A minimal psychological intervention in chronically ill elderly patients with depression: a randomized trial.

BACKGROUND: Among older persons with chronic somatic diseases, depression often remains unrecognized and untreated in primary care. The Depression in Elderly with Long-Term Afflictions (DELTA) study aimed to evaluate the effectiveness of a nurse-led minimal psychological intervention (MPI) in chronically ill elderly persons with depression. METHODS: A randomized controlled trial was conducted, comparing the MPI with usual care in 361 primary care patients. Four nurses had an average of 4 sessions with the intervention patients, each lasting 1 h, over a maximum period of 3 months. Patients were aged 60 years and older, had a minor depression or mild-to-moderate major depression, and either had type II diabetes or chronic obstructive pulmonary disease. RESULTS: Nine months after the intervention, patients receiving the MPI had significantly fewer depressive symptoms; the intervention patients were also more likely than usual-care controls to show a >or=50% reduction in depressive symptoms relative to baseline values. At 9 months, diabetic MPI patients had a better quality of life than diabetic controls. CONCLUSIONS: The nurse-led MPI appears to be a feasible and moderately effective method of managing minor-to-moderate depression in chronically ill elderly persons. However, we cannot rule out attention-placebo effects, and the disappointing finding of a recent economic evaluation showing only a 63% chance of the MPI being cost-effective. From a clinical point of view, however, it is of interest to further evaluate adaptations of the MPI, with a stronger emphasis on detection, watchful waiting and mental health problems in general.

The Maastricht social participation profile: development and clinimetric properties in older adults with a chronic physical illness.

PURPOSE: To develop and test the Maastricht Social Participation Profile (MSPP), an instrument measuring the actual social participation by older adults with a chronic physical illness, in accordance with their own definition of social participation. METHODS: The development process consisted of a number of steps, ending with a field test in two waves (n = 412 and n = 125) among a random sample of people older than 59 years with either COPD or diabetes mellitus. Reproducibility was evaluated with intraclass correlation coefficients (ICCs) and smallest real differences at group level (SRDs(group)). Convergent and discriminant validity were evaluated with Pearson correlation coefficients between the MSPP and the Frenchay Activities Index (FAI). RESULTS: The MSPP consists of four indices: consumptive participation, formal social participation, informal social participation-acquaintances and informal social participation-family. Each index measured diversity and frequency of participation. ICCs ranged between 0.63 and 0.83. SRDs(group) ranged between 0.05 and 0.09. Convergent and discriminant validity were supported by the correlations between the MSPP(frequency) and the FAI. CONCLUSIONS: The MSPP has good validity and acceptable reproducibility. Its distinguishing features are its focus on actual social participation and the possibility to calculate both diversity and frequency scores.

Does offering prenatal screening influence pregnant women's attitudes regarding prenatal testing?

OBJECTIVES: This study aims to find out whether offering prenatal screening for Down syndrome and neural tube defects influences pregnant women's attitudes toward having a screening test. METHODS: Women were randomised into a group that was offered prenatal screening and a group that was not offered screening (controls). Both groups completed questionnaires before screening was offered, after the offer (not the control group), and in the last trimester of pregnancy. RESULTS: Women with a neutral attitude at baseline who accepted the screening test had a more positive attitude, decliners became more negative and the attitude of the control group did not change. CONCLUSION: Offering prenatal screening triggers a change in some pregnant women's attitude regarding prenatal testing. This instability of women's attitudes may pose a problem for determining whether some women made an informed choice.

Lack of basic and luxury goods and health-related dysfunction in older persons; findings from the longitudinal SMILE study.

BACKGROUND: More so than the traditional socioeconomic indicators, such as education and income, wealth reflects the accumulation of resources and makes socioeconomic ranking manifest and explicitly visible to the outside world. While the lack of basic goods, such as a refrigerator, may affect health directly, via biological pathways, the lack of luxury goods, such as an LCD television, may affect health indirectly through psychosocial mechanisms. We set out to examine, firstly, the relevance of both basic and luxury goods in explaining health-related dysfunction in older persons, and, secondly, the extent to which these associations are independent of traditional socioeconomic indicators. METHODS: Cross-sectional and longitudinal data from 2067 men and women aged 55 years and older who participated in the Study on Medical Information and Lifestyles Eindhoven (SMILE) were gathered. Logistic regression analyses were used to study the relation between a lack of basic and luxury goods and health-related function, assessed with two sub-domains of the SF-36. RESULTS: The lack of basic goods was closely related to incident physical (OR = 2.32) and mental (OR = 2.12) dysfunction, even when the traditional measures of socioeconomic status, i.e. education or income, were taken into account. Cross-sectional analyses, in which basic and luxury goods were compared, showed that the lack of basic goods was strongly associated with mental dysfunction. Lack of luxury goods was, however, not related to dysfunction. CONCLUSION: Even in a relatively wealthy country like the Netherlands, the lack of certain basic goods is not uncommon. More importantly, lack of basic goods, as an indicator of wealth, was strongly related to health-related dysfunction also when traditional measures of socioeconomic status were taken into account. In contrast, no effects of luxury goods on physical or mental dysfunction were found. Future longitudinal research is necessary to clarify the precise mechanisms underlying these effects.

Conceptualizing autonomy in the context of chronic physical illness: relating philosophical theories to social scientific perspectives.

The aim of this article is to conceptualize autonomy in the context of chronic physical illness. To this end, we compare and contrast a selection of contemporary philosophical theories of autonomy with social scientific perspectives on chronic illness, particularly models of disability and symbolic interactionism. The philosophical theories mainly depart from a positive conceptualization of autonomy, which involves actively shaping one's life and identifying with fundamental values. This conceptualization is preferred over a negative conceptualization, which defines autonomy as non-interference, for its compatibility with social models of disability and with the assumption that people are interdependent. Interference may disable, but also enable people with a chronic illness to shape their lives. What matters is that people can realize what they want to realize. We suggest that, in the context of chronic physical illness, autonomy might be conceptualized as correspondence between what people want their lives to be like and what their lives are actually like. Disturbed autonomy might be restored either by expanding opportunities to arrange life or by adjusting how one wants life to be arranged. The grounds for the latter approach might be questioned, first, if people have not adjusted what they want carefully, and second, if reorganization of the material and social environment would have made it unnecessary to adjust one's arrangement of life.

Health-related behaviors of Sudanese adolescents.

CONTEXT: Adolescence is the age period from 10-19 years when lifestyle patterns of behavior are being formed. These behaviors set the stage for future health problems. Behaviors and lifestyles are determinants of future health, illness, disability, and premature mortality. OBJECTIVES: To gain new insight into health behaviors, lifestyles and their context in adolescents in order to assess the determinants and barriers to the improvement of health. METHODS: A cross-sectional descriptive study. A random sample of 1200 adolescents within the age group of 10-19 years (53.2% girls and 46.8% boys) were interviewed individually. A self-reported questionnaire was developed for data collection by trained interviewers. Bivariate and logistic regression analyses were conducted. OUTCOMES: The overall prevalence of smoking among adolescents was 4.9%. More boys (9.1%) than girls (1.3%) reported smoking. Older participants and those with higher levels of education reported higher rates of tobacco use (10.4 % and 7.9%). Consumption of alcohol was significantly more common for boys (2.3%). More boys than girls reported they were actively engaged in sports. Inactivity was significantly higher among older age groups and was associated with lack of education. 58% of girls and 8.7% of boys were physically inactive. More than half of the boys go hungry due to lack of availability of food in the house and this was somewhat less common for girls (43%). Adolescents 16 years and older reported significantly less consumption of both nutritious and non-nutritious foods than other age groups. CONCLUSION: Our research contributed to greater understanding of current health-related behaviors of Sudanese adolescents. There are a number of implications for potential interventions (e.g. physical inactivity of girls and hunger experiences).

Associations between lifestyle and depressed mood: longitudinal results from the Maastricht Aging Study.

OBJECTIVES: We examined whether healthy lifestyles are associated with absence of depressed mood. METHODS: A sample of 1169 adult participants in the Maastricht Aging Study provided baseline and 6-year follow-up data on smoking, alcohol use, physical exercise, body mass index, and mood. We examined associations between lifestyles and depressed mood using longitudinal analyses controlling for baseline depressive symptoms and covariates. RESULTS: Reports of excessive alcohol use at baseline predicted depressed mood at follow-up (relative risk [RR] = 2.48; 95% confidence interval [CI] = 1.08, 5.69), and reports of more than 30 minutes of physical exercise per day at baseline were associated with an absence of depressed mood at follow-up (RR=0.52; 95% CI=0.29, 0.92). Reports of being engaged in physical exercise throughout the 6-year follow-up period were also associated with absence of depressed mood (RR=0.56; 95% CI=0.34, 0.93). CONCLUSIONS: In this relatively healthy population sample, certain lifestyles either predicted or protected against depressed mood. Adopting or maintaining healthy lifestyles might be a starting point in preventing or treating depressed mood over time.

Is there a biomedical explanation for socioeconomic differences in incident mobility limitation?

BACKGROUND: The association between low socioeconomic status and poor physical functioning has been well described; biomedical factors may play an important role in explaining these differences. This study examines the association between socioeconomic status and incident mobility limitation in well-functioning older adults, and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data were obtained from 3066 men and women, aged 70--79 years from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition (Health ABC) study. Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Mobility limitation was defined as reporting difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 4.5 years. Biomedical factors included a wide range of diseases (e.g., heart and cerebrovascular disease) and biological risk factors (e.g. hypertension, poor pulmonary function, and high serum levels of inflammatory markers). RESULTS: Adjusted hazard ratios of incident mobility limitation were significantly higher in those persons with low education, low income, and few assets. Hazard ratios ranged from 1.66 to 2.80 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the hazard ratios by an average of 41% for education, 17% for income, and 29% for assets. CONCLUSION: Biomedical factors can account for some of the association between socioeconomic status and incident mobility limitation. However, to reduce physical disabilities and, in particular, the socioeconomic differences therein, it may not be sufficient to solely intervene upon biological risk factors and risks of diseases.

Determinants of headache in lansoprazole users in The Netherlands: results from a nested case-control study.

OBJECTIVE: During proton pump inhibitor (PPI) use, in clinical trials, headache is one of the most frequently reported adverse events (frequency 1.3 to 8.8%), while results of one observational study indicate that headache is the fifth most frequently reported adverse event (incidence densities 2.5 to 4.6 per 1000 patient-months of exposure). However, there are no observational studies performed regarding the occurrence and features of headache during use of PPIs in daily practice. For this reason this study was set up with the aim to assess the incidence and characteristics of headache and to investigate possible associated co-factors in PPI users in daily practice. DESIGN: Data were used from a prospective, observational study in which 10 008 lansoprazole users were followed over time. The study was designed according to the Safety Assessment of Marketed Medicines guidelines. A nested case-control design was used to compare PPI users reporting headache or not. RESULTS: The frequency of headache was 2.5% in users of lansoprazole and the incidence density was 7.2 per 1000 patient-months of PPI lansoprazole use. Two-thirds of patients with headache had tension headache and one-third had migraine. The analysis of co-factors revealed that women, patients with previous use of analgesics and patients reporting several adverse events, were at risk to develop headache during PPI use. Patients with headache also, significantly more often, reported diarrhoea, nausea and dizziness. A discontinuation of PPI therapy resulted in a cessation or reduction of the headache in 80.0% (20 of 25). CONCLUSIONS: As can be expected, headache was reported less frequently in this study compared with clinical trials with lansoprazole. The incidence density was comparable with other observational data of lansoprazole and omeprazole users. Besides several commonly accepted co-factors such as female gender and a history of analgesic use, we also found the reporting of other adverse events to be associated with the reporting of headache during lansoprazole use. The cessation of headache after a discontinuation of use of the PPI and the observed dose relationship suggested that headache was indeed an adverse effect of lansoprazole use.

Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners.

Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor's speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10-30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification 'dealing with illness worry' showed limited feasibility.

Disparities by education level in outcomes of a self-management intervention: the DELTA trial in The Netherlands.

OBJECTIVE: The study examined whether education level was associated with benefits derived from a self-management intervention. Because such interventions increase one's sense of control, it was hypothesized that persons with less education, who generally have a diminished sense of control, would derive greater benefit. METHODS: A randomized trial was conducted with 361 patients aged 60 and older with type 2 diabetes or chronic obstructive pulmonary disease and mild to moderate depression. The intervention provided individualized contacts (two to ten) with nurses who taught participants to take control of their disease. RESULTS: Positive effects on depression, health-related quality of life, feelings of mastery, and self-efficacy were confined to patients with more education; those with only a primary education did not benefit. CONCLUSIONS: Only more highly educated patients profited from a cognitive-behavioral approach to self-management. Patients with chronic conditions who have less education may derive greater benefits if environmental adversities or lower cognitive abilities are taken into account.

The relative contributions of hostility and depressive symptoms to the income gradient in hospital-based incidence of ischaemic heart disease: 12-Year follow-up findings from the GLOBE study.

There is evidence to support the view that both hostility and depressive symptoms are psychological risk factors for ischaemic heart disease (IHD), additional to the effects of lifestyle and biomedical risk factors. Both are also more common in lower socioeconomic groups. Studies to find out how socioeconomic status (SES) gets under the skin have not yet determined the relative contributions of hostility and depression to the income gradient in IHD. This has been examined in a Dutch prospective population-based cohort study (GLOBE study), with participants aged 15-74 years (n=2374). Self-reported data at baseline (1991) and in 1997 provided detailed information on income and on psychological, lifestyle and biomedical factors, which were linked to hospital admissions due to incident IHD over a period of 12 years since baseline. Cox proportional hazard models were used to study the contributions of hostility and depressive symptoms to the association between income and time to incident IHD. The relative risk of incident IHD was highest in the lowest income group, with a hazard ratio of 2.71. Men on the lowest incomes reported more adverse lifestyles and biomedical factors, which contributed to their higher risk of incident IHD. An unhealthy psychological profile, particularly hostility, contributed to the income differences in incident IHD among women. The low number of IHD incidents in the women however, warrants additional research in larger samples.

The combined relations of adiposity and smoking on mortality.

BACKGROUND: Smoking and high adiposity are strong independent health risk factors but are also interrelated. Smoking is related to a lower body mass index (BMI) but not necessarily with a smaller waist circumference. Smoking cessation is associated with increased body weight and a substantial increase in waist circumference. How this affects mortality risk is unknown. OBJECTIVE: This study examined the combined relations of smoking status with BMI and waist circumference and smoking status to all-cause mortality. DESIGN: Data were from 149 502 men and 88 184 women aged 51-72 y participating in the National Institutes of Health-AARP Diet and Health Study. All-cause mortality was assessed over 10 y of follow-up from 1996 to 2006. RESULTS: Current smokers with a BMI (in kg/m(2)) <18.5 or >or=35 had a mortality risk 6-8 times that of persons within the normal BMI range who never smoked. Current smokers with a large waist circumference had a mortality risk about 5 times that of never smokers with a waist circumference in the second quintile. CONCLUSION: Both smoking and adiposity are independent predictors of mortality, but the combination of current or recent smoking with a BMI >or= 35 or a large waist circumference is related to an especially high mortality risk.

Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in The Netherlands.

OBJECTIVE: To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home. DESIGN: In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers. SETTING: Second Dutch National Survey in General Practice. SUBJECTS: A total of 743 patients who received palliative care according to their GP. MAIN OUTCOME MEASURES: Interdisciplinary cooperation between GP and other healthcare providers. RESULTS: During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care. CONCLUSION: In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.

Chronic patients in undergraduate education: didactic value as perceived by students.

OBJECTIVES: Medical education should prepare students for future clinical practice. However, this preparation is inadequate for the most prevalent problem in health care: chronic disease. This applies to the continuous aspect of chronic disease. Within the context of a newly developed programme, we investigated what makes a chronic patient interesting in the eyes of medical students, what they learned from a specific programme in which each student had contact with a chronic patient 4 times in 8 months, and what they learned from their patients. METHODS: A total of 240 Year 3 students were enrolled in the programme, 89 of whom filled in questionnaires at both the start and end of the programme. Topics included the characteristics of the ideal and the actual patient, the Ideal Physician Questionnaire, and several questions on the expected and actual amount of knowledge gained from the patient. RESULTS: Students preferred patients who demonstrated clear symptoms and had frequent contacts with health care professionals during the programme to 'well adapted' patients. The perceived knowledge obtained from the patient was less than they had expected at the start of the programme. A didactic gain perceived as low was mainly due to low expectations of gaining knowledge at the start of the programme, a doctor-centred attitude and a high level of discrepancy between the student's ideal patient and the actual patient. CONCLUSIONS: Programmes that aim to present chronic patients to medical students focus on patient selection so that patients who differ only very slightly from healthy persons are eliminated. In addition, realistic information on the types of patients with whom students can expect to have contact may help students appreciate the knowledge to be gained from these patients.

Defining the patient population: one of the problems for palliative care research.

There is a lack of clear definition and clear inclusion criteria in palliative care research. The aim of this study was to describe consequences of three inclusion criteria in the build up of different study populations, studied in terms of size, number of doctor-patient contacts and demographic characteristics. General practitioners received a questionnaire for all patients who died during the second Dutch National Survey of General Practice (n=2194), to determine whether (1) patients received non-curative treatment; (2) patients received palliative care; and (3) death was expected (total response rate =73%). The criterion 'death was expected' included most patients (62%) followed by 'palliative care' (46%) and 'noncurative treatment' (39%). Similarity between the definition-based populations was fair to moderate. More 'palliative care' and 'death was expected' in patients who had cancer than 'non-curative treatment' patients. The conclusions show substantial differences in populations according to the different inclusion criteria used to select them. Future research in palliative care should acknowledge the limitations of using certain inclusion criteria and explore potential bias.

Relationship between changes in depressive symptoms and unhealthy lifestyles in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam.

BACKGROUND: depressed mood is common in late life, more prevalent among the chronically diseased than in the general population, and has various health-related consequences. So far, the association between depression and unhealthy lifestyles among chronically diseased has not been examined longitudinally in older persons. PRIMARY OBJECTIVE: to determine if depressed mood is associated with unhealthy lifestyles in late middle aged and older people, with or without chronic somatic diseases. METHODS: in a sample of 1,280 community-dwelling people from the Netherlands, the associations between depressive symptoms and lifestyle domains were analysed cross-sectionally and longitudinally - using logistic regression analyses and multivariate analyses of variance. RESULTS: after controlling for confounders, depressed people (n=176 at baseline) were more likely to be smokers (odds ratio 1.71; 95% confidence interval 1.17-2.52). A persistent depression was associated with an increase in cigarette consumption (P=0.036). Having an emerging depression (n=155) was most likely to co-occur with a person's change from being physically active to being sedentary (relative risk-ratio 1.62; 95% confidence interval 1.05-2.52), and was associated with the largest decrease in minutes of physical activity (P=0.038). This effect was not modified or confounded by chronic somatic disease. A persistent depression tended to be associated with incident excessive alcohol use (relative risk-ratio 4.04; 95% confidence interval 0.97-16.09; P=0.056). CONCLUSIONS: depression is associated with smoking behaviour, and with an increase in cigarette consumption. An emerging depression is associated with becoming sedentary, irrespective of a person's disease status at baseline, and is associated with decrease in minutes of physical activity.