Estado funcional y mortalidad en pacientes neoplásicos hospitalizados

Objetivos: Analizar el estado funcional y su relación con morbimortalidad en pacientes con neoplasias internados en Cínica Médica. Material y métodos: Estudio descriptivo, protocolizado y observacional. Se analizaron variables clínicas, estado funcional, situación anímica y morbimortalidad en pacientes oncológicos hospitalizados y se compararon pacientes con Índice de Karnofsky <40 puntos (grupo A) y >40 puntos (grupo B). Los datos fueron analizados en EPI Info 6.04. Informe de los primeros 3 meses. Resultados: En el período de estudio, ingresaron 66 pacientes con neoplasias, 21 (31.8%) en A, con Karnofsky promedio de 25 puntos (DS±12.09) y 45 (68.2%) en B, con Karnofsky promedio de 77 puntos (DS±16.65). El 77.3% presentó tumores sólidos y el 22.7% hematológicos y las neoplasias más frecuentes fueron del tracto gastrointestinal (19.6%), mama (12.1%), pulmón (9.1%) y primario oculto (7.6%). El estadio tumoral IV fue el más frecuente en ambos grupos (89.5% de A y 88.9% de B)(pNS). La edad media en A fue de 59.57 (DS±13.71) y 52.48 años (DS±15.65) en B (pNS) y el género masculino fue más frecuente en A (66.7 y 44.4% respectivamente) (p<0.05). La permanencia media fue de 17.57 en A (DS±20.84) y de 13.53 días (DS±16.29) en B (pNS). La evaluación de Actividades Básicas de la Vida Diaria [0.81 (DS±1.25) vs 4.57 puntos (DS±1.15)] y Actividades Instrumentales [0.57 (DS±0.74) vs 4 puntos (DS±1.37)] fue superior en B (p<0.05) y no hubo diferencias en la comorbilidad (85.7 vs 82.2%)(pNS). Las infecciones (52.4 vs 26.7%), causa social (38.1 vs 4.4%), complicaciones neoplásicas (81 vs 51.1%) y dolor (81 vs 51.1%) fueron los motivos de internación más frecuentes en A (p<0.05). Los pacientes de A recibieron con mayor frecuencia cuidados paliativos (90.5 vs46.7%) y quimioterapia (90.5 vs 46.7%)(p<0.05), sin diferencias en radioterapia (23.8 vs 13.3%) y cirugía (33.3 vs 33.3%)(pNS). No hubo diferencias entre ambos grupos en la presencia de depresión clínica (69.9 vs 53.3%) y pérdida de peso (86.4 vs 84.2%)(pNS). El síndrome confusional (85.7 vs 11.1%), postración (61.9 vs 6.7%) y escaras (23.8 vs 4.4%) fueron más frecuentes en A (p<0.05). La mortalidad hospitalaria fue 52.4% en A y 8.9% en B (p<0.05). Conclusiones: El grado de estado funcional evaluado por Karnofsky menor de 40 puntos se asoció significativamente a: mayor mortalidad, uso de quimioterapia, cuidados paliativos, internación por infecciones, dolor y complicaciones neoplásicas y presencia de síndrome confusional, postración y escaras de decúbito (p<0.05).

Stress and antidepressants differentially regulate neurotrophin 3 mRNA expression in the locus coeruleus.

The mechanisms by which stress and anti-depressants exert opposite effects on the course of clinical depression are not known. However, potential candidates might include neurotrophic factors that regulate the development, plasticity, and survival of neurons. To explore this hypothesis, we examined the effects of stress and antidepressants on neurotrophin expression in the locus coeruleus (LC), which modulates many of the behavioral and physiological responses to stress and has been implicated in mood disorders. Using in situ hybridization, we demonstrate that neurotrophin 3 (NT-3) is expressed in noradrenergic neurons of the LC. Recurrent, but not acute, immobilization stress increased NT-3 mRNA levels in the LC. In contrast, chronic treatment with antidepressants decreased NT-3 mRNA levels. The effect occurred in response to antidepressants that blocked norepinephrine uptake, whereas serotonin-specific reuptake inhibitors did not alter NT-3 levels. Electroconvulsive seizures also decreased NT-3 expression in the LC as well as the hippocampus. Ntrk3 (neurotrophic tyrosine kinase receptor type 3; formerly TrkC), the receptor for NT-3, is expressed in the LC, but its mRNA levels did not change with stress or antidepressant treatments. Because, NT-3 is known to be trophic for LC neurons, our results raise the possibility that some of the effects of stress and antidepressants on LC function and plasticity could be mediated through NT-3. Moreover, the coexpression of NT-3 and its receptor in the LC suggests the potential for autocrine mechanisms of action.

How does mental health status relate to accessibility and remoteness?

Objective: To determine whether mental illness is associated with accessibility and remoteness. Design: A cross-sectional, population-based, computer-assisted telephone interview survey, stratified by Accessibility and Remoteness Index of Australia (ARIA) categories. Setting: Secondary analysis of data collected from 2545 South Australian adults in October and November 2000. Outcome measures: Psychological distress and depression as determined by the Kessler 10 Psychological Distress Scale, the SF-12 measure of health status, and self-reported mental illness diagnosed by a doctor in the previous 12 months. Results: Overall, mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), clinical depression (12.9%) and self-reported mental health problem (12.7%). For each measure, there was no statistically significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the accessible category. There was no trend suggesting higher levels of mental illness among residents of rural and remote regions. Conclusions: The prevalence rates of psychological distress, depression and self-reported mental illness are high. However, we found no evidence that the prevalence of these conditions varies substantially across ARIA categories in South Australia. This finding may challenge existing stereotypes about higher levels of mental illness outside metropolitan Australia.

Memory for emotional faces in naturally occurring dysphoria and induced sadness

The aim was to establish if the memory bias for sad faces, reported in clinically depressed patients (Gilboa-Schechtman, Erhard Weiss, & Jeczemien, 2002; Ridout, Astell, Reid, Glen, & O'Carroll, 2003) generalises to sub-clinical depression (dysphoria) and experimentally induced sadness. Study 1: dysphoric (n = 24) and non-dysphoric (n = 20) participants were presented with facial stimuli, asked to identify the emotion portrayed and then given a recognition memory test for these faces. At encoding, dysphoric participants (DP) exhibited impaired identification of sadness and neutral affect relative to the non-dysphoric group (ND). At memory testing, DP exhibited superior memory for sad faces relative to happy and neutral. They also exhibited enhanced memory for sad faces and impaired memory for happy relative to the ND. Study 2: non-depressed participants underwent a positive (n = 24) or negative (n = 24) mood induction (MI) and were assessed on the same tests as Study 1. At encoding, negative MI participants showed superior identification of sadness, relative to neutral affect and compared to the positive MI group. At memory testing, the negative MI group exhibited enhanced memory for the sad faces relative to happy or neutral and compared to the positive MI group. Conclusion: MCM bias for sad faces generalises from clinical depression to these sub-clinical affective states.

Depresión subclínica en España:prevalencia e impacto sobre la salud

INTRODUCCIÓN: La depresión subclínica es una condición prevalente que presenta importantes implicaciones para el funcionamiento y el bienestar de los pacientes. Sin embargo, faltan estudios que operativicen su definición y que profundicen en su significación clínica y su impacto en la salud. El presente trabajo analiza el impacto de la depresión subclínica sobre un indicador de salud compuesto por ocho dominios de funcionamiento, y su prevalencia en la población española. MÉTODO: La muestra se ha extraído de la base de datos de la Encuesta Mundial de Salud de la OMS, seleccionando las respuestas para España de personas con depresión subclínica y sin depresión. RESULTADOS: Controlando la interacción de las distintas variables demográficas, ser mujer resulta ser el único predictor significativo para la presencia de depresión subclínica. Un peor estado de salud se asocia significativamente con presentar depresión subclínica, ser mujer, tener una edad elevada, un bajo nivel de ingresos, un menor número de años de educación formal y ser viudo. La disminución resulta significativa en los ocho dominios de funcionamiento que conforman el índice. CONCLUSIONES: Se pone de manifiesto la necesidad de conceptualizar mejor la naturaleza de la depresión subclínica, profundizando en la línea de recientes propuestas que abogan por una definición basada en su significación clínica más que en el número de síntomas depresivos, con el objetivo de no patologizar el sufrimiento humano y el malestar inherente a muchas situaciones vitales. INTRODUCTION: Subclinical depression is a prevalent condition with important implications for patients' functioning and wellbeing. However, there is a lack of studies operationalising its definition and studying its clinical significance and health impact in depth. This work analyses subclinical depression impact on a health satus score derived from eight heath domains, and its prevalence in Spanish population. METHODS: The sample was selected from World Health Survey database, choosing the answers for Spain of people with a dignosis of subclinical depression and no depressive disorders. RESULTS: Controlling the interaction of the different demographic variables, being female was the only significant predictor for the presence of subclinical depression. A worse health status is associated with subclinical depression, being female, a higher age, lower incomes, less years of formal education and being widowed. The decrease is significant in the eight health domains composing the score. CONCLUSIONS: The necessity of a better conceptualization of the nature of clinical depression is highlighted, going in depth in different proposals defending a definition based on clinical signification rather than in the number of depressive symptoms, with the goal of avoiding the pathologization of human suffering and inherent distress to several vital situations.

It takes an institution's village to retain a student: A comprehensive look at two early warning system undergraduate retention programs and administrators' perceptions of students' experiences and the retention services they provide students in the early warning system retention programs

Institutions have implemented many campus interventions to address student persistence/retention, one of which is Early Warning Systems (EWS). However, few research studies show evidence of interventions that incorporate noncognitive factors/skills, and psychotherapy/psycho-educational processes in the EWS. A qualitative study (phenomenological interview and document analysis) of EWS at both a public and private 4-year Florida university was conducted to explore EWS through the eyes of the administrators of the ways administrators make sense of students' experiences and the services they provide and do not provide to assist students. Administrators' understanding of noncognitive factors and the executive skills subset and their contribution to retention and the executive skills development of at-risk students were also explored. Hossler and Bean's multiple retention lenses theory/paradigms and Perez's retention strategies were used to guide the study. Six administrators from each institution who oversee and/or assist with EWS for first time in college undergraduate students considered academically at-risk for attrition were interviewed. Among numerous findings, at Institution X: EWS was infrequently identified as a service, EWS training was not conducted, numerous cognitive and noncognitive issues/deficits were identified for students, and services/critical departments such as EWS did not work together to share students' information to benefit students. Assessment measures were used to identify students' issues/deficits; however, they were not used to assess, track, and monitor students' issues/deficits. Additionally, the institution's EWS did address students' executive skills function beyond time management and organizational skills, but did not address students' psychotherapy/psycho-educational processes. Among numerous findings, at Institution Y: EWS was frequently identified as a service, EWS training was not conducted, numerous cognitive and noncognitive issues/deficits were identified for students, and services/critical departments such as EWS worked together to share students' information to benefit students. Assessment measures were used to identify, track, and monitor students' issues/deficits; however, they were not used to assess students' issues/deficits. Additionally, the institution's EWS addressed students' executive skills function beyond time management and organizational skills, and psychotherapy/psycho-educational processes. Based on the findings, Perez's retention strategies were not utilized in EWS at Institution X, yet were collectively utilized in EWS at Institution Y, to achieve Hossler and Bean's retention paradigms. Future research could be designed to test the link between engaging in the specific promising activities identified in this research (one-to-one coaching, participation in student success workshops, academic contracts, and tutoring) and student success (e.g., higher GPA, retention). Further, because this research uncovered some concern with how to best handle students with physical and psychological disabilities, future research could link these same promising strategies for improving student performance for example among ADHD students or those with clinical depression.

Duelo, ansiedad y depresión en familiares de pacientes en una unidad de cuidados paliativos a los dos meses de la pérdida

Aim: This study is going to assess the prevalance of prolonged grief diagnoses and it will evaluate the severity of the symptoms of depression, anxiety and complicated grief two months after a loved one is lost. We also intend to study which variables associated with the risk of grief could be more decisive when diagnosing it, its symptoms and the consequent emotional distress.Method: A total of 66 families of patients in the Palliative Care Unit (PCU) at Hospital San Cecilio in Granada have been evaluated. Measurements were taken two months after the death. This investigation has explored the existing emotional distress using the following questionnaires: Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI), Inventory of Complicated Grief (ICG) and Prolongued Grief Disorder (PG-12).Results: The results show that 33.3% and 21.21% of the sufferers had high levels of depression and clinical anxiety two months after the death. The prevalence of prolongued grief diagnoses, according to the PG-12, is 10.6% and 53.03% of the participants showed symptoms of complicated grief according to the ICG. Additionally, statistically significant differences are found in the sufferers with and without a prolongued grief diagnosis and scores in the ICG and BDI-II. The family’s financial situation is linked to the presence of symptoms of anxiety and depression and complicated grief, with the most determining variable being the risk of grief. Finally, the greater the age of the deceased and the longer the time spent in the PCU is linked to fewer symptoms of grief. However, important links have been found between the sufferers who have experienced stressful critical events prior to losing their loved one, with symptoms of depression, anxiety and complicated grief.Conclusions: The high numbers of cases of symptoms of complicated grief and levels of anxiety and clinical depression two months after a death suggests that early interventions should be carried out in those individuals with greater vulnerability.

Psychotherapy in Australia : clinical psychology and its approach to depression

In Australia, clinical psychology training is dominated by cognitive and behavioral treatments (CBTs), although there is exposure to other theoretical orientations. Since 2001, over 20% of general medical practitioners (GPs) have received training in CBT, and psychiatry training increasingly incorporates CBT elements. Psychotherapy by medical practitioners is financially supported by universal health care funding with supplementation by patients and their private health insurance. Federally funded health benefits for up to 12 psychology consultations per year are provided on referral from GPs and psychiatrists, and initial take up has been very strong. Mrs. A would be a typical patient for such a referral. However, she would not fulfil criteria for priority access from state-funded mental health services. Mrs. A would probably consult a GP and receive antidepressants, although she may also access a range of other community support programs. Access to and acceptance of psychotherapy would be greater in urban areas, and if she were of Anglo-Saxon and non- indigenous origin.

The relationship between emotional intelligence and depression in a clinical sample

Background and Objectives: Although depression is a commonly occurring mental illness, research concerning strategies for early detection and prophylaxis has not until now focused on the possible utility of measures of Emotional Intelligence (EI) as a potential predictive factor. The current study aimed to investigate the relationship between EI and a clinical diagnosis of depression in a cohort of adults. Methods: Sixty-two patients (59.70% female) with a DSM-IV-TR diagnosis of a major affective disorder and 39 aged matched controls (56.40% female) completed self-report instruments assessing EI and depression in a cross-sectional study. Results: Significant associations were observed between severity of depression and the EI dimensions of Emotional Management (r = -0.56) and Emotional Control (r = -0.62). The results show a reduced social involvement, an increased prior institutionalization and an increased incidence of "Schizophrenic Psychosis" and "Abnormal Personalities" in the sub-group of repeated admissions. Conclusions: Measures of EI may have predictive value in terms of early identification of those at risk for developing depression. The current study points to the potential value of conducting further studies of a prospective nature.

The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes

Objective To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. Setting 14 nursing homes in Sydney and Brisbane, Australia. Participants 92 residents with a mean age of 85 years. Measurements Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. Results The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. Conclusion When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

General practice-recorded depression and antidepressant use in young people with newly diagnosed Type 1 diabetes: a cohort study using the Clinical Practice Research Datalink

Aims - To investigate whether young people with Type 1 diabetes have an increased rate of depression andantidepressant use and whether their risk varies by age group, time from diabetes diagnosis, calendar period ofdiagnosis or complications status. Methods - A cohort of incident cases of patients with Type 1 diabetes diagnosed before 35 years of age (n = 5548) wasidentified within the Clinical Practice Research Datalink and individually age and sex matched with up to two controlsubjects without diabetes (n = 10 657). Patients with depression were identified through general practice-recordeddepression codes and antidepressant prescriptions. Cox regression models gave hazard ratios for depression in peoplewith Type 1 diabetes compared with control subjects. Results - People with Type 1 diabetes were twice as likely to have a record of antidepressant use and generalpractice-diagnosed depression as their matched control subjects (hazard ratio 2.08, 95% CI 1.73–2.50, P < 0.001).These associations varied by time from diagnosis, with marked increases observed within the first 5 years of diagnosis(hazard ratio 2.14, 95% CI 1.51–3.03, P < 0.001), and by age at diabetes diagnosis, with excesses noted even in the 10-to 19-year age group (hazard ratio 1.45, 95% CI 1.06–1.98, P = 0.02). Conclusions - This population-based study shows that people with Type 1 diabetes have higher rates of generalpractice-recorded depression and antidepressant use. The excess is present within 5 years of diabetes diagnosis,suggesting psychological input for patients is warranted in the early years of their condition.

Long-term citalopram administration reduces responsiveness of HPA axis in patients with major depression: relationship with S-citalopram concentrations in plasma and cerebrospinal fluid (CSF) and clinical response.

RATIONALE: A dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is a well-documented neurobiological finding in major depression. Moreover, clinically effective therapy with antidepressant drugs may normalize the HPA axis activity. OBJECTIVE: The aim of this study was to test whether citalopram (R/S-CIT) affects the function of the HPA axis in patients with major depression (DSM IV). METHODS: Twenty depressed patients (11 women and 9 men) were challenged with a combined dexamethasone (DEX) suppression and corticotropin-releasing hormone (CRH) stimulation test (DEX/CRH test) following a placebo week and after 2, 4, and 16 weeks of 40 mg/day R/S-CIT treatment. RESULTS: The results show a time-dependent reduction of adrenocorticotrophic hormone (ACTH) and cortisol response during the DEX/CRH test both in treatment responders and nonresponders within 16 weeks. There was a significant relationship between post-DEX baseline cortisol levels (measured before administration of CRH) and severity of depression at pretreatment baseline. Multiple linear regression analyses were performed to identify the impact of psychopathology and hormonal stress responsiveness and R/S-CIT concentrations in plasma and cerebrospinal fluid (CSF). The magnitude of decrease in cortisol responsivity from pretreatment baseline to week 4 on drug [delta-area under the curve (AUC) cortisol] was a significant predictor (p<0.0001) of the degree of symptom improvement following 16 weeks on drug (i.e., decrease in HAM-D21 total score). The model demonstrated that the interaction of CSF S-CIT concentrations and clinical improvement was the most powerful predictor of AUC cortisol responsiveness. CONCLUSION: The present study shows that decreased AUC cortisol was highly associated with S-CIT concentrations in plasma and CSF. Therefore, our data suggest that the CSF or plasma S-CIT concentrations rather than the R/S-CIT dose should be considered as an indicator of the selective serotonergic reuptake inhibitors (SSRIs) effect on HPA axis responsiveness as measured by AUC cortisol response.

Discovering biomarkers for antidepressant response: protocol from the Canadian biomarker integration network in depression (CAN-BIND) and clinical characteristics of the first patient cohort

Background Major Depressive Disorder (MDD) is among the most prevalent and disabling medical conditions worldwide. Identification of clinical and biological markers (“biomarkers”) of treatment response could personalize clinical decisions and lead to better outcomes. This paper describes the aims, design, and methods of a discovery study of biomarkers in antidepressant treatment response, conducted by the Canadian Biomarker Integration Network in Depression (CAN-BIND). The CAN-BIND research program investigates and identifies biomarkers that help to predict outcomes in patients with MDD treated with antidepressant medication. The primary objective of this initial study (known as CAN-BIND-1) is to identify individual and integrated neuroimaging, electrophysiological, molecular, and clinical predictors of response to sequential antidepressant monotherapy and adjunctive therapy in MDD. Methods CAN-BIND-1 is a multisite initiative involving 6 academic health centres working collaboratively with other universities and research centres. In the 16-week protocol, patients with MDD are treated with a first-line antidepressant (escitalopram 10–20 mg/d) that, if clinically warranted after eight weeks, is augmented with an evidence-based, add-on medication (aripiprazole 2–10 mg/d). Comprehensive datasets are obtained using clinical rating scales; behavioural, dimensional, and functioning/quality of life measures; neurocognitive testing; genomic, genetic, and proteomic profiling from blood samples; combined structural and functional magnetic resonance imaging; and electroencephalography. De-identified data from all sites are aggregated within a secure neuroinformatics platform for data integration, management, storage, and analyses. Statistical analyses will include multivariate and machine-learning techniques to identify predictors, moderators, and mediators of treatment response. Discussion From June 2013 to February 2015, a cohort of 134 participants (85 outpatients with MDD and 49 healthy participants) has been evaluated at baseline. The clinical characteristics of this cohort are similar to other studies of MDD. Recruitment at all sites is ongoing to a target sample of 290 participants. CAN-BIND will identify biomarkers of treatment response in MDD through extensive clinical, molecular, and imaging assessments, in order to improve treatment practice and clinical outcomes. It will also create an innovative, robust platform and database for future research.