Reliability and validity of the Estonian version of the Clinical Institute of Withdrawal Assessment for Alcohol scale.

AIMS: Our aim was to adapt the Clinical Institute of Withdrawal Assessment for Alcohol scale (CIWA-Ar) into Estonian and test its reliability and validity. METHODS: A total of 72 patients with alcohol withdrawal syndrome participated in the study. In order to assess the interrater reliability, at first assessment the CIWA-Ar was simultaneously completed by two nurses. In order to assess the sensitivity of the CIWA-Ar to the changes in the severity of the withdrawal syndrome, as well as its correlations to several indices characterizing the subjects' current condition, the CIWA-Ar, the Clinical Global Impression Severity subscale (CGI-S), the visual analogue scales for the assessment of the general feeling of malaise, anxiety and depression were filled in and the vital signs were measured at inclusion, in 4 h and after the withdrawal syndrome had been resolved. RESULTS: The intraclass correlation coefficient (ICC) for the Estonian version of the CIWA-Ar total score, used as an indicator of interrater reliability, was excellent. The CIWA-Ar had significant correlations with the psychiatrists' CGI-S ratings of the severity of the patient's condition at all assessment points. Significant correlations were also found between CIWA-Ar and patients' self-ratings, the highest correlations found with self-rated anxiety and general feeling of malaise. CIWA-Ar total score did not correlate with simultaneously measured heart rate, systolic and diastolic blood pressure at the first assessment. At the second assessment, heart rate had a significant correlation with the CIWA-Ar total score. CONCLUSION: Our study provides confirmation that the CIWA-Ar tool is well applicable in the Estonian language and culture setting.

Personality traits and escitalopram treatment outcome in major depression.

BACKGROUND: Selective serotonin re-uptake inhibitors (SSRI) have proven to be effective in treatment of depression. Still, treatment efficacy varies significantly from patient to patient and about 40% of patients do not respond to initial treatment. Personality traits have been considered one source of variability in treatment outcome. AIM: Current study aimed at identifying specific personality traits that could be predictive of treatment response and/or the dynamics of symptom change in depressive patients. METHOD: In a sample of 132 outpatients with major depressive disorder (MDD) treated with an SSRI-group antidepressant escitalopram, the Swedish universities Scales of Personality (SSP) were used in order to find predictive personality traits. For the assessment of the severity of depressive symptoms and the improvement rates, the Hamilton Depression Scale (HAM-D) and Montgomery-Åsberg Depression Rating Scale (MADRS) were used. RESULTS: Escitalopram-treated MDD patients with higher social desirability achieved more rapid decrease in symptom severity. None of the studied traits predicted the end result of the treatment. CONCLUSION: The findings suggest that specific personality traits may predict the trajectory of symptom change rather than the overall improvement rate.

Association between personality traits and Escitalopram treatment efficacy in panic disorder.

BACKGROUND: There is strong evidence to suggest that personality factors may interact with the development and clinical expression of panic disorder (PD). A greater understanding of these relationships may have important implications for clinical practice and implications for searching reliable predictors of treatment outcome. AIMS: The study aimed to examine the effect of escitalopram treatment on personality traits in PD patients, and to identify whether the treatment outcome could be predicted by any personality trait. METHOD: A study sample consisting of 110 outpatients with PD treated with 10-20 mg/day of escitalopram for 12 weeks. The personality traits were evaluated before and after 12 weeks of medication by using the Swedish universities Scales of Personality (SSP). RESULTS: Although almost all personality traits on the SSP measurement were improved after 12 weeks of medication in comparison with the baseline scores, none of these changes reached a statistically significant level. Only higher impulsivity at baseline SSP predicted non-remission to 12-weeks treatment with escitalopram; however, this association did not withstand the Bonferroni correction in multiple comparisons. LIMITATIONS: All patients were treated in a naturalistic way using an open-label drug, so placebo responses cannot be excluded. The sample size can still be considered not large enough to reveal statistically significant findings. CONCLUSIONS: Maladaptive personality disposition in patients with PD seems to have a trait character and shows little trend toward normalization after 12-weeks treatment with the antidepressant, while the association between impulsivity and treatment response needs further investigation.

Quality of life and emotional state in chronic skin disease.

The aim of this study was to evaluate the associations between chronic inflammatory skin conditions and patients' emotional state and quality of life. The following self-rated questionnaires were used: Emotional State Questionnaire, a self-report scale assessing depression and anxiety symptoms; Dermatology Life Quality Index (DLQI); and RAND-36, a measure of health-related quality of life. The study group comprised 40 patients with psoriasis, 40 with eczema, 40 with acne, 15 with seborrhoeic dermatitis and 40 healthy controls. Patients with chronic skin diseases had lower DLQI and lower RAND-36 physical functioning scores, more perceived physical limitations and pain, and lower emotional well-being and general health ratings compared with the control group. In conclusion, chronic skin diseases are associated with symptoms of emotional distress, in particular insomnia and general anxiety.

Mental health and alcohol problems among Estonian cleanup workers 24 years after the Chernobyl accident.

PURPOSE: To study the long-term mental health consequences of the 1986 Chernobyl nuclear accident among cleanup workers from Estonia. METHODS: In 2010, 614 Estonian Chernobyl cleanup workers and 706 geographically and age-matched population-based controls completed a mail survey that included self-rated health, the Posttraumatic Stress Disorder Checklist (PCL), alcohol symptoms (AUDIT), and scales measuring depressive, anxiety, agoraphobia, fatigue, insomnia, and somatization symptoms. Respondents were dichotomized into high (top quartile) and low symptom groups on each measure. RESULTS: Logistic regression analysis detected significant differences between cleanup workers and controls on all measures even after adjustment for ethnicity, education, marital status, and employment status. The strongest difference was found for somatization, with cleanup workers being three times more likely than controls to score in the top quartile (OR = 3.28, 95% CI 2.39-4.52), whereas for alcohol problems the difference was half as large (OR = 1.52, 95% CI 1.16-1.99). Among cleanup workers, arrival at Chernobyl in 1986 (vs. later) was associated with sleep problems, somatization, and symptoms of agoraphobia. CONCLUSION: The toll of cleanup work was evident 24 years after the Chernobyl accident among Estonian cleanup workers indicating the need for focused mental health interventions.

Implementing a digital solution for patients with migraine-Developing a methodology for comparing digitally delivered treatment with conventional treatment: A study protocol.

Migraine is one of the most frequent and expensive neurological disease in the world. Non-pharmacological and digitally administered treatment options have long been used in the treatment of chronic pain and mental illness. Digital solutions increase the patients' possibilities of receiving evidence-based treatment even when conventional treatment options are limited. The main goal of the study is to assess the efficacy of interdisciplinary digital interventions compared to conventional treatment. The maximum number of participants in this multi-centre, open-label, prospective, randomized study is 600, divided into eight treatment groups. The participants will take part in either a conventional or a digital intervention, performing various tests and interdisciplinary tasks. The primary outcome is expected to be a reduction in the number of headache days. We also undertake to measure various other headache-related burdens as a secondary outcome. The sample size, digital interventions not conducted via video calls, the lack of human connection, limited intervention program, and the conducting of studies only in digitally sophisticated countries are all significant limitations. However, we believe that digitally mediated treatment options are at least as effective as traditional treatment options while also allowing for a significantly higher patient throughput. The future of chronic disease treatment is remote monitoring and high-quality digitally mediated interventions.The study is approved by the Ethics Committee of the University of Tartu for Human Research (Permission No. 315T-17, 10.08.2020) and is registered at ClinicalTrials.gov: NTC05458817 (14.07.2022).

Help-seeking for emotional problems in major depression : findings of the 2006 Estonian health survey.

To study help-seeking among the general population and people with major depression. 12-month help-seeking for emotional problems was assessed in a cross-sectional 2006 Estonian Health Survey. Non-institutionalized individuals aged 18-84 years (n = 6,105) were interviewed. A major depressive episode was assessed using the Mini-International Neuropsychiatric Interview. The factors associated with help-seeking, received help, and health service use were analyzed. The prevalence of 12-month help-seeking for emotional symptoms was 4.8%. The rate of 12-month help-seeking in the depressed sample was 34.1%. Depressed people used non-mental health services 1.5-3 times more than non-depressed persons even when adjusted for the chronic somatic disorder. Only one third of depressed persons sought help, which was most of all associated with severity of depression. Underdiagnosis and undertreatment of depression leads to an increased use of expensive but non-specific health services by depressed persons.

Changes in the Mental Health Indicators and Training Opportunities for Estonian Elite Athletes Compared to the COVID-19 Isolation Period.

Background: In spring 2020, two-thirds of Estonian elite athletes had symptoms of emotional distress. The aim of this study was to evaluate the mental health indicators and training opportunities for elite Estonian athletes a year after the complete COVID-19 isolation period compared to June 2020. Methods: In both cross-sectional studies, athletes completed self-reported questionnaires, including the Emotional State Questionnaire. Descriptive statistics, t-tests, and Chi2 tests were applied to compare the study groups (p < 0.05). Results: A total of 172 out of approximately 600 elite Estonian athletes participated in the survey (102 in 2020 and 70 in 2021). More than a year after the COVID-19 lockdown period, the mental health problems of elite athletes (particularly the symptoms of depression and fatigue) are even greater concern than in June 2020, despite the recovery in training conditions and competition. Of all of the subjects, 80% had high levels of distress in 2021 compared to 36% in 2020. According to the athletes, the availability of health care services was good (78.6%), but there was a lack of close cooperation with the coach. However, the athletes considered their coaches to be their main supporters, along with their family members and partners. Only 4.3% of the respondents considered a sports psychologist to be their main supporter (n = 6). Conclusions: More than a year after the COVID-19 lockdown period, the mental health indicators of Estonian elite athletes were worrisome. Most of subjects had high levels of distress even though their training conditions had returned to normal (i.e., to as they had been before COVID-19).

Heavy episodic drinking in Europe: a cross section study in primary care in six European countries.

AIMS: We examined the prevalence of heavy episodic drinking in general practice attenders who were non-hazardous drinkers, the associated risk factors and the outcome over 6 months. METHODS: Consecutive attenders aged 18-75 were recruited from the UK, Spain, Slovenia, Estonia, the Netherlands and Portugal and followed up after 6 months. Data were collected on alcohol use using the Alcohol Use Disorder Identification test (at recruitment and 6 months) and risk factors for heavy episodic alcohol use at recruitment. RESULTS: The prevalence of heavy episodic drinking in non-hazardous drinkers was 4.5% across Europe [lowest in Portugal (1.5%); highest Netherlands (8.4%)]. It was less frequent in Spain, Slovenia, Estonia and Portugal compared with the UK and Netherlands. It was higher in men [odd ratio (OR) 4.4, 95% confidence interval (CI) 3.3, 5.9], people between 18 and 29 years of age, those employed (OR 1.8, 95% CI 1.3, 2.6) and those using recreational drugs (OR 2.1, 95% CI 1.4, 3.3). It was lower in people with existing DSMIV major depression (OR 0.54, 95% CI 0.31, 0.96). Heavy episodic drinkers were more likely to become hazardous drinkers at 6 months (male: OR 7.2, 95% CI 4.1, 12.7; female: OR 9.4, 95% CI 4.3, 20.6). CONCLUSION: Women and men in the UK, men in the Netherlands and younger people in all countries are at the greatest risk of exhibiting heavy episodic drinking behaviours even in the absence of hazardous alcohol use. There is hence an urgent need for general practitioners to consider early detection and management of heavy episodic drinking behaviour in this population.

Factors associated with recurrent depression: a prospective study in family practice.

BACKGROUND: Depression has a high rate of recurrence. Finding the variables that predict which patients are at higher risk of experiencing a recurrent episode of depression would benefit an individual patient. OBJECTIVE: To determine the factors associated with recurrent depression >12 months. METHODS: Consecutive patients (N = 1094), aged 18-75 years, were recruited from 23 family practices across Estonia. The patients were followed up at 6- and 12-month intervals as suggested in the PredictD study. Depression was assessed using the Composite International Diagnostic Interview. Each participant filled in a questionnaire to assess their risk factors for depression. RESULTS: Major depression was diagnosed in 13% of the patients. Twenty-eight per cent of the depressed patients had a recurrent episode of depression 12 months later. The odds of having recurrent depression were significantly higher for patients who had a history of drug abuse, odds ratio (OR) 7.48 [95% confidence interval (CI) = 1.42-39.43), for patients who had experienced discrimination, OR 2.92 (95% CI = 1.05-8.11) and for patients with a history of childhood abuse, OR 1.58 (95% CI = 1.05-2.38). CONCLUSIONS: One-third of the patients developed recurrent depression. Drug abuse, discrimination and childhood abuse predicted recurrent depression. These factors should be taken into consideration by family doctors when managing patients with depression.

Impact of the COVID-19 Pandemic on Estonian Elite Athletes: Survey on Mental Health Characteristics, Training Conditions, Competition Possibilities, and Perception of Supportiveness.

Background: The postponement and cancellation of the competition season due to COVID-19 could cause significant mental health problems for an elite athlete. The aim of this study was to describe the mental health characteristics of Estonian elite athletes, their training conditions, competition possibilities, and the support they received during COVID-19. Methods: Athletes completed self-reported questionnaires (including Emotional State Questionnaire). The authors applied descriptive statistics, t-test, and χ2 test for comparison of study groups (p < 0.05). Results: Altogether 102 athletes (♂ = 44) were surveyed. The most disturbing issue for athletes was the closing of training centers (57.8%) and cancellation of competitions (50%); 64.7% of athletes reported a negative response from not being able to visit healthcare specialists. Fortunately, athletes could receive virtual coaching. Two-thirds of the athletes had some indication of distress (♀ > ♂): 25% of males and 39.7% of females had symptoms indicating depression; ♀ = 27.6%, ♂ = 13.6% anxiety; ♀ = 56.9%, ♂ = 31.8% fatigue (p = 0.021); ♀ = 55.1%, ♂ = 27.2% insomnia (p = 0.009); 27.5% thought about ending their career (frequency in high distress group compared with low: p = 0.022); and 2.9% were certain they would stop their training completely. Family members were the biggest emotional supporters; 16.7% did not get support from anyone. Conclusion: The Estonian sport community needs to adapt to life in a pandemic environment and help athletes to maintain training and competition activities and in turn, their mental health.

Associations between personality traits and CCK-4-induced panic attacks in healthy volunteers.

In this study we examined how personality disposition may affect the response to cholecystokinin tetrapeptide (CCK-4; 50 microg) challenge in healthy volunteers (n=105). Personality traits were assessed with the Swedish universities Scales of Personality (SSP). Statistical methods employed were correlation analysis and logistic regression. The results showed that the occurrence of CCK-4-induced panic attacks was best predicted by baseline diastolic blood pressure, preceding anxiety and SSP-defined traits of lack of assertiveness, detachment, embitterment and verbal aggression. Significant interactions were noted between the above mentioned variables, modifying their individual effects. For different subsets of CCK-4-induced symptoms, the traits of physical aggression, irritability, somatic anxiety and stress susceptibility also appeared related to panic manifestations. These findings suggest that some personality traits and their interactions may influence vulnerability to CCK-4-induced panic attacks in healthy volunteers.

Personality traits measured by the Swedish universities Scales of Personality: factor structure and position within the five-factor model in an Estonian sample.

The study aims to test the reliability and validity of the Estonian version of the Swedish universities Scales of Personality (SSP), and to characterize the position of the SSP-measured traits within the basic personality dimensions of the five-factor model. A total of 529 participants completed the Estonian version of the SSP. A subsample of 197 persons completed the SSP together with the Revised NEO Personality Inventory (NEO-PI-R). The internal consistency of the SSP scales was satisfactory. Principal component analysis yielded three factors representing neuroticism, aggression and disinhibition. The factor solution obtained in the Estonian sample was similar to the original SSP study in the Swedish normative sample. NEO-PI-R Neuroticism had highest correlations with SSP neuroticism factor scales. Extraversion had strongest relationship with adventure seeking and low detachment. Agreeableness correlated positively with SSP social desirability and negatively to aggression-irritability scales. Conscientiousness facet Deliberation correlated with Impulsiveness. The Estonian SSP showed acceptable reliability and validity, which confirms that SSP is applicable in different social and cultural background. The SSP measures traits that correspond to the major personality models. The SSP characterizes three broad dimensions of personality, namely neuroticism, disinhibition and aggression, which are useful in assessment of personality correlates of mental disorders.

Soluble interleukin-2 receptor and tumor necrosis factor levels in depressed patients in Estonia.

Several studies have reported immune system alterations in depressed patients. Furthermore, correlations between some interleukins and specific depressive symptoms have been found, but results are ambiguous. It might be caused by heterogeneous patient population and concomitant administration of antidepressants. The aim of our study was to look at differences in the levels of soluble interleukin-2 receptor (sIL-2R) and tumor necrosis factor-alpha (TNFalpha) between currently depressed patients with first or recurrent episode of depression, patients in full remission and healthy controls. Secondly, we looked for correlations between sIL-2R and TNFalpha and different depressive symptoms. A total of 75 medication-free currently depressed patients (76% of females), 17 patients in the full remission phase of major depression (58.8% of females), and 55 healthy controls (58.2% of females) participated in this study. The results showed that the level of sIL-2R was significantly lower in depressed patients in remission phase compared to the healthy controls and subjects with recurrent depression. Drug-nalve patients with major depressive disorder with recurrent episode had higher levels of sIL-2R than previously treated or patients with the first episode. TNFalpha levels were higher in drug-nalve patients with major depressive disorder with recurrent episode compared with previously treated patients. Further analysis of patients revealed that sIL-2R was positively correlated with decreased activity and agitation. TNFalpha was associated with decreased activity and suicidality.

Prediction of depression in European general practice attendees: the PREDICT study.

BACKGROUND: Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation. METHODS/DESIGN: This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent. DISCUSSION: Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

Family doctors' problems and motivating factors in management of depression.

BACKGROUND: Depression is a frequent psychiatric disorder, and depressive patient may be more problematic for the family doctors (FD) than a patient suffering from a somatic disease. Treatment of patients with depressive disorders is a relatively new task for Estonian FDs. The aim of our study was to find out the family doctors' attitudes to depression related problems, their readiness, motivating factors and problems in the treatment of depressive patients as well as the existence of relevant knowledge. METHODS: In 2002, altogether 500 FDs in Estonia were invited to take part in a tailor-made questionnaire survey, of which 205 agreed to participate. RESULTS: Of the respondents 185(90%) considered management of depressive patients and their treatment to be the task of FDs. One hundred and eighty FDs (88%) were themselves ready to deal with depressed patients, and 200(98%) of them actually treated such patients. Commitment to the interests of the patients, better cooperation with successfully treated patients, the patients' higher confidence in FDs and disappearance of somatic complaints during the treatment of depression were the motivating factors for FDs. FDs listed several important problems interfering with their work with depressive patients: limited time for one patient, patients' attitudes towards the diagnosis of depression, doctors' difficulties to change the underlying causes of depression, discontinuation of the treatment due to high expenses and length. Although 115(56%) respondents maintained that they had sufficient knowledge for diagnostics and treatment of depression, 181(88%) were of the opinion that they needed additional training. CONCLUSION: FDs are ready to manage patients who might suffer from depression and are motivated by good doctor-patient relationship. However, majority of them feel that they need additional training.

Sleep quality and more common sleep-related problems in medical students.

BACKGROUND AND PURPOSE: The aim of this paper is to conduct a survey based on a questionnaire that would characterize nighttime and daytime habits in medical students; to estimate how subjective sleep quality is associated with nighttime and daytime habits and sleep problems in students; to estimate how academic progress and workload is associated with subjective sleep quality, nighttime and daytime habits and sleep problems in students; and to estimate the prevalence of self-reported sleep problems in Estonian medical students. PATIENTS AND METHODS: The study group included 413 medical students of the University of Tartu, aged 19-33 years. The self-reported Sleep and Daytime Habits Questionnaire (S&DHQ) covered demographic characteristics (4 questions) and sleep and daytime habits (24 questions). Of the latter, 18 multiple-choice questions provided answers expressed as discontinuous variables on a nominal scale, 4 questions provided answers expressed as continuous variables on an interval scale, and 2 questions provided answers expressed as quality characterization on a five-point scale. The supplement includes information about lifestyle and academic progress on a four-point scale. RESULTS: The S & DHQ could be used to study sleep problems in young medical students. The subjective sleep quality of students was as follows: excellent-29%; good-40%; satisfactory-24%; poor 6%; very poor-1%. Sleep quality is associated with academic progress (R=0.174; P<0.001), leisure activity (R=0.210; P<0.001), and living conditions (R=0.195; P<0.001). Sleep quality is not associated with students' daily (R=0.021; P>0.05) or nightly workload (R=0.0664; P>0.05). Daytime sleepiness poses a significant problem for students and is associated both with sleep disorders and work while studying. CONCLUSIONS: The study demonstrates that complaints about sleep problems are common in young medical students.

Symptoms of depression in the Estonian population: prevalence, sociodemographic correlates and social adjustment.

OBJECTIVE: The current study presents data on the prevalence of depressive symptoms in the Estonian population and examines associated sociodemographic factors and subjective aspects of social adjustment. METHOD: The data came from the Estonian Health Interview Survey where 4711 persons aged 15-79 were interviewed. This study included 4677 respondents who answered the Emotional State Questionnaire (EST-Q), a self-rating scale of depression and anxiety. Data on the sociodemographic factors and domains of social adjustment were derived from structured interviews. RESULTS: Depressive symptoms were observed in 11.1% of the respondents. Depressiveness was more common among women, in older age groups, among those not married, in ethnic groups other than Estonians, in lower income groups, and among the unemployed and economically inactive respondents. Depressive subjects were less satisfied, had a more pessimistic prognosis about the future and lower self-rated health. A low level of perceived control was a significant correlate of depression. The association of depressiveness with poor subjective social adjustment remained significant even after controlling for objective circumstances. LIMITATIONS: Depression was identified by a self-rate questionnaire, therefore results can not be generalized to clinical depression without caution. CONCLUSION: Depressive symptoms in the Estonian population were strongly related to socioeconomic functioning. Results emphasize that subjective social adjustment and perceived control are important characteristics of depression and should be considered in assessment and treatment.

Development and validation of a risk model for prediction of hazardous alcohol consumption in general practice attendees: the predictAL study.

BACKGROUND: Little is known about the risk of progression to hazardous alcohol use in people currently drinking at safe limits. We aimed to develop a prediction model (predictAL) for the development of hazardous drinking in safe drinkers. METHODS: A prospective cohort study of adult general practice attendees in six European countries and Chile followed up over 6 months. We recruited 10,045 attendees between April 2003 to February 2005. 6193 European and 2462 Chilean attendees recorded AUDIT scores below 8 in men and 5 in women at recruitment and were used in modelling risk. 38 risk factors were measured to construct a risk model for the development of hazardous drinking using stepwise logistic regression. The model was corrected for over fitting and tested in an external population. The main outcome was hazardous drinking defined by an AUDIT score ≥8 in men and ≥5 in women. RESULTS: 69.0% of attendees were recruited, of whom 89.5% participated again after six months. The risk factors in the final predictAL model were sex, age, country, baseline AUDIT score, panic syndrome and lifetime alcohol problem. The predictAL model's average c-index across all six European countries was 0.839 (95% CI 0.805, 0.873). The Hedge's g effect size for the difference in log odds of predicted probability between safe drinkers in Europe who subsequently developed hazardous alcohol use and those who did not was 1.38 (95% CI 1.25, 1.51). External validation of the algorithm in Chilean safe drinkers resulted in a c-index of 0.781 (95% CI 0.717, 0.846) and Hedge's g of 0.68 (95% CI 0.57, 0.78). CONCLUSIONS: The predictAL risk model for development of hazardous consumption in safe drinkers compares favourably with risk algorithms for disorders in other medical settings and can be a useful first step in prevention of alcohol misuse.

Associations between unemployment and major depressive disorder: evidence from an international, prospective study (the predict cohort).

Unemployment is known to be associated with poor mental health, but it is not clear how strongly unemployment leads to onset of diagnosed clinical depression (causation), or if depression raises the risks of becoming unemployed (health selection), or indeed if both pathways operate. We therefore investigate the direction of associations between clinical depression and unemployment in a cross-cultural prospective cohort study. 10,059 consecutive general practice attendees (18-75 years) were recruited from six European countries and Chile between 2003 and 2004 and followed up at six, 12 and (in a subset) 24 months. The analysis sample was restricted to 3969 men and women who were employed or unemployed and seeking employment and had data on depression measures. The outcomes were depressive episodes, assessed using the Depression Section of the Composite International Diagnostic Interview (CIDI) and self-reported employment status. Among 3969 men and women with complete data on depression and unemployment, 10% (n = 393) had depression symptoms and a further 6% (n = 221) had major depression at 12 months. 11% (n = 423) of the sample were unemployed by 6 months. Participants who became unemployed between baseline and 6 months compared to those employed at both times had an adjusted relative risk ratio for 12-month depression of 1.58 (95% Confidence Interval 0.76, 3.27). Participants with depression at baseline and 6 months compared to neither time had an odds ratio for 6-month unemployment of 1.58 (95% Confidence Interval 0.97, 2.58). We found evidence that causation and (to a lesser extent) health selection raise the prevalence of depression in the unemployed. Unemployed adults are at particular risk for onset of major clinical depression and should be offered extra services or screened. Given the trend for adults with depression to perhaps be at greater risk of subsequent unemployment, employees with depressive symptoms should also be supported at work as a precautionary principle.