The association of depression and all-cause mortality: Explanatory factors and the influence of gender.

BACKGROUND: The association of depression with mortality and the significance of explanatory factors, in particularly gender, have remained an issue of debate. We therefore aimed to estimate the effect of depression on all-cause mortality, to examine potential explanatory factors and to assess effect modification by gender. METHODS: We used Cox regression models to estimate the effect of depression on mortality based on data from the Gutenberg Health Study, which is a prospective cohort study of the adult population in the districts of Mainz and Mainz-Bingen, Germany. Baseline assessment was between 2007 and 2012. Effect modification by gender was measured on both additive and multiplicative scales. RESULTS: Out of 14,653 participants, 7.7% were depressed according to Patient Health Questionnaire 9 (PHQ-9), and 1,059 (7.2%) died during a median follow-up of 10.7 years. Depression elevated the risk of mortality in men and women in age-adjusted models (HR: 1.41, 95%-CI: 1.03-1.92; resp. HR: 1.96, 95%-CI: 1.43-2.69). Adjustment for social status, physical health and lifestyle covariates attenuated the effect and in the fully-adjusted model the hazard ratio was 0.96 (95%-CI: 0.69-1.33) in men and 1.53 (95%-CI: 1.10-2.12) in women. For effect modification by gender, the measure on multiplicative interaction was 0.68 (95%-CI 0.44-1.07) and on additive interaction was RERI=-0.47 (95%-CI -1.24-0.30). LIMITATIONS: The PHQ-9 is a single self-report measure of depression reflecting symptoms of the past two weeks, limiting a more detailed assessment of depression and course of symptoms, which likely affects the association with mortality. CONCLUSIONS: Depression elevates mortality by multifactorial pathways, which should be taken into account in the biopsychosocially informed treatment of depression. Effect modification by gender was not statistically significant.

Adult attachment representation moderates psychotherapy treatment efficacy in clinically depressed inpatients.

BACKGROUND: We explored in a sample of clinically depressed patients the influence of attachment security and unresolved trauma on psychotherapeutic outcome as well as changes in attachment representation through psychotherapeutic intervention. METHODS: The sample consisted of 85 women (aged 19-52), 43 clinically depressed patients from a psychosomatic inpatient unit, and 42 healthy control subjects matched for age and education. Average length of hospitalization in the patient group was eight weeks. Attachment representations were assessed with the Adult Attachment Interview at the time of admission (baseline) and at discharge. Depressive symptoms were measured using the PHQ-9 at T1 and T2. RESULTS: Insecure attachment representations were overrepresented in depressed patients. Treatment effects were moderated by baseline attachment representation: patients with higher attachment security scores at admission benefited more from the inpatient treatment and were less depressed at time of discharge than less secure patients (η(2)=.07). Generally, attachment security increased (η(2)=.19) and depressive symptoms decreased (η(2)=.23) after inpatient psychotherapy treatment in the patient group. No significant effects for unresolved symptoms were found. LIMITATIONS: The study is not a randomized controlled study, but used a quasi-experimental matched control group design with female subjects only. CONCLUSIONS: Our results suggest that attachment representations play a major role in both the development and treatment of clinical depression. Baseline attachment security may influence psychotherapeutic outcome, perhaps through relational factors such as therapeutic working alliance. Inpatient psychotherapy may also need to address psychological issues associated with depression such as attachment insecurity.

Methylation of the oxytocin receptor gene in clinically depressed patients compared to controls: The role of OXTR rs53576 genotype.

The emerging field of epigenetics provides a biological basis for gene-environment interactions relevant to depression. We focus on DNA methylation of exon 1 and 2 of the oxytocin receptor gene (OXTR) promoter. The research aims of the current study were to compare OXTR DNA methylation of depressed patients with healthy control subjects and to investigate possible influences of the OXTR rs53576 genotype. The sample of the present study consisted of 43 clinically depressed women recruited from a psychosomatic inpatient unit and 42 healthy, female control subjects - mean age 30 years (SD = 9). DNA methylation profiles of the OXTR gene were assessed from leukocyte DNA by means of bisulfite sequencing. Depressed female patients had decreased OXTR exon 1 DNA methylation compared to non-depressed women. The association between depression and methylation level was moderated by OXTR rs53576 genotype. Exon 2 methylation was associated with OXTR rs53576 genotype but not with depression. Our findings suggest exon-specific methylation mechanisms. Exon 1 methylation appears to be associated with depressive phenotypes whereas exon 2 methylation is influenced by genotype. Previously reported divergent associations between OXTR genotype and depression might be explained by varying exon 1 methylation. In order to further understand the etiology of depression, research on the interplay between genotype, environmental influences and exon-specific methylation patterns is needed.

Early discharge after vaginal hysterectomy.

Over eight months, 66 patients seen in the author's private practice were deemed suitable candidates for vaginal hysterectomy; 41 of these chose to participate in a continuing study of the feasibility of early discharge after the operation. The principal indication for surgery in these women, who ranged in age from 24-68 years, was abnormal bleeding. Other procedures performed in addition to vaginal hysterectomy did not, in most patients, interfere with early dismissal from the hospital. With the exception of one woman, all were discharged within 24 hours after surgery. There were no cases of delayed infection, hemorrhage, or other postoperative complications that could be attributed to early hospital dismissal. Most patients were able to return to their normal activities much sooner than the usually expected four to six weeks after surgery.

Urinary stone formation in children with prenatally diagnosed uropathies.

Among a series of 312 patients with prenatally diagnosed uropathies, 4 male children developed urinary calculi at ages varying from 2 to 5 years. All had upper urinary tract dilatation not associated with vesicoureteric reflux or with renographically defined obstruction; 3 followed Proteus urinary infections. Strategies for prevention are discussed.

Current management of duplex-system ureteroceles: experience with 41 patients.

Experience is described of 41 infants and children with duplex-system ureteroceles, 25 presenting clinically and 16 by prenatal ultrasonography. Bladder outflow obstruction was rare but lower polar vesicoureteric reflux (VUR), usually of lesser grades, was common. Upper polar function, as assessed by 99mTc-DMSA, was negligible in children with truly ectopic ureteroceles but well preserved in those where the lesion lay wholly intravesically. Lower polar function was good, even in the presence of secondary obstruction, except in 2 infants with major VUR. Twenty-three patients were treated by upper polar nephrectomy plus aspiration of the ureterocele; 2 subsequently required ureterocele excision. Histology of excised specimens indicated that a more conservative approach would not have been rewarded. Where upper polar function was good, conservation was maintained in 3 cases by pyelopyelostomy and in 5 more by excision of the ureterocele plus bipolar ureteric reimplantation. Other operative strategies were employed in 2 cases. Finally, a defined group of 8 children was managed expectantly without untoward results. It was concluded that the variable anatomy and function associated with duplex-system ureteroceles require a flexibile approach to treatment, including, possibly, no treatment at all.

Incidence of normal micturition in myelomeningocele patients.

Among 108 consecutive patients with myelomeningocele aged 5-12 years initially treated by a selective policy, seven (6.5%) achieved spontaneous urinary continence, five with normal micturition and two with urgency. All had positive conus reflexes and incomplete cord lesions which, with one exception, comprised motor as well as sensory sacral sparing.

Retroperitoneal fibrosis in association with urothelial tumor.

One of the less common associations of retroperitoneal fibrosis is malignancy. Although there have been many reports on tumors associated with retroperitoneal fibrosis urothelial tumors are rare. We report a case of retroperitoneal fibrosis and urothelial malignancy of the renal pelvis.

Localized deep microwave hyperthermia in the treatment of poor operative risk patients with benign prostatic hyperplasia.

Non-invasive localized deep microwave hyperthermia was applied as an alternative treatment to surgery in 29 patients with contraindications for prostatectomy. Patients were treated twice weekly, on Mondays and Thursdays, for 1 hour, without sedation on an outpatient basis. All patients tolerated treatment well without secondary effects. The results indicate that localized deep microwave hyperthermia applied by this method is safe and effective in the treatment of benign prostatic hyperplasia.