Outcome of anxiety and depression at two and a half years after baseline interview: associations with changes in psychiatric morbidity among three samples of elderly people living at home

Psychiatric morbidity, using the General Health Questionnaire, which detects mainly anxiety and depression, was examined in three samples of elderly people at baseline and at follow-up 2 ½– 3 years later. One sample comprised all people aged 85 plus who could be traced from Family Health Services Authority records living in an East End district of London (City and Hackney) and the other two samples were representative random samples of people aged 65– 85, one sample from the same inner city area and the other from a semi-rural area for comparison with the younger sample (Braintree, Essex). The analyses reported here relate to changes in psychiatric morbidity at follow-up 2 ½– 3 years later. Previous analyses showed that poor health and functional ability were the strongest predictors of baseline psychiatric morbidity. The results from the follow-up data show that the most significant predictor of changes in psychiatric morbidity at follow-up was baseline psychiatric status, followed by health status. Poor health and functional ability explained 15% of the variance between the groups among the 85 plus sample and 17% and 16% in the two younger 65 plus samples. The strength of the study is its longitudinal design and verification of the results in three samples of elderly people, including one very elderly group. It contributes to the small body of literature on outcome of psychiatric morbidity. The lack of consistent associations with recovery from psychiatric morbidity (eg depression) in the literature enhances the importance of studies which aim to identify factors associated with different outcomes.     

Psychological disorders and symptoms in primary care

Background Psychological symptoms that do not reach the threshold for formal diagnosis are disregarded in prevalence rates and are apparently assumed to be transient and of little clinical importance. Method Consecutive primary care attenders (n = 2379) were screened using the 12-item General Health Questionnaire (GHQ-12) and a stratified random sample (n = 704) completed baseline structured diagnostic interview, disability assessment, and the 28-item version of the GHQ (GHQ-28). Subjects with significant psychiatric symptoms and a random sample of those without (n = 263) were evaluated with the same measures 12 months later. Results While 25 % of the baseline sample scored 5 or more on the GHQ-28, only 10 % met the ICD-10 criteria for one or more disorders. At baseline, caseness on either the GHQ or ICD-10 was associated with poor self-rated overall health, interviewer-rated occupational disability and with more disability days in prior month. At 12-month follow-up, being a case on the GHQ at baseline, but not on ICD-10, was associated with disability, poor health perception and high health service utilization. Conclusion Psychological symptoms that may not reach diagnostic threshold are associated with impaired functioning over 12 months. Individuals with such symptoms may be identified using self-report questionnaires for dimensional symptoms, such as the GHQ-28. Accepted: 8 February 2002     

The prevalence of psychiatric morbidity among people aged 85 and over living at home

Summary A survey of all people aged 85 years and over, living in an inner London borough, was carried out. In 1987, 662 people who lived at home were traced from family practitioner committee records and interviewed. The General Health Questionnaire was administered to measure psychiatric morbidity (after excluding people with evidence of disorientation or confusional states). 27% of respondents were rated as having probable psychiatric morbidity (cases). These cases were more likely to report somatic health problems, particularly those associated with stress. There was no relationship with psychiatric morbidity and age, sex, social network type, or feelings of loneliness. However, fewer of those rated as cases, and who also independently reported problems with nerves, stress or depression, said they had reported these feelings to their general practitioners. Multiple regression analysis showed no significant relationship with General Health Questionnaire score and recency of contact with general practitioners.     

Perceived Rearing Attitudes and Minor Psychiatric Morbidity among Japanese Adolescents

Abstract: The relationship between perceived rearing experiences and minor psychiatric morbidity was studied in a sample of Japanese adolescents. Their perceived rearing experiences were measured by the Parental Bonding Instrument (PBI) and minor psychiatric morbidity by the General Health Questionnaire (GHQ). The total GHQ score was slightly but significantly higher (r=0.28) among those recording high maternal protection than among those with low maternal protection, but of the subscale scores of the GHQ, only the anxiety and insomnia subscale retained this same relationship with perceived rearing experiences. The parental age, educational career, and sibship position showed no correlation with the PBI scores.     

STRESS OF CAREGIVERS OF DEMENTIA PATIENTS IN THE SINGAPORE CHINESE FAMILY

In a study of 50 family caregivers of elderly Chinese patients with dementia in Singapore, 28 (56%) scored five points or more on the 28-item General Health Questionnaire (GHQ). The GHQ scores correlated significantly with duration of care; presence of delusion, hallucination, depression, insomnia, incontinence and agitation; and the total score of the Behavioural Pathology in Alzheimer's Disease Rating Scale. On multiple regression analysis the only variables to achieve a significant relationship with the GHQ scores were duration of care, depression and the total behavioural score. © 1997 by John Wiley & Sons, Ltd.     

Family factors associated with the use of psychotropic drugs, alcohol abuse, and minor psychiatric morbidity in the community

The association of family health and family structure factors with psychotropic drug consumption, alcohol abuse, and minor psychiatric morbidity was investigated in a representative community sample of 151 respondents by means of a logistic multiple regression analysis. A General Health Questionnaire GHQ score of 5 or above was best predicted by undesirable events, sex, the number of generations, marital status, and the number of family members with a high GHQ score. Psychotropic drug consumption was best predicted by the number of family members with distress manifestations, while alcohol abuse in men was predicted best by events of the exit type.     

Factors associated with psychiatric morbidity in women--a general practice survey

1517 women between 20 and 59 years of age were screened for current psychiatric disturbance using the General Health Questionnaire, and 382 of the subjects were also interviewed. The women gave information on a variety of family, demographic and reproductive or gynaecological items. Items concerning personal relationships with mother, husband and father were significantly associated with high scores on the GHQ as were demographic items such as marital status, numbers of children and social class and gynaecological items such as sterilization and painful, heavy or irregular periods. The many cross associations between items included in the study need to be considered when interpreting the findings. In particular the highly significant association of relationship and demographic factors with psychiatric morbidity in women must be taken into account when investigating the impact of reproductive physiology and gynaecological procedures on mental health.     

Early psychological adjustment in breast cancer patients: A prospective study

Objective: A significant proportion of breast cancer patients experiences psychiatric morbidity in the first year after a breast cancer diagnosis and/or beginning of treatment. This study attempted to identify and understand the risk factors for developing such problems. Methods: A consecutive series of 87 patients, aged 40–75 years, was assessed prior to diagnosis of breast cancer and followed-up approximately 8 weeks after beginning of cancer treatment and again 9 months after first follow-up. Assessments included measures of psychiatric morbidity using the General Health Questionnaire (GHQ-12), coping style using the Mental Adjustment to Cancer (MAC) Scale, symptom attribution, beliefs about breast cancer, social support, socio-demographic and clinical variables. Results: A total of 85.1% of patients completed both follow-ups. Pre-diagnostically, 32.2% of breast cancer patients scored as a GHQ-12 ‘case.’ GHQ scores fell significantly between pre-diagnostic and both post-diagnostic assessments, especially in women who had thought they had cancer. Predictors of psychological morbidity at first follow-up included pre-diagnostic GHQ-12 score, lack of social support and feelings of ‘personal responsibility/avoidance.’ GHQ-12 ‘caseness’ at second follow-up was predicted by lack of social support alone. Conclusions: Overall, psychiatric morbidity is higher prior to, than following, a definitive diagnosis of breast cancer. Early reactions of this kind are predictive of post-treatment adjustment. However, only the presence of social support in this study seems to be associated with successful adjustment in the first year following a breast cancer diagnosis. Women at increased risk of psychological morbidity after a breast cancer diagnosis may be thus identifiable and targeted therapeutically.     

Identification of psychological morbidity in older people in primary care by practice nurses

Older people with psychological morbidity generally first present to health services in primary care, where they are increasingly seen by primary care nurses. In order to evaluate primary care nurses' identification of psychological morbidity, 190 older patients attending eight practice nurses completed the General Health Questionnaire (GHQ) and the practice nurses made an assessment as to the presence or absence of psychological problems. The practice nurses identified only 26% of probable cases of psychological morbidity identified by the GHQ. Their threshold for identification was high, rating only 12% of patients as experiencing psychological problems compared to 29% probable cases identified by the GHQ, and their accuracy was low (kappa for agreement between GHQ and nurse ratings = 0.23). Likelihood of identification depended on length and type of visit. The findings suggest that it may be unrealistic to expect practice nurses, without additional training and reorganisation of their work, to identify more than a minority of older patients with psychological morbidity in the course of their routine work.     

High score on the Relative Stress Scale, a marker of possible psychiatric disorder in family carers of patients with dementia

OBJECTIVE: To compare the scores on the Relative Stress Scale (RSS) with those on the General Health Questionnaire (GHQ) and the Geriatric Depression Scale (GDS), and to establish a cut-off score for RSS in order to distinguish carers with symptoms of psychiatric disorders from those without. METHODS: One hundred and ninety-four carers of 194 patients suffering from dementia according to ICD-10 were included in the study. Burden of care was assessed by the 15-items RSS, and psychiatric symptoms by means of the GHQ-30 and the 30-items GDS. A case score above 5 on GHQ and above 13 on GDS were used to define carers with probable psychiatric morbidity. Sensitivity (SS), specificity (SP), accuracy and likelihood ratio for a positive test (LR+) were calculated for different cut-points of the RSS. RESULTS: Fifty-six percent of the carers had a GHQ score above 5, and 22% had a GDS score above 13. A two-step cluster analysis using 192 of the 194 carers, identified three groups of carers; a low risk group for psychiatric morbidity (LRG), 82 carers with GHQ < or = 5 and GDS < or = 13; a medium risk group (MRG), 69 carers with GHQ > 5 and GDS < or = 13; and a high-risk group (HRG), 40 carers with GHQ > 5 and GDS > 13. The optimal RSS cut-off to distinguish between the LRG and the others was > 23 (SS 0.72, SP 0.82, accuracy 0.76, LR + 4.0), whereas the optimal cut-off to separate the HRG from the others was >30 (SS 0.74, SP 0.87, accuracy 0.84, LR + 5.7). CONCLUSION: The RSS is a useful instrument to stratify carers according to their risk of psychiatric morbidity.     

Is the General Health Questionnaire (12 item) a culturally biased measure of psychiatric disorder?

There have been suggestions that some self-administered questionnaires designed to assess psychiatric disorder tend to overestimate prevalence in samples from Latin America. This phenomenon may be obscured when the General Health Questionnaire (GHQ) is used, as it is recommended that researchers determine the threshold in each setting by comparing the GHQ with a standardised interview. Reports in the literature suggest that Latin American samples have a higher threshold for case definition using the GHQ than that found in British samples. The present study confirmed this finding when comparing the 12-item GHQ in a Chilean primary care sample with a sample of primary care attenders from the United Kingdom. The increase in GHQ scores in the Chilean sample persisted after adjustment for age, sex, marital status and the score on the Revised Clinical Interview Schedule (CIS-R). The increase in scores seen in the Chilean sample was only found in that half of the GHQ that asks about negative aspects of mental health.     

Non-psychotic psychiatric disorders in women one year after childbirth

A two-stage cross-sectional community survey has been conducted of non-psychotic psychiatric disorders in women a year after childbirth. In the first stage a sample of 820 women were screened using the General Health Questionnaire. Probable prevalence of psychiatric disorder was estimated as 19.7%. There was a significant association between high scores on the GHQ and being young, unmarried and of lower social class. In the second stage, 71 GHQ probable cases and 71 probable non-cases matched on demographic criteria were interviewed. Most probable cases were suffering from depression and over a third (35%) reported a disorder beginning early in the puerperium and persisting throughout the post-partum year. Factors associated with morbidity were a history of general practitioner consultation for psychiatric symptoms, lack of marital support and reports of a difficult baby.     

Psychiatric morbidity in general practice in Italy

Summary Psychiatric morbidity among 505 attenders on a single day at 32 general practices in South Verona was assessed using the General Health Questionnaire (GHQ-30) and recordings of practitioners' evaluations. The usual GHQ scoring system with a cut-off point of 5/6 resulted in 52% of high-scorers while the scoring system for longstanding psychological distress conditions (C-GHQ) yielded 37% of high-scorers (cut-off point 11/12). General practitioners identified 28% of attenders as cases. One-day population based prevalence estimates for the GHQ-30 and practitioners' assessment gave values of 6.6 and 4.5 per 1000 at risk. Among several possible risk factors, only presence of previous psychiatric illness increased significantly the relative risk of being a case in terms of GHQ, C-GHQ scores and practitioners' assessments. These findings are discussed in relation to the results of other surveys in the same area and other general practice studies.     

Psychological morbidity and caregiver burden in parents of children with Tourette's disorder and psychiatric comorbidity

OBJECTIVE: To investigate the mental health and caregiver burden in parents of children with Tourette's disorder (TD) compared with parents of children with asthma. METHOD: A cross-sectional cohort survey was conducted at TD and pediatric asthma hospital outpatient clinics over a 6-month period. Main outcome measures were parent mental health (General Health Questionnaire [GHQ]-28) and caregiver burden (Child and Adolescent Impact Assessment) scores. RESULTS: The response rate achieved was 89.7%. Of the parents of children with TD, 76.9% achieved caseness on the GHQ-28 compared with 34.6% of the parents of children with asthma; this effect remained significant after controlling for demographic variables. Parents of children with TD also experienced greater caregiver burden, and this burden was significantly correlated with GHQ caseness. CONCLUSIONS: Parents of children with TD are at risk of psychiatric morbidity; an intervention targeting caregiver burden might be helpful in reducing this.     

Psychiatric morbidity among New Zealand Cambodians: the role of psychosocial factors

A community survey of the relationship between minor psychiatric morbidity and life events, chronic post-migration stressors, social support and coping style among adult Cambodians living in Dunedin was conducted using the 28-item version of the General Health Questionnaire (GHQ-28) as the case identification instrument. Chronic post-migration stressors, life events, poor coping style and poor social support were all associated with minor psychiatric morbidity. Social support or coping style did not moderate the relationship between life events/post-migration stressors and GHQ caseness, but had an independent relationship with the latter.     

Illness behaviour as a determinant of referral to a psychiatric consultation/liaison service

Recognition of psychiatric disturbance and rate of referral to psychiatric units in general hospitals falls far short of the prevalence of psychiatric morbidity in such hospitals. This study has sought to determine whether particular patterns of "illness behaviour" contribute to the decision to refer. A group of patients referred to a psychiatric service was compared to a group of non-referred patients using the General Health Questionnaire (GHQ) as a general measure of morbidity, the Inventory to Diagnose Depression (IDD), the State-Trait Anxiety Inventory (STAI) and the Illness Behaviour Questionnaire (IBQ). The rate of referral to the service was 2.9%. The estimated prevalence of psychiatric morbidity was 30%. Referred patients scored more highly on all measures of morbidity (GHQ, IDD, STAI) and on the IBQ scale Affective Disturbance, and scored lower on the Denial Scale. Data are reported which suggest that patients with a strong somatic focus are less likely to be referred for psychiatric assessment despite the presence of significant psychiatric morbidity. The implications for health care delivery and identification of psychiatric morbidity are discussed.     

Early psychological adjustment in breast cancer patients: a prospective study

Objective: A significant proportion of breast cancer patients experiences psychiatric morbidity in the first year after a breast cancer diagnosis and/or beginning of treatment. This study attempted to identify and understand the risk factors for developing such problems. Methods: A consecutive series of 87 patients, aged 40-75 years, was assessed prior to diagnosis of breast cancer and followed-up approximately 8 weeks after beginning of cancer treatment and again 9 months after first follow-up. Assessments included measures of psychiatric morbidity using the General Health Questionnaire (GHQ-12), coping style using the Mental Adjustment to Cancer (MAC) Scale, symptom attribution, beliefs about breast cancer, social support, socio-demographic and clinical variables. Results: A total of 85.1% of patients completed both follow-ups. Pre-diagnostically, 32.2% of breast cancer patients scored as a GHQ-12 ‘case.’ GHQ scores fell significantly between pre-diagnostic and both post-diagnostic assessments, especially in women who had thought they had cancer. Predictors of psychological morbidity at first follow-up included pre-diagnostic GHQ-12 score, lack of social support and feelings of ‘personal responsibility/avoidance.’ GHQ-12 ‘caseness’ at second follow-up was predicted by lack of social support alone. Conclusions: Overall, psychiatric morbidity is higher prior to, than following, a definitive diagnosis of breast cancer. Early reactions of this kind are predictive of post-treatment adjustment. However, only the presence of social support in this study seems to be associated with successful adjustment in the first year following a breast cancer diagnosis. Women at increased risk of psychological morbidity after a breast cancer diagnosis may be thus identifiable and targeted therapeutically.     

A randomised controlled trial of an educational intervention for depression among Asian women in primary care in the United Kingdom

OBJECTIVE: To determine the effect of patient education on patient perspectives and outcome of depression in a sample of Asian women in primary care. DESIGN: A randomised, clinical trial of "patient education" versus "usual care". SETTING: A general practice in London, which has a high proportion of Asians. SUBJECTS: Seventy patients with psychiatric morbidity (a score of 3 or more on the General Health Questionnaire 12) were recruited for the trial. OUTCOME MEASURES: Patient's explanatory models of illness (the patient's perspective on depression; recognition of depression as illness and recommend a medical intervention for this condition) and psychiatric morbidity at follow-up after two months were the primary outcome measures. RESULTS: One hundred and fifty-five women of Asian decent were contacted. One hundred and forty-eight (95.5%) agreed to take part in the study. Seventy (47.3%) were classed as cases of common mental disorder using the General Health Questionnaire 12. Thirty-five were randomly allocated to receive education about the nature, causes, prevalence and treatment of depression, 35 did not receive such information. There were no statistical differences between the two groups on baseline characteristics. Sixty-six (94.3%) subjects were followed up at two months. An intention to treat analysis showed that there was no difference in explanatory model measures between the two groups at the end of the study. However, more patients who received education were no longer cases (a score of 2 or less on the GHQ) (15/35; 42.9%) compared to controls (7/35; 20%) (p < 0.05) as did those with lower GHQ scores at entry (p < 0.03). Receipt of educational intervention (OR 3.4; 95% CI 1.01, 11.5) and lower GHQ scores at entry (OR 7.1; 95% CI 1.05, 30.2) remained significantly associated with recovery after adjusting for baseline variables using logistic regression. CONCLUSIONS: Patients with common mental disorders, especially those with milder forms of the condition, who received the educational material had a higher recovery rate than patients who do not receive such education. The mechanism for this improvement was unclear, not being reflected in patient's apparent understanding of depression nor explained by change in general practitioner's response. The results of this study need to be replicated.     

Psychiatric morbidity, platelet monoamine oxidase and tribulin output in headache

A significantly higher proportion of patients with headache showed scores in the psychopathological range of the General Health Questionnaire (GHQ) compared with controls, with ratings particularly high on the anxiety and depression subscales. Across the whole group, there was a significant negative correlation between platelet monoamine oxidase (MAO) activity and GHQ score overall, and with the anxiety and depression subscales. There was a significant positive correlation between platelet MAO activity and urinary output of the endogenous MAO inhibitor, tribulin. Within the migraine group, there was a significant negative correlation between tribulin output and GHQ score. These findings suggest that the biochemical nature of the anxiety associated with migraine may differ from that in other conditions such as generalized anxiety disorder where high platelet MAO activity and high tribulin output have been reported.     

Factors associated with dysmorphic concern and psychiatric morbidity in plastic surgery outpatients

OBJECTIVES: To compare new referrals to a plastic surgery clinic for cosmetic (non-medically explained) reasons with a control group of equal size with medically explained symptoms. METHOD: Patients attending for cosmetic (non-medically explained) reasons were compared with the controls using the general health questionnaire (GHQ), and dysmorphic concern questionnaire (DCQ). Patients were divided into high and low DCQ scores on the basis of their median scores. RESULTS: Ninety subjects were approached of whom 84 (93%) participated giving 42 patients each in the cosmetic (non-medically explained) and control groups. Forty-four per cent were referred for mammoplasty (n = 37) and 8% for rhinoplasty (n = 7). The other 40 cases (48%) were for other procedures including excision, abdominoplasty and blepharoplasty. Thirty-two per cent of the sample were GHQ cases (n = 27). Patients presenting for cosmetic (non-medically explained) reasons were 13 times more likely to be female (95% CI = 4.3-41), nine times more likely to have high DCQ scores (95% CI = 3.3-24), six times more likely to be GHQ cases (95% CI = 2.1-17), and seven times more likely to present for mammoplasty. The same factors were associated with high DCQ scores. Patients with high DCQ scores were 32 times as likely to be GHQ cases (95% CI = 6.8-151). On multivariate analysis, dysmorphic concern emerged as the only independent predictor of GHQ caseness rather than sex, surgical diagnosis or procedure (adjusted OR = 32.0, 95 % CI = 6.5-156). Similarly, only GHQ caseness and presentation for cosmetic (non-medically explained) surgery independently predicted DCQ score. CONCLUSIONS: Patients presenting for cosmetic (non-medically explained) surgery have high rates of dysmorphic concern and psychiatric morbidity