Mental health problems among adults in tsunami-affected areas in southern Thailand

Context  On December 26, 2004, an undersea earthquake occurred off the northwestern coast of Sumatra, Indonesia. The tsunami that followed severely affected all 6 southwestern provinces of Thailand, where 5395 individuals died, 2991 were unaccounted for, and 8457 were injured. Objective  To assess the prevalence of symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression among individuals residing in areas affected by the tsunami in southern Thailand as part of a public health emergency response and rapid assessment. Design, Setting, and Participants  A multistage, cluster, population-based mental health survey was conducted from February 15 to 22, 2005, of random samples of displaced (n = 371) and nondisplaced persons in Phang Nga province (n = 322) and nondisplaced persons in the provinces of Krabi and Phuket (n = 368). Data were collected using an interviewer-administered questionnaire on handheld computers. A surveillance follow-up survey of the displaced persons (n = 371) and nondisplaced persons (n = 322) in Phang Na was conducted in September 2005. Main Outcomes Measures  Medical Outcomes Study-36 Short-Form Health Survey SF-36 to assess self-perceived general health, bodily pain, and social and emotional functioning; the Harvard Trauma Questionnaire to assess tsunami-specific traumatic events; and the Hopkins Checklist-25 to detect symptoms of anxiety and depression. Results  Participation rates for displaced and nondisplaced persons in the rapid assessment survey were 69% and 58%, respectively. Symptoms of PTSD were reported by 12% of displaced and 7% of nondisplaced persons in Phang Nga and 3% of nondisplaced persons in Krabi and Phuket. Anxiety symptoms were reported by 37% of displaced and 30% of nondisplaced persons in Phang Nga and 22% of nondisplaced persons in Krabi and Phuket. Symptoms of depression were reported by 30% of displaced and 21% of nondisplaced persons in Phang Nga and 10% of nondisplaced persons in Krabi and Phuket. In multivariate analysis, loss of livelihood was independently and significantly associated with symptoms of all 3 mental health outcomes (PTSD, anxiety, and depression). In the 9-month follow-up surveillance survey of 270 (73%) displaced and 250 (80%) nondisplaced participants in Phang Nga, prevalence rates of symptoms of PTSD, anxiety, and depression among displaced persons decreased to 7%, 24.8%, and 16.7%, respectively, and among nondisplaced persons, prevalence rates decreased to 2.3%, 25.9%, and 14.3%, respectively. Conclusions  Among survivors of the tsunami in southern Thailand, elevated rates of symptoms of PTSD, anxiety, and depression were reported 8 weeks after the disaster, with higher rates for anxiety and depression than PTSD symptoms. Nine months after the disaster, the rates of those reporting these symptoms decreased but were still elevated. This information is important for directing, strengthening, and evaluating posttsunami mental health needs and interventions.      

Exposure to war crimes and implications for peace building in northern Uganda

Context  Since the late 1980s, the Lord's Resistance Army has waged war against the Ugandan People's Democratic Army and the people of northern Uganda. Ending the conflict and achieving peace have proven to be challenges. In this context, it is important to examine population-based data on exposure to war crimes to understand how survivors perceive mechanisms aimed at achieving a lasting peace. Objectives  To assess the level of exposure to war-related violence and the prevalence of posttraumatic stress disorder (PTSD) and depression symptoms in northern Uganda and to determine how these variables are associated with respondents' views about peace. Design, Setting, and Participants  Multistage, stratified, random cluster survey of 2585 adults aged 18 years or older conducted in villages and camps for internally displaced persons in 4 districts of northern Uganda in April and May 2005. Main Outcome Measures  Rates and patterns of exposure to trauma; symptom criteria for PTSD, assessed via the PTSD Checklist–Civilian Version with a total severity score of 44; symptoms of depression, assessed via the Johns Hopkins Depression Symptom Checklist with a cutoff of 42; and opinions and attitudes about peace. Results  Among the respondents, 1774 of 2389 (74.3%) met PTSD symptom criteria and 1151 of 2585 (44.5%) met depression symptom criteria. Four patterns of exposure to trauma were distinguished: those with low exposure (group 1; 21.4%), witnesses to war-related violence (group 2; 17.8%), those threatened with death and/or physically injured (group 3; 16.4%), and those abducted (group 4; 44.3%). Respondents in groups 3 and 4, who experienced the most traumatic exposures, were more likely to have PTSD symptoms compared with group 1 (group 3 vs group 1: odds ratio [OR], 7.04 [95% confidence interval {CI}, 5.02-9.87]; group 4 vs group 1: OR, 6.07 [95% CI, 4.77-7.71]). Groups 3 and 4 were also more likely to meet depression symptom criteria (group 3 vs group 1: OR, 5.76 [95% CI, 4.34-7.65]; group 4 vs group 1: OR, 4.00 [95% CI, 3.16-5.06]). Respondents who met the PTSD symptom criteria were more likely to identify violence as a means to achieve peace (OR, 1.31; 95% CI, 1.05-1.65). Respondents who met the depression symptom criteria were less likely to identify nonviolence as a means to achieve peace (OR, 0.77; 95% CI, 0.65-0.93). Conclusions  Our study found high prevalence rates for symptoms of PTSD and depression in a conflict zone. Respondents reporting symptoms of PTSD and depression were more likely to favor violent over nonviolent means to end the conflict.      

Remissions in maternal depression and child psychopathology: a STAR*D-child report

Context  Children of depressed parents have high rates of anxiety, disruptive, and depressive disorders that begin early, often continue into adulthood, and are impairing. Objective  To determine whether effective treatment with medication of women with major depression is associated with reduction of symptoms and diagnoses in their children. Design  Assessments of children whose depressed mothers were being treated with medication as part of the multicenter Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial conducted (between December 16, 2001 and April 24, 2004) in broadly representative primary and psychiatric outpatient practices. Children were assessed by a team of evaluators not involved in maternal treatment and unaware of maternal outcomes. Study is ongoing with cases followed at 3-month intervals. Setting and Patients  One hundred fifty-one mother-child pairs in 8 primary care and 11 psychiatric outpatient clinics across 7 regional centers in the United States. Children were aged 7 to 17 years. Main Outcome Measures  Child diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia; child symptoms based on the Child Behavior Checklist; child functioning based on the Child Global Assessment Scale in mothers whose depression with treatment remitted with a score of 7 or lower or whose depression did not remit with a score higher than 7 on the Hamilton Rating Scale for Depression. Results  Remission of maternal depression after 3 months of medication treatment was significantly associated with reductions in the children's diagnoses and symptoms. There was an overall 11% decrease in rates of diagnoses in children of mothers whose depression remitted compared with an approximate 8% increase in rates of diagnoses in children of mothers whose depression did not. This rate difference remained statistically significant after controlling for the child's age and sex, and possible confounding factors (P = .01). Of the children with a diagnosis at baseline, remission was reported in 33% of those whose mothers' depression remitted compared with only a 12% remission rate among children of mothers whose depression did not remit. All children of mothers whose depression remitted after treatment and who themselves had no baseline diagnosis for depression remained free of psychiatric diagnoses at 3 months, whereas 17% of the children whose mothers remained depressed acquired a diagnosis. Findings were similar using child symptoms as an outcome. Greater level of maternal response was associated with fewer current diagnoses and symptoms in the children, and a maternal response of at least 50% was required to detect an improvement in the child. Conclusions  Remission of maternal depression has a positive effect on both mothers and their children, whereas mothers who remain depressed may increase the rates of their children's disorders. These findings support the importance of vigorous treatment for depressed mothers in primary care or psychiatric clinics and suggest the utility of evaluating the children, especially children whose mothers continue to be depressed.      

Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial

Context  Prior qualitative work with internally displaced persons in war-affected northern Uganda showed significant mental health and psychosocial problems. Objective  To assess effect of locally feasible interventions on depression, anxiety, and conduct problem symptoms among adolescent survivors of war and displacement in northern Uganda. Design, Setting, and Participants  A randomized controlled trial from May 2005 through December 2005 of 314 adolescents (aged 14-17 years) in 2 camps for internally displaced persons in northern Uganda. Interventions  Locally developed screening tools assessed the effectiveness of interventions in reducing symptoms of depression and anxiety, ameliorating conduct problems, and improving function among those who met study criteria and were randomly allocated (105, psychotherapy-based intervention [group interpersonal psychotherapy]; 105, activity-based intervention [creative play]; 104, wait-control group [individuals wait listed to receive treatment at study end]). Intervention groups met weekly for 16 weeks. Participants and controls were reassessed at end of study. Main Outcome Measures  Primary measure was a decrease in score (denoting improvement) on a depression symptom scale. Secondary measures were improvements in scores on anxiety, conduct problem symptoms, and function scales. Depression, anxiety, and conduct problems were assessed using the Acholi Psychosocial Assessment Instrument with a minimum score of 32 as the lower limit for clinically significant symptoms (maximum scale score, 105). Results  Difference in change in adjusted mean score for depression symptoms between group interpersonal psychotherapy and control groups was 9.79 points (95% confidence interval [CI], 1.66-17.93). Girls receiving group interpersonal psychotherapy showed substantial and significant improvement in depression symptoms compared with controls (12.61 points; 95% CI, 2.09-23.14). Improvement among boys was not statistically significant (5.72 points; 95% CI, –1.86 to 13.30). Creative play showed no effect on depression severity (–2.51 points; 95% CI, –11.42 to 6.39). There were no statistically different improvements in anxiety in either intervention group. Neither intervention improved conduct problem or function scores. Conclusions  Both interventions were locally feasible. Group interpersonal psychotherapy was effective for depression symptoms among adolescent girls affected by war and displacement. Other interventions should be investigated to assist adolescent boys in this population who have symptoms of depression. Trial Registration  clinicaltrials.gov Identifier: NCT00280319      

Impact of Torture on Refugees Displaced Within the Developing World: Symptomatology Among Bhutanese Refugees in Nepal

Context.— Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown. Objective.— To examine the impact of torture on Bhutanese refugees in Nepal. Design.— Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression. Setting.— Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal. Participants.— A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex. Main Outcome Measures.— The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety. Results.— The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-R PTSD symptoms (P<.005) and had higher HSCL-25 anxiety and depression scores (P<.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system– and respiratory system–related complaints (P<.001 for both). Conclusion.— Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.      

Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial

Context  Despite the importance of mental illness in Africa, few controlled intervention trials related to this problem have been published. Objectives  To test the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction and to evaluate the feasibility of conducting controlled trials in Africa. Design, Setting, and Participants  For this cluster randomized, controlled clinical trial (February-June 2002), 30 villages in the Masaka and Rakai districts of rural Uganda were selected using a random procedure; 15 were then randomly assigned for studying men and 15 for women. In each village, adult men or women believed by themselves and other villagers to have depressionlike illness were interviewed using a locally adapted Hopkins Symptom Checklist and an instrument assessing function. Based on these interviews, lists were created for each village totaling 341 men and women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression or subsyndromal depression. Interviewers revisited them in order of decreasing symptom severity until they had 8 to 12 persons per village, totaling 284. Of these, 248 agreed to be in the trial and 9 refused; the remainder died or relocated. A total of 108 men and 116 women completed the study and were reinterviewed. Intervention  Eight of the 15 male villages and 7 of the 15 female villages were randomly assigned to the intervention arm and the remainder to the control arm. The intervention villages received group interpersonal psychotherapy for depression as weekly 90-minute sessions for 16 weeks. Main Outcome Measures  Depression and dysfunction severity scores on scales adapted and validated for local use; proportion of persons meeting DSM-IV major depression diagnostic criteria. Results  Mean reduction in depression severity was 17.47 points for intervention groups and 3.55 points for controls (P<.001). Mean reduction in dysfunction was 8.08 and 3.76 points, respectively (P<.001). After intervention, 6.5% and 54.7% of the intervention and control groups, respectively, met the criteria for major depression (P<.001) compared with 86% and 94%, respectively, prior to intervention (P = .04). The odds of postintervention depression among controls was 17.31 (95% confidence interval, 7.63-39.27) compared with the odds among intervention groups. Results from intention-to-treat analyses remained statistically significant. Conclusions  Group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction. A clinical trial proved feasible in the local setting. Both findings should encourage similar trials in similar settings in Africa and beyond.      

Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial

Context  The prevalence of posttraumatic stress disorder (PTSD) is elevated among women who have served in the military, but no prior study has evaluated treatment for PTSD in this population. Prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD. Objective  To compare prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD. Design, Setting, and Participants  A randomized controlled trial of female veterans (n=277) and active-duty personnel (n=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through October 2005. Intervention  Participants were randomly assigned to receive prolonged exposure (n = 141) or present-centered therapy (n = 143), delivered according to standard protocols in 10 weekly 90-minute sessions. Main Outcome Measures  Posttraumatic stress disorder symptom severity was the primary outcome. Comorbid symptoms, functioning, and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up. Results  Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment. Conclusions  Prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings. Trial Registration  clinicaltrials.gov Identifier: NCT00032617      

Disability Associated With Psychiatric Comorbidity and Health Status in Bosnian Refugees Living in Croatia

Context  The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known. Objective  To determine if risk factors, such as demographics, trauma, health status, and psychiatric illness, are associated with disability in Bosnian refugees. Design, Setting, and Participants  Cross-sectional survey conducted in 1996 of Bosnian refugee adults living in a camp established by the Croatian government near the city of Varadin. One adult aged 18 years or older was randomly selected from each of 573 camp families; 534 (93%) agreed to participate (mean age, 50 years; 41% male). Main Outcome Measures  Culturally validated measures for depression and posttraumatic stress disorder (PTSD) included the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire, respectively. Disability measures included the Medical Outcomes Study Short-Form 20, a physical functioning scale based on World Health Organization criteria, and self-reports of socioeconomic activity, levels of physical energy, and perceived health status. Results  Respondents reported a mean (SD) of 6.5 (4.7) unduplicated trauma events; 18% (n=95) had experienced 1 or more torture events. While 55.2% reported no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet DSM-IV criteria for depression and PTSD, respectively; 20.6% reported symptoms comorbid for both disorders. A total of 25.5% reported having a disability. Refugees who reported symptoms comorbid for both depression and PTSD were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval [CI], 3.05-8.26; adjusted OR, 2.06; 95% CI, 1.10-3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability. Conclusions  In a population of Bosnian refugees who had recently fled from the war in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability independent of the effects of age, trauma, and health status.      

Mental health symptoms following war and repression in eastern Afghanistan

Context  Decades of armed conflict, suppression, and displacement resulted in a high prevalence of mental health symptoms throughout Afghanistan. Its Eastern province of Nangarhar is part of the region that originated the Taliban movement. This may have had a distinct impact on the living circumstances and mental health condition of the province's population. Objectives  To determine the rate of exposure to traumatic events; estimate prevalence rates of symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety; identify resources used for emotional support and risk factors for mental health symptoms; and assess the present coverage of basic needs in Nangarhar province, Afghanistan. Design, Setting, and Participants  A cross-sectional multicluster sample survey of 1011 respondents aged 15 years or older, conducted in Nangarhar province during January and March 2003; 362 households were represented with a mean of 2.8 respondents per household (72% participation rate). Main Outcome Measures  Posttraumatic stress disorder symptoms and traumatic events using the Harvard Trauma Questionnaire; depression and general anxiety symptoms using the Hopkins Symptom Checklist; and resources for emotional support through a locally informed questionnaire. Results  During the past 10 years, 432 respondents (43.7%) experienced between 8 and 10 traumatic events; 141 respondents (14.1%) experienced 11 or more. High rates of symptoms of depression were reported by 391 respondents (38.5%); anxiety, 524 (51.8%); and PTSD, 207 (20.4%). Symptoms were more prevalent in women than in men (depression: odds ratio [OR], 7.3 [95% confidence interval {CI}, 5.4-9.8]; anxiety: OR, 12.8 [95% CI, 9.0-18.1]; PTSD: OR, 5.8 [95% CI, 3.8-8.9]). Higher rates of symptoms were associated with higher numbers of traumas experienced. The main resources for emotional support were religion and family. Medical care was reported to be insufficient by 228 respondents (22.6%). Conclusions  In this survey of inhabitants of Nangarhar province, Afghanistan, prevalence rates of having experienced multiple traumatic events and having symptoms of anxiety, depression, and PTSD were high. These findings suggest that mental health symptoms in this region should be addressed at the population and primary health care level.      

Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial

Context  Both antidepressant medication and structured psychotherapy have been proven efficacious, but less than one third of people with depressive disorders receive effective levels of either treatment. Objective  To compare usual primary care for depression with 2 intervention programs: telephone care management and telephone care management plus telephone psychotherapy. Design  Three-group randomized controlled trial with allocation concealment and blinded outcome assessment conducted between November 2000 and May 2002. Setting and Participants  A total of 600 patients beginning antidepressant treatment for depression were systematically sampled from 7 group-model primary care clinics; patients already receiving psychotherapy were excluded. Interventions  Usual primary care; usual care plus a telephone care management program including at least 3 outreach calls, feedback to the treating physician, and care coordination; usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone. Main Outcome Measures  Blinded telephone interviews at 6 weeks, 3 months, and 6 months assessed depression severity (Hopkins Symptom Checklist Depression Scale and the Patient Health Questionnaire), patient-rated improvement, and satisfaction with treatment. Computerized administrative data examined use of antidepressant medication and outpatient visits. Results  Treatment participation rates were 97% for telephone care management and 93% for telephone care management plus psychotherapy. Compared with usual care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom Checklist Depression Scale depression scores (P = .02), a higher proportion of patients reporting that depression was "much improved" (80% vs 55%, P<.001), and a higher proportion of patients "very satisfied" with depression treatment (59% vs 29%, P<.001). The telephone care management program had smaller effects on patient-rated improvement (66% vs 55%, P = .04) and satisfaction (47% vs 29%, P = .001); effects on mean depression scores were not statistically significant. Conclusions  For primary care patients beginning antidepressant treatment, a telephone program integrating care management and structured cognitive-behavioral psychotherapy can significantly improve satisfaction and clinical outcomes. These findings suggest a new public health model of psychotherapy for depression including active outreach and vigorous efforts to improve access to and motivation for treatment.      

Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial

Context  Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients. Objective  To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis. Design, Setting, and Participants  Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (=" BORDER="0">60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline. Intervention  Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). Main Outcome Measures  Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months. Results  In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P = .009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P = .004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P = .002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months. Conclusions  In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.      

Obesity and estrogen as risk factors for gastroesophageal reflux symptoms

Context  Gastroesophageal reflux and obesity are both increasing in prevalence. The scientific evidence for an association between these conditions is sparse and contradictory. A difference between sexes concerning this relation has been proposed. Objective  To evaluate the relation between body mass and gastroesophageal reflux symptoms and determine how this relation is influenced by female sex hormones. Design  Population-based, cross-sectional, case-control study. Setting  Two consecutive public health surveys within the county of Nord-Trondelag, Norway, conducted in 1984-1986 and 1995-1997. Participants  Among 65 363 adult participants in the second survey, 3113 individuals who reported severe heartburn or regurgitation during the last 12 months were defined as cases, whereas 39 872 persons without reflux symptoms were defined as controls. Main Outcome Measure  Risk of reflux, estimated using multivariate logistic regression, with odds ratios (ORs) and 95% confidence intervals (CIs) as measures of association. Results  There was a dose-response association between increasing body mass index (BMI) and reflux symptoms in both sexes (P for trend <.001), with a significantly stronger association in women (P<.001). Compared with those with a BMI less than 25, the risk of reflux was increased significantly among severely obese (BMI >35) men(OR, 3.3; 95% CI, 2.4-4.7) and women (OR, 6.3; 95% CI, 4.9-8.0). The association between BMI and reflux symptoms was stronger among premenopausal women compared with postmenopausal women (P<.001), although use of postmenopausal hormone therapy increased the strength of the association (P<.001). Reduction in BMI was associated with decreased risk of reflux symptoms. Conclusions  There is a significant association between body mass and symptoms of gastroesophageal reflux. The association is stronger among women, especially premenopausally, and use of hormone therapy strengthens the association, suggesting that estrogens may play an important role in the etiology of reflux disease.      

National Trends in the Outpatient Treatment of Depression

Context  Recent advances in pharmacotherapy and changing health care environments have focused increased attention on trends in outpatient treatment of depression. Objective  To compare trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. Design and Setting  Analysis of service utilization data from 2 nationally representative surveys of the US general population, the 1987 National Medical Expenditure Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N = 32 636). Participants  Respondents who reported making 1 or more outpatient visits for treatment of depression during that calendar year. Main Outcome Measures  Rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment. Results  The rate of outpatient treatment for depression increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (P<.001). The proportion of treated individuals who used antidepressant medications increased from 37.3% to 74.5% (P<.001), whereas the proportion who received psychotherapy declined (71.1% vs 60.2%, P = .006). The mean number of depression treatment visits per user declined from 12.6 to 8.7 per year (P = .05). An increasingly large proportion of patients were treated by physicians for their condition (68.9% vs 87.3%, P<.001), and treatment costs were more often covered by third-party payers (39.3% to 55.2%, P<.001). Conclusions  Between 1987 and 1997, there was a marked increase in the proportion of the population who received outpatient treatment for depression. Treatment became characterized by greater involvement of physicians, greater use of psychotropic medications, and expanding availability of third-party payment, but fewer outpatient visits and less use of psychotherapy. These changes coincided with the advent of better-tolerated antidepressants, increased penetration of managed care, and the development of rapid and efficient procedures for diagnosing depression in clinical practice.      

Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults

Elisabeth B. Binder, MD, PhD; Rebekah G. Bradley, PhD; Wei Liu, PhD; Michael P. Epstein, PhD; Todd C. Deveau, BS; Kristina B. Mercer, MPH; Yilang Tang, MD, PhD; Charles F. Gillespie, MD, PhD; Christine M. Heim, PhD; Charles B. Nemeroff, MD, PhD; Ann C. Schwartz, MD; Joseph F. Cubells, MD, PhD; Kerry J. Ressler, MD, PhD

JAMA. 2008;299(11):1291-1305.

Context  In addition to trauma exposure, other factors contribute to risk for development of posttraumatic stress disorder (PTSD) in adulthood. Both genetic and environmental factors are contributory, with child abuse providing significant risk liability.

Objective  To increase understanding of genetic and environmental risk factors as well as their interaction in the development of PTSD by gene x environment interactions of child abuse, level of non–child abuse trauma exposure, and genetic polymorphisms at the stress-related gene FKBP5.

Design, Setting, and Participants  A cross-sectional study examining genetic and psychological risk factors in 900 nonpsychiatric clinic patients (762 included for all genotype studies) with significant levels of childhood abuse as well as non–child abuse trauma using a verbally presented survey combined with single-nucleotide polymorphism (SNP) genotyping. Participants were primarily urban, low-income, black (>95%) men and women seeking care in the general medical care and obstetrics-gynecology clinics of an urban public hospital in Atlanta, Georgia, between 2005 and 2007.

Main Outcome Measures  Severity of adult PTSD symptomatology, measured with the modified PTSD Symptom Scale, non–child abuse (primarily adult) trauma exposure and child abuse measured using the traumatic events inventory and 8 SNPs spanning the FKBP5 locus.

Results  Level of child abuse and non–child abuse trauma each separately predicted level of adult PTSD symptomatology (mean [SD], PTSD Symptom Scale for no child abuse, 8.03 [10.48] vs 2 types of abuse, 20.93 [14.32]; and for no non–child abuse trauma, 3.58 [6.27] vs 4 types, 16.74 [12.90]; P < .001). Although FKBP5 SNPs did not directly predict PTSD symptom outcome or interact with level of non–child abuse trauma to predict PTSD symptom severity, 4 SNPs in the FKBP5 locus significantly interacted (rs9296158, rs3800373, rs1360780, and rs9470080; minimum P = .0004) with the severity of child abuse to predict level of adult PTSD symptoms after correcting for multiple testing. This gene x environment interaction remained significant when controlling for depression severity scores, age, sex, levels of non–child abuse trauma exposure, and genetic ancestry. This genetic interaction was also paralleled by FKBP5 genotype-dependent and PTSD-dependent effects on glucocorticoid receptor sensitivity, measured by the dexamethasone suppression test.

Conclusions  Four SNPs of the FKBP5 gene interacted with severity of child abuse as a predictor of adult PTSD symptoms. There were no main effects of the SNPs on PTSD symptoms and no significant genetic interactions with level of non–child abuse trauma as predictor of adult PTSD symptoms, suggesting a potential gene-childhood environment interaction for adult PTSD.

     

Mental health of Cambodian refugees 2 decades after resettlement in the United States

Context  Little is known about the long-term mental health of trauma-exposed refugees years after permanent resettlement in host countries. Objective  To assess the prevalence, comorbidity, and correlates of psychiatric disorders in the US Cambodian refugee community. Design, Setting, and Participants  A cross-sectional, face-to-face interview conducted in Khmer language on a random sample of households from the Cambodian community in Long Beach, Calif, the largest such community in the United States, between October 2003 and February 2005. A total of 586 adults aged 35 to 75 years who lived in Cambodia during the Khmer Rouge reign and immigrated to the United States prior to 1993 were selected. One eligible individual was randomly sampled from each household, with an overall response rate (eligibility screening and interview) of 87% (n = 490). Main Outcome Measures  Exposure to trauma and violence before and after immigration (using the Harvard Trauma Questionnaire and Survey of Exposure to Community Violence); weighted past-year prevalence rates of posttraumatic stress disorder (PTSD) and major depression (using the Composite International Diagnostic Interview version 2.1); and alcohol use disorder (by the Alcohol Use Disorders Identification Test). Results  All participants had been exposed to trauma before immigration. Ninety-nine percent (n = 483) experienced near-death due to starvation and 90% (n = 437) had a family member or friend murdered. Seventy percent (n = 338) reported exposure to violence after settlement in the United States. High rates of PTSD (62%, weighted), major depression (51%, weighted), and low rates of alcohol use disorder were found (4%, weighted). PTSD and major depression were highly comorbid in this population (n = 209; 42%, weighted) and each showed a strong dose-response relationship with measures of traumatic exposure. In bivariate analyses, older age, having poor English-speaking proficiency, unemployment, being retired or disabled, and living in poverty were also associated with higher rates of PTSD and major depression. Following multivariate analyses, premigration trauma remained associated with PTSD (odds ratio [OR], 2.08; 95% CI, 1.37-3.16) and major depression (OR, 1.56; 95% CI, 1.24-1.97); postmigration trauma with PTSD (OR, 1.65; 95% CI, 1.21-2.26) and major depression (OR, 1.45; 95% CI, 1.12-1.86); and older age with PTSD (OR, 1.76; 95% CI, 1.46-2.13) and major depression (OR, 1.47; 95% CI, 1.15-1.89). Conclusion  More than 2 decades have passed since the end of the Cambodian civil war and the subsequent resettlement of refugees in the United States; however, this population continues to have high rates of psychiatric disorders associated with trauma.      

Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers

Context  Tens of thousands of the estimated 250 000 child soldiers worldwide are abused or have been abused during the last decade in Africa's Great Lakes Region. In the process of rebuilding the war-torn societies, it is important to understand how psychological trauma may shape the former child soldiers' ability to reconcile. Objective  To investigate the association of posttraumatic stress disorder (PTSD) symptoms and openness to reconciliation and feelings of revenge in former Ugandan and Congolese child soldiers. Design, Setting, and Participants  Cross-sectional field study of 169 former child soldiers (aged 11-18 years) in rehabilitation centers in Uganda and the Democratic Republic of the Congo, conducted in 2005. Main Outcome Measures  Potentially traumatic war-related experiences assessed via a sample-specific events scale; PTSD symptoms assessed using the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI), with a score of 35 or higher indicating clinically important PTSD symptoms; and openness to reconciliation and feelings of revenge assessed via structured questionnaires. Results  Children participating in this study were a mean of 15.3 years old. These former child soldiers reported that they had been (violently) recruited by armed forces at a young age (mean [SD], 12.1 [2] years), had served a mean of 38 months (SD, 24 months), and had been demobilized a mean of 2.3 months before data collection (SD, 2.4 months). The children were exposed to a high level of potentially traumatic events (mean [SD], 11.1 [2.99]). The most commonly reported traumatic experiences were having witnessed shooting (92.9%), having witnessed someone wounded (89.9%), and having been seriously beaten (84%). A total of 54.4% reported having killed someone, and 27.8% reported that they were forced to engage in sexual contact. Of the 169 interviewed, 59 (34.9%; 95% confidence interval, 34.4%-35.4%) had a PTSD symptom score higher than 35. Children who showed more PTSD symptoms had significantly less openness to reconciliation (= –0.34, P < .001) and more feelings of revenge (= 0.29, P < .001). Conclusions  PTSD symptoms are associated with less openness to reconciliation and more feelings of revenge among former Ugandan and Congolese child soldiers. The effect of psychological trauma should be considered when these children are rehabilitated and reintegrated into civilian society.      

Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial

Context  Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings. Objective  To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices. Design, Setting, and Participants  Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States. Intervention  Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients’ depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment. Main Outcome Measures  Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. Secondary outcomes were mental health–related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale. Results  Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean [SD] CES-D scores, 19.0 [11.9] vs 21.4 [13.1]; P = .02), higher mental health–related quality of life (mean [SD] MCS-12 scores, 44.6 [11.3] vs 42.8 [12.9]; P = .03), and greater satisfaction with mental health care (mean [SD] scores, 3.8 [0.9] vs 3.5 [1.0]; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007). Conclusions  A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.      

Treating depression in predominantly low-income young minority women: a randomized controlled trial

Context  Impoverished minority women experience a higher burden from depression than do white women because they are less likely to receive appropriate care. Little is known about the effectiveness of guideline-based care for depression with impoverished minority women, most of whom do not seek care. Objective  To determine the impact of an intervention to deliver guideline-based care for depression compared with referral to community care with low-income and minority women. Design, Setting, and Participants  A randomized controlled trial conducted in the Washington, DC, suburban area from March 1997 through May 2002 of 267 women with current major depression, who attended county-run Women, Infants, and Children food subsidy programs and Title X family planning clinics. Outcomes  Hamilton Depression Rating Scale measured monthly from baseline through 6 months; instrumental role functioning (Social Adjustment Scale) and social functioning (Short Form 36-Item Health Survey) measured at baseline and 3 and 6 months. Interventions  Participants were randomly assigned to an antidepressant medication intervention (trial of paroxetine switched to buproprion, if lack of response) (n = 88), a psychotherapy intervention (8 weeks of manual-guided cognitive behavior therapy) (n = 90), or referral to community mental health services (n = 89). Results  Both the medication intervention (P<.001) and the psychotherapy intervention (P = .006) reduced depressive symptoms more than the community referral did. The medication intervention also resulted in improved instrumental role (P = .006) and social (P = .001) functioning. The psychotherapy intervention resulted in improved social functioning (P = .02). Women randomly assigned to receive medications were twice as likely (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P = .057) to achieve a Hamilton Depression Rating Scale score of 7 or less by month 6 as were those referred to community care. Conclusions  Guideline-concordant care for major depression is effective for these ethnically diverse and impoverished patients. More women engaged in a sufficient duration of treatment with medications compared with psychotherapy, and outcome gains were more extensive and robust for medications.      

Invasive meningococcal disease in adolescents and young adults

Context  Incidence of invasive meningococcal disease has increased recently in persons aged 15 through 24 years. Objective  To characterize meningococcal infection in adolescents and young adults in Maryland during the 1990s. Design and Setting  Population-based surveillance study for meningococcal disease from January 1, 1990, through December 31, 1999, in Maryland. Patients  Maryland residents diagnosed as having invasive meningococcal disease. Main Outcome Measure  Invasive meningococcal infection. Results  Of 295 total cases, 71 (24.1%) occurred among persons aged 15 through 24 years. Sixteen (22.5%) of these cases were fatal. The annual incidence rate increased from 0.9 to 2.1 cases per 100 000 among 15 through 24 year olds (P = .01). The proportion of all disease increased from 16.0% to 28.9% (P = .03). The incidence and proportion of cases subsequently decreased to 1.0 and 16.4% in 1998 through 1999, respectively. Infection in 15 through 24 year olds was more likely to be fatal than infection in those younger than age 15 years (22.5% vs 4.6%; P = .001). Infection in 15 through 24 year olds, compared with those aged 25 years or older, was more likely to be associated with male sex (66.2% vs 34.8%; P<.001) and serogroup C infection (46.9% vs 20.2%; P<.001), respectively. Infections were potentially preventable with the licensed meningococcal vaccine in 82.8% of 15 through 24 year olds, 68.1% of those younger than 15 years, and 76.8% of adults aged 25 years or older. Conclusions  Incidence of meningococcal infection in 15 through 24 year olds in Maryland increased and then declined during the 1990s. Infection in this age group was associated with an unusually high case-fatality ratio, and the vast majority of cases were potentially vaccine preventable.      

Educational and organizational interventions to improve the management of depression in primary care: a systematic review

Context  Depression is commonly encountered in primary care settings yet is often missed or suboptimally managed. A number of organizational and educational strategies to improve management of depression have been proposed. The clinical effectiveness and cost-effectiveness of these strategies have not yet been subjected to systematic review. Objective  To systematically evaluate the effectiveness of organizational and educational interventions to improve the management of depression in primary care settings. Data Sources  We searched electronic medical and psychological databases from inception to March 2003 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane Controlled Trials Register, United Kingdom National Health Service Economic Evaluations Database, Cochrane Depression Anxiety and Neurosis Group register, and Cochrane Effective Professional and Organisational Change Group specialist register); conducted correspondence with authors; and used reference lists. Search terms were related to depression, primary care, and all guidelines and organizational and educational interventions. Study Selection  We selected 36 studies, including 29 randomized controlled trials and nonrandomized controlled clinical trials, 5 controlled before-and-after studies, and 2 interrupted time-series studies. Outcomes relating to management and outcome of depression were sought. Data Extraction  Methodological details and outcomes were extracted and checked by 2 reviewers. Summary relative risks were, where possible, calculated from original data and attempts were made to correct for unit of analysis error. Data Synthesis  A narrative synthesis was conducted. Twenty-one studies with positive results were found. Strategies effective in improving patient outcome generally were those with complex interventions that incorporated clinician education, an enhanced role of the nurse (nurse case management), and a greater degree of integration between primary and secondary care (consultation-liaison). Telephone medication counseling delivered by practice nurses or trained counselors was also effective. Simple guideline implementation and educational strategies were generally ineffective. Conclusions  There is substantial potential to improve the management of depression in primary care. Commonly used guidelines and educational strategies are likely to be ineffective. The implementation of the findings from this research will require substantial investment in primary care services and a major shift in the organization and provision of care.