Depression : an important comorbidity with metabolic syndrome in a general population

OBJECTIVE—There is a recognized association among depression, diabetes, and cardiovascular disease. The aim of this study was to examine in a sample representative of the general population whether depression, anxiety, and psychological distress are associated with metabolic syndrome and its components.

RESEARCH DESIGN AND METHODS—Three cross-sectional surveys including clinical health measures were completed in rural regions of Australia during 2004–2006. A stratified random sample (n = 1,690, response rate 48%) of men and women aged 25–84 years was selected from the electoral roll. Metabolic syndrome was defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III (NCEP ATP III), and International Diabetes Federation (IDF) criteria. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale and psychological distress by the Kessler 10 measure.

RESULTS—Metabolic syndrome was associated with depression but not psychological distress or anxiety. Participants with the metabolic syndrome had higher scores for depression (n = 409, mean score 3.41, 95% CI 3.12–3.70) than individuals without the metabolic syndrome (n = 936, mean 2.95, 95% CI 2.76–3.13). This association was also present in 338 participants with the metabolic syndrome and without diabetes (mean score 3.37, 95% CI 3.06–3.68). Large waist circumference and low HDL cholesterol showed significant and independent associations with depression.

CONCLUSIONS—Our results show an association between metabolic syndrome and depression in a heterogeneous sample. The presence of depression in individuals with the metabolic syndrome has implications for clinical management.

An examination of the 'gold standard' diagnosis of major depression in aged-care settings

Objectives: Individual clinical interviews are typically viewed as the “gold standard” when diagnosing major depressive disorder (MDD) and when examining the validity of self-rated questionnaires. However, this approach may be problematic with older people, who are known to underreport depressive symptomatology. This study examined the effect of including an informant interview on prevalence estimations of MDD in an aged-care sample.

Design: The results of an individual clinical interview for MDD were compared with those obtained when an informant interview was incorporated into the assessment. Results from each diagnostic approach were compared with scores on a self-rated depression instrument.

Setting: Low-level aged-care residential facilities in Melbourne (equivalent to “residential homes,” “homes for the elderly,” or “assisted living facilities” in other countries).

Participants: One hundred and sixty-eight aged-care residents (mean age: 84.68 years; SD: 6.16 years) with normal cognitive functioning.

Measurements: Individual clinical interviews were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders. This interview was modified for use with staff informants. Self-reported depression was measured using the Geriatric Depression Scale-15 (GDS-15).

Results: The estimated point prevalence of MDD rose from 16% to 22% by including an informant clinical interview in the diagnostic procedure. Overall, 27% of depressed residents failed to disclose symptoms in the clinical interview. The concordance of the GDS-15 with a diagnosis of MDD was substantially lower when an informant source was included in the diagnostic procedure.

Conclusion: Individual interviews and self-report questionnaires may be insufficient to detect depression among older adults. This study supports the use of an informant interview as an adjunct when diagnosing MDD among cognitively intact aged-care residents.

Raising the profile of depression in the workplace

The prevalence of depression in the Australian workforce is unknown. Epidemiological surveys (e.g., the National Health Survey and National Survey of Mental Health and Wellbeing) do not routinely include a depression scale and within the mental health field, few studies focus on depression and employment groups specifically. Although the inclusion of a direct measure of depression in  national surveys is preferable, the prevalence of depression may be inferred from short screening scales of general mental health. In this paper, scores on the  General Health Questionnaire (GHQ-12) and the Kessler psychological distress scale (K10) for a sample of employed persons were mapped onto the CES-D (Iowa) measure of depression. The results of this study indicate that the  recommended GHQ-12 cut-off point is appropriate for estimating work-related depression prevalence. However, the cut-off point on the K10 (the short-scale  currently used in Australian national surveys) may need to be substantially  reduced if scores on the K10 are to be used to identify workers at risk of  depression. The routine inclusion of a direct depression measure in national  surveys is recommended, particularly considering the number of employed persons in Australia and large proportion of the sample classified as depressed in this study.

Quality of life and depression among older patients waiting for joint replacement surgery

Purpose: Older patients waiting for joint replacement surgery in many western countries experience lengthy waits for their surgery. Although these patients suffer with mobility problems the nature of the disability associated with waiting for surgery is unclear. The purpose of this study was to determine health-related quality of life and symptoms of depression in persons waiting for their initial orthopaedic consultation following referral for total knee or total hip replacement surgery.

Methods: All patients who were waiting for an initial orthopaedic consultation for lower-limb joint replacement as at 25 August 2005 were surveyed. Participants were mailed questionnaires concerning demographic information, medical history, health-related quality of life (the Assessment of Quality of Life (AQoL) instrument), and symptoms of depression (Center for Epidemiologic Studies – Depression (CES-D) Scale).

Results: The 84 respondents (response rate 64%) had a mean age of 68.3 (SD 11.5 years), and 60% or respondents were women. Respondents reported an average of 1.6 (SD 0.9) medical conditions, and 85% reported osteoarthritis.} The average health-related quality of life was low (mean AQoL 0.38; SD 0.27), and near death-equivalent or worse than death-equivalent health-related quality of life (AQoL<0.1 of a maximum possible 1.0) was reported by 23% of the participants.The mean depression scale score was 16.5 (SD 11.1), and symptoms of depression (CES-D>16 of a maximum possible 60) were reported by 35% of the sample. There was a strong correlation between health-related quality of life and depression (r=–0.6).

Conclusions: Almost a third of patients waiting to see an orthopaedic surgeon about joint replacement surgery for their hip or knee had symptoms of depression. Geriatric rehabilitation services often provide interventions to these patients. The very poor quality of life reported suggests that more than exercise and strengthening will be needed to reduce disability.

Age-specific norms and determinants of anxiety and depression in 731 women with breast cancer recruited through a population-based cancer registry

The aim of this study was to determine population norms and determinants of anxiety and depression in a population-based sample of 731 women with breast cancer (aged 23–60 years) with the Hospital Anxiety and Depression scale (HADS). The prevalence of ‘probable’ psychological morbidity due to anxiety was 23% and due to depression was 3%. When the women identified as ‘possible’ cases were included, the respective proportions were 45 and 12%. Higher anxiety was present in younger, less educated women not born in Australia. There was no clear pattern of risk factors for depression. These population-based findings highlight the need for clinicians to be aware that age, education and country of birth may identify a particularly vulnerable subgroup. While brief scales such as the HADS are limited in their ability to accurately predict a clinical diagnosis, high scores identify those who may warrant referral for clinical evaluation.

Identification of depression in diabetes the efficacy of PHQ-9 and HADS-D

Background
Clinical guidelines advise screening for depression in patients with diabetes. The Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) are commonly used in primary care.

Aim
To compare the efficacy of HADS-D and PHQ-9 in identifying moderate to severe depression among primary care patients with type 2 diabetes.

Design of study
Self-report postal survey, clinical records assessed by GPs.

Setting
Seven metropolitan and rural general practices in Victoria, Australia.

Method
Postal questionnaires were sent to all patients with diabetes on the registers of seven practices in Victoria. A total of 561 completed postal questionnaires were returned, giving a response rate 47%. Surveys included demographic information, and history of diabetes and depression. Participants completed both the PHQ-9 and HADS-D. Clinical data from patient records included glycosylated hemoglobin (HbA1c) levels and medications.

Results
The proportion of the total sample completing HADS-D was 96.8% compared with 82.4% for PHQ-9. Level of education was unrelated to responses on the HADS-D but was related to completion of the PHQ-9. Using complete data (n = 456) from both measures, 40 responders showed HADS-D scores in the moderate to severe range, compared with 103 cases identified by PHQ-9. Only 35 cases were classified in the moderate to severe category by both the PHQ-9 and HADS-D. Items with the highest proportions of positive responses on the PHQ-9 were related to tiredness and sleeping problems and, on the HADS-D, feeling slowed down.

Conclusion
It may be that the items contributing to the higher prevalence of moderate to severe depression using the PHQ-9 are due to diabetes-related symptoms or sleep disorders.

A nurse-assisted screening and referral program for depression among survivors of colorectal cancer : feasibility study

Objective: To test the feasibility and acceptability of a telephone-based program to screen survivors of colorectal cancer (CRC) for distress, and to refer distressed patients to their treating health service.

Design, setting and participants: A prospective, multicentre study involving 59 patients with CRC recruited from six public and private health services in Melbourne, Victoria, from 15 June 2008 to 22 September 2009. Patients who had completed adjuvant chemotherapy for CRC were contacted (7–10 days after recruitment [outcall one] and again 4 weeks later [outcall two]) by the Cancer Council Victoria’s helpline nurse, and screened for distress with the Distress and Impact Thermometer (DIT); participants were given tailored information and support and those with distress scores of ≥5, and impact scores of ≥4, were referred for follow-up. Telephone interviews were conducted 4 weeks after outcall two. Participating helpline and health service staff were surveyed on the feasibility and acceptability of the service. Main outcome measure: Anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS).

Results: Of the 59 patients (87%) who agreed to participate, 63% were men; their mean age was 59 years (SD, 9.5 years). HADS depression decreased significantly from baseline (mean score, 4.93; SD, 4.22) to follow-up (mean score, 3.84; SD, 4.10; Z = −2.375; P= 0.02). However, there was no significant difference in HADS anxiety between baseline (mean score, 5.29; SD, 4.11) and follow-up (mean score, 4.78; SD, 3.65). Outcall one generated two referrals (4% of participants) and outcall two generated four referrals
(8%); five of these six participants took up the referrals. Satisfaction with the program among participants was high; 82% found outcall one “quite or very helpful” and 79% found outcall two “quite or very helpful”. Helpline and health service staff reported a straightforward process that did not adversely affect workloads.

Conclusion: This model of care carries the potential to meet ongoing psychosocial needs of survivors of CRC.

Association between magnesium intake and depression and anxiety in community-dwelling adults : The Hordaland Health Study

Objective: Systemic inflammation is associated with both the dietary intake of magnesium, and depression. Limited experimental and clinical data suggest an association between magnesium and depression. Thus, there are reasons to consider dietary magnesium as a variable of interest in depressive disorders. The aim of the present study was to examine the association between magnesium intake and depression and anxiety in a large sample of community-dwelling men and women. This sample consisted of 5708 individuals aged 46–49 or 70–74 years who participated in the Hordaland Health Study in Western Norway.

Methods: Symptoms of depression and anxiety were self-reported using the Hospital Anxiety and Depression Scale, and magnesium intake was assessed using a comprehensive food frequency questionnaire.

Results: There was an inverse association between standardized energy-adjusted magnesium intake and standardized depression scores that was not confounded by age, gender, body habitus or blood pressure (β=−0.16, 95% confidence interval (CI)=−0.22 to −0.11). The association was attenuated after adjustment for socioeconomic and lifestyle variables, but remained statistically significant (β=−0.11, 95%CI=−0.16 to −0.05). Standardized magnesium intake was also related to case-level depression (odds ratio (OR)=0.70, 95%CI=0.56–0.88), although the association was attenuated when adjusted for socioeconomic and lifestyle factors (OR=0.86, 95%CI=0.69–1.08). The inverse relationship between magnesium intake and score and case-level anxiety was weaker and not statistically significant in the fully adjusted models.

Conclusion: The hypothesis that magnesium intake is related to depression in the community is supported by the present findings. These findings may have public health and treatment implications.

Mothers' AdvocateS In the Community (MOSAIC)- non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care

Background : Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

Methods : MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months.

Intervention: 12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals.

Main outcome measures: Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up.

Analysis: Intention-to-treat using multivariable logistic regression and propensity scoring.

Results : There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations.

Conclusion : Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care.

Co-morbid cardiovascular disease and depression : sequence of disease onset is linked to mental but not physical self-rated health. Results from a cross-sectional, population-based study

Purpose: Self-rated health has been linked to important health and survival outcomes in individuals with co-morbid depression and cardiovascular disease (CVD). It is not clear how the timing of depression onset relative to CVD onset affects this relationship. We aimed to first identify the prevalence of major depressive disorder (MDD) preceding CVD and secondly determine whether sequence of disease onset is associated with mental and physical self-rated health. Methods: This study utilised cross-sectional, populationbased data from 224 respondents of the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB). Participants were those diagnosed with MDD and reported ever having a heart/circulatory condition over their lifetime. Age of onset was reported for each condition. Logistic regression was used to explore differences in self-rated mental and physical health for those reporting pre-cardiac and post-cardiac depression. Results: The proportion of individuals in whom MDD preceded CVD was 80.36% (CI: 72.57-88.15). One-fifth (19.64%, CI: 11.85-27.42) reported MDD onset at the time of, or following, CVD. After controlling for covariates, the final model demonstrated that those reporting post-cardiac depression were significantly less likely to report poor selfrated mental health (OR:0.36, CI: 0.14-0.93) than those with pre-existing depression. No significant differences were found in self-rated physical health between groups (OR:0.90 CI: 0.38-2.14). Conclusions: MDD is most common prior to the onset of CVD. Further, there is an association between pre-morbid MDD and poorer self-rated mental health. To our knowledge, this is the first time this has been demonstrated in a national, population-based survey. As self-rated health has been shown to predict important outcomes such as survival, we recommend that those with MDD be identified as vulnerable to CVD onset and poorer health outcomes

Preventing early infant sleep and crying problems and postnatal depression: a randomized trial

Objective
To evaluate a prevention program for infant sleep and cry problems and postnatal depression.

Methods
Randomized controlled trial with 781 infants born at 32 weeks or later in 42 well-child centers, Melbourne, Australia. Follow-up occurred at infant age 4 and 6 months. The intervention including supplying information about normal infant sleep and cry patterns, settling techniques, medical causes of crying and parent self-care, delivered via booklet and DVD (at infant age 4 weeks), telephone consultation (8 weeks), and parent group (13 weeks) versus well-child care. Outcomes included caregiver-reported infant night sleep problem (primary outcome), infant daytime sleep, cry and feeding problems, crying and sleep duration, caregiver depression symptoms, attendance at night wakings, and formula changes.

Results
Infant outcomes were similar between groups. Relative to control caregivers, intervention caregivers at 6 months were less likely to score >9 on the Edinburgh Postnatal Depression Scale (7.9%, vs 12.9%, adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.34 to 0.94), spend >20 minutes attending infant wakings (41% vs 51%, adjusted OR 0.66, 95% CI 0.46 to 0.95), or change formula (13% vs 23%, P < .05). Infant frequent feeders (>11 feeds/24 hours) in the intervention group were less likely to have daytime sleep (OR 0.13, 95% CI 0.03 to 0.54) or cry problems (OR 0.27, 95% CI 0.08 to 0.86) at 4 months.

Conclusions
An education program reduces postnatal depression symptoms, as well as sleep and cry problems in infants who are frequent feeders. The program may be best targeted to frequent feeders.

Unmet needs and depression among carers of people newly diagnosed with cancer

AIMS: The aims of this analysis were to examine levels of unmet needs and depression among carers of people newly diagnosed with cancer and to identify groups who may be at higher risk, by examining relationships with demographic characteristics. METHODS: One hundred and fifty dyads of people newly diagnosed with cancer and their carers, aged 18years and older, were recruited from four Australian hospitals. People with cancer receiving adjuvant cancer treatment with curative intent, were eligible to participate. Carers completed the Supportive Care Needs Survey-Partners & Caregivers (SCNS-P&C45), and both carers and patients completed the Centre of Epidemiologic-Depression Scale (CES-D). RESULTS: Overall, 57% of carers reported at least one, 37% at least three, 31% at least five, and 15% at least 10 unmet needs; the most commonly endorsed unmet needs were in the domains of information and health care service needs. Thirty percent of carers and 36% of patients were at risk of clinical depression. A weak to moderate positive relationship was observed between unmet needs and carer depression (r=0.30, p<0.001). Carer levels of unmet needs were significantly associated with carer age, hospital type, treatment type, cancer type, living situation, relationship status (in both uni- and multi-factor analysis); person with cancer age and carer level of education (in unifactor analysis only); but not with carer gender or patient gender (in both uni- and multi-factor analyses). CONCLUSION: Findings highlight the importance of developing tailored programmes to systematically assist carers who are supporting patients through the early stages of cancer treatment.

Prediction of perinatal depression from adolescence and before conception (VIHCS): 20-year prospective cohort study

BACKGROUND: Perinatal depression is a neglected global health priority, affecting 10-15% of women in high-income countries and a greater proportion in low-income countries. Outcomes for children include cognitive, behavioural, and emotional difficulties and, in low-income settings, perinatal depression is associated with stunting and physical illness. In the Victorian Intergenerational Health Cohort Study (VIHCS), we aimed to assess the extent to which women with perinatal depressive symptoms had a history of mental health problems before conception. METHODS: VIHCS is a follow-up study of participants in the Victorian Adolescent Health Cohort Study (VAHCS), which was initiated in August, 1992, in the state of Victoria, Australia. In VAHCS, participants were assessed for health outcomes at nine timepoints (waves) from age 14 years to age 29 years. Depressive symptoms were measured with the Revised Clinical Interview Schedule and the General Health Questionnaire. Enrolment to VIHCS began in September, 2006, during the ninth wave of VAHCS; depressive symptoms at this timepoint were measured with the Composite International Diagnostic Interview. We contacted women every 6 months (from age 29 years to age 35 years) to identify any pregnancies. We assessed perinatal depressive symptoms with the Edinburgh Postnatal Depression Scale (EPDS) by computer-assisted telephone interview at 32 weeks of gestation, 8 weeks after birth, and 12 months after birth. We defined perinatal depression as an EPDS score of 10 or more. FINDINGS: From a stratified random sample of 1000 female participants in VAHCS, we enrolled 384 women with 564 pregnancies. 253 (66%) of these women had a previous history of mental health problems at some point in adolescence or young adulthood. 117 women with a history of mental health problems in both adolescence and young adulthood had 168 pregnancies, and perinatal depressive symptoms were reported for 57 (34%) of these pregnancies, compared with 16 (8%) of 201 pregnancies in 131 women with no preconception history of mental health problems (adjusted odds ratio 8·36, 95% CI 3·34-20·87). Perinatal depressive symptoms were reported at one or more assessment points in 109 pregnancies; a preconception history of mental health problems was reported in 93 (85%) of these pregnancies. INTERPRETATION: Perinatal depressive symptoms are mostly preceded by mental health problems that begin before pregnancy, in adolescence or young adulthood. Women with a history of persisting common mental disorders before pregnancy are an identifiable high-risk group, deserving of clinical support throughout the childbearing years. Furthermore, the window for considering preventive intervention for perinatal depression should extend to the time before conception. FUNDING: National Health and Medical Research Council (Australia), Victorian Health Promotion Foundation, Colonial Foundation, Australian Rotary Health Research and Perpetual Trustees.

Anxiety, depression and fatigue at 5-year review following CNS demyelination

BACKGROUND: Anxiety and depression are common in multiple sclerosis (MS). We evaluated the prevalence and factors associated with anxiety, depression and fatigue at the 5-year review of a longitudinal cohort study following a first clinical diagnosis of CNS demyelination (FCD).

METHODS: Cases with a FCD were recruited soon after diagnosis and followed annually thereafter. A variety of environmental, behavioural and clinical covariates were measured at five-year review. Anxiety and depression were measured using the Hospital Anxiety & Depression Scale (HADS), and fatigue by the Fatigue Severity Scale (FSS).

RESULTS: Of the 236 cases, 40.2% had clinical anxiety (median HADS-A: 6.0), 16.0% had clinical depression (median HADS-D: 3.0), and 41.3% had clinical fatigue (median FSS: 4.56). The co-occurrence of all three symptoms was 3.76 times greater than expectation. Younger age, higher disability, concussion or other disease diagnosis were independently associated with a higher anxiety score; male sex, higher disability, being unemployed, less physical activity, and antidepressant and/or anxiolytic-sedative medication use were independently associated with a higher depression score. Higher disability, immunomodulatory medication use, other disease diagnosis and anxiolytic-sedative medication use were independently associated with having fatigue, while female sex, higher BMI, having had a concussion, being unemployed and higher disability were associated with a higher fatigue score.

CONCLUSION: These results support previous findings of the commonality of anxiety, depression and fatigue in established MS and extend this to post-FCD and early MS cases. The clustering of the three symptoms indicates that they may share common antecedents.

An aggravated trajectory of depression and anxiety co-morbid with Hepatitis C: a within-groups study of 61 Australian outpatients.

BACKGROUND: This study aimed to explore the course of depression and anxiety in chronic hepatitis C patients. METHODS:   Data were combined from two studies: (1) Hospital Anxiety and Depression Scale (HADS) scores in 395 consecutive Australian outpatients from 2006 to 2010 formed the baseline measurement; and (2) Depression Anxiety Stress Scales (DASS) scores in a survey of a sub-sample of these patients in 2011 formed the follow-up measurement. After converting DASS to HADS scores, changes in symptom scores and rates of case-ness (≥8), and predictors of follow-up symptoms were assessed. RESULTS:   Follow-up data were available for 61 patients (70.5% male) whose age ranged from 24.5 to 74.6 years (M=45.6). The time to follow-up ranged from 20.7 to 61.9 months (M=43.8). Baseline rates of depression (32.8%) and anxiety (44.3%) increased to 62.3% and 67.2%, respectively. These findings were confirmed, independent of the conversion, by comparing baseline HADS and follow-up DASS scores with British community norms. Baseline anxiety and younger age predicted depression, while baseline anxiety, high school non-completion, and single relationship status predicted anxiety. CONCLUSION:  This study demonstrated a worsening trajectory of depression and anxiety. Further controlled and prospective research in a larger sample is required to confirm these findings.