post-injury assessments at 8 weeks and 5 and 12 months. SETTING: the study is part of the larger, population-based prospective and longitudinal Groningen Longitudinal Aging Study on the determinants of health-related quality of life of people aged 57 and over, who are living independently in the north of the Netherlands. SUBJECTS: 171 patients who sustained injuries at various sites on the limbs and who had completed all four assessments (66% of the eligible population). Patients were grouped according to injury site. OUTCOME MEASURE: self-reported grades of difficulties with performing basic and instrumental activities of daily living as measured by the Groningen Activity Restriction Scale. RESULTS: 1 year after the injury, pre-injury (mean) levels of functioning were not regained in any of the groups studied. However, only those with fractures of the wrist or hip experienced a substantial decrease in ability to perform basic and instrumental activities of daily living between baseline and the final assessment. Furthermore, of the 44 subjects with wrist fractures, seven (15.9%) needed help with at least one relevant activity at baseline and 18 (40.9%) at 12 months. Of the 34 subjects with hip fractures, four (11.8%) needed help with at least one activity at baseline and 18 (52.9%) at 12 months. Practically no changes were found in any of the groups after 5 months post-injury. CONCLUSIONS: not only hip fractures, but also wrist fractures may reduce older people's chances of remaining independent. Prospects of further recovery are minimal 5-6 months after the injury.

Quality of life in patients with paroxysmal atrial fibrillation and its predictors: importance of the autonomic nervous system.

AIMS: To determine the impact of paroxysmal atrial fibrillation on quality of life and to determine the predictors of quality of life, particularly the role of symptomatology and autonomic function. METHODS AND RESULTS: The study group comprised 73 patients with paroxysmal atrial fibrillation (mean age 54.1 years, 51 males). On average, patients had a 3-year history of one paroxysm per week lasting 2 h. Quality of life was assessed using the SF-36 (Medical Outcomes Study Short-Form Health Survey) and compared with age-matched controls. Autonomic function was assessed using Holter monitoring with analysis of heart rate variability and autonomic function tests. Symptoms during paroxysms of atrial fibrillation were also scored. Multivariate analysis was performed to identify independent predictors of quality of life. Quality of life scores were markedly lower in patients than in controls in four of the eight subscales (P<0.001): physical role function, emotional role function, vitality and general health. Structural heart disease did not predict quality of life, whereas frequency of paroxysms was predictive only of physical role function. In contrast, autonomic variables (baroreflex-sensitivity, total power (heart rate variability), response to deep breathing, 30-15 ratio (standing up)) were predictive in all four respective subscales (P<0.05), depressed vagal function being predictive of low scores. Symptoms, particularly severe perspiration, were also predictive of low scores (P<0.05). CONCLUSIONS: This study shows that paroxysmal atrial fibrillation causes significant impairment of quality of life. Further, symptomatology and autonomic function are important predictors of quality of life in this patient group.

The Saba health study: methodology and main results

'The Saba Health Study' is the first large scale health interview survey of the island. This book presents the main results of the study. It discusses the population's health status, use of health services, and satisfaction with health care. Known health risks, such as smoking, alcohol consumption, and overweight are evaluated and compared with situations on the sister island of Curacao and in western countries. Attention is focused on the identification of risk groups in need of specific policy interventions and health promotion programs (AU)

Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.

OBJECTIVES: We sought to study the influence of frequency of exercise training during cardiac rehabilitation on functional capacity (i.e., peak oxygen consumption [VO2] and ventilatory anaerobic threshold [VAT]) and quality of life (QoL). BACKGROUND: Although the value of cardiac rehabilitation is now well established, the influence of the different program characteristics on outcome has received little attention, and the effect of frequency of exercise training is unclear. Functional capacity is regularly evaluated by peak VO2 but parameters of submaximal exercise capacity such as VAT should also be considered because submaximal exercise capacity is especially important in daily living. METHODS: Patients with coronary artery disease (n = 130, 114 men; mean age 52 +/- 9 years) were randomized to either a high- or low-frequency program of six weeks (10 or 2 exercise sessions per week of 2 h, respectively). Functional capacity and QoL were assessed before and after cardiac rehabilitation. Global costs were also compared. RESULTS: Compared with baseline, mean exercise capacity increased in both programs: for high- and low-frequency, respectively: peak VO2 = 15% and 12%, Wmax = 18% and 12%, VAT = 35% and 12% (all p < 0.001). However, when the programs were compared, only VAT increased significantly more during the high-frequency program (p = 0.002). During the high-frequency program, QoL increased slightly more, and more individuals improved in subjective physical functioning (p = 0.014). We observed superiority of the high-frequency program, especially in younger patients. Mean costs were estimated at 4,455 and 2,273 Euro, respectively, for the high- and low-frequency programs. CONCLUSIONS: High-frequency exercise training is more effective in terms of VAT and QoL, but peak VO2 improves equally in both programs. Younger patients seem to benefit more from the high-frequency training.

Diabetic neuropathy examination: a hierarchical scoring system to diagnose distal polyneuropathy in diabetes.

OBJECTIVE: Existing physical examination scoring systems for distal diabetic polyneuropathy (PNP) do not fulfill all of the following criteria: validity, manageability, predictive value, and hierarchy The aim of this study was to adapt the Neuropathy Disability Score (NDS) to diagnose PNP in diabetes so that it fulfills these criteria. RESEARCH DESIGN AND METHODS: A total of 73 patients with diabetes were examined with the NDS. Monofilaments and biothesiometry were used as clinical standards for PNP to modify the NDS. RESULTS: A total of 43 men and 30 women were studied; mean duration of diabetes was 15 years (1-43), and mean age was 57 years (19-90). A total of 24 patients had type 1 diabetes, and 49 patients had type 2 diabetes. Clinically relevant items were selected from the original 35 NDS items (specific item scored positive in >3 patients). The resulting 8-item Diabetic Neuropathy Examination (DNE) score could accurately predict the results of the clinical standards and is strongly hierarchical (H value 0.53). The sensitivity and specificity of the DNE at a cut-off level of 3 to 4 were 0.96 and 0.51 for abnormal monofilament scores, respectively. For abnormal vibration perception threshold scores, these values were 0.97 and 0.59, respectively. Reproducibility as assessed by inter- and intrarater agreement was good. CONCLUSIONS: The DNE is a sensitive and well-validated hierarchical scoring system that is fast and easy to perform in clinical practice.

The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and Positive Affect in cancer patients and healthy reference subjects.

This study examined the reliability and validity of a two-factor structure of the Center for Epidemiologic Studies Depression (CES-D) scale. The study was conducted in a large group of cancer patients (n = 475) and a matched reference group (n = 255). Both groups filled in a questionnaire at two points in time; patients 3 and 15 months after diagnosis. Factor analysis confirmed our hypothesis that the 16 negatively and four positively formulated items measure two relatively independent factors, i.e. Depressed Affect and Positive Affect. Therefore, these items should not be combined into an overall sumscore. In both groups, Depressed Affect proved to be a reliable and valid measure of depressive symptomatology, as indicated by its good internal consistency, its strong correlations with other measures of psychological distress and neuroticism, and its effectiveness in discriminating patients from the reference group on depressive symptomatology. In contrast, the validity of the Positive Affect factor could not be confirmed, since it was only weakly related to other measures of psychological distress and extraversion. Depressed and Positive Affect were about equally related to self-esteem, life satisfaction, and quality of life. These findings support the use of a sumscore based on the 16 negatively formulated CES-D items as a more valid measure of depressive symptomatology, in cancer patients and in healthy individuals from the general population.

Models of health-related quality of life in a population of community-dwelling Dutch elderly.

OBJECTIVE: Though health-related quality of life (HRQoL) is now commonly measured as an outcome in clinical trials, the relationships between its components remain unclear. The relation of physical symptoms, physical function, and psychological symptoms to each other and to overall quality of life is of special interest. METHOD: Cross-sectional data from 5,279 community-dwelling elders who participated in the Groningen Longitudinal Aging Study were analyzed using structural equation modeling techniques. Three models were examined. One "Linear" model included: number of chronic medical conditions, physical symptoms, physical functioning, activity interference, social function, perceived health and overall quality of life in a simple linear progression. Another 'non-linear' model included these variables, but allowed effects between non-adjacent variables. A third 'non-linear' model included these variables plus anxiety and depressive symptoms. RESULTS: The Linear Model did not satisfactorily account for the observed data [X2(15df) = 2946.96], so the saturated Non-Linear Model, incorporating paths between non-adjacent components, is described. When anxiety and depressive symptoms were added to this Non-Linear Model, they fit best in a position mediating the relation between perceived health and overall quality of life [X2(5df) = 136.78]. CONCLUSIONS: Overall quality of life appears to be related to symptom status as directly as it is related to functional status. Anxiety and depressive symptoms appear to mediate the relation between general health perceptions and overall quality of life. Quality of life measures should therefore include assessments of physical and psychological symptom severity as well as functional status if they are to truly reflect what matters to patients. The disability-adjusted life year (DALY) measure used by the WHO may inadequately reflect the effect of symptoms on patient's quality of life.

Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time.

STUDY OBJECTIVE: To measure the pre-hospital delay times in patients with proven acute myocardial infarction (AMI) and to identify possibilities for reduction of treatment delay. DESIGN: Descriptive three centre study. SETTING: One university teaching hospital and two regional hospitals in Groningen, the Netherlands. PATIENTS: 400 consecutive confirmed AMI patients, age below 75 years, admitted to coronary care departments. MAIN RESULTS: Mean age was 59 years and 78% of patients were men. Within two hours after onset of symptoms half of the patients with AMI arrived at the hospital. Patient, doctor, and ambulance delay times (median values) were 30, 38, and 35 minutes respectively. Calling the personal general practitioner (GP) or the locum tenens and whether or not the AMI occurred during a weekend or on a working day had no consequences for pre-hospital delay times. At night patients waited longer before calling a GP than in the daytime. There was a positive correlation between patient and doctor delay. Twenty two per cent of AMI patients waited two hours or more before calling a GP. Total pre-hospital delay times differed between men and women. Longer doctor delay in women (36 minutes for men and 52 minutes for women) was caused by displacement of specific symptoms, in particular in women. AMI patients who were alone during onset of symptoms showed higher patients delay (72 compared with 23 minutes). CONCLUSION: In hospital admitted patients younger than 75 years pre-hospital delay times are within acceptable limits. In some subgroups further reduction is attainable, for example in patient delay outside office hours and when patients are alone during onset of symptoms, in doctor delay in cases where women present with symptoms suggestive for AMI. Improvement of facilities for pre-hospital electrocardiographic diagnosis may facilitate decision making by GPs. Good opportunities for further reduction of treatment delay exist in shortening of hospital delay.

A comprehensive model of stress. the roles of experienced stress and neuroticism in explaining the stress-distress relationship.

BACKGROUND: In this study, a complex theoretical model regarding the stress-distress relationship was evaluated. The various components in the model included experienced stress (daily hassles), psychological distress, neuroticism, problem-focused coping, avoidant coping, satisfaction with received social support and unassertiveness. On the basis of various previous findings, experienced stress was assumed to have a direct effect on psychological distress. In addition, neuroticism was assumed to have a direct effect on psychological distress as well as an indirect effect through its association with experienced stress, problem-focused coping, avoidant coping, satisfaction with social support and unassertiveness. Further, both problem-focused and avoidant coping were assumed to affect the level of psychological distress directly as well as indirectly through their influence on experienced stress. Similarly, satisfaction with social support was assumed to have a direct beneficial effect on psychological distress in addition to an indirect effect through its association with coping and experienced stress. Finally, unassertiveness was assumed to have a direct effect on psychological distress as well as an indirect effect through its influence on experienced stress and coping. METHODS: A covariance path analysis technique (LISREL) was used. RESULTS: A considerable predictive power of the model could be demonstrated. Experienced stress and neuroticism turned out to be most predictive of psychological distress. The effects of social support, coping and unassertiveness on psychological distress were seriously attenuated by their common association with neuroticism. CONCLUSION: Above all, the present findings underscore the need to investigate all variables that are expected to play a role simultaneously so as to be able to take their interdependency into account. It is argued that although such comprehensive models may be more difficult to interpret as of yet, they are likely to more closely resemble reality.

The relationship of functional limitations to disability and the moderating effects of psychological attributes in community-dwelling older persons.

This paper examines the moderating effects of three psychological attributes (neuroticism, self-efficacy expectancies and mastery) on the association between functional limitations (motor and cognitive limitation, vision and hearing loss) and disability ((instrumental) activities of daily living, role function and social function) in a sample of 624 community-dwelling older persons. In contrast to our hypothesis, we did not find any evidence for interaction effects. This means that low levels of psychological resources do not exacerbate the effect of functional limitation on disability in community-dwelling older persons. We found significant unique contributions of the psychological attributes to disability. Even when all three psychological attributes were taken into account, neuroticism and mastery had unique effects on social and role function, and self-efficacy expectancies had unique effects on (instrumental) activities of daily living. We conclude that the effects of functional limitation and psychological attributes on disability can be considered as additive. Older persons with less psychological resources are particularly at risk in developing disability.