Psychoeducation against depression,anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave

Objectives: Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) – in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS).

Design: Pilot study.

Setting: Three Swedish primary care centers serving 20,000 people.

Intervention: 8 weekly 2-hour sessions with a 5–7 participant group led by two instructors - followed by 10 individual hour-long sessions.

Subjects: Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia.

Outcome measures: Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS.

Results: The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p?Conclusions: A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had?>80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting.

• Key Points

• ?A pilot study of a psychoeducational intervention – The Affect School and Script Analyses (ASSA) – was performed in primary care

• ??The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia

• ??92% completed the 8 weeks/16?hours Affect School and 83% completed the entire 26-hour ASSA intervention

• ??9 of 11 self-reported measures improved significantly one-week post intervention

• ??7 of 11 self-reported measures improved significantly 18 months post-intervention

     

Long sleep duration and afternoon napping are associated with higher risk of incident diabetes in middle-aged and older Chinese: the Dongfeng-Tongji cohort study

Background In this study, we investigated the independent and combined effects of sleep duration and afternoon napping on the risk of incident diabetes among a cohort of middle-aged and older Chinese adults.

Methods Information of sleep and napping was obtained by questionnaires during face-to-face interviews. We categorized sleep duration into?<7?h, 7～<8?h (reference), 8～<9?h, 9～<10?h, and?≥?10?h. Afternoon napping was divided into no napping (0?min) (reference), 1–30?min, 31–60?min, 61–90?min, and?>?90?min. Cox proportional hazard regression models were used.

Results Compared with referential sleeping group, subjects sleeping?≥10?h had a 42% higher risk of developing diabetes. The HR was 1.28 for napping?>?90?min when compared with no napping. These associations were more pronounced in individuals without hypertension. Combined effects of long sleep duration and afternoon napping were further identified. Individuals with both sleep duration?≥?10?h and napping?>?60?min had a 72% higher risk of incident diabetes than those with sleeping 7～<8?h and napping 0?min (all above p?Conclusions Both long sleep duration and afternoon napping were independently and jointly associated with higher risk of incident diabetes.

• Key messages

• Sleep duration was associated with diabetes, but whether it is a real cause of incident diabetes especially in Chinese still remains to be elucidated.

• The association of afternoon napping and diabetes was not consistent and definite, we clarified this association in a large prospective study.

• Long sleep duration and afternoon napping were independently and jointly associated with higher risk of incident diabetes.

     

The role of social support in anxiety and depression among Parkinson’s disease patients

Abstract

Purpose: To explore how social support is associated with anxiety and depression in Parkinson’s disease (PD) patients controlling for gender, disease duration and disease severity. Methods: The sample consisted of 124 patients (52.4% male; mean age 68.1?±?8.4 years; mean disease duration 6.3?±?5.5 years). Anxiety and depression were measured with the Hospital Anxiety and Depression Scale, social support with the Multidimensional Scale of Perceived Social Support and disease severity with the Unified Parkinson Disease Rating Scale. Data were analyzed using linear regression. Results: Gender, disease duration, disease severity and social support explained 31% of the total variance in anxiety in younger PD patients but did not significantly contribute to the explanation of depression. In the older group, this model explained 41% of the variance in depression but did not significantly contribute to the explanation of anxiety. Conclusion: PD patients experience the positive influence of social support differently according to age. In the younger group, disease duration plays the primary role regarding anxiety. In the older group, poor social support especially from friends is associated with more depression after controlling for the relevant variables.

• Implications of Rehabilitation

• PD is a disease of older age with a neurodegenerative character and treatment should focus on increasing quality of life.

• Anxiety and depression are common co-morbidities in PD patients.

• The support network should also be screened regularly and involved in enhancing the quality of life.

     

Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP)

Abstract

Purpose: This study investigates the prevalence of insomnia and its relationship to other symptoms and health aspects in patients with chronic pain. Methods: Patients with chronic pain conditions (n?=?845) referred to a multidisciplinary pain centre completed surveys provided by the Swedish quality registry for pain rehabilitation (SQRP). The SQRP collects data on socio-demographics, health status, symptoms of pain, mood and insomnia and life satisfaction. Results: The majority of patients (65.3%) had clinical insomnia according to the insomnia severity index (ISI). Insomnia correlated significantly but weakly with pain, depression, anxiety and coping; the strongest multivariate correlations were found with depression and anxiety followed by pain interference and pain severity. Pain intensity, depression and anxiety correlated stronger than ISI with respect to the two investigated aspects of health. Conclusions: The prevalence of insomnia is high in patients with chronic pain conditions, but the level of importance in relation to other symptoms for health aspects is low, and the associations with other important symptoms are relatively weak. One way to increase the effects of multimodal rehabilitation programs may be to provide interventions directed specifically at insomnia rather than focusing only on interventions that address pain, depression and anxiety.

• Implications for Rehabilitation

• The prevalence of insomnia is high in patients with complex chronic pain conditions.

• Relatively low correlations existed between insomnia and pain intensity, depression, anxiety and other psychological aspects.

• Pain intensity, anxiety and depression were more important for perceived health aspects than insomnia.

• One way to increase the effects of multimodal rehabilitation programs may be to also include interventions directed directly to insomnia.

     

Childhood obesity in specialist care – searching for a healthy obese child

Abstract

Introduction One in three obese adults is classified as metabolically healthy, but there is less evidence in obese children. We studied the overall clinical presentation of Finnish obese children and the prevalence of cardiometabolic risk factors with child-specific cut-offs.

Material and methods This is a cross-sectional register-based study of 2–18-year-old children (n?=?900) evaluated for obesity in three hospitals in 2005–2012. Clinical and metabolic data were related to sex, age, puberty, and obesity grade and analyzed using chi-square and non-parametric tests.

Results In 80% of cases at least one cardiovascular risk factor was present. Only 3% of subjects for whom complete metabolic data were available (n?=?360) had no metabolic disorder. Systolic blood pressure was hypertensive in 50.2% and diastolic in 14.5% of the children. The youngest children had highest body mass index SD score. Obesity was more severe in boys than girls (p?<?0.001). Hypertensive systolic blood pressure values (p?=?0.012), prediabetes (p?<?0.001), fatty liver (p?<?0.001), and dyslipidemia (p?=?0.025) were more prevalent in 15–18-year-old boys than girls.

Conclusion Most obese children in specialist care have cardiovascular risk factors; this indicates that earlier intervention is needed.

• Key messages

• Most obese children evaluated in specialist care have one or more cardiovascular risk factors, and very few have no metabolic disturbances.

• In late adolescence these risk factors are more common in obese boys than girls.

• Primary care personnel are less likely to intervene in cases of obesity in young children than in adolescents, leading to a delay in treatment.

• Hypertensive blood pressure values require more attention in clinical work.

     

Increased risk of subclinical atherosclerosis associated with high visceral adiposity index in apparently healthy Korean adults: the Kangbuk Samsung Health Study

Background: The visceral adiposity index (VAI) is a mathematical tool that reflects a patient’s visceral adiposity and insulin resistance. Recent studies have noted an association between VAI and cardiovascular event. We analyzed the association between VAI and coronary artery calcium score (CACS) in Korean adults.

Methods: For 33,468 participants (mean age 42 yrs) in a health screening program, VAI was calculated using the following formulae: [waist circumference (WC)/{39.68?+?(1.88 * body mass index (BMI))}] * (triglyceride/1.03) * {1.31/high-density lipoprotein cholesterol (HDL-C)} for men and [WC/{36.58?+?(1.89 * BMI)}] * (triglyceride/0.81) * (1.52/HDL-C) for women. Coronary artery calcium scores were measured with multi-detector computed tomography.

Results: CACS was positively correlated with VAI (r?=?0.027, p?0 as the dependent variable, subjects in the highest tertile of VAI (>1.777) had significantly increased odds ratio for CACS >0 compared to subjects in the lowest tertile (<0.967), even after adjusting for confounding variables, including BMI (OR 1.26, 95% CI 1.147–1.381).

Conclusions: Subjects with high VAI had increased risk for subclinical atherosclerosis, as assessed by CACS.

• Key messages

• Recent studies have noted an association between visceral adiposity index (VAI) and cardiovascular event.

• Subjects with coronary artery calcification (CAC) showed significantly higher VAI compared to those without CAC.

• The subjects with high VAI showed increased odds ratio for CAC as compared to subjects with low VAI, suggesting high VAI reflects increased risk for subclinical atherosclerosis

     

Situationally influenced tinnitus coping strategies: a mixed methods approach

Abstract

Purpose: The primary aim of this study was to identify coping strategies used to manage problematic tinnitus situations. A secondary aim was to determine whether different approaches were related to the level of tinnitus distress, anxiety, depression, and insomnia experienced.

Materials and methods: A cross-sectional survey design was implemented. The study sample was adults interested in undertaking an Internet-based intervention for tinnitus. Self-reported measures assessed the level of tinnitus distress, depression, anxiety, and insomnia. An open-ended question was used to obtain information about how problematic tinnitus situations were dealt with. Responses were investigated using qualitative content analysis to identify problematic situations. Further data analysis comprised of both qualitative and quantitative methods.

Results: There were 240 participants (137 males, 103 females), with an average age of 48.16 years (SD: 22.70). Qualitative content analysis identified eight problematic tinnitus situations. Participants had either habituated to their tinnitus (7.9%), used active (63.3%), or passive (28.8%) coping styles to manage these situations. Those who had habituated to tinnitus or used active coping strategies had lower levels of tinnitus distress, anxiety, and depression.

Conclusions: The main problematic tinnitus situations for this cohort were identified. Both active and passive coping styles were applied to approach these situations. The coping strategies used most frequently and utilised in the widest range of problematic situations were using sound enrichment and diverting attention.

• Implications for Rehabilitation

• The main problematic tinnitus situations for this group of participants were identified.

• Overall, a limited range of strategies were used to deal with individual problematic situations. The use of sound enrichment and diverting attention was applied in the widest range of problematic situations.

• The use of both active and passive coping styles was evident to approach these situations. The use of passive strategies in certain situations was associated with higher levels of tinnitus distress, depression, and anxiety over the last week as measured by self-reported questionnaires.

     

The profiles of health care utilization among a non-depressed population and patients with depressive symptoms with and without clinical depression

Abstract

Objective: To examine health service (HS) utilization profiles among a non-depressive population and patients with depressive symptoms (DS) with and without clinical depression.

Design, subjects and setting: The study population was based on primary care patients with DS scoring ≥10 in the 21-item Beck Depression Inventory (BDI) and who were at least 35 years old and had been referred to depression nurse case managers (n?=?705). Their psychiatric diagnosis was confirmed with the Mini-International Neuropsychiatric Interview (M.I.N.I.). Of these patients, 447 had clinical depression. The number of patients with DS without clinical depression was 258. The control group consisted of a random sample of 414 residents with a BDI score < 10. Use of HS (visits and phone calls to a doctor and a nurse) was based on patient records.

Main outcome measures: Number of visits and calls to physicians and nurses.

Results: Patients with DS regardless of their depression diagnosis used primary health care (PHC) services three times more than the controls (p?<?0.001). In the secondary care, the differences were smaller but significant. Of the controls, 70% had 0–4 HS contacts per year whereas a majority of the patients having DS had more than 5 contacts per year. The number of contacts correlated with the BDI from a score of 0 to 10 but not as clearly in the higher scores.

Conclusion: Depressive symptoms, both with or without clinical depression, are associated with increased HS use, especially in PHC. This study suggests that even mild depressive symptoms are associated with an increased use of HS.

• KEY POINTS

• We analyzed the health service (HS) use among primary health care patients screened for depression and non-depressive population.

• Screen positive patients without clinical depression used as much HS as those having clinical depression.

• Regardless of depression diagnosis, screen positive patients visited a GP and nurse three times more often than the control population.

• In the screen negative control population, milder depressive symptoms were correlated with the use of HS.

• Primary health care was responsible for most of the HS use among patients having depressive symptoms.

     

Depression and anxiety screening after stroke: adherence to guidelines and future directions

Purpose: This article examines practical approaches to increasing rates of screening for depression and anxiety in hospital-based stroke services. Method: The literature on depression and anxiety following stroke is briefly reviewed together with evidence relating to screening. A small-scale trial of an educational and support package to improve screening rates compared 30 consecutive admissions before and after the intervention. An extended commentary on the outcome considered alternative approaches to improving screening. Results: The literature review confirmed that depression after stroke has multiple adverse effects and that screening is not universally applied. There has been less research into anxiety after stroke, but it is likely that anxiety screening is also incomplete. The trial of the intervention to promote screening demonstrated strong trends towards improvement for depression (23.3%; odds ratio 2.67; χ² p = 0.067) and a trend for anxiety (16.7%; odds ratio 1.96; χ² p = 0.20). Conclusions: Education and training about depression and anxiety screening and access to screening materials improved rates of screening to a limited degree. An extended commentary explored how screening rates might be further improved by considering the intervention strategy, the staffing model, the training approach and the screening methods themselves. Finally, consideration is given to treatment approaches for mood disorders.

Implications for Rehabilitation

• Screening is necessary to identify stroke patients who require treatment for psychological disorders. However, anxiety and depression are not explicitly screened for, or considered, in up to half of all stroke patients.

• Simple interventions providing education and support for training may improve rates of screening.

• Major improvements in screening rates will require the development of systematic protocols, using the principles of knowledge translation, that consider organizational factors, the staff involved, the training required and the screening instruments to use.

     

Previous gestational diabetes history is associated with impaired coronary flow reserve

Abstract

Background Gestational diabetes mellitus (GDM) is a prediabetic state that is known to increase the risk of cardiovascular diseases. We have investigated coronary flow velocity reserve (CFVR) and epicardial fat thickness (EFT), and left ventricular diastolic function in patients with a history of previous GDM (p-GDM).

Methods Ninety-three women with GDM history and 95 healthy women without GDM history were recruited. We used transthoracic Doppler echocardiography to assess CFVR, EFT, and left ventricular diastolic function. Insulin resistance of each subject was assessed with homeostasis model assessment insulin resistance (HOMA-IR). Hemoglobin A1c and high-sensitivity C-reactive protein (hsCRP) were also measured in all patients.

Results CFVR values were significantly lower (2.34?±?0.39 versus 2.80?±?0.24, p?<?0.001) and EFT values were significantly higher in patients with p-GDM than the control group (5.5?±?1.3 versus 4.3?±?1.1, p?<?0.001). E/E' ratio (7.21?±?1.77 versus 6.53?±?1.38, p?=?0.003), hemoglobin A1c (5.2?±?0.4 and 5.0?±?0.3, p?=?0.001), HOMA-IR (2.8?±?1.4 versus 1.7?±?0.9, p?=?0.04), and hsCRP levels were significantly higher in the p-GDM group than the control group. Multivariate analysis revealed that gestational diabetes history is independently associated with CFVR.

Conclusion Women with a GDM history may be at more risk regarding coronary microvascular dysfunction compared to the healthy ones.

• Key Messages

• What is already known about this subject?

• Impairment of CFVR reflects coronary microvascular dysfunction and has been shown to be an early manifestation of atherosclerosis and coronary artery disease.

• Several studies have shown an association between p-GDM and atherosclerosis by measuring intima-media thickness.

• What are new findings?

• This preliminary study on coronary microvascular function of patients with p-GDM revealed that CFVR is significantly impaired in p-GDM patients.

• Although the number of patients included in this study is limited, these results suggest that impaired CFVR may be an early manifestation of coronary vascular involvement in patients with p-GDM.

• How might it impact on clinical practice in the foreseeable future?

• In patients with p-GDM, the presence of impaired CFVR should render the clinician aware of the development of coronary artery disease.

     

Anxiety and depression after stroke: a 5 year follow-up

Purpose: The aim was to document the prevalence and predictors of anxiety and depression 5 years after stroke, across four European centres. Method: A cohort of 220 stroke patients was assessed at 2, 4 and 6 months and 5 years after stroke. Patients were assessed on the Hospital Anxiety and Depression Scale and measures of motor function and independence in activities of daily living. Results: At 5 years, the prevalence of anxiety was 29% and depression 33%, with no significant differences between centres. The severity of anxiety and depression increased significantly between 6 months and 5 years. Higher anxiety at 6 months and centre were significantly associated with anxiety at 5 years, but not measures of functional recovery. Higher depression scores at 6 months, older age and centre, but not measures of functional recovery, were associated with depression at 5 years. Conclusions: Anxiety and depression were more frequent at 5 years after stroke than at 6 months. There were significant differences between four European centres in the severity of anxiety and depression. Although the main determinant of anxiety or depression scores at 5 years was the level of anxiety or depression at 6 months, this accounted for little of the variance. Centre was also a significant predictor of mood at 5 years. There needs to be greater recognition of the development of mood disorders late after stroke and evaluation of variation in management policies across centres.

Implications for Rehabilitation

• Depression and anxiety persisted up to 5 years after stroke in about a third of patients.

• Variation in the rates of anxiety and depression between different European centres suggest management policies rather than stroke related factors may determine their persistence.

• The effect of variations in stroke management policies should be investigated.

• Patients’ mood should be monitored over time in order to detect those with late onset mood disorders after stroke.

     

Longer time spent in bed attempting to sleep is associated with rapid renal function decline: the Dongfeng–Tongji cohort study

Introduction: Prospective evidence on the relation between time in bed and renal dysfunction remains limited. We aimed to investigate the association of time spent in bed attempting to sleep (TSBS) with renal function decline in a middle-aged and elderly Chinese population.

Methods: About 16,733 eligible participants with a mean age of 62.3 years at baseline were included. Rapid renal function decline was defined as (baseline eGFR???revisit eGFR)/years of follow-up ≥5?mL/min per 1.73 m²/year. A total of 1738 study participants experienced rapid renal function decline after a median 4.6-year follow-up. Logistic regression models were used for multivariate analyses.

Results: The adjusted odds ratio (OR) of rapid renal function decline was 1.18 (95% CI: 1.02, 1.37) for TSBS ≥9?h/night compared with TSBS 7 to <8?h/night. This association remained significant (OR?=?1.19, 95% CI: 1.03, 1.38) after further adjustment for sleep quality, midday napping and usage of sleeping pills. Particularly, the association appeared to be prominent in individuals with diabetes.

Conclusions: Longer TSBS (≥9?h) was independently associated with an increased risk of rapid renal function decline. Our findings emphasized the importance to have optimal TSBS.

• Key messages

• Our study firstly investigated the association between time spent in bed attempting to sleep (TSBS) and renal dysfunction in Chinese adults.

• Compared with individuals TSBS 7 to <8?h, individuals with TSBS ≥9?h had 19% increased risk for rapid renal function decline after adjustment for multivariate confounders.

• The association appeared to be prominent in individuals with diabetes.

     

Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction

Purpose: This study examined the role of anxiety and upper limb dysfunction, amongst other variables, as predictors of health related quality of life (HRQOL) 6 months after stroke. Method: Participants: Stroke survivors (n = 85) who had previously participated in a randomised controlled trial of a physiotherapy intervention. Dependent variable: HRQOL – Nottingham Health Profile (NHP). Predictor variables: Mood – Hospital Depression and Anxiety Scale; Upper Limb Functioning - Action Research Arm Test; Rivermead Motor Assessment; Activities of Daily Living – Modified Barthel Index; Clinical and demographic factors. Results: Anxiety and depression significantly predicted 49% of variance in overall HRQOL (p < 0.05), but only anxiety significantly predicted NHP pain (13% variance, p < 0.001), emotional reactions (41% variance, p < 0.001), sleep (19% variance, p = 0.02) and social isolation (23% variance, p = 0.02). Depression and anxiety together significantly predicted 30% variance in energy level (p < 0.001). UL motor impairment and activities of daily living predicted 36% of variance in NHP physical activity score (p < 0.001). Conclusions: This study indicates that where anxiety is assessed, it appears more important in determining HRQOL than depression. UL impairment and ADL independence predicted perceived physical activity. Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL.

Implications for Rehabilitation

• Anxiety is a major predictor of quality of life six months after stroke.

• Post-stroke anxiety should be routinely assessed in rehabilitation.

• Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period.

• Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke.

• Rehabilitation of the upper limb should continue into the chronic post-stroke period.

     

Diabetic Retinopathy –Incidence And Risk Factors In A Community Setting- A Longitudinal Study

Aim: To evaluate the natural history of diabetic retinopathy (DR) in diabetic patients and to assess long term risk for other chronic diseases associated with DR.

Methods: Retrospective, community-based study. Diabetics who underwent their first fundoscopic examination during 2000–2002, and had at least one follow- up examination by the end of 2007 were included. The primary outcome was the development of DR (proliferative diabetic retinopathy (PDR), non PDR (NPDR) or macular edema.

Patients were followed for another 9 years for documentation of new diagnosis of related diseases.

Results: 516 patients' (1,032 eyes) records were included and were followed first for an average of 4.15?±?1.27 years. During follow-up, 28 (2.7%) of the total 1,032 eyes examined were diagnosed with PDR. An additional 194 (18.8%) eyes were diagnosed with new NPDR. The cumulative incidence of NPDR was 310/1,032 (30.0%). All the patients who developed PDR had prior NDPR. By the end of the 9 years extended follow up, patients with NPDR had a greater risk for developing chronic renal failure HR?=?1.71 (1.14–2.56), ischemic heart disease HR?=?1.57 (1.17–2.09), and had an increased mortality rate HR?=?1.26 (1.02–1.57)

Conclusion: DR is associated with a higher rate of diabetes complications. Patients with DR should be followed more closely.

• Key points

• During a mean follow-up of 4.5 years, the cumulative incidence of diabetic retinopathy in a community cohort was 18.8%.

• NDPR (non-proliferative diabetic retinopathy) is a predictor of PDR (proliferative diabetic retinopathy).

• In a real life setting NPDR is a marker of a poorer prognosis.

• Patients with NDPR should be monitored more closely.

     

Severe to profound hearing impairment: quality of life,psychosocial consequences and audiological rehabilitation

Abstract

Purpose: To study the quality of life (QoL) and psychosocial consequences in terms of sick leave and audiological rehabilitation given to patients with severe to profound hearing impairment. Method: A retrospective study of data on 2319 patients with severe to profound hearing impairment in The Swedish Quality Register of Otorhinolaryngology, followed by a posted questionnaire including The Hospital Anxiety and Depression Scale (HADS). Results: The results indicate greater levels of anxiety and depression among patients with severe or profound hearing impairment than in the general population, and annoying tinnitus and vertigo had strong negative effects on QoL. The proportion of sick leave differed between the studied dimensions in the study. The proportion of patients who received extended audiological rehabilitation was 38% in the present study. Conclusions: Treatment focused on anxiety, depression, tinnitus and vertigo must be given early in the rehabilitation process in patients with severe or profound hearing impairment. Because sick leave differs greatly within this group of patients, collaboration with the regional Social Insurance Agency is crucial part of the rehabilitation. The study also shows that presently, only a small proportion of patients in Sweden with severe to profound hearing impairment receive extended audiological rehabilitation.

• Implications for Rehabilitation

• Greater levels of anxiety and depression have been found among patients with severe or profound hearing impairment than in the general population, and annoying tinnitus and vertigo have strong negative effects on QoL in this group of patients.

• Only a small proportion of patients with severe to profound hearing impairment receive extended audiological rehabilitation today, including medical, technical and psychosocial efforts.

• Extended audiological rehabilitation focused on anxiety, depression, tinnitus and vertigo must be given, together with technical rehabilitation, early in the rehabilitation process in patients with severe or profound hearing impairment.

     

Depression,antidepressant use,and risk of venous thromboembolism: systematic review and meta-analysis of published observational evidence

Abstract

Purpose: Evidence on the association between depression, antidepressant use and venous thromboembolism (VTE) risk is conflicting. We conducted a systematic review and meta-analysis of published observational studies evaluating the associations of depression and antidepressant use with VTE risk.

Design: Eligible studies were identified in a literature search of MEDLINE, Embase, Web of Science and reference list of relevant studies up to April 2018. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were aggregated using random effects models.

Results: Eight observational studies with data on 960 113 nonoverlapping participants and 9027 VTE cases were included. The pooled RR (95% CI) for VTE comparing antidepressant use with no antidepressant use was 1.27 (1.06–1.51). Tricyclic antidepressants, selective serotonin reuptake inhibitors and other antidepressants were each associated with an increased VTE risk; 1.16 (1.06–1.27), 1.12 (1.02–1.23), and 1.59 (1.21–2.09), respectively. In pooled analysis of three studies that compared patients with depression versus individuals without depression, the RR for VTE was 1.31 (1.13–1.53).

Conclusions: Pooled observational evidence suggests that depression and use of antidepressants are each associated with an increased VTE risk. The effect of antidepressant drugs on VTE may be a class effect. The mechanistic pathways underlying these associations deserve further evaluation.

Systematic review registration: PROSPERO 2018: CRD42018095595

• Key messages

• Emerging evidence suggests that depression and antidepressant use may be associated with venous thromboembolism (VTE) risk, but the evidence is conflicting.

• This first systematic review and meta-analysis of observational studies shows that depression and use of antidepressants are each associated with an increased risk of VTE.

• There may be a class effect of antidepressant drugs on VTE.

     

Observed changes in cardiovascular risk factors among high-risk middle-aged men who received lifestyle counselling: a 5-year follow-up

Objective: To examine the long-term impact of health counselling among middle-aged men at high risk of CVD.

Design: An observational study with a 5-year follow-up.

Setting and intervention: All men aged 40 years in Helsinki have been invited to a visit to evaluate CVD risk from 2006 onwards. A modified version of the North Karelia project risk tool (CVD risk score) served to assess the risk. High-risk men received lifestyle counselling based on their individual risk profile in 2006 and were invited to a follow-up visit in 2011.

Subjects: Of the 389 originally high-risk men, 159 participated in the follow-up visits in 2011. Based on their follow-up in relation the further risk communication, we divided the participants into three groups: primary health care, occupational health care and no control visits.

Main outcome measures: Lifestyle and CVD risk score change.

Results: All groups showed improvements in lifestyles. The CVD risk score decreased the most in the group that continued the risk communication visits in their primary health care centre (6.1 to 4.8 [95% CI ?1.6 to ?0.6]) compared to those who continued risk communication visits in their occupational health care (6.0 to 5.4 [95% CI ?1.3 to 0.3]), and to those with no risk communication visits (6.0 to 5.9 [95% CI ?0.5 to 0.4]).

Conclusions: These findings indicate that individualized lifestyle counselling improves health behaviour and reduces total CVD risk among middle-aged men at high risk of CVD. Sustained improvement in risk factor status requires ongoing risk communication with health care providers.

• KEY POINTS

• Studies of short duration have shown that lifestyle changes reduce the risk of cardiovascular disease among high-risk individuals.

• Sustaining these lifestyle changes and maintaining the lower disease risk attained can prove challenging.

• Cardiovascular disease (CVD) risk assessment and individualized health counselling for high-risk men, when implemented in primary health care, have the potential to initiate lifestyle changes that support risk reduction.

• Attaining a sustainable reduction in CVD risk requires a willingness to engage in risk-related communication from both health care providers and the individual at high risk.

     

Impact of depression following a stroke on the participation component of the International Classification of Functioning,Disability and Health

Purpose: To assess the impact of post-stroke depression on the participation component of the International Classification of Functioning, Disability and Health (ICF).

Method: Thirty-five stroke survivors with chronic hemiparesis were divided into two groups: those with and without depression. The Geriatric Depression Scale (GDS) was used for the analysis of depressive symptoms. Participation was analysed using the Stroke Specific Quality of Life scale. The Mann–Whitney test was used to compare the participation scores between the two groups. Spearman’s correlation coefficients were calculated to determine the strength of the association between the assessment tools. Simple linear regression was used to determine the impact of depression on participation. An alpha risk of 0.05 was considered indicative of statistical significance.

Results: The group with depression had low participation scores (p?=?0.04). A statistically significant negative correlation of moderate magnitude was found between depression and participation (r?= ?0.6; p ?=?0.04). The linear regression model demonstrated that depression is a moderate predictor of participation (r²?=?0.51; p?=?0.001).

Conclusions: Depression is a moderate predictor of participation among stroke survivors, explaining 51% of the decline of this aspect. Thus, depression should be diagnosed, monitored and treated to ensure a better prognosis regarding social participation following a stroke.

• Implications for Rehabilitation

• Individuals with post-stroke depression experience a lower degree of social participation.

• Depression explains 51% of the decline in participation following a stroke.

• The present findings can serve as a basis to assist healthcare professionals involved in the rehabilitation of stroke survivors and can assist in the establishment of adequate treatment plans in stroke rehabilitation.

     

Qualitative perspectives on aquatic exercise initiation and satisfaction among persons with multiple sclerosis

Purpose: To identify the individual and social experiences underlying the initiation and satisfaction with aquatic exercise among persons with MS.

Methods: A convenience sample (n?=?45) of persons aged?≥18 with MS who had engaged in water-based exercise within the previous six months completed a 60–90?min semi-structured telephone interview regarding their aquatic exercise experiences.

Results: An aquatic exercise history was not a prerequisite for the adoption of aquatic exercise. Rather, participants described aquatic exercise routines as stemming from recognition of a decline in physical function combined with encouragement and invitations to join aquatic programs. Despite regular visits, health care providers were not a common source of information regarding the feasibility of aquatic exercise. Participants’ aquatic activities included MS-specific and generalized aquatics courses, with class satisfaction resting on the instructor, class “fit” and a feeling of acceptance.

Conclusion: Communication regarding local aquatic opportunities is critical for ensuring aquatics engagement among persons with MS. Providers could play a stronger role in emphasizing the feasibility and benefits of aquatic programs. In addition, persons with MS should be encouraged to try local MS and more generalized aquatic programs in order to identify a program matching their social and physical goals.

• Implications for Rehabilitation

• Directed communication regarding aquatic opportunities is essential to prompting the initiation of aquatic exercise

• Both MS-specific and general aquatics classes can provide positive exercise experiences for persons with MS

• A history of regular exercise or aquatic experiences is not a prerequisite for the initiation of aquatic exercise among persons with MS

• Health care provider visits may represent missed opportunities for promoting aquatics; providers should consider the suitability of aquatics for all patients with MS, regardless of the patient’s exercise history.