Factors associated with acute fatigue in primary care.

BACKGROUND: To examine the role of psychological distress, negative life events, social support and lack of fitness (using breathlessness on exertion as a proxy) in the development of new onset fatigue in a primary care population. METHOD: Adults between the ages of 18 and 45 years who were registered with five general practices in South East England were asked to complete a fatigue questionnaire and the 12-item General Health Questionnaire. Between 1 and 12 months later, subjects who visited the general practitioner (GP) with a suspected viral infection were recruited to the study and asked to complete measures of fatigue, psychological distress, life events, social support and allergies (stage 2). The next person to present to the GP with a complaint other than a viral illness was recruited as a control. Factors assessed at stage 2 that were associated with the development of fatigue were examined with stepwise logistic regression. RESULTS: Acute fatigue was not associated with a viral illness. Negative life events and breathlessness on exertion (interpreted as lack of fitness) were associated with incident cases of fatigue. However, when controlling for concurrent psychological distress, the independent association of negative life events disappeared. CONCLUSIONS: Psychological distress was strongly associated with new onset fatigue and hence emphasizes the significance of psychological distress as a concomitant complaint in fatigue. Further, the salient association between breathlessness and fatigue may indicate the need to recommend exercise as a therapeutic strategy to improve physical fitness in the primary care setting.

Risk factors for suicidality in Europe: results from the ESEMED study.

BACKGROUND: Precise knowledge of the epidemiology of suicidality provides necessary information for designing prevention programs. The aims of the present study were to investigate the prevalence and correlates of suicidal ideas and attempts in the general population of Europe. METHODS: The European Study on the Epidemiology of Mental Disorders (ESEMED) is a cross-sectional household survey carried out in a probability representative sample of non-institutionalised adults (aged 18 years or older) of six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain). The Composite International Diagnostic Interview (CIDI 3.0) was administered to 21,425 individuals. RESULTS: Lifetime prevalence of suicidal ideation was 7.8% and of suicidal attempts 1.3%. Being women, younger and divorced or widowed were associated with a higher prevalence of suicide ideation and attempts. Psychiatric diagnoses were strongly related to suicidality. Among them, major depressive episode (Rate ratio 2.9 for lifetime ideas and 4.8 for lifetime attempts), dysthymia (RR 2.0 and 1.6), GAD (RR 1.8 and 2.3 for lifetime), PTSD (RR 1.9 and 2.0) and alcohol dependence (RR 1.7 and 2.5) were the most important. Population attributable risks for lifetime suicidal attempt was 28% for major depression. LIMITATIONS: Information about suicidal ideas and attempts was self reported, psychiatric diagnoses were made using fully structured lay interviews rather than clinician-administered interviews. CONCLUSIONS: In spite of meaningful country variation in prevalence, risk factors for suicidality are consistent in the European countries. Population prevention programmes should focus on early diagnosis and treatment of major depression and alcohol abuse and in those individuals with recent appearance of suicidal ideas.

Grief shortly after suicide and natural death: a comparative study among spouses and first-degree relatives.

Chronic dysfunction after complicated grief is not rare and emphasizes the need to identify bereaved individuals at risk. Three months following bereavement, self-reported psychiatric and general health of 153 relatives of 74 suicides was worse than of 70 relatives of 39 natural deaths. Moreover, the felt need for professional help was higher among the former, even after adjustment for expectedness of death, sociodemographic differences, and relatives'/spouses' neuroticism. This suggests that suicide-bereaved individuals may constitute a high-risk group of mourners in need of targeted postvention.

[Suicidal tendencies, a disorder that crosses boundaries between disciplines]. / Suïcidaliteit--een stoornis die specialismen overstijgt.

BACKGROUND: Suicidality is considered to be a facultative symptom of certain psychiatric disorders. AIM: To provide evidence in support of the view that suicidality is not only a symptom of other disorders or comorbid with them but is often a disorder in its own right. METHOD: We conducted a review of the literature. RESULTS: Suicidality manifests itself as a disorder in its own right without any one-to-one relationships with other psychiatric or somatic disorders or illnesses. CONCLUSION: Suicidality has specific features of its own such as susceptibility to interindividual contagion. By preventing suicide we may be able to forestall the development of other types of ill-health and thus improve the quality of the life that has been saved.

Psychiatric morbidity is related to a chain of prenatal and perinatal adversities.

BACKGROUND: Most studies on the effects of early risk factors on future mental health focus on specific obstetric complications as risk factors for specific disorders. However, obstetric complications rarely occur in isolation, and the same holds for psychiatric problems. AIMS: To study prenatal and perinatal risk factors for psychiatric multimorbidity in early adulthood and to determine whether these differ from risk factors for monomorbidity. STUDY DESIGN: Monomorbidity and multimorbidity of six types of psychiatric disorders were determined by a standardised psychiatric interview. Using univariate and multivariate logistic and ordinal logistic regression, associations of mono- and multimorbidity with prospectively collected early risk factors were examined. SUBJECTS: Two hundred and eighty-five young adults selected from a prospective birth cohort on the basis of their Obstetric Optimality Scores. OUTCOME MEASURES: Six types of psychiatric disorder and their co-occurrence. RESULTS: Monomorbidity was related to isolated early risk factors such as low birth weight or a low Apgar score, and to an accumulation of unfavourable pre- and perinatal events. Multimorbidity on the other hand, was only related to a chain of pre- and perinatal adversities. CONCLUSION: Research and prevention strategies should not focus solely on isolated early risk factors, but also on the entire pre- and perinatal situation.

Obstetric optimality and emotional problems and substance use in young adulthood.

BACKGROUND: Pregnancy and delivery are complex processes, and isolated obstetric complications rare and often accompanied or followed by a number of others. AIMS: To study the relationship between the overall obstetric situation (as opposed to single obstetric risk factors) and emotional and substance use disorders in young adulthood, and to analyse whether these links are mediated by temperaments in childhood. STUDY DESIGN: In a prospective birth cohort (n=3162), questionnaires were sent to mothers and teachers when the child was 7-10 years old, and to the children when they were 20-25 years old. SUBJECTS: Six hundred and eighty-two cohort members with complete data sets at three ages (perinatal, childhood, and young adulthood). OUTCOME MEASURES: Emotional problems and substance use in young adulthood. MAIN RESULTS: Substance use in young adulthood was predicted better by the overall obstetrical optimality score than emotional problems were. Links studied were stronger for men than for women. CONCLUSIONS: This study demonstrated the use of an aggregated obstetrical optimality score in analysing the associations between early risk factors and emotional problems and substance use in young adulthood.

Neuroticism, a central link between somatic and psychiatric morbidity: path analysis of prospective data.

BACKGROUND: Neuroticism and somatic complaints are linked, and the aim of this study is to disentangle which mechanisms may be responsible for this association. METHOD: In a stratified sample of 7076 adults (18-65 years), neuroticism, 22 self-reported chronic somatic conditions and five broad CIDI-diagnosed psychiatric syndromes were assessed at baseline and, in 3625 (51%) subjects, 3 years later. Using path analysis we examined whether neuroticism has direct links with future somatic morbidity and, conversely, whether morbidity at baseline is linked with higher neuroticism later on. RESULTS: Neuroticism at baseline is associated with psychiatric and somatic morbidity at follow-up after 3 years (31% and 24%, respectively, are direct associations, i.e. unmediated by each other or neuroticism at follow-up and independent of morbidity at baseline). Conversely, somatic and psychiatric morbidity at baseline are associated with increased neuroticism at follow-up (27% and 15%, respectively, are direct associations). CONCLUSIONS: Neuroticism raises risk for psychiatric and somatic morbidity but also results from them. It represents a central nexus in the process of morbidity accumulation.

Posttraumatic stress disorder following preeclampsia and HELLP syndrome.

Posttraumatic stress disorder (PTSD) in connection with pregnancy was first described in the 1990s--initially in relation to childbirth but later more specifically to the mode of delivery. Instrumental vaginal delivery carries the highest risk of PTSD followed by emergency caesarean section and normal spontaneous delivery. Loss of pregnancy, spontaneous abortion or intrauterine death for example can also lead to PTSD. Little systematic research has been performed regarding the psychological consequences of severe preeclampsia or HELLP syndrome, although it would seem obvious that these conditions may have a great effect The combination of suffering a serious illness combined with an unexpected caesarean section or delivery, often of a premature child, is a heavy burden to bear both physically and psychologically. We describe here three patients who developed PTSD after pregnancies complicated by severe preeclampsia or HELLP syndrome. PTSD can develop after preeclampsia or HELLP syndrome.

Effect of antenatal exposure to maternal smoking on behavioural problems and academic achievement in childhood: prospective evidence from a Dutch birth cohort.

AIM: To examine effects of maternal smoking during pregnancy on academic achievement and emotional and behavioural problems during childhood. METHODS: Least squares regression was used to examine associations between maternal smoking prior to delivery and subsequent academic performance and behaviour of 1186 children aged 5.5-11 years. Crude associations were adjusted for risk factors that were significantly related to the respective outcomes. MAIN OUTCOME MEASURES: Parents and teachers were asked to indicate, on a 10-item questionnaire, whether they regarded the child as more, the same, or less shy/withdrawn (internalising), troublesome (externalising), and attention deficient than the average child. Reading, spelling, and arithmetic performance levels were assessed with short standardised Dutch tests. RESULTS: After adjustment for confounders like socio-economic status and pre- and perinatal complications, children of mothers who smoked during pregnancy showed more signs of attention deficit and displayed higher levels of troublesome (externalising) behaviour than non-cigarette-exposed children. Also, children of smoking mothers performed worse on arithmetic and spelling tasks. Spelling problems were more pronounced when the mother continued to smoke after the child's birth. Excessively withdrawn (internalising) behaviour was not related to maternal smoking but to factors like the mother's use of psychotropic drugs and bottle-instead of breastfeeding. CONCLUSION: Perinatal antecedents of internalising behaviour on the one hand and externalising behaviour, attention deficit, and learning problems on the other seem to be distinct. Only the latter are independently associated with maternal smoking during pregnancy and thus potentially amenable to early preventive effort, for instance, through continued health education emphasising the health hazards of nicotine use by pregnant women.

Positive life change and remission of non-psychotic mental illness. A competing outcomes approach.

BACKGROUND: Episode duration in non-psychotic mental illness is associated with personal characteristics of patients, like age or personality. Part of these links may be mediated by life change, a predictor of episode duration in its own right. METHODS: In 170 primary care patients who suffered 4171 person-months of non-psychotic mental illness diagnosed according to Bedford College Criteria, we examined to what extent associations with episode duration of nine person-linked variables including personal vulnerability, coping styles and social support, are mediated by their effects on the occurrence, during episodes, of positive life changes (PLC) assessed using the Life Events and Difficulties Schedule. Cox regression for competing endpoints was used to analyse the simultaneous effects of baseline variables on PLC and on remission, whether spontaneous or not. RESULTS: Irrespective of diagnosis and symptom intensity, PLC during episodes increases remission rates 2.9-fold (P<0.001). Remission rates are higher in patients with larger social networks and who seek more help but this is partly because such persons experience more PLC earlier during episodes. Lower neuroticism is also linked with shorter episode duration but this effect is unmediated by PLC. LIMITATIONS: Mental state may bias dating and reporting of life change. Treatment aspects were not recorded. Elderly subjects were not included. CONCLUSION: PLC occurrence during common mental illness is associated with psychosocial variables which are also overall predictors of episode remission. Thus, PLC mediates between patients' psychosocial make-up and their chances of speedy recovery. This has implications for the management of non-psychotic mental illness.

The neurology of learning and behavioural problems in pre-adolescent children.

OBJECTIVE: The aim of the study was to evaluate whether in pre-adolescent children specific types of minor neurological dysfunction (MND) are related to specific types of learning and behavioural problems, and whether it is the type or the severity of neurological dysfunction that matters most. METHOD: A total of 1186, 5.5-11-year-old, children were examined for the presence of clusters of signs of MND. Parents and teachers completed brief behaviour rating scales. In school-aged children (n = 580) cognitive achievement was assessed using standardized Dutch tests. Least-squares regression was used to examine neurobehavioural and neurocognitive links. RESULTS: Children with more MND clusters performed worse scholastically and had more signs of attention deficit than others. Externalizing and internalizing behaviour were only linked to specific forms of MND. CONCLUSION: Evaluation of the neurological condition of the child with learning and behavioural problems offers insight into the aetiology and pathogenesis of these problems.

Propensity to psychiatric and somatic ill-health: evidence from a birth cohort.

BACKGROUND: Somatic and psychiatric morbidity may cluster because of reciprocal effects between them but also as a result of common underlying factors. METHODS: The data come from the 1946 MRC birth cohort (N = 5362). Clustering of 20 chronic medical conditions at the participants' 43rd year was analysed using multi-morbidity coefficients. Associations of somatic and psychiatric morbidity at 43 years, with temperament and behaviour, assessed from adolescence to early adulthood, and background variables like paternal social class, were examined using structural equation modelling. The focus was on whether links applied to both morbidity types or one only, and were direct or were indirect, mediated by prior morbidity. RESULTS: Reported chronic medical conditions clustered strongly. Somatic multi-morbidity and psychiatric ill-health at 43 years were associated with temperamental and behavioural features assessed between the subjects' 13th and 26th birthday, like neuroticism and aggression, as well as with external variables like parental death before the participants' 16th birthday. However, only neuroticism holds direct links with somatic as well as with psychiatric ill-health, 28% of the former and 52% of the latter association being independent of the simultaneous presence of the other morbidity type and of participants' health status 7 years earlier. CONCLUSIONS: Personality traits like neuroticism not only raise the risk of psychiatric disorder but also, irrespective of whether manifest psychiatric disorders have developed, of a broad spectrum of chronic somatic diseases. This suggests that clinicians and researchers should focus not only on the psychiatric disorders associated with such personality traits but also on their medical consequences.

Quantifying psychiatric comorbidity--lessions from chronic disease epidemiology.

BACKGROUND: Comorbidity research in psychiatric epidemiology mostly uses measures of association like odds or risk ratios to express how strongly disorders are linked. In contrast, chronic disease epidemiologists increasingly use measures of clustering, like multimorbidity (cluster) coefficients, to study comorbidity. This article compares measures of association and clustering. METHODS: Narrative review, algebraical examples, a secondary analysis of an existing dataset and a pooled analysis of published data. RESULTS: Odds and risk ratios, but the former more than the latter, confound clustering with coincidental comorbidity. Multimorbidity coefficients provide a pure estimate of clustering which is the proportion of the association between disorders that is of etiological interest. Odds and risk ratios can express comorbidity between no more than two disorders, whilst clustering coefficients, although computationally laboursome, can capture multimorbidity of any number of disorders. Cluster coefficients depend less on the prevalence of illness in study groups than measures of association. CONCLUSION: Odds and risk ratios are well suited for comorbidity research which focuses on which sets of disorders or syndromes tend to occur in combination and the implications of this for, for instance, nosological classification, a traditional interest of psychiatric epidemiology. However, the cluster coefficient is to be preferred if the interest is more aetiological, addressing for example why certain individuals are prone to multiple health problems.

Beyond risk theory: suicidal behavior in its social and epidemiological context.

The effect of exposure to risk factors for suicidal behavior varies from place to place and from period to period. This may be due to contextual influences, which arise if individuals' suicide risk depends not only on their personal exposure to risk or protective factors, but also on how these are distributed in their social, cultural, economic, or even physical environments. There has been relatively little explicit attention in suicide research for such contextual influences even though they are an important component of the cross-level bias, which can arise when aggregate level associations are assumed to also apply in individuals and vice versa. Contextual effects are conceptually related to the issues of social selection vs. causation, population density, and network effects. Because of a lack of prospective multilevel research, it is unclear exactly which mechanisms underlie the phenomenon that the distribution of risk factors in an individual's context may affect their suicide risk above and beyond their personal exposure. A number of mechanisms, like deviancy amplification, formalization of restraints, and buffering effects of social support are proposed. Contextual effects may result in a concentration of suicide risk in persons when the risk factors they are exposed to become rare--whether spontaneously or through focused prevention. This has important but mostly overlooked implications for population-based prevention strategies.

[Suicidality]. / Suïcidaliteit.

Prevention of suicidal behaviour remains difficult, despite increasing knowledge of its determinants. Health service efforts hardly affect suicide rates. Recent shifts in the epidemiology of suicidal behaviour are rising rates among the young and increasing use of violent methods; these can be linked to emerging aetiological insights. Early stages of the suicidal process often manifest themselves at an early age, as emotional and behavioural instability. Epidemiological evidence suggests that the suicidal process increasingly concentrates itself in a vulnerable minority in whom it progresses rapidly to a phase of relative unresponsiveness to environmental influences including preventive efforts. Thus, prevention should focus not only on persons in the later stages of the suicidal process like psychiatric patients, but especially on individuals who, as youngsters, show signs of entering its very first stages. Since high suicide risk implies high risk of other adverse health outcomes as well, this should, in time, yield health gains in more domains than suicide reduction only.

The distribution of psychiatric and somatic III health: associations with personality and socioeconomic status.

OBJECTIVE: Psychiatric and somatic disorders frequently co-occur in the same individuals. We examined whether this happens because these types of morbidity share risk factors or because they are risk factors for each other. METHODS: Negative binomial regression was used to examine, in a random sample of Dutch adults (N = 7076), cross-sectional associations of sociodemographic and personality variables like income and neuroticism with the presence, over 1 year, of 30 somatic and 13 psychiatric disorders, with the latter diagnosed by structured interview. We examined to what extent the links of these variables with these two morbidity types were independent of each other. RESULTS: This population experienced 5050 somatic and 2438 psychiatric disorders during the preceding year. Subjects reporting more somatic disorders had more psychiatric disorders. Neuroticism, followed closely by low educational attainment, was the strongest correlate of both morbidity types. After adjustment for all other covariates including somatic morbidity, the number of psychiatric diagnoses rose 1.84-fold (95% confidence interval = 1.74-1.94) per standard deviation increase in neuroticism. Likewise, adjusted for all other covariates including psychiatric diagnoses, 1.42 (95% confidence interval = 1.35-1.50) times more somatic disorders were reported per standard deviation increase in neuroticism. CONCLUSIONS: Personal features like neuroticism and low educational attainment are linked with psychiatric and with somatic morbidity. These links are largely independent. Although this study was cross-sectional, the results suggest that these different types of morbidity may have overlapping etiologies. Key words: Comorbidity, multimorbidity coefficient, negative binomial regression, epidemiology, neuroticism, social class.

A continuum of premature death. Meta-analysis of competing mortality in the psychosocially vulnerable.

BACKGROUND: Suicide may be an extreme expression of liability to death of any type. If true, suicide risk factors should also increase other mortality, and, given exposure, excess risk should be higher for suicide than for other mortality. METHODS: Of 304 publications identified in Index Medicus (1966-June 1988) by the string (suicide) and (mortality or death) and (accidental or natural), 24 reported total and cause-specific mortality associated with exposure to 16 established suicide risk factors; reference scanning yielded 122 more. These 146 publications reported on 163 cohorts (total subjects = 1179 126) mortality. Meta-analysis gave random effects standardized mortality ratios (SMR) for natural, accidental and suicidal death, stratified over the 16 risk groups. RESULTS: Overall, SMR were 8.6 (95% CI : 7.1-10.4) for suicide, 3.4 (95% CI : 2.9-4.0) for accidental and 2.1 (95% CI : 1.9-2.3) for natural death. Compatible with the first hypothesis, in most groups, mortality of any type was raised. Supporting the second hypothesis, excesses increased from lowest for natural death to highest for suicide. This trend was most pronounced following deliberate self-harm, intermediate in substance abusers, and weakest, but present, in bereaved and low social class cohorts and reversed in smokers and epileptic people. CONCLUSIONS: Many suicide risks apply to any type of premature death, whilst also retaining some specificity for suicide. Primary prevention, targeting such generic risk factors, will not only reduce rates of suicide but also of other types of death. Conversely, when prevention focuses on specific outcomes-such as suicide-only, other types of mortality may increase.

Ethnic density and deliberate self harm; a small area study in south east London.

STUDY OBJECTIVE: Relative risks are frequently used to convey how strongly outcomes like mental illness and suicidal behaviour are associated with personal characteristics like ethnic background. This study examined whether RRs for deliberate self harm (DSH) in ethnic groups vary between small areas according to their ethnic mix. DESIGN: Small area study of DSH rates in ethnic groups, by local ethnic density, using negative binomial regression. SETTING: 73 south London electoral wards, 1994-1997. SUBJECTS: 1643 people attending casualty after DSH. MAIN RESULTS: African-Caribbean and Asian DSH rates, relative to the white population, varied between wards. A linear model indicated a decline by factors (relative rate ratios) 0.76 (95% confidence intervals (CI) 0.64 to 0.90) and 0.59 (95% CI 0.36 to 0.97) respectively per SD increase in the local size of these minority populations. However, for both groups, an inverted U shaped curve provided a better fit for the link between the relative DSH rate in these groups and their local population density. CONCLUSIONS: The DSH rate of minority groups relative to the white group is low (suggesting protection) in some areas, and high (suggesting risk) elsewhere. This has implications for management of suicidal behaviour in ethnic groups but also for interpretation, and policy implementation, of research on risk for suicidal behaviour, and, probably, many other outcomes. Relative risks or rates are not stable indicators of association in psychiatric epidemiology.