Pain severity as a mediator of the association between depressive symptoms and physical performance in knee osteoarthritis.

OBJECTIVE: Depressive symptoms in knee osteoarthritis (OA) are associated with increased pain severity and declines in physical performance. This study examined whether pain severity mediates the association between depressive symptoms and physical performance in persons with radiographic knee OA. METHOD: Three years of annual data from participants (n = 1,463) with radiographic knee OA in the Osteoarthritis Initiative (OAI) were analyzed. Depressive symptoms were measured using the Center for Epidemiological Studies Depression (CES-D) scale. Pain severity was evaluated with the Western Ontario and McMaster Universities Arthritis Index. Physical performance was assessed via standardized gait speed. Marginal structural models were used to assess the direct (unmediated) effects of depressive symptoms on physical performance and indirect (mediated) effects through pain severity. RESULTS: Direct and indirect effects for a difference in CES-D score of 0-1 were -0.0051 (95% confidence intervals (CI): -0.0053, -0.0049) and -0.0016 (95% CI: -0.0024, -0.0007) standard deviations in gait speed, respectively. Higher depressive symptom severity exhibited diminishing, incremental, direct and indirect effects and for a difference in CES-D score of 15-16 were -0.0045 (95% CI: -0.0047, -0.0042) and -0.0009 (95% CI: -0.0014, -0.0004) standard deviations in gait speed, respectively. Therefore, the magnitude of the mediated, indirect effect, was never larger than 24%. CONCLUSION: Pain severity mediated approximately one-fifth of the association between depressive symptoms and physical performance in persons with radiographic knee OA, and the diminishing incremental effects may explain why unimodal treatment strategies with a single disease target are often ineffective in depressed OA patients.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers.

Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

Cost-effective analysis of genotyping using oral cells in the geriatric population.

We evaluated the cost-effectiveness of using buccal swab brushes in comparison with blood samples for obtaining DNA for large epidemiological studies of the elderly population. The data reported here are from the third phase of the Integral Study of Depression among the Elderly in Mexico City's Mexican Institute of Social Security, conducted in 2007. The total cost of the two procedures was determined. The measurement of effectiveness was the quality and quantity of DNA measured in ng/µL and the use of this DNA for the determination of apolipoprotein E (APO E) polymorphism by PCR. Similar rates of amplification were obtained with the two techniques. The cost of the buccal swab brushes, including sample collection and DNA extraction, was US$16.63, compared to the cost per blood sample of US$23.35. Using the buccal swab, the savings was US$6.72 per patient (P < 0.05). The effectiveness was similar. Quantity and quality of DNA obtained were similar for the oral and blood procedures, demonstrating that the swab brush technique offers a feasible alternative for large-scale epidemiological studies.

Association of sleep characteristics with suicidal ideation and suicide attempt among adults aged 50 and older with depressive symptoms in low- and middle-income countries.

OBJECTIVES: Investigate the association of sleep characteristics with suicidal ideation and suicide attempt among middle-aged and older adults with depressive symptoms in five low- and middle-income countries (LMICs). DESIGN: Cross-sectional. SETTING: China, Ghana, India, Russia, and South Africa. PARTICIPANTS: Adults aged ≥50 years with depressive symptoms from the World Health Organization (WHO) Study on Global AGEing and Adult Health (n=2,040). MEASUREMENTS: Predictors were self-reported average sleep duration for the past 2 nights (<7 hours (shorter), 7 to <9 hours (reference), ≥9 hours (longer)), sleep quality for the past 2 nights (moderate/good/very good [both nights], poor/very poor [≥1 night]), past-month insomnia symptoms (none/mild, moderate, severe/extreme), and past-day daytime sleepiness. Outcomes were past-year suicidal ideation and suicide attempt. Analyses were adjusted for age, sex, household wealth, marital status, self-rated health, cognitive performance, number of depressive symptoms, and country of residence. RESULTS: Participants with poor/very poor sleep quality ≥1 night had greater odds of suicidal ideation (vs. moderate/good/very good sleep quality both nights). Participants with moderate and severe/extreme insomnia symptoms had greater odds of suicidal ideation and suicide attempt (vs. none/mild insomnia symptoms). In moderation analyses, greater insomnia symptoms were associated with higher odds of suicidal ideation among women only and those aged 60-60 years and ≥80 years only. CONCLUSIONS: Among middle-aged and older adults with depressive symptoms in LMICs, sleep characteristics are markers of-and potential contributors to-suicidal ideation and suicide attempt, and there was evidence of moderation by age and sex. Interventions aimed at preventing suicide-related outcomes in these populations should consider the role of sleep.

Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades.

It is anticipated that the number of people older than 65 years with psychiatric disorders in the United States will increase from about 4 million in 1970 to15 million in 2030. The current health care system serves mentally ill older adults poorly and is unprepared to meet the upcoming crisis in geriatric mental health. We recommend the formulation of a 15- to 25-year plan for research on mental disorders in elderly persons. It should include studies of prevention, translation of findings from bench to bedside, large-scale intervention trials with meaningful outcome measures, and health services research. Innovative strategies are needed to formulate new conceptualizations of psychiatric disorders, especially those given scant attention in the past. New methods of clinical and research training involving specialists, primary care clinicians, and the lay public are warranted.

Empirical examination of current depression categories in a population-based study: symptoms, course, and risk factors.

OBJECTIVE: Research studies on the validity of current diagnostic and subthreshold categories of depression that use a population-based follow-up design are rare. The authors examined the validity and utility of four current depression categories by examining subject transition between categories and the symptoms, course, and risk factors of each. METHOD: A general population sample of 1,920 adults from the Baltimore Epidemiologic Catchment Area 13-year follow-up study were examined. Data on diagnoses, symptoms, course, and risk factors were collected by using the National Institute of Mental Health Diagnostic Interview Schedule, the Life Chart Interview, and an office visit. Polychotomous regression was used to examine the heterogeneity of four diagnostic categories: major depressive disorder, depressive syndrome, dysthymia, and a comorbid depression condition (major depressive disorder and dysthymia). RESULTS: Transitions between the four depression categories occurred over the 13 years. Symptom profiles for the four categories were parallel but differed in severity. Course characteristics among the four categories slightly differed. Risk factor profiles showed significant differences. Family history was associated with both depressive syndrome and major depressive disorder. Stressful life events were most strongly associated with depressive syndrome. Female gender was most strongly associated with the comorbid depression category. CONCLUSIONS: The evidence suggests that except for dysthymia, the depression categories are genetically homogeneous and environmentally heterogeneous. Stress is associated with mild depression, and gender is associated with severe depression. The apparent familial transmission of the subthreshold entity, depressive syndrome, needs further investigation.

Antiviral quinolinehydrazones. A modified Free-Wilson analysis.

Eighty-four 4-quinolinehydrazones were synthesized and tested for antiviral activity. Thirty nine derivatives were active against influenza A2 and/or Coxsackie B1 in mice at a dose of 25 mg/kg sc. Structure-activity relationships of 44 derivatives (21 inactive) were analyzed qualitatively using a modified Free-Wilson approach.

Performance characteristics of a two-stage dementia screen in a population sample.

We analyzed the performance of a two-stage screening protocol [the Modified Mini-Mental State Exam (3MS) or the Informant Questionnaire for Cognitive Decline (IQCODE), and the Dementia Questionnaire (DQ)] in a weighted stratified sample of 839 subjects from a population survey of dementia in Cache County, UT. The subjects were subsequently examined using a standardized diagnostic assessment protocol. Using the method of receiver operating characteristic (ROC) analysis, the main outcome measure was area under the ROC curve (AUC). The overall AUC estimates were 0.956 (95% confidence interval 0.943-0.968) for the 3MS/IQCODE and 0.945 (0.931-0.960) for the DQ. After adjustment for age, the efficiency of the both 3MS/IQCODE and the DQ was better for subjects with genotype epsilon4/epsilon4 at APOE, better among women, and better in those with two or more years duration of dementia. The optimal threshold for this two-stage screen yielded sensitivity and specificity estimates of 91.0% and 92.0%, respectively.

The driving habits of adults aged 60 years and older.

OBJECTIVES: We describe the driving habits of adults aged 60 years and older who were interviewed in the context of a community survey focused on mental disturbances. Our goal was to identify clinical cues that might signal driving difficulty in older adults who might present to the primary care physician for health care. DESIGN: A population-based survey. SETTING: Continuing participants in a follow-up study of community-dwelling adults who were living in East Baltimore in 1981. PARTICIPANTS: Subjects were 1920 continuing participants of the Baltimore sample of the Epidemiologic Catchment Area Program; 589 were aged 60 years and older and provided information on driving habits. MEASUREMENTS: Respondents were asked about their driving status: had they made adaptations to driving and had they experienced any adverse driving events in the 2 years before the interview. Driving behaviors were assessed in relation to chronic disease, sensory impairment, functional status, and mental status. RESULTS: Former drivers were more likely to be older, female, and nonwhite. Diabetes, vision impairment, functional impairment, and making an error on the copy design task of the Mini-Mental State Examination (MMSE) were associated with no longer driving. Women were more likely to report having made adaptations to driving, as were persons with heart disease, arthritis, vision impairment, and those who made an error on the copy design task of the MMSE. Heart disease and hearing impairment were associated with report of an adverse driving event. In multivariate models that included terms for potentially influential characteristics such as age, gender, and miles driven, only the copy design task was associated with driving status, and only heart disease was associated with driving adaptation and adverse driving events. CONCLUSION: Simple tests that tap visuospatial ability, such as the copy design task of the MMSE, may warrant additional study for use in driving assessment of older adults in primary care. The results underscore the importance of making an inquiry about driving as a separate and independent component of functional assessment.

Depression without sadness: functional outcomes of nondysphoric depression in later life.

OBJECTIVES: We hypothesized that depressive symptoms not meeting full standard criteria for Major Depression would be associated with significant functional impairment among older adults over the course of a 13-year follow-up interval. Specifically, we developed criteria for a form of depression whose core symptoms did not include sadness or dysphoria. DESIGN: Population-based 13-year follow-up survey. SETTING: Community-dwelling adults living in East Baltimore in 1981. PARTICIPANTS: Subjects were the 1612 participants of the Baltimore sample of the Epidemiologic Catchment Area Program aged 50 years and older at the initial interview in 1981. MEASUREMENTS: The subjects were sorted into four categories based on their responses at baseline: (1) persons meeting standard criteria for Major Depression; (2) persons meeting alternative criteria for depression with dysphoria or (3) without dysphoria; and (4) a comparison category of persons not meeting any criteria for depression ("noncases"). The mortality and functional status of each group were compared after a 13-year follow-up interval. RESULTS: Compared with non-cases, participants aged 50 years and older who reported depressive symptoms but who denied sadness or dysphoria (nondysphoric depression) were at increased risk for death (relative risk (RR) = 1.70; 95% confidence interval (CI) (1.09, 2.67)), impairment in activities of daily living (RR = 3.76; 95% CI (1.73, 8.14)), impairment in instrumental activities of daily living (RR = 5.07; 95% CI (2.24, 11.44)), psychologic distress (RR = 3.68; 95% CI (1.47, 9.21)), and cognitive impairment (RR = 3.00; 95% CI (1.31, 6.89)) after a 13-year follow-up interval. The findings were not wholly explained by potentially influential baseline characteristics such as age, education, selected comorbid medical conditions, and functional status. CONCLUSION: Among adults aged 50 years and older, nondysphoric depression may be as important as Major Depression in relation to the development of functional disability and other long-term outcomes.

Understanding the heterogeneity of depression through the triad of symptoms, course and risk factors: a longitudinal, population-based study.

BACKGROUND: There is an ongoing research effort to test if depression is a homogeneous clinical syndrome and to identify valid and useful subtypes based on the number and nature of depressive symptoms. This study summarizes the patterns of depressive symptoms evident in a prospective study of the general population and examines the validity of potential subtypes by studying their course and etiologic heterogeneity. METHODS: A general population sample of 1920 adults (aged 18-96) from the Baltimore Epidemiologic Catchment Area (ECA) follow-up study (1981 to 1993/6) were examined. Data on diagnoses, symptoms, course and risk factors were collected using the Diagnostic Interview Schedule (DIS). Latent class analysis was applied to summarize symptom patterns. Course characteristics and risk factor profiles were compared among potential subtypes based on the number of symptom groups or symptom patterns. Logistic regression models were used to examine the etiologic heterogeneity among potential subtypes based on symptoms. RESULTS: The number of symptom groups gave the most efficient insight into differential etiologic processes. Severe depression (7-9 symptom groups) was associated with female gender, family history of depression but not with stressful life events before the onset of the first episode. Moderate (5-6 symptom groups) and mild depression (3-4 symptom groups) were associated with family history of depression, stressful life events before the onset, but not with female gender. The latent class model generated patterns of depressive psychopathology as follows: anhedonia, suicidal, psychomotor, and severely depressed subtypes. The Anhedonia subtype showed a course and risk factor profile distinct from the others. LIMITATIONS: The measurement of psychopathology was based on self-reported DIS interviews instead of psychiatric assessments. Recall or report bias cannot be excluded in the ascertainment of family history and stressful life events. CONCLUSIONS: Depression is heterogeneous, even below the threshold of syndromal diagnosis. The severity of an episode appears to be more informative than the pattern of symptoms, with the possible exception of a putative anhedonic subtype.

Depressive symptoms of whites and African Americans aged 60 years and older.

Consistent with prior work, our hypothesis was that older African Americans are less likely to report dysphoria than are older Whites. Study subjects were 968 participants aged 60 years and older in Baltimore, Maryland, and 1,486 participants aged 60 years and older in the Durham-Piedmont region of North Carolina who identified themselves as African American or White and who had complete data on symptoms of depression active in the one month prior to interview, as well as several covariates thought to be related to depression. The effect of self-reported race on the endorsement of symptoms from the section on Major Depression in the Diagnostic Interview Schedule was estimated employing structural equations with a measurement model. Older African Americans were less likely to report dysphoria than older Whites, although this only achieved statistical significance by conventional standards at the Durham-Piedmont site. Older African Americans at both sites were significantly more likely to report thoughts of death.

The epidemiology of common late-life mental disorders in the community: themes for the new century.

OBJECTIVE: The prevalence and incidence of the major mental disorders of late life that are common in the community and in primary health care are reviewed. METHODS: Community-based studies in English that included older adults were identified through MEDLINE searches and were reviewed. RESULTS: As the population ages, dementia, depression, and other mental conditions of the aged will demand more attention from clinicians and investigators to minimize their effects on disability, the use of health care services, and the quality of life for older adults and caregivers. Up to 15 to 20 percent of older adults have significant depressive symptoms, and it is estimated that as many as 45 percent of persons age 85 years and older have significant cognitive impairment and dementia. Other mental-health-related conditions, such as anxiety disorders, alcohol abuse, and prescription medicine misuse, are also important considerations but have not been as well studied as depression and dementia. Because an increasing proportion of older adults are members of minority groups, clinicians need to increase their awareness of how cultural factors relate to risk for mental disorders in late life. CONCLUSIONS: Attention to three themes may help clinicians and investigators meet the challenge of treating the common mental disorders of later life: the effect of these disorders on functioning, prevention of the consequences of mental disorders, and integration of mental health care and primary health care services.

The association of gynecological symptoms with psychological distress in women of reproductive age: a survey from gynecology clinics in Beirut, Lebanon.

To date there has been no previous research into a possible association between psychological distress and gynecologic symptoms in the Arab world. We hypothesized that psychological distress would be associated with specific gynecologic complaints as well as with psychosocial factors. We conducted a cross-sectional study of women attending gynecology clinics in Beirut, Lebanon. The study sample consisted of 355 women aged 18 to 49 years who were seeking healthcare from gynecologists affiliated with two general teaching hospitals in Beirut. Psychological distress was assessed using the General Health Questionnaire (GHQ). Gynecologic complaints were assessed by asking women about presenting gynecologic symptoms. Women who visited the gynecologists for specific complaints, for post-surgical follow-up, or for insertion of coils or other services were more likely to be distressed than women who were attending for a general checkup (chi 2 = 9.466, p = 0.024). About 50% of women who reported abdominal pain or breast pain also reported significant psychological distress. Only bleeding and infertility were not significantly associated with psychological distress. It is concluded that a high proportion of women who attend gynecology clinics with specific complaints report psychological distress. Our findings highlight the importance of considering the psychological component of gynecological morbidity.

A factor analysis of the fagerstrom tolerance questionnaire.

A factor analysis of 1309 Fagerstrom Tolerance Questionnaires (FTQ) was performed with LISCOMP software, which utilizes tetrachoric correlations to account for the dichotomous responses of the FTQ. Three factors with eigenvalues greater than 1.0 were obtained, accounting for 56.6% of the variance. Factor 1 was loaded by questions "How soon on waking do you smoke your first cigarette?," "Do you find it difficult to refrain from smoking in places it is forbidden?," "How many cigarettes a day do you smoke?," and "Do you smoke if you are so ill that you are in bed most of the day?" Factor 2 was loaded by questions "Which cigarette would you hate to give up?" and "Do you smoke more during the morning than during the rest of the day?" Factor 3 was loaded exclusively by question "What brand do you smoke?" The question "Do you inhale always, sometimes, or never?" loaded exclusively on a fourth factor, however its eigenvalue did not reach significance. Support is provided for the modification of the eight-item FTQ to the six-item Fagerstrom Test for Nicotine Dependence (FTND). Based on the wording of the questions that loaded on each factor, we propose that Factor 2 assesses the degree of urgency to initiate smoking after overnight abstinence and that Factor 1 reflects the persistence of smoking during waking hours.

The effect of social support on depression in caregivers of the elderly.

Caregivers play a critical role in providing the social support that allows impaired elders to remain at home. The demands of caregiving, however, may stretch the physical and psychological resources of the caregiver, thus jeopardizing the elder. The social support available to the caregiver may help buffer or mitigate the ill effects of caregiving. The purpose of this review is to examine the effect of social support on the development of depression in the caregiver, with a consideration of the components and measurement of social support. The practical as well as the research implications are discussed. Although the anticipated difficulty of caregiving depends on assessment of the elder's mental and functional disability as well, the clinician must not neglect to consider the caregiver's appraisal of the social support available. This assessment need not be elaborate and might include inquiring (1) whether the caregiver has someone in whom to confide; (2) who visits the caregiver, how often, and whether the caregiver is happy with these relationships; (3) what aspects of caregiving are most disturbing; and (4) whether there are symptoms of depression.

[Mucocele of the frontal sinus simulating metastasis of follicular thyroid carcinoma in an 131I scan]. / Mucocele del seno frontal simulando metástasis de carcinoma folicular de tiroides en un rastreo con 131I.

The 131I scan is the preferred test in the follow-up of differentiated thyroid cancer patients although the many unusual circumstances of radioiodine uptake that can provide false positive results must be identified. We present the case of a woman who had undergone a thyroidectomy and was being treated for follicular carcinoma with an ablative dose os radioiodine whose pre- and post-treatment scans only revealed post-surgical residual thyroid tissues. A total body scan with 131I performed at one year demonstrated the success of the ablation. However, a left supra-orbital pathological deposit was observed during a subsequent routine 131I scan. The thyroglobulin serum level was below the sensitivity level for the assay (< 1 ng/ml) and the serum antibodies against thyroglobulin were not detected. A simple x-ray and bone scintigraphy were inconclusive. The CT and MRI revealed the presence of a mucocele in the left frontal sinus which was confirmed through histological examination. The possibility of a false positive results in an 131I scan must always be kept in mind, especially in the presence of atypical uptakes and undetectable thyroglobulin serum levels. As far as we know, only one similar case has been published previously.

[Intratumoral versus subareolar injection in breast cancer sentinel lymph node biopsy. A case report]. / Inyección intratumoral versus subareolar en el diagnóstico de la biopsia del ganglio centinela, en el carcinoma de mama. A propósito de un caso.

The use of deep (intratumoral, peritumoral) and superficial (subdermal, subareolar) administration is recognized as valid in sentinel lymph node biopsy for breast cancer. Herein, we are presenting a clinical case in which a personalized methodology was a determining factor in axillary staging. Initially, the radiotracer was injected intratumorally guided by ultrasound. The ultrasound scan identified a previously unknown axillary lymphadenopathy, with focal cortical thickening, this being a non-specific ultrasound finding, but with possibility of biopsy. The lymphoscintigraphy did not show uptake in the mentioned node, hence, a second subareolar dose was administered. On this occasion, the lymphoscintigraphy detected drainage to the sentinel node, which was the only one positive for micrometastases.