Cardiovascular mortality risk in young adults with isolated systolic hypertension: findings from population-based MONICA/KORA cohort study.

The clinical significance of isolated systolic hypertension in young adults (ISHY) remains a topic of debate due to evidence ISHY could be a spurious condition resulting from exageratted pulse pressure amplification in "young tall men with elastic arteries". Hence, we aimed to investigate whether ISHY is associated with an increased risk of cardivascular (CVD) mortality in a sample of 5597 young adults (49.8% men, 50.2% women) between 25 and 45 years old from the prospective population-based MONICA/KORA cohort. ISHY was prevalent in 5.2% of the population, affecting mostly men (73.1%), and associated with increased smoking, obesity, and hypercholesterolemia in comparison to participants with normal blood pressure (BP). Within a follow-up period of 25.3 years (SD ± 5.2; 141,768 person-years), 133(2.4%) CVD mortality cases were observed. Participants with ISHY had a hazard ratio (HR) of 1.89(1.01-3.53, p < 0.05) times higher risk of CVD mortality than participants with normal BP, even following adjustment for CVD risk factors. However, adjustment for antihypertensive medication (HR 0.46; 0.26-0.81, p < 0.001) and increasing height (HR 0.96; 0.93-0.99, p < 0.05) revealed independently protective effects against CVD mortality, suggesting that although ISHY is associated with an increased risk of CVD mortality, the protective effects of increasing height or antihypertensive medication should be considered in treatment rationale.

Different information needs in subgroups of people with diabetes mellitus: a latent class analysis.

BACKGROUND: Current evidence suggests that the information needs of people with diabetes mellitus differ across patient groups. With a view to being able to provide individualized information, this study aims to identify (i) the diabetes-related information needs of people with diabetes mellitus; (ii) different subgroups of people with specific information needs; and (iii) associated characteristics of the identified subgroups, such as sociodemographic characteristics, diabetes-related comorbidities, and well-being. METHODS: This cross-sectional study was based on data from 837 respondents with diabetes mellitus who participated in the population-based KORA (Cooperative Health Research in the Augsburg Region) Health Survey 2016 in Southern Germany (KORA GEFU 4 study) (45.6% female, mean age 71.1 years, 92.8% Type 2 diabetes). Diabetes-related information needs were assessed with a questionnaire asking about patients' information needs concerning 11 diabetes-related topics, e.g. 'long-term complications' and 'treatment/therapy'. Subgroups of people with different information needs and associated characteristics were identified using latent class analysis. RESULTS: We identified the following four classes of people with different information needs: 'high needs on all topics', 'low needs on all topics', 'moderate needs with a focus on complications and diabetes in everyday life', and 'advanced needs with a focus on social and legal aspects and diabetes research'. The classes differed significantly in age, years of education, type of diabetes, diabetes duration, diabetes-related comorbidities, smoking behaviour, diabetes education, current level of information, and time preference. CONCLUSIONS: Knowledge about different patient subgroups can be useful for tailored information campaigns or physician-patient interactions. Further research is needed to analyse health care needs in these groups, changes in information needs over the course of the disease, and prospective health outcomes.

The times we are born into and our lifestyle choices determine our health trajectories in older age - Results from the KORA-Age study.

Health projections often extrapolate from observations in current ageing cohorts, but health in older age may depend not only on individual characteristics but also on a person's historical context. Our objective was to investigate how health deficit accumulation trajectories after age 65 differed in five adjacent birth cohorts and according to individual life course characteristics. Data originate from the 2008/09 KORA (Cooperative Health Research in the Region of Augsburg)-Age cohort study from Southern Germany and their 2012 and 2016 follow-ups. Deficit accumulation was assessed using a Frailty Index. The effects of birth cohort membership and individual life course characteristics on deficit accumulation trajectories were analyzed using generalized linear mixed models. Out of 2701 participants (49% male) from five birth cohorts (1919-23, 1924-28, 1929-33, 1934-38, 1939-43), we included 2512 individuals with 5560 observations. Frailty Index levels were higher for women, smokers, alcohol abstainers, obese participants and persons with a sedentary lifestyle or living below the poverty threshold. We found higher age-specific Frailty Index levels for the two most recent birth cohorts (e.g. 61%, CI: [13%; 130%] for the 1934-38 as compared to the 1919-23 cohort), but the rate of deficit accumulation with age (7% per life year, (CI: [5%, 9%]) was cohort-independent. Results indicate that the historical context (birth cohort membership) may influence the number of accumulated health deficits after age 65 in addition to poverty and other individual life course characteristics, but BMI, physical activity and smoking remain the modifiable risk factors offering the highest prevention potential.

Validated inference of smoking habits from blood with a finite DNA methylation marker set.

Inferring a person's smoking habit and history from blood is relevant for complementing or replacing self-reports in epidemiological and public health research, and for forensic applications. However, a finite DNA methylation marker set and a validated statistical model based on a large dataset are not yet available. Employing 14 epigenome-wide association studies for marker discovery, and using data from six population-based cohorts (N = 3764) for model building, we identified 13 CpGs most suitable for inferring smoking versus non-smoking status from blood with a cumulative Area Under the Curve (AUC) of 0.901. Internal fivefold cross-validation yielded an average AUC of 0.897 ± 0.137, while external model validation in an independent population-based cohort (N = 1608) achieved an AUC of 0.911. These 13 CpGs also provided accurate inference of current (average AUCcrossvalidation 0.925 ± 0.021, AUCexternalvalidation0.914), former (0.766 ± 0.023, 0.699) and never smoking (0.830 ± 0.019, 0.781) status, allowed inferring pack-years in current smokers (10 pack-years 0.800 ± 0.068, 0.796; 15 pack-years 0.767 ± 0.102, 0.752) and inferring smoking cessation time in former smokers (5 years 0.774 ± 0.024, 0.760; 10 years 0.766 ± 0.033, 0.764; 15 years 0.767 ± 0.020, 0.754). Model application to children revealed highly accurate inference of the true non-smoking status (6 years of age: accuracy 0.994, N = 355; 10 years: 0.994, N = 309), suggesting prenatal and passive smoking exposure having no impact on model applications in adults. The finite set of DNA methylation markers allow accurate inference of smoking habit, with comparable accuracy as plasma cotinine use, and smoking history from blood, which we envision becoming useful in epidemiology and public health research, and in medical and forensic applications.

Different Psychosocial Factors Are Associated with Seasonal and Perennial Allergies in Adults: Cross-Sectional Results of the KORA FF4 Study.

BACKGROUND: Psychosocial factors are supposed to play a central role in the development of allergic diseases. Associations with seasonal and perennial forms of allergies have not been investigated, yet. OBJECTIVES: The aim of the study was to investigate the associations of psychosocial factors (social status, depression, generalized anxiety, psychosocial stress, Type-D personality) with seasonal, perennial, and other forms of allergies in adults. METHOD: The analysis of self-reported data of the KORA FF4 study was performed with SAS 9.4. The sample consisted of 1,782 study participants in the study region of Augsburg (39-88 years, 61 years, 51.1% female). Descriptive bivariate statistics and multinomial logistic regression models were performed. Age, sex, family predisposition, and smoking status were considered possible confounders. Moreover, several sensitivity analyses were carried out to check whether missing values distorted the results. RESULTS: A positive association between generalized anxiety and seasonal allergies was found in the multivariate model. Depression was positively, and anxiety negatively, associated with perennial allergies. No association between the analyzed psychosocial factors and other forms of allergies could be found. CONCLUSION: The results support the relevance of psychosocial factors in association with allergies. Looking at the psychosocial factors, a separate consideration of seasonal and perennial allergies seems reasonable. Further longitudinal studies should investigate the direction of the associations, the underlying mechanisms, and other psychosocial factors, such as coping mechanisms, in confirmed allergies.

Lack of supportive leadership behavior predicts suboptimal self-rated health independent of job strain after 10 years of follow-up: findings from the population-based MONICA/KORA study.

OBJECTIVES: Emerging cross-sectional research has identified lack of supportive leadership behavior (SLB) as a risk factor for workforce health. However, prospective evidence is hitherto lacking. SLB denotes support in difficult situations, recognition and feedback on work tasks. This study aims to determine the effect of SLB on suboptimal self-rated health (SRH) after 10 years considering potential moderators such as ages, sex, occupation and job strain. METHODS: The sample included 884 employed participants drawn from the population-based prospective MONICA/KORA Study. SLB, SRH, as well as job strain were assessed by questionnaire. Logistic regressions estimated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the effect of SLB at baseline on suboptimal SRH at follow-up. Analyses were adjusted for age, gender, lifestyle (alcohol, smoking, physical activity), socioeconomic status as well as for SRH and job strain at baseline. RESULTS: Lack of SLB was associated with suboptimal SRH at baseline [OR 2.00, (95% CI 1.19-3.46)] and at follow-up [OR 2.33, (95% CI 1.40-3.89)]. Additional adjustment for job strain did not substantially alter this association [OR 2.06, (95% CI 1.20-3.52)]. However, interactions between SLB and job strain as well as gender became evident, indicating moderating influences on the association between SLB and SRH. CONCLUSION: Lack of supportive leadership was associated with suboptimal SRH at 10 years' follow-up in men, even if SRH at baseline and other risk factors were taken into account. This effect is likely to be moderated by job strain.

Muscular Strength is Independently Associated with Cystatin C: The KORA-Age Study.

The purpose of this study was to investigate if there is a link between muscular strength (MS) and markers of chronic kidney disease (CKD) among older adults. The cross-sectional analysis based on 1041 men and women, aged 65-94 years, who participated in the KORA-Age study. Participants underwent an interview and extensive examinations including anthropometric measurements, diseases and drug intake registration, determination of health-related behaviors, collection of blood samples for measurements of cystatin C and maximal muscle strength evaluation. One-Way ANOVA revealed significant differences in both mean cystatin C (1.16±0.37 vs. 1.03±0.29 vs. 0.93±0.24 mg/L, p<0.001) and mean eGFRcysC (63.61±18.61 vs. 72.14±18.92 vs. 79.87±18.19 ml/min/1.73 m2, p<0.05) across thirds of maximal muscular strength (from lowest to highest). MS in the lowest third was significantly associated with increased odds of having elevated cystatin C (OR: 1.70, 95% CI: 1.01-2.85, p=0.043) after controlling for age, gender, fat mass, fat-free mass, alcohol intake, smoking status, number of regularly used medications, multimorbidity status, hs-CRP, telomere length and levels of physical activity. Lower levels of MS are independently associated with higher concentrations of cystatin C and lower eGFRcysC in older individuals. Increasing the levels of muscular strength may be useful to prevent the age-related CKD disease of older adults.

Socioeconomic factors in coronary artery disease - Results from the SPIRR-CAD study.

Low socio-economic status (SES) has been associated with an increased coronary risk in Western countries. All stress experiences are more pronounced in low SES patients with stress emanating from problems with family, job, or money. The SPIRR-CAD study offered an excellent opportunity to examine these risk factors in German speaking mildly and medium depressed patients. In the SPIRR CAD study, a German multi centre randomized clinical trial of 450 male and 120 female coronary patients, we examined the standard and psychosocial risk factor profiles in relation to SES, as assessed by educational level. All differences in risk factors between low and high SES were in the inverse direction. Of standard risk factors, only smoking was socially graded and more common in low SES. Of psychosocial factors and emotions, exhaustion showed the strongest and most consistent inverse social gradient, but also anger, anxiety and depression were socially graded. The findings suggest that in German patients, as in other national groups, social gradients in CHD risk are considerable. They can be ascribed to both psychosocial and to standard risk factors. In the present two years follow-up, the prospective significance of psychological and social risk factors was analyzed showing that emotional factors played an important role, in that low and high SES patients differed in the expected direction. However, the differences were not statistically significant and therefore firm conclusions from follow up were not possible. TRIAL REGISTRATION: ISRCTN 76240576; NCT00705965.

Room for depressed and exhausted mood as a risk predictor for all-cause and cardiovascular mortality beyond the contribution of the classical somatic risk factors in men.

BACKGROUND AND AIMS: Depressed mood and exhaustion (DEEX) have gained attention as a risk predictor for cardiovascular disease (CVD). Studies to estimate its ranking in prediction models are sparse. METHODS: The study included 3428 men aged 45-74 years who participated in one of three population-based MONICA/KORA Augsburg surveys conducted between 1984 and 1995. Within a follow-up time of 10 years (31,791 person-years), 557 cases of all-cause mortality and 269 fatal CVD events were observed. Adjusted Cox proportional hazards models were used to assess mortality risks for DEEX and five classical cardiovascular risk factors. The predictive ability was evaluated by the area under the receiver-operating characteristic curve, the integrated discrimination improvement statistics and the net classification improvement. RESULTS: The (crude) absolute mortality risk for DEEX was 23.1 cases per 1000 person-years for all-cause and 11.2 for CVD mortality. The adjusted hazard ratios of 1.52 for all-cause and 1.52 for CVD mortality (p < 0.01) were higher than those for hypercholesterolemia and obesity, but lower than for hypertension, smoking and diabetes. The improvements in risk prediction from DEEX were comparable to those of hypercholesterolemia and obesity, but substantially lower than those of hypertension, smoking and diabetes. The adjusted population-attributable risk (PAR) for DEEX accounted for about 15% for all-cause and CVD mortality, which gives DEEX a middle ranking amongst the classical risk factors. CONCLUSIONS: DEEX is a strong predictor of mortality risk, ranking in a medium position amongst classical somatic risk factors.

An Analysis of Two Genome-wide Association Meta-analyses Identifies a New Locus for Broad Depression Phenotype.

BACKGROUND: The genetics of depression has been explored in genome-wide association studies that focused on either major depressive disorder or depressive symptoms with mostly negative findings. A broad depression phenotype including both phenotypes has not been tested previously using a genome-wide association approach. We aimed to identify genetic polymorphisms significantly associated with a broad phenotype from depressive symptoms to major depressive disorder. METHODS: We analyzed two prior studies of 70,017 participants of European ancestry from general and clinical populations in the discovery stage. We performed a replication meta-analysis of 28,328 participants. Single nucleotide polymorphism (SNP)-based heritability and genetic correlations were calculated using linkage disequilibrium score regression. Discovery and replication analyses were performed using a p-value-based meta-analysis. Lifetime major depressive disorder and depressive symptom scores were used as the outcome measures. RESULTS: The SNP-based heritability of major depressive disorder was 0.21 (SE = 0.02), the SNP-based heritability of depressive symptoms was 0.04 (SE = 0.01), and their genetic correlation was 1.001 (SE = 0.2). We found one genome-wide significant locus related to the broad depression phenotype (rs9825823, chromosome 3: 61,082,153, p = 8.2 × 10-9) located in an intron of the FHIT gene. We replicated this SNP in independent samples (p = .02) and the overall meta-analysis of the discovery and replication cohorts (1.0 × 10-9). CONCLUSIONS: This large study identified a new locus for depression. Our results support a continuum between depressive symptoms and major depressive disorder. A phenotypically more inclusive approach may help to achieve the large sample sizes needed to detect susceptibility loci for depression.

[Cognitive dysfunction in cardiovascular diseases]. / Kognitive Dysfunktionen bei Herz-Kreislauf-Erkrankungen.

A multitude of modifiable risk factors during the median phase of life are often causative for cognitive dysfunction (CD) in old age. High evidence exists for cigarette smoking, diabetes, physical inactivity and sleeping disorders. Single large scale population based studies proof it for hypertension, hypercholesterinemia and depression, conflicting evidence exists for obesity and work stress. Little attention is paid to the close association between cardiovascular disease conditions and CD, particularly for atrial fibrillation, heart failure and for older patients with coronary heart disease. Undetected CD may be responsible for non-adherence and failure of self-care programs in chronic heart patients.

What is the impact of different spirometric criteria on the prevalence of spirometrically defined COPD and its comorbidities? Results from the population-based KORA study.

BACKGROUND: There is an ongoing debate about the appropriate spirometric criterion for airway obstruction to detect COPD. Furthermore, the association of different criteria with comorbidity prevalence and inflammatory biomarkers in advanced age is unclear. MATERIALS AND METHODS: Spirometry was performed in a population-based study (n=2,256) covering an age range of 41-90 years. COPD was spirometrically determined either by a fixed ratio (FR) of <0.7 for forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) or by FEV1/FVC below the lower limit of normal (LLN). Comorbidity prevalences and circulating biomarker levels (C-reactive protein [CRP], interleukin [IL]-6) were compared between subjects with or without COPD by the two criteria using logistic and multiple regression models, adjusting for sex and age. RESULTS: The prevalence of spirometrically defined COPD by FR increased with age from 10% in subjects aged <65 years to 26% in subjects aged ≥75 years. For LLN-defined COPD, it remained below 10% for all age groups. Overall, COPD diagnosis was not associated with specific comorbidities, except for a lower prevalence of obesity in both FR- and LLN-defined cases. Both CRP and IL-6 tended to be higher in cases by both criteria. CONCLUSION: In a population-based cohort of adults up to the age of 90 years, the prevalence of spirometrically defined COPD was higher for the FR criterion than for the LLN criterion. This difference increased with age. Neither prevalences of common comorbidities nor levels of the biomarkers, CRP or IL-6, were conclusively associated with the selection of the COPD criterion. Results have to be considered in light of the predominantly mild cases of airway obstruction in the examined study population.

Symptoms of Insomnia and Sleep Duration and Their Association with Incident Strokes: Findings from the Population-Based MONICA/KORA Augsburg Cohort Study.

OBJECTIVE: To examine the relationship between symptoms of insomnia and sleep duration and incident total (non-fatal plus fatal) strokes, non-fatal strokes, and fatal strokes in a large cohort of men and women from the general population in Germany. METHODS: In four population-based MONICA (monitoring trends and determinants in cardiovascular disease)/KORA (Cooperative Health Research in the Region of Augsburg) surveys conducted between 1984 and 2001, 17,604 men and women (aged 25 to 74 years) were asked about issues like sleep, health behavior, and medical history. In subsequent surveys and mortality follow-ups, incident stroke cases (cerebral hemorrhage, ischemic stroke, transient ischemic attack, unknown stroke type) were gathered prospectively until 2009. Sex-specific hazard ratios (HR) and their 95% confidence intervals (CI) were estimated using sequential Cox proportional hazards regression models. RESULTS: During a mean follow-up of 14 years, 917 strokes (710 non-fatal strokes and 207 fatal strokes) were observed. Trouble falling asleep and difficulty staying asleep were not significantly related to any incident stroke outcome in either sex in the multivariable models. Among men, the HR for the association between short (≤5 hours) and long (≥10 hours) daily sleep duration and total strokes were 1.44 (95% CI: 1.01-2.06) and 1.63 (95% CI: 1.16-2.29), after adjustment for basic confounding variables. As for non-fatal strokes and fatal strokes, in the analyses adjusted for age, survey, education, physical activity, alcohol consumption, smoking habits, body mass index, hypertension, diabetes, and dyslipidemia, the increased risks persisted, albeit somewhat attenuated, but no longer remained significant. Among women, in the multivariable analyses the quantity of sleep was also not related to any stroke outcome. CONCLUSION: In the present study, symptoms of insomnia and exceptional sleep duration were not significantly predictive of incident total strokes, non-fatal strokes, and fatal strokes in either sex.

Oxytocin-induced coping with stressful life events in old age depends on attachment: findings from the cross-sectional KORA Age study.

BACKGROUND: Whether oxytocin functions as a stress hormone in older age is unknown. We investigated oxytocin levels and the perceived stress of an adverse life event in an older population-representative sample and considered the effect of a secure/insecure attachment style on this association. METHODS: Non-fasting plasma oxytocin was measured from 952 participants (65-90 years) of the cross sectional KORA-Age study. The psychological impact of an adverse life event was assessed based on the Psychosocial Stress Questionnaire. Attachment style was determined by the Relationship-Specific Attachment Scales for Adults. Linear regression models of oxytocin, stratified for attachment style, were controlled for age, sex, and further for alcohol, smoking, and physical activity. Adjusted least squares means of oxytocin were calculated. RESULTS: Oxytocin levels did not differ between men and women (mean, 95% confidence interval (CI), 321 (277-365) and 309 (272-345)pg/ml, respectively). Oxytocin levels were positively associated with the experience of an adverse event (n=273, 29%) versus no event (n=679, 71%), in securely attached (ß estimate=0.17, standard error (SE)=0.08, P value=0.03) but not in insecure participants (-0.10, 0.09), P=0.28). Oxytocin was positively associated with diminished stress among securely attached participant (event with little suffering: ß=0.35. SE=0.12, great suffering: ß=0.15. SE=0.14, severe suffering: ß=0.03. SE=0.12). Among participants who reported minimal suffering, insecure individuals had lower oxytocin (adjusted mean, 95%CI: 172, 127-216 pg/ml) than securely attached individuals (279, 222-352 pg/ml, P=0.006). CONCLUSIONS: These epidemiologic data support the hypothesis that oxytocin may have an attenuating effect on perceived stress due to adverse life events in old age. The conditional role of attachment style in stress-induced endogenous oxytocin production is highlighted.

Determinants of completed railway suicides by psychiatric in-patients: case-control study.

BACKGROUND: Suicide prediction during psychiatric in-patient treatment remains an unresolved challenge. AIMS: To identify determinants of railway suicides in individuals receiving in-patient psychiatric treatment. METHOD: The study population was drawn from patients admitted to six psychiatric hospitals in Germany during a 10-year period (1997-2006). Data from 101 railway suicide cases were compared with a control group of 101 discharged patients matched for age, gender and diagnosis. RESULTS: Predictors of suicide were change of therapist (OR = 22.86, P = 0.004), suicidal ideation (OR = 7.92, P<0.001), negative or unchanged therapeutic course (OR = 7.73, P<0.001), need of polypharmaceutical treatment (OR = 2.81, P = 0.04) and unemployment (OR = 2.72, P = 0.04). Neither restlessness nor impulsivity predicted in-patient suicide. CONCLUSIONS: Suicidal ideation, unfavourable clinical course and the use of multiple psychotropic substances (reflecting the severity of illness) were strong determinants of railway suicides. The most salient finding was the vital impact of a change of therapist. These findings deserve integration into the clinical management of patients with serious mental disease.

Adverse conditions at the workplace are associated with increased suicide risk.

OBJECTIVE: The present study addressed potential harms of a negative working environment for employed subjects. The main aim was to evaluate if adverse working conditions and job strain are related to an increase in suicide mortality. METHODS: The study population consisted of 6817 participants drawn from the MONICA/KORA Augsburg, Germany, surveys conducted in 1984-1995, being employed at baseline examination and followed up on average for 12.6 years. Adverse working conditions were assessed by an instrument of 16 items about chronobiological, physical and psychosocial conditions at the workplace, job strain was assessed as defined by Karasek. Suicide risks were estimated by Cox regression adjusted for suicide-related risk factors. RESULTS: A number of 28 suicide cases were observed within follow-up. High levels of adversity in chronobiological/physical working conditions significantly increased the risk for suicide mortality (HR 3.28, 95% CI 1.43-7.54) compared to low/intermediate levels in a model adjusted for age, sex and survey (p value 0.005). Additional adjustment for living alone, low educational level, smoking, high alcohol consumption, obesity and depressed mood attenuated this effect (HR 2.73) but significance remained (p value 0.022). Adverse psychosocial working conditions and job strain, in contrast, had no impact on subsequent suicide mortality risk (p values > 0.200). CONCLUSIONS: A negative working environment concerning chronobiological or physical conditions at the workplace had an unfavourable impact on suicide mortality risk, even after controlling for relevant suicide-related risk factors. Employer interventions aimed to improve workplace conditions might be considered as a suitable means to prevent suicides among employees.

Position paper on the importance of psychosocial factors in cardiology: Update 2013.

BACKGROUND: The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008. METHODS: The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients. RESULTS: A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered. CONCLUSIONS: The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

Are psychosocial stressors associated with the relationship of alcohol consumption and all-cause mortality?

BACKGROUND: Several studies have shown a protective association of moderate alcohol intake with mortality. However, it remains unclear whether this relationship could be due to misclassification confounding. As psychosocial stressors are among those factors that have not been sufficiently controlled for, we assessed whether they may confound the relationship between alcohol consumption and all-cause mortality. METHODS: Three cross-sectional MONICA surveys (conducted 1984-1995) including 11,282 subjects aged 25-74 years were followed up within the framework of KORA (Cooperative Health Research in the Region of Augsburg), a population-based cohort, until 2002. The prevalences of diseases as well as of lifestyle, clinical and psychosocial variables were compared in different alcohol consumption categories. To assess all-cause mortality risks, hazard ratios (HRs) were estimated by Cox proportional hazards models which included lifestyle, clinical and psychosocial variables. RESULTS: Diseases were more prevalent among non-drinkers than among drinkers: Moreover, non-drinkers showed a higher percentage of an unfavourable lifestyle and were more affected with psychosocial stressors at baseline. Multivariable-adjusted HRs for moderate alcohol consumption versus no consumption were 0.74 (95% confidence interval (CI): 0.58-0.94) in men and 0.87 (95% CI: 0.66-1.16) in women. In men, moderate drinkers had a significantly lower all-cause mortality risk than non-drinkers or heavy drinkers (p=0.002) even after multivariable adjustment. In women, moderate alcohol consumption was not associated with lowered risk of death from all causes. CONCLUSIONS: The present study confirmed the impact of sick quitters on mortality risk, but failed to show that the association between alcohol consumption and mortality is confounded by psychosocial stressors.

Living alone, obesity, and smoking increase risk for suicide independently of depressive mood findings from the population-based MONICA/KORA Augsburg cohort study.

BACKGROUND: Suicide is strongly associated with mental disorders, particularly with depression. There is insufficient knowledge to what extent sociodemographic and behavioral characteristics contribute to suicide risk. METHODS: A population-based cohort study on three independent cross-sectional MONICA/KORA Augsburg surveys with 12,888 subjects (6456 men, 6432 women) was followed up on average for 12.0 years. Information on sociodemographic characteristics, chronic disease conditions, smoking habits, alcohol consumption, depressive symptoms, personality type, and other psychodiagnostic parameters was assessed by standardized interviews. Cox proportional hazards regression analyses were used to compute hazard ratios (HRs) as estimates of relative risks for suicide mortality. Additionally, population-attributable risks were calculated. RESULTS: Within the follow-up period, a total of 1449 persons had died, 38 of them by suicide. Although several variables were associated with increased risk in the basic analyses, only obesity (HR=2.73), smoking (HR=2.23), and living alone (HR=2.19) remained significantly associated with suicide additionally to male sex (HR=3.57) and depressed mood (HR=2.01) in a multivariate analysis. LIMITATIONS: The generalization of our findings to countries with different social, economic or cultural conditions may be questioned. CONCLUSIONS: Our findings extend the knowledge about sociodemographic and behavioral risk factors for suicide in the general population: Suicide prevention measures should not consider only subjects with mental disorders but also address other adverse conditions.

Diagnostic utility of a one-item question to screen for depressive disorders: results from the KORA F3 study.

BACKGROUND: Screening for depressive disorders in the general adult population is recommended, however, it is unclear which instruments combine user friendliness and diagnostic utility. We evaluated the test performance of a yes/no single item screener for depressive disorders ("Have you felt depressed or sad much of the time in the past year?") in comparison to the depressive disorder module of the Patient Health Questionnaire (PHQ-9). METHODS: Data from 3184 participants of the population-based KORA F3 survey in Augsburg/ Germany were used to analyse sensitivity, specificity, ROC area, positive likelihood ratio (LR+), negative likelihood ratio (LR-), positive predictive value (PPV), and negative predictive value (NPV) of the single item screener in comparison with "depressive mood" and "major depressive disorder" defined according to PHQ-9 (both interviewer-administered versions). RESULTS: In comparison to PHQ-9 "depressive mood", sensitivity was low (46%) with an excellent specificity (94%), (PPV 76%; NPV 82%; LR + 8.04; LR- .572, ROC area .702). When using the more conservative definition for "major depressive disorder", sensitivity increased to 83% with a specificity of 88%. The PPV under the conservative definition was low (32%), but NPV was 99% (LR + 6.65; LR- .196; ROC area .852). Results varied across age groups and between males and females. CONCLUSIONS: The single item screener is able to moderately decrease post-test probability of major depressive disorders and to identify populations that should undergo additional, more detailed evaluation for depression. It may have limited utility in combination with additional screening tests or for selection of at-risk populations, but cannot be recommended for routine use as a screening tool in clinical practice.