Linda McGowan

Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis.

Objective This systematic review and meta-analysis examined the strength of association between rheumatoid arthritis and depression. In addition, we investigated the extent to which sociodemographic characteristics, level of pain, and method of assessing depression might affect the degree of depression. Methods CD-ROM databases and bibliographies were searched to identify all studies comparing depression in patients with rheumatoid arthritis and control subjects using standardized assessments. Effect sizes (Pearson’s r) and probabilities were combined across studies. We examined the extent to which the association between rheumatoid arthritis and depression could be attributed to level of pain (using contrasts), sociodemographic differences between groups (combining methodologically restricted studies), and methods of assessing depression (examining heterogeneity across studies). Results Twelve independent studies comparing depression in patients with rheumatoid arthritis with depression in healthy control subjects were found. Effect sizes for depression were small to moderate (r = .21, p < .0001; heterogeneous). This effect was not reduced in studies controlling for sociodemographic characteristics (r = .27, p < .0001). The effect sizes did vary in a linear manner in proportion to the effect size for pain (z = 2.67, p = .0064). The effect sizes produced by different measures of depression were heterogeneous (&khgr;2 for Fisher’s Z = 24.6, p = .0002), with the Hospital Anxiety and Depression Scale giving effect sizes most dissimilar to those of other measures. Conclusions Depression is more common in patients with rheumatoid arthritis than in healthy individuals. This difference is not due to sociodemographic differences between groups, but it may be attributable, in part, to the levels of pain experienced. Variation in the methods of assessing depression partly accounts for the differences among studies examining the levels of depression in patients with rheumatoid arthritis.

Impact of depression on experimental pain perception: A systematic review of the literature with meta-analysis

Objective This systematic review and meta-analysis was performed to examine the impact of depression on the perception of experimental pain stimuli. Methods CD-ROM databases and bibliographies were searched to identify studies comparing the psychophysical responses to experimental pain stimuli of depressed subjects with that of healthy controls. Effect sizes (Cohen’s d) and probabilities were combined across studies; positive effect sizes indicated higher thresholds in depressed groups. Results Six methodologically rigorous, independent studies were found comparing psychophysical responses to experimental pain stimuli in depressed subjects and healthy controls. Pain perception threshold was higher in depressed subjects (6 studies, d = 0.38, p = .001). This finding was not the result of publication bias. Absolute sensory perception threshold was much higher in depressed subjects (2 studies, d = 0.68, p = .002), though the findings for pain tolerance (2 studies) were too heterogeneous to enable us to combine results. Conclusions Depressed subjects are less likely to perceive a sensory stimulus as being painful compared with nondepressed controls. The influence of depression on attention to the pain stimulus may account for this effect. More studies are required to enable us to determine the impact of depression on absolute sensory perception threshold and pain tolerance. Furthermore, more studies would enable the examination of depression on the perception of different modalities.

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.

Lack of a close confidant, but not depression, predicts further cardiac events after myocardial infarction

Objective: To assess the role of depression and lack of social support before myocardial infarction (MI) in determining outcome in a large representative sample of patients admitted after MI in the UK. Design: Prospective cohort design. Patients: 1034 consecutive patients were screened 3–4 days after MI. Main outcome measures: Mortality and further cardiac events over one year after an MI. Results: At 12 months’ follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p  =  0.022). Conclusion: Lack of a close confidant but not depression before MI was associated with adverse outcome after MI in this sample. This association may be mediated by unhealthy behaviours and lack of compliance with medical recommendations, but it is also compatible with difficulties in early life leading to heart disease.

The relationship between vital exhaustion, depression and comorbid illnesses in patients following first myocardial infarction

OBJECTIVE Vital exhaustion and depression are both independent risk factors for cardiovascular disease, yet the relationship between these highly similar dimensions remains unclear. We have examined the association between depression and vital exhaustion and investigated the extent to which any association is the result of comorbid illnesses. METHODS Three hundred and five consecutive patients were examined on average 3.6 days following hospital admission with first myocardial infarction (MI). The Maastricht Questionnaire (MQ; vital exhaustion) was administered together with the Hospital Anxiety and Depression Scale (HADS), and details of comorbid physical illness were recorded. The factor structure of the MQ was explored using factor analysis. RESULTS Depression and vital exhaustion were highly correlated (r=.61, P<.01). This correlation did not diminish on controlling for age, sex, and comorbidity (r=.59, P<.01). Factor analysis of MQ score gave a four-factor solution: fatigue (18.2% of variance), depression (17.9%), lack of concentration (9.5%), and sleep difficulties (8.1%). The fatigue dimension of the MQ remained highly associated with HADS depression score (r=.50, P<.01), controlling for age, sex, and comorbidity. CONCLUSIONS Depression and fatigue are highly correlated and their association is not attributable to comorbid physical illnesses or the tendency of the MQ to measure depression. Future studies should investigate fatigue instead of vital exhaustion as a potential risk factor for poor cardiac prognosis independent of the influence of depression.

The risk factors for depression in first myocardial infarction patients

BACKGROUND Depression affects outcome following myocardial infarction but the risk factors for such depression have been little studied. This study considered whether the causes of depression occurring before and after myocardial infarction were similar to those of depression in the general population. METHOD Consecutive patients admitted to hospital following their first myocardial infarction were interviewed with the Schedule for Clinical Assessment in Neuropsychiatry to detect psychiatric disorders and the Life Events and Difficulties Schedule to assess recent stress. Participants completed the Hospital Anxiety and Depression Scale (HADS) at entry to the study and 1 year later and the risk factors associated with a high score at both times were assessed. RESULTS Of 314 (88% of eligible) patients who were recruited, 199 (63%) were male and 63 (20%) had depressive disorders. Logistic regression identified the following as independently associated with depressive disorder that had been present for at least I month before the myocardial infarction: younger age, female sex, past psychiatric history, social isolation, having marked non-health difficulties and lack of a close confidant. At follow-up 269/298 (90%) responded; of 189 participants not depressed at first assessment, 39 (21%) became depressed by the 1 year follow-up. Logistic regression identified frequent angina as the only significant predictor of raised HADS scores at 12 months. CONCLUSIONS Depression developing during the year following myocardial infarction does not have the same risk factors as that which precedes myocardial infarction. Further clarification of the mechanisms linking depression to poor outcome may require separation consideration of pre- and post-myocardial infarction depression, and its risk factors.

A qualitative study of mild to moderate psychological distress during pregnancy

BACKGROUND Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild-moderate psychological distress. OBJECTIVE This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care. DESIGN A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis. SETTING A large teaching maternity hospital in North West England. PARTICIPANTS Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care. RESULTS Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements. CONCLUSIONS Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have.

Chronic pelvic pain: A meta-analytic review

Abstract Chronic pelvic pain (CPP) in women of reproductive age is a common complaint; for many women no identifiable pathology can be found. Research has suggested that women who have chronic pelvic pain without obvious pathology differ on a range of psychological characteristics, such as anxiety and depression, compared with those with identified pathology. A meta-analysis of 22 studies was undertaken to clarify these issues. Results showed that there were no significant differences on a range of psychological variables between women who were identified, via laparoscopy and clinical judgement, as having organic disorders and those who were not so identified. When women with chronic pelvic pain were compared with pain-free groups a profile of elevated depression, anxiety, neuroticism and psychopathology was found which is consistent with findings from studies of other painful conditions.

Negative illness perceptions are associated with new-onset depression following myocardial infarction

OBJECTIVE To test the hypothesis that negative perceptions about heart disease at the time of the myocardial infarction (MI) were associated with the onset of new episodes of depression following MI. METHOD We recruited 269 subjects admitted following first MI and monitored their depression status over the subsequent 12 months. At baseline, we recorded demographic information, family and personal history of cardiac disease and severity of MI; subjective health beliefs were assessed using the Illness Perceptions Questionnaire (IPQ). We assessed depression at baseline, 6 and 12 months following MI using a standardised questionnaire, validated in this population against a semistructured research interview. RESULTS In the days following MI, patients who subsequently developed depression were more likely to anticipate that their heart disease would last a long time (P=.012) and was unlikely to be cured (P=.038). Controlling for potential confounding variables, scores on the IPQ remained associated with subsequent depression (P = .036), with anticipation that heart disease would last a long time [odds ratio (OR)=2.7, P=.013] and that heart disease could be cured (OR=0.45, P=.048) showing strongest association. CONCLUSIONS Negative perceptions about heart disease in the days following admission to hospital with first MI are associated with the development of subsequent new episodes of depression.

‘How do you explain a pain that can't be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle

OBJECTIVES Chronic pelvic pain (CPP) has an adverse effect on womens quality of life. Research has suggested that many women become dissatisfied with their care and withdraw from seeking help despite continuing symptoms. The aim of this study was to explore the processes which lead to disengagement and to understand the psychosocial processes that affect this group of women. DESIGN A qualitative narrative approach was used, guided by phenomenological-hermeneutic tradition, and informed by the philosophy of Paul Ricoeur. METHOD Thirty-two women with CPP were asked to write their stories about their illness trajectories. These written stories served as data which were analysed thematically according to narrative theory. RESULTS In the search for validation and recognition women engaged in the diagnostic cycle. Many women do not complete this cycle, become stuck at a certain point, or re-enter the cycle repeatedly. They can only opt out if the problem is resolved or by choosing to disengage with medical care. CONCLUSIONS While the medical consultation was a dominant theme, a complex interaction of factors was required to initiate disengagement. The dualistic nature of the diagnostic process prohibits women from telling their stories. Women were left feeling disempowered and in limbo, and they were at a loss as to how to manage their pain.