Relationship between mood and TSH response to TRH stimulation in bipolar affective disorder.

Moderate to severe depression and mania are associated with a reduced thyroid stimulating hormone (TSH) response to TSH releasing hormone (TRH). Continued reduction of this response after clinical recovery seems indicative of early relapse. The aim of the present study was to test the relationship between mild changes in mood and the TSH response to TRH stimulation in patients with bipolar affective disorder. Nineteen outpatients with bipolar affective disorder were followed prospectively for three years. Every third month, mood symptoms were rated using the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Bech-Rafaelsen Mania Scale (BRMS). A TRH test was performed in connection with each rating session (IV injection of 200 microg TRH), and serum TSH was measured at 0, 20, and 60 min. The maximum TSH response (D-max TSH) and the temporal change in D-max TSH between succeeding rating sessions (DD-max TSH) were determined. Psychometric rating and TRH data were obtained for a total of 198 examinations. The temporal change in mood symptom rating score was negatively correlated with the temporal change in D-max TSH, thus suggesting that increasing severity of mood symptoms was related to a reduced TSH response to TRH stimulation. The temporal change in TSH response to TRH stimulation correlated with the actual score on an overall index of symptom severity. In conclusion, milder fluctuations in mood in bipolar affective disorder seem to correlate with the TSH response to TRH stimulation: Increasing severity of mood symptoms seems to be associated with reduced TSH response.

Incapacity for work in elective orthopaedic surgery: a study of occurrence and the probability of returning to work after treatment.

STUDY OBJECTIVE: The extent to which patients undergoing elective surgery for orthopaedic disorders were incapacitated for work while they were on the waiting list and whether they were able to return to work after surgery were studied. DESIGN: This was a prospective cohort study of patients admitted to hospital for elective orthopaedic surgery. Main outcome measures were occurrence of sickness certification during the waiting time, and whether those incapacitated for work at the time of surgery returned to work during the first year after treatment. Multivariate logistic regression was used to estimate adjusted odds ratios for factors influencing return to work. SETTING: Orthopaedic department in charge of all elective orthopaedic surgery in a population of 197,354 persons in central Norway. SUBJECTS: All 2803 patients admitted to hospital for chronic orthopaedic disorders in the defined population between 1 September 1988 and 31 August 1990 were included in the study. MAIN RESULTS: Of the 1333 patients who were employed, 42% had been certified sick due to the orthopaedic disorder for some period of the waiting time. Sickness benefits from the national insurance scheme (paid from the 15th day of sickness certification) had been received by 33% and were received by 29% at the time of surgery. Of 380 patients incapacitated for work at the time of surgery, 53% returned to work within the first year after surgery. Using those treated within one month of being placed on the waiting list as the reference group, the adjusted odds ratios for not returning to work during the first year after surgery were 9.2 (p < 0.0001) for those who waited more than a year for surgery, 6.2 (p = 0.002) for those waiting nine to 12 months, and 4.9 (p = 0.02) for those waiting for six to nine months. CONCLUSIONS: A high proportion of these patients were incapacitated for work, 53% of those incapacitated returned to work within the first year after surgery. The probability of returning to work after surgery is strongly influenced by the length of time on the waiting list. Waiting for more than one year, compared with immediate treatment, was associated with an adjusted odds ratio of 9.2 for not returning to work.

Sexual behaviour and attitudes of Danish middle-aged men-methodological considerations.

A Danish cohort-investigation of health risk-factors (started in 1976) included descriptions of the sexuality of the participants. This paper examines the validity/representativity of the results of the sexological investigation of the male participants, when in 1987 they were 51 years old. Remaining results will be published in separate articles about each main theme. The participants, 439 men, completed a questionnaire concerning sexuality (behaviour, attitudes and experience) and had their serum-LH and serum-free testosterone measured. Thereafter 100 of the 439 men were interviewed. The present examination shows that the participants are representative of same-aged men from all over Denmark concerning the sexological results. The answer ratio of the questionnaire was 70-95% and the non-responders of the questionnaire gave different interview answers than the rest. Complemented with their answers (answer ratio of nearly 100%) the interview results are more representative than the results of the questionnaire. The interview information is in this study considered more valid than the information obtained by the questionnaire--because the former more frequently than the latter contain answers embarrassing to the participants (e.g. high frequency of masturbation) or difficult for them to recall. The interview thereby adds vital information to that of the questionnaire.

Extramarital sexual relationships of middle-aged Danish men: attitudes and behavior.

This study explored Danish men's attitudes and behavior towards extramarital sexual relations (ESR), seen from two sides: men who had engaged in such relations (involved) and men who had not (non-involved). The participants, 439 men aged 51, completed a questionnaire concerning sexuality (behavior, attitudes and experience) as a part of a Danish cohort-investigation of health risk-factors. Thereafter 100 of the 439 men were interviewed. A high degree of permissiveness toward ESR emerged in both involved and non-involved individuals but approval of ESR was higher among the participants who were involved in ESR. The frequency of ESR increased with higher social rank. Both involved and non-involved participants mostly did not consider the ESR as a serious threat to the marital happiness. Attitudes-behavior discrepancies are discussed seen in the light of the social norms and known attitudes-behavior models.

Middle-aged Danish men's ideas of a male climacteric--and of the female climacteric.

The concept of a male climacteric as a parallel to the female climacteric appeared in both popular and scientific literature before 1940. The present population study describes the ideas regarding a male climacteric reported by a sample of men at the ages of 40, 45 and 51. The proportion who believed in the occurrence of a male climacteric decreased as the men became older, although 30% still believed in the phenomenon at the age of 51. Around a fifth (18%) of the 51-year-old men had felt or still felt that they were climacteric. This feeling was significantly related to the men's concern about a climacteric partner and to the presence of 'hot flushes or sweating' in the men. No relation was found with either the men's hormone levels (serum luteinizing hormone and serum free testosterone), or the myths that often surrounded the midlife crisis. The male climacteric therefore seems to serve as an explanation for various common non-specific complaints.

Case-based hospital financing: the case of Norway.

Several European countries are experimenting with new ways of organising and financing the hospital sector. This paper discusses the present Norwegian reform, where a system of fixed grants is replaced by a combination of payment per case and fixed grants. Initially implemented in four hospitals only, the decision to move to a full-scale reform will be based on the evaluation of this pilot project. The paper presents two alternative hypotheses on how a system with case-based financing will influence the performance of hospitals. Given that hospitals adjust passively to the constraints imposed by the financing system, increased efficiency is to be expected. If hospitals and hospital owners (i.e. the counties) interact in a game dominated by the hospital, however, the efficiency of the hospital will not be influenced by the financing system. We argue that the design of the pilot project limits the possibility of discriminating between these two hypotheses. Nevertheless, a comparison of key variables in the pilot hospitals with a set of reference hospitals indicates that the change of financing system has not had any substantial effect on hospital efficiency. Thus we are inclined to believe that hospitals in fact are able to set the level of efficiency independent of whether they are financed by fixed grants or a payment per case.

[Organic disease among patients at an open psychiatric outpatient clinic]. / Organisk sygdom hos patienter i en åben psykiatrisk modtagelse.

All of the new consultations in the Copenhagen Municipal psychiatric outpatient department during a period of three month were registered. Out of these, 1,149 did not lead to admission of the patient. In 47% of these information about somatic condition was available and in 31% information about somatic disease was present. Were 21% of the 1,149 patients were concerned, there were indications for treatment of the somatic disease. 50% of these were treated by the medical staff of the department, 17% were treated in other psychiatric departments, 21% were treated in departments for somatic disease and 11% were referred to their general practitioners or practising specialists for further treatment. These findings emphasize the importance of medical referral in an open psychiatric clinic with direct therapeutic contact.

[Somatic disease at a department for acute psychiatric disease]. / Somatisk sygdom hos patienter i en akut psykiatrisk modtageafdeling.

All of the patients admitted to the psychiatric inpatient department of the Municipal Hospital in Copenhagen during a period of three months were, on discharge, registered as regards somatic disease. 70% (95% confidence limits 66-75%) had somatic disease (38% of these were newly diagnosed). Treatment of these was carried out by the medical staff of the department and in 46% of the cases this was carried out in cooperation with the medical staffs of somatic departments. The close geographic contact with the departments for somatic diseases facilitated this cooperation. The staff in departments for emergency inpatient treatment of psychiatric disease should be able to observe and treat somatic disease on account of the high incidence of this. A psychiatric/medical special department could probably provide optimal treatment in cases of combined psychiatric and somatic disease.

[The significance of unemployment for admissions to a psychiatric department]. / Arbejdsløsheds betydning for indlagte på psykiatrisk afdeling.

A total of 295 patients, 152 women and 143 men, aged 18-70 years, were admitted to a psychiatric department during a period of three months. They were interviewed about their occupational conditions, the background for admission and help desired. Thirty-three women and 66 men were unemployed and half of these had been unemployed for over one year. The unemployed patients stated that misuse of alcohol or medicine was the reason for admission more frequently than the remainder of the patients. Half of the patients stated that unemployment contributed to admission to hospital but only 6% stated that this was the primary cause. Unemployed men desired employment most of all whereas the women desired improved social network. Three case reports are presented to illustrate the interaction between unemployment, stress at work and vulnerability and these illustrate the significances of the individuals factors for the nature of the relevant suitable help.

Frequency of sexual problems and sexual dysfunction in middle-aged Danish men.

The frequency of sexual dysfunction of a representative group of Danish middle-aged men was recorded, using a questionnaire and an interview that contained, respectively, 12 and 23 questions about sexual problems. The study sample consisted of 439 51-year-old men, all of whom received the questionnaire. Of these men, 100 were also interviewed. Interviewed men more frequently reported erectile dysfunction and previous contact with a therapist due to sexual problems at interview than in the questionnaire. Thus, 16 men (4% of the study population) who reported erectile dysfunction in the questionnaire constituted only a fraction of the true number. At interview nearly 40% of the men reported some kind of sexual dysfunction. There were, however, only 7% who found their problems abnormal for their age--and only 5% of the interviewed men intended to seek treatment for their problems.

Adverse effects of psychosocial stress on gonadal function and insulin levels in middle-aged males.

OBJECTIVES: To investigate the relationship between gonadal function, insulin and psychosocial stress in middle-aged men. DESIGN: A population-based, cross-sectional, observational study. SETTING: Glostrup Hospital, Copenhagen, Denmark. SUBJECTS: Four hundred and thirty-nine males, all aged 51 years. MAIN VARIABLES: Body-mass index (BMI), waist-to-hip ratio (WHR), insulin, C-peptide, free testosterone, luteinizing hormone (LH), lipids, fibrinogen, lung function tests (FVC, FEV1, PEF), blood pressure, a self-administered questionnaire with questions on psychosocial variables, lifestyle and self-rated health. RESULTS: Free testosterone correlated inversely (P < 0.05) with weight, BMI, WHR, and fibrinogen, and positively with FEV1. An independent correlation between free testosterone and insulin (P < or = 0.03), but not with C-peptide, was seen after controlling for BMI and WHR. Subjects with low levels of free testosterone, or those in the lowest quintile of the distribution of the hypogonadal index (HI: free testosterone/LH), showed a cluster of negative psychosocial variables, and psychological as well as health-related problems. Furthermore, hypogonadal men had lower (P < 0.05) levels of FEV1, peak flow and FVC, but higher (P < 0.01) levels of fibrinogen and higher pulse pressure than men with normal gonadal function. This gradient of variables, relative to HI, was not seen for possible confounders like BMI, WHR, and tobacco or alcohol consumption. CONCLUSION: Psychosocial stress may be associated with a process of premature ageing in middle-aged males, corresponding to a hypogonadal state as well as to indirect signs of increased insulin resistance.

The validity of the depression rating scales in discriminating between citalopram and placebo in depression recurrence in the maintenance therapy of elderly unipolar patients with major depression.

The World Federation of Societies of Biological Psychiatry guidelines for treatment of unipolar major depression has recommended three depression rating scales for evaluating outcome: The Hamilton Depression Rating Scale (HAM-D), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Bech-Rafaelsen Melancholia Scale (MES). In this study we evaluated the ability of these scales to differentiate between citalopram and placebo in the recurrence prevention of unipolar depression. The study is a psychometric reexamination of a trial on the efficacy of citalopram versus placebo in the maintenance therapy of elderly patients with unipolar depression. Internal validity (the Cronbach coefficient alpha, the Loevinger coefficient of homogeneity, and factor analysis) of the three scales has been examined to evaluate their unidimensionality. In the outcome analysis for depression recurrence, the conventional cutoff scores of the three scales are used. In total, 60 patients received citalopram and 61 patients received placebo in the maintenance phase of 48 weeks. The results showed that the internal validity was higher for MES and MADRS than for HAM-D. Using the MADRS, 67.2 % of the patients on placebo and 31.6 % of the patients on citalopram developed a depression recurrence (ratio 2.12); using HAM-D17, 42.6 % on placebo and 13.3 % on citalopram developed a depression recurrence (ratio 3.20); and using the MES, 34.4 % on placebo and 11.7 % on citalopram developed a depression recurrence (ratio 2.94). The conventional cutoff scores of HAM-D17 and MES for depression recurrence indicated a ratio between citalopram and placebo of around 3, while the conventional cutoff scores of MADRS for depression recurrence indicated a ratio of only around 2. In future trials on the recurrence prevention of unipolar depression, a cutoff score of 25 rather than 22 on the MADRS is recommended.

Relapse prevention by citalopram in SAD patients responding to 1 week of light therapy. A placebo-controlled study.

OBJECTIVE: We have tested the relapse-preventive effect of citalopram when compared with placebo in 282 patients with Seasonal Affective Disorder (SAD) responding to 1 week of light therapy. METHOD: The response rate to 1-week light therapy and relapse during the continuation phase of 15 weeks were assessed by use of the Hamilton Depression Rating Scale (HAM-D17), the six-item subscale (HAM-D6), the Melancholia Scale (MES), and the combined HAM-D/SIGH-SAD. RESULTS: The response rate to light therapy was 62.5% on the HAM-D17 and the HAM-D6, 56.1% on the HAM-D/SIGH-SAD, 52.8% on the MES. In the continuation phase, citalopram was found superior to placebo on all scales, but the difference was only of statistical significance on the HAM-D6 and the MES. Mean citalopram dose was 26.3 mg. CONCLUSION: Light therapy was found to have and early onset of action. On the HAM-D6 and the MES citalopram significantly reduced the relapse rate in the continuation phase.