Barbara Tomenson

Coronary risk factors in people from the Indian subcontinent living in West London and their siblings in India

Several reports have shown that migrants from southeast Asia tend to have an increased risk of coronary heart disease when settled in their new country. We compared coronary risk factors in a randomly selected group of 247 migrants from the Indian subcontinent of Punjabi origin living in West London and 117 of their siblings living in the Punjab in India. The West London cohort had a greater body mass index (p < 0.001), systolic blood pressure (p = 0.0087), serum cholesterol (p < 0.001), apolipoprotein B (p < 0.001), lower high-density lipoprotein cholesterol (p < 0.05) and higher fasting blood glucose (p < 0.05) than their siblings in the Punjab. Insulin sensitivity, derived from the homoeostatic assessment mathematical model, was lower in men in West London than in their counterparts in India (p < 0.05). Indians in West London had lower beta cell function than those in the Punjab (p < 0.001). Serum lipoprotein (a) concentrations were similar in both the West London and Punjab population, but were significantly higher (p = 0.01) than those of white European populations in the UK. Increases in serum cholesterol after migration from India lead to increased coronary risk conferred by high serum lipoprotein (a) concentrations and greater insulin resistance. Such between-country comparisons are an important means of establishing the importance of coronary risk factors.

Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn's disease

OBJECTIVE:The determinants of health-related quality of life in inflammatory bowel disease are not completely understood. The present study aimed to assess two factors in patients with inflammatory bowel disease: a) whether health-related quality of life is independently associated with both bowel disease severity and psychological disorder, and b) whether Crohns disease is associated with more marked psychological disorder than ulcerative colitis.METHODS:116/170 (68%) consecutive patients with inflammatory bowel disease attending a GI clinic (37 patients with ulcerative colitis, 75 patients with Crohns disease, and four unspecified) completed the following self-report questionnaires: demographic details, a modified disease activity index, a total severity measure, the Hospital Anxiety and Depression Scale, and the Short Form-36.RESULTS:Thirty patients (25.9%) scored 11 or more on either the depression or anxiety subscales of the Hospital Anxiety and Depression Scale indicating probable psychological disorder; 55% (47.4%) scored over 8 indicating possible psychological disorder. Stepwise multiple regression analyses showed that both psychological symptoms and disease severity or activity contributed independently to impaired health-related quality of life. After severity of disease was taken into account, there were no significant differences between Crohns disease and ulcerative colitis in terms of depression scores and health-related quality of life.CONCLUSIONS:The presence of psychological disorder in inflammatory bowel disease contributes to poor health-related quality of life, regardless of the severity of the condition. Detection and treatment of psychological disorder in inflammatory bowel disease carries the potential to improve health-related quality of life for these patients.

Embarking upon a medical career: psychological morbidity in first year medical students

This study was undertaken to measure the prevalence of psychological morbidity, and the nature and source of stress, in first year medical students. Two hundred and four first year medical students at a university in the north of England were sent a postal, self‐report questionnaire. They were asked to complete the General Health Questionnaire (GHQ), the Stress Incident Record and to give details of their alcohol consumption. A total of 172 students (84·3%) replied. Thirty‐six per cent of the students scored above the threshold of the GHQ, indicating probable psychological disturbance. There was no difference between men and women. Approximately half of the students described a stressful incident, the majority of which were related to medical training rather than to personal problems. Male students reported drinking significantly more alcohol than female students, but there was no relationship between levels of alcohol consumption and either psychological disturbance or reporting of stress.

Depression and social stress in Pakistan

BACKGROUND The high prevalence of depression in developing countries is not well understood. This study aimed to replicate the previous finding of a high prevalence of depression in Pakistan and assess in detail the associated social difficulties. METHOD A two-phase survey of a general population sample in a Pakistani village was performed. The first-phase screen used the Personal Health Questionnaire (PHQ) and the self-rating questionnaire (SRQ). A one in two sample of high scorers and a one in three sample of the low scorers were interviewed using the Psychiatric Assessment Schedule (PAS) and Life Events and Difficulties Schedule (LEDS). RESULTS A total of 259 people were screened (96% response rate). The second stage yielded 55 cases, of whom 54 had depressive disorder, and 48 non-cases. The adjusted prevalence of depressive disorders was 44-4% (95% CI 35.3 to 53.6): 25.5% in males and 57.5% in females. Nearly all cases had lasted longer than 1 year. Comparison of the cases and non-cases indicated that cases were less well educated, had more children and experienced more marked, independent chronic difficulties. Multivariate analysis indicated that severe financial and housing difficulties, large number of children and low educational level were particularly closely associated with depression. CONCLUSION This study confirms the high prevalence of depressive disorders in Pakistan and suggests that this may be higher than other developing countries because of the high proportion of the population who experience social adversity.

Estimating treatment effects from randomized clinical trials with noncompliance and loss to follow-up: the role of instrumental variable methods:

Perfectly implemented randomized clinical trials, particularly of complex interventions, are extremely rare. Almost always they are characterized by imperfect adherence to the randomly allocated treatment and variable amounts of missing outcome data. Here we start by describing a wide variety of examples and then introduce instrumental variable methods for the analysis of such trials. We concentrate mainly on situations in which compliance is all or nothing (either the patient receives the allocated treatment or they do not - in the latter case they may receive no treatment or a treatment other than the one allocated). The main purpose of the review is to illustrate the use of latent class (finite mixture) models, using maximum likelihood, for complier-average causal effect estimation under varying assumptions concerning the mechanism of the missing outcome data.

New onset depression following myocardial infarction predicts cardiac mortality.

Objective: Studies investigating the effects of depression on mortality following myocardial infarction (MI) have produced heterogeneous findings. We report on a study investigating whether the timing of the onset of depression, with regard to the MI, affected its impact on subsequent cardiac mortality. Methods: Five hundred and eighty-eight subjects admitted following MI underwent assessments of cardiac status, cardiac risk factors, and noncardiac illness. We identified separately subjects who were depressed before their MI (pre-MI depression) and those who developed depression in the 12 months after MI (new-onset depression), using a standardized questionnaire and a research interview. Patients dying of cardiac cause were identified during 8-year follow-up using information from death certificates. Results: Multivariate predictors of cardiac death during follow-up included: greater age (hazards ratio (HR) = 1.06, p = .007), previous angina (HR = 4.15, p < .0005), high Killip Class (HR = 2.21, p = .013), prescription of beta-blockers on discharge (HR = 0.37, p = .02), and new-onset depression (HR = 2.33, p = .038). Pre-MI depression did not convey any additional risk of cardiac mortality. Conclusion: We have shown increased cardiac mortality in patients who develop depression after suffering MI. Further observational studies need to separate pre- and post-MI depression if we are to determine underlying mechanisms by which depression is associated with mortality following MI. MI = myocardial infarction; CPK = creatine phosphokinase; ECG = electrocardiogram; WHO = World Health Organization; HADS = Hospital Anxiety and Depression Scale; ICD-10 = 10th version of the International Classification of Diseases; SCAN = schedule for assessment in neuropsychiatry; ACE Inhibitors = angiotensin converting enzyme inhibitors; CABG = coronary artery bypass graft; SD = standard deviation.

Psychosocial predictors of health-related quality of life and health service utilisation in people with chronic low back pain

&NA; Psychological and social factors have been shown, separately, to predict outcome in individuals with chronic low back pain. Few previous studies, however, have integrated both psychological and social factors, using prospective study of clinic populations of low back pain patients, to identify which are the most important targets for treatment. One hundred and eight patients with chronic low back pain, newly referred to an orthopaedic outpatient clinic, completed assessments of demographic characteristics, details of back pain, measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS), fearful beliefs about pain (Fear Avoidance Beliefs Questionnaire), social stresses (Life Events and Difficulties Schedule) and physical aspects of health‐related quality of life [SF‐36 Physical Component summary Score scale (PCS)]. Six months later subjects completed the SF‐36 PCS and the number of healthcare contacts during follow‐up was recorded. Independent predictors of SF‐36 PCS at 6‐month follow‐up were duration of pain [(standardised regression coefficient (β) = −0.18, p = 0.04), HADS score (β) = −0.27, p = 0.003] and back pain related social difficulties (β = −0.42, p < 0.0005). Number of healthcare contacts over the 6 months ranged from 1 to 29, and was independently predicted by perceived cause of pain [Incident Rate Ratio (IRR) = 1.46, p = 0.03], Fear Avoidance Beliefs about work (IRR = 1.02, p = 0.009) and back pain related social difficulties (IRR = 1.16, p = 0.03). To conclude, anxiety, depression, fear avoidance beliefs relating to work and back pain related stresses predict impairment in subsequent physical health‐related quality of life and number of healthcare contacts. Interventions targeting these psychosocial variables in clinic patients may lead to improved quality of life and healthcare costs.

Randomised controlled trial of day patient versus inpatient psychiatric treatment.

OBJECTIVE--To assess the proportion of acutely ill psychiatric patients who can be treated in a day hospital and compare the outcome of day patient and inpatient treatment. DESIGN--Prospective randomised controlled trial of day patient versus inpatient treatment after exclusion of patients precluded by severity of illness or other factors from being treated as day patients. All three groups assessed at three and 12 months. SETTING--Teaching hospital serving small socially deprived inner city area. Day hospital designed to take acute admissions because of few beds. PATIENTS--175 Patients were considered, of whom 73 could not be allocated. Of the remaining 102 patients, 51 were allocated to each treatment setting but only 89 became established in treatment--namely, 41 day patients and 48 inpatients. 73 Of these 89 patients were reassessed at three months and 70 at one year. INTERVENTIONS--Standard day patient and inpatient treatment. MAIN OUTCOME MEASURES--Discharge from hospital and return to previous level of social functioning; reduction of psychiatric symptoms, abnormal behaviour, and burden on relatives. RESULTS--33 Of 48 inpatients were discharged at three months compared with 17 of 41 day patients. But at one year 9 of 48 inpatients and three of 41 day patients were in hospital. 18 Of 35 day patients and 16 of 39 inpatients were at their previous level of social functioning at one year. The only significant difference at three months was a greater improvement in social role performance in the inpatients. At one year there was no significant difference between day patients and inpatients in present state examination summary scores and social role performance, burden, or behaviour. CONCLUSIONS--Roughly 40% of all acutely ill patients presenting for admission to a psychiatric unit may be treated satisfactorily in a well staffed day hospital. The outcome of treatment is similar to that of inpatient care but might possibly reduce readmissions. The hospital costs seem to be similar but further research is required to assess the costs in terms of extra demands on relatives, general practitioners, and other community resources.

A prospective study of psychiatric disorder and cognitive function in systemic lupus erythematosus.

OBJECTIVES--To investigate change in psychiatric disorder and change in cognitive function in patients with systemic lupus erythematosus (SLE) assessed on two occasions two years apart. METHODS--A prospective cohort study of 49 patients with SLE using standardised psychiatric and clinical research methods. RESULTS--The point prevalence of psychiatric disorder (20% and 24%), and of cognitive impairment (23% and 18%), was similar at first and second interview for the whole group. There was, however, considerable change in individual patients psychiatric status and cognitive function: only 1/9 patients with impairment on two or more cognitive tests at first interview was still impaired at second interview. Change in cognitive function appeared to mirror change in psychiatric status. CONCLUSIONS--These findings suggest that the previously reported high prevalence of cognitive impairment in SLE may be explained by coexisting psychiatric disorder, rather than reflecting subclinical central nervous system (CNS) involvement.

Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: A comparison with routine attenders

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8--18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3--47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5--2959.0), and more GP visits (95% CI for difference=-10.2 to -5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.