Incidence of major depression diagnoses in the Canadian Armed Forces: longitudinal analysis of clinical and health administrative data.

PURPOSE: Major depression is a leading cause of morbidity in military populations. However, due to a lack of longitudinal data, little is known about the rate at which military personnel experience the onset of new episodes of major depression. We used a new source of clinical and administrative data to estimate the incidence of major depression diagnoses in Canadian Armed Forces (CAF) personnel, and to compare incidence rates between demographic and occupational factors. METHODS: We extracted all data recorded in the electronic medical records of CAF Regular Force personnel, at every primary care and mental health clinical encounter since 2016. Using a 12-month lookback period, we linked data over time, and identified all patients with incident diagnoses of major depression. We then linked clinical data to CAF administrative records, and estimated incidence rates. We used multivariate Poisson regression to compare adjusted incidence rates between demographic and occupational factors. RESULTS: From January to December 2017, CAF Regular Force personnel were diagnosed with major depression at a rate of 29.2 new cases per 1000 person-years at risk. Female sex, age 30 years and older, and non-officer ranks were associated with significantly higher incidence rates. CONCLUSIONS: We completed the largest study to date on diagnoses of major depression in the Canadian military, and have provided the first estimates of incidence rates in CAF personnel. Our results can inform future mental health resource allocation, and ongoing major depression prevention efforts within the Canadian Armed Forces and other military organizations.

Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury.

BACKGROUND: A link between moral injury (i.e., the psychological distress caused by perceived moral transgressions) and adverse mental health outcomes (AMHO) has been recently proposed. However, the prevalence of exposure to morally injurious events and the associated risk of experiencing AMHO remains understudied. METHOD: The impact of exposure to potentially morally injurious experiences (PMIEs) was explored in relation to past-year PTSD and MDD, using the 2013 Canadian Armed Forces Mental Health Survey dataset of Afghanistan mission deployed regular force and reserve personnel. A series of logistic regressions were conducted, controlling for relevant sociodemographic, military, deployment, and trauma-related variables. RESULTS: Over half of the deployed personnel endorsed at least one PMIE. Several demographic and military variables were associated with exposure to PMIEs. Those exposed to PMIEs demonstrated a greater likelihood of having past-year PTSD and MDD; feeling responsible for the death of Canadian or ally personnel demonstrated the strongest association with PTSD and MDD. Mental health training was not a moderator for PMIE exposure and AMHO. CONCLUSIONS: Exposure to PMIEs during deployments is common and represents an independent risk factor for past-year PTSD and MDD. Improved training that targets moral-ethical dilemmas and treatment interventions that address moral injury expressions is warranted.

Contribution of mental and physical disorders to disability in military personnel.

Background: Combat operations in Southwest Asia have exposed millions of military personnel to risk of mental disorders and physical injuries, including traumatic brain injury (TBI). The contribution of specific disorders to disability is, however, uncertain. Aims: To estimate the contributions of mental and physical health conditions to disability in military personnel. Methods: The sample consisted of military personnel who participated in the cross-sectional 2013 Canadian Forces Mental Health Survey. Disability was measured using the World Health Organization Disability Assessment. The International Classification of Functioning, Disability, and Health was used to classify participants with moderate/severe disability. Chronic mental disorders and physical conditions were measured by self-reported health professional diagnoses, and their contribution to disability was assessed using logistic regression and resulting population attributable fractions. Results: Data were collected from 6696 military members. The prevalence of moderate/severe disability was 10%. Mental disorders accounted for 27% (95% confidence interval [CI] 23-31%) and physical conditions 62% (95% CI 56-67%) of the burden of disability. Chronic musculoskeletal problems 33% (95% CI 26-39%), back problems 29% (95% CI 23-35%), mood disorders 16% (95% CI 11-19%) and post-traumatic stress disorder (PTSD) 9% (95% CI 5-12%) were the leading contributors to disability. After-effects of TBI accounted for only 3% (95% CI 1-4%) of disability. Mental and physical health interacted broadly, such that those with mental disorders experienced disproportionate disability in the presence of physical conditions. Conclusions: Chronic musculoskeletal conditions, back problems, mood disorders and PTSD are primary areas of focus in prevention and control of disability in military personnel.

Insomnia, psychiatric disorders and suicidal ideation in a National Representative Sample of active Canadian Forces members.

BACKGROUND: Past research on the association between insomnia and suicidal ideation (SI) has produced mixed findings. The current study explored the relationship between insomnia, SI, and past-year mental health status among a large Canadian Forces (CF) sample. METHOD: Data was obtained from the 2013 Canadian Forces Mental Health Survey (CFMHS), and included a large representative sample of Canadian Regular Forces personnel (N = 6700). A series of univariate logistic regressions were conducted to test individual associations between past-year mental health status, insomnia, and potential confounds and SI. Mental health status included three groups: 0, 1, or two or more probable diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD) and alcohol abuse/dependence. Stepwise multivariate logistic regression was used to assess the relationship between insomnia and SI with mental health status as a moderator. RESULTS: 40.8% of respondents reported experiencing insomnia. Both insomnia and number of mental health conditions incrementally increased the risk of SI. However, past-year mental health status was a significant moderator of this relationship, such that for CF personnel with either no (AOR = 1.61, 1.37-1.89) or only one past-year mental health condition (AOR = 1.39, 1.12-1.73), an incremental increase in insomnia was associated with an increased likelihood of SI. However, in personnel with two or more past-year mental health disorders, insomnia was no longer significantly associated with SI (AOR = 1.04, 0.81-1.33). CONCLUSIONS: Insomnia significantly increased the odds of SI, but only among individuals with no or one mental health condition. Findings highlight the importance of assessing insomnia among CF members in order to further suicide prevention efforts.

Stroke in users of low-dose oral contraceptives.

PIP: Researchers conducted a population-based, retrospective, case control study to determine whether or not women using combined oral contraceptives (OCs) containing less than 50 mcg estrogen face an increased risk for hemorrhagic or ischemic stroke. The racially and ethnically diverse group of 1.1 million women 15-44 years old was enrolled in the Kaiser Permanente Medical Plans of northern and southern California. The women were observed for over 3.6 million women-years. 408 of the women had suffered a stroke during 1991-1994, for an incidence rate of 11.3/100,000 women-years. Compared to former users and never users, among current OC users the adjusted odds ratio was 1.18 for ischemic infarction (95% confidence interval [CI], 0.54-2.59) and 1.14 for hemorrhagic stroke (95% CI, 0.60-2.16). That the CI for the odds ratios include 1.00 suggests that current OC users do not face a significantly increased risk for stroke overall. Current OC use combined with smoking did appear to affect the outcome of hemorrhagic stroke. Limitations of the study include: the women had consistent access to medical care at little or no cost (different results may have been seen among poor women at public clinics), the low risk of stroke in young women limits the statistical power of the study, and the researchers did not inquire about migraine in study participants. These findings imply that most users of and potential candidates for low-dose OCs face little or no increased risk for stroke. Among non-smokers regardless of age, the risk of death from pregnancy is greater than it is from OC use. Among smokers 40 years or younger, the risk of death as a result of pregnancy may be higher than that due to OC use, still smokers 35 and older should not use OCs.^ieng

Social anxiety disorder: common, disabling, and treatable.

BACKGROUND: Social anxiety disorder (also known as social phobia) is characterized by extreme fear, avoidance, or both of one or more social or performance situations, such as making a presentation, meeting new people, or eating in front of others. This condition is common, with a lifetime prevalence of up to 13%, and one third of affected persons have major dysfunction. METHODS: The English-language literature on social anxiety disorder indexed on MEDLINE was searched using the phrases "social phobia" or "social anxiety disorder;" this search was supplemented with other data sources, such as recent textbooks, to determine common clinical symptoms, differential diagnosis, and management in the primary care setting. RESULTS: Recognition and treatment of social anxiety disorder is poor; only a small minority of patients with this condition have it appropriately diagnosed or treated. Primary care physicians should suspect social anxiety disorder in patients who have specific symptoms and signs (such as hyperhidrosis, flushing, tremor, and white-coat hypertension), in patients who have symptoms of anxiety (such as chest pain, palpitations, or dizziness), or in patients who have another known anxiety disorder, depression, or substance abuse. Drug treatment consists of serotonin-reuptake inhibitors, monoamine oxidase inhibitors, or high-potency benzodiazepines. A specific type of psychotherapy called cognitive behavioral therapy is another effective treatment, but it is not acceptable or accessible to most patients. CONCLUSIONS: Because social anxiety disorder is common, disabling, and treatable, primary care physicians should intensify their efforts to recognize it.

NHBPEP report on high blood pressure in pregnancy: a summary for family physicians.

The National High Blood Pressure Education Program's Working Group on High Blood Pressure in Pregnancy recently issued a report implicating hypertension as a complication in 6 to 8 percent of pregnancies. Hypertension in pregnancy is related to one of four conditions: (1) chronic hypertension that predates pregnancy; (2) preeclampsia-eclampsia, a serious, systemic syndrome of elevated blood pressure, proteinuria and other findings; (3) chronic hypertension with superimposed preeclampsia; and (4) gestational hypertension, or nonproteinuric hypertension of pregnancy. Edema is no longer a criterion for preeclampsia, and the definition of blood pressure elevation is 140/90 mm Hg or higher. Patients with gestational hypertension have previously unrecognized chronic hypertension, emerging preeclampsia or transient hypertension of pregnancy, an obstetrically benign condition. Because distinguishing among these conditions can be done only in retrospect, clinical management of gestational hypertension consists of repeated evaluations to look for signs of emerging preeclampsia. Women with chronic hypertension should be followed for evidence of fetal growth restriction or superimposed preeclampsia. Management options for chronic hypertension in most women include discontinuing antihypertensive medications during pregnancy, switching to methyldopa or continuing previous antihypertensive therapy.

Management of suspected fetal macrosomia.

Fetal macrosomia, arbitrarily defined as a birth weight of more than 4,000 g (8 lb, 13 oz) complicates more than 10 percent of all pregnancies in the United States. It is associated with increased risks of cesarean section and trauma to the birth canal and the fetus. Fetal macrosomia is difficult to predict, and clinical and ultrasonographic estimates of fetal weight are prone to error. Elective cesarean section for suspected macrosomia results in a high number of unnecessary procedures, and early induction of labor to limit fetal growth may result in a substantial increase in the cesarean section rate because of failed inductions. Pregnancies complicated by fetal macrosomia are best managed expectantly. When labor fails to progress as expected, the possibility of fetopelvic disproportion should be considered within the context of the best estimate of the fetal weight.

Preeclampsia and hypertensive disorders of pregnancy.

Hypertensive conditions encountered during pregnancy are classified as preeclampsia, transient hypertension and chronic hypertension. The pathophysiology, consequences and management of these disorders differ, but their clinical presentations overlap substantially. Preeclampsia is a syndrome of the second half of pregnancy, characterized by hypertension, edema and proteinuria, but all three findings are not required to make the diagnosis. Preeclampsia can progress unpredictably to a variety of crises, including eclamptic seizures, and contributes significantly to maternal and perinatal mortality. Management consists of prompt delivery for a mature fetus. Management of preeclampsia at earlier stages of gestation requires balancing the risks of immediate delivery of an immature fetus against the risks to both mother and child of a complication of preeclampsia. Transient hypertension is a clinically benign condition characterized by isolated high blood pressure in late pregnancy; its significance lies in the difficulty of distinguishing it from early preeclampsia. Chronic hypertension is a risk factor for intrauterine growth restriction and intrauterine fetal demise, as well as for preeclampsia. The management strategy consists of control of maternal blood pressure, ongoing antepartum assessment of fetal well-being and surveillance for superimposed preeclampsia.

Advances in the prevention, diagnosis and treatment of deep venous thrombosis.

Deep venous thrombosis of the leg is associated with hospitalization in up to 600,000 Americans each year. Prevention is possible; the preventive strategy varies according to the degree of risk. Noninvasive techniques, especially impedance plethysmography, have revolutionized the diagnosis of deep venous thrombosis and should be the diagnostic methods of first choice. Patients with suspected calf vein thrombi but negative impedance plethysmography studies need not receive anticoagulation therapy as long as serial studies remain negative. Five days of intravenous heparin constitutes adequate treatment, and warfarin can be initiated on the first day of heparin therapy. Intravenous heparin will most likely be replaced by the subcutaneous, low-molecular-weight form once it becomes widely available. Bleeding is the principal side effect of anticoagulation therapy; careful attention to pharmacokinetics and pharmacodynamics can minimize this side effect. Use of the prothrombin time international normalized ratio allows safer, more reproducible anticoagulation with oral agents.

Subcellular distribution of alpha 2-adrenergic receptors, pertussis-toxin substrate and adenylate cyclase in human platelets.

The subcellular distribution of the alpha 2-adrenergic receptor, pertussis-toxin substrates (Gi, the inhibitory G-protein) and adenylate cyclase was determined in human platelets. The alpha 2-adrenergic receptor and pertussis-toxin substrate activity codistribute with surface membranes identified by a novel fluorescent-lectin method. The platelet granule fractions did not contain detectable Gi. Only 2-4% of the total pertussis-toxin substrate activity appears in soluble fractions, and this amount was not increased upon addition of purified beta gamma units or after pretreatment of platelets with adrenaline. There is no evidence for compartmentation of the alpha 2-adrenergic receptor or Gi to account for the low-affinity component of agonist binding to the alpha 2-adrenergic receptor in human platelet membranes. Translocation of Gi from plasma membrane to platelet cytosol or granules does not appear to play any significant role in the mechanism of alpha 2-receptor-mediated platelet activation.