Matthew Hotopf

Health of UK servicemen who served in Persian Gulf War

BACKGROUND Various symptoms in military personnel in the Persian Gulf War 1990-91 have caused international speculation and concern. We investigated UK servicemen. METHODS We did a cross-sectional postal survey on a random sample of Gulf War veterans (Gulf War cohort, n=4248) and, stratified for age and rank, servicemen deployed to the Bosnia conflict (Bosnia cohort, n=4250) and those serving during the Gulf War but not deployed there (Era cohort, n=4246). We asked about deployment, exposures, symptoms, and illnesses. We analysed men only. Our outcome measures were physical health, functional capacity (SF-36), the general health questionnaire, the Centers for Disease Control and Prevention (CDC) multisymptom criteria for Gulf War illness, and post-traumatic stress reactions. FINDINGS There were 8195 (65.1%) valid responses. The Gulf War cohort reported symptoms and disorders significantly more frequently than those in the Bosnia and Era cohorts, which were similar. Perception of physical health and ability were significantly worse in the Gulf War cohort than in the other cohorts, even after adjustment for confounders. Gulf War veterans were more likely than the Bosnia cohort to have substantial fatigue (odds ratio 2.2 [95% CI 1.9-2.6]), symptoms of post-traumatic stress (2.6 [1.9-3.4]), and psychological distress (1.6 [1.4-1.8]), and were nearly twice as likely to reach the CDC case definition (2.5 [2.2-2.8]). In the Gulf War, Bosnia, and Era cohorts, respectively, 61.9%, 36.8%, and 36.4% met the CDC criteria, which fell to 25.3%, 11.8%, and 12.2% for severe symptoms. Potentially harmful exposures were reported most frequently by the Gulf War cohort. All exposures showed associations with all of the outcome measures in the three cohorts. Exposures specific to the Gulf were associated with all outcomes. Vaccination against biological warfare and multiple routine vaccinations were associated with the CDC multisymptom syndrome in the Gulf War cohort. INTERPRETATION Service in the Gulf War was associated with various health problems over and above those associated with deployment to an unfamiliar hostile environment. Since associations of ill health with adverse events and exposures were found in all cohorts, however, they may not be unique and causally implicated in Gulf-War-related illness. A specific mechanism may link vaccination against biological warfare agents and later ill health, but the risks of illness must be considered against the protection of servicemen.

Medically unexplained symptoms: an epidemiological study in seven specialities.

OBJECTIVES This study aimed to estimate the prevalence and risk factors for medically unexplained symptoms across a variety of specialities. METHODS A cross-sectional survey was conducted at two general hospitals in southeast London between 1995 and 1997. Eight hundred and ninety consecutive new patients from seven outpatient clinics were included. Demographic and clinical characteristic variables were assessed. RESULTS Five hundred eighty-two (65%) of the subjects surveyed returned completed questionnaires. A final diagnosis was available in 550 (62%). Two hundred twenty-eight (52%) fulfilled criteria for medically unexplained symptoms. The highest prevalence was in the gynecology clinic (66%). After adjustment for confounders, medically unexplained symptoms were associated with being female, younger, and currently employed. Psychiatric morbidity per se was not associated with the presence of medically unexplained symptoms, but was more likely in those complaining of multiple symptoms. Those with medically unexplained symptoms were less disabled, but more likely to use alternative treatment in comparison with those whose symptoms were medically explained. Patients with medically unexplained symptoms were more likely to attribute their illness to physical causes as opposed to lifestyle factors. CONCLUSIONS Medically unexplained symptoms are common across general/internal medicine and represent the most common diagnosis in some specialities. Medical behavior, training, and management need to take this into account.

The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study.

BACKGROUND Concerns have been raised about the mental and physical health of UK military personnel who deployed to the 2003 war in Iraq and subsequent tours of duty in the country. METHODS We compared health outcomes in a random sample of UK armed forces personnel who were deployed to the 2003 Iraq war with those in personnel who were not deployed. Participants completed a questionnaire covering the nature of the deployment and health outcomes, which included symptoms of post-traumatic stress disorder, common mental disorders, general wellbeing, alcohol consumption, physical symptoms, and fatigue. FINDINGS The participation rate was 62.3% (n=4722) in the deployed sample, and 56.3% (n=5550) in the non-deployed sample. Differences in health outcomes between groups were slight. There was a modest increase in the number of individuals with multiple physical symptoms (odds ratio 1.33; 95% CI 1.15-1.54). No other differences between groups were noted. The effect of deployment was different for reservists compared with regulars. In regulars, only presence of multiple physical symptoms was weakly associated with deployment (1.32; 1.14-1.53), whereas for reservists deployment was associated with common mental disorders (2.47, 1.35-4.52) and fatigue (1.78; 1.09-2.91). There was no evidence that later deployments, which were associated with escalating insurgency and UK casualties, were associated with poorer mental health outcomes. INTERPRETATION For regular personnel in the UK armed forces, deployment to the Iraq war has not, so far, been associated with significantly worse health outcomes, apart from a modest effect on multiple physical symptoms. There is evidence of a clinically and statistically significant effect on health in reservists.

Depression in advanced disease: a systematic review - Part 1. Prevalence and case finding

Objective: To identify all literature regarding depression in patients with advanced cancer and among mixed hospice populations, and to summarise the prevalence of depression according to different definitions. Methods: A systematic review was performed using extensive electronic and hand searches. All studies with quantitative data on prevalence of depression were included and categorised according to their definition of depression. Results: We identified 46 eligible studies giving information on the prevalence of depression, and a further four which gave information on case finding. The most widely used assessment of depression was the Hospital Anxiety and Depression Scale (HADS), which gave a median prevalence of ‘definite depression’ (i.e., a score on the depression subscale of 10 of 29%, (interquartile range, IQR, 19.50 34.25%). Studies that used psychiatric interviews indicated a prevalence of major depressive disorder ranging from 5% to 26%, with a median of 15%. Studies were generally small (median sample size 88.5, IQR 50 108), had high numbers of nonresponders, and rarely gave confidence intervals for estimates of prevalence. Conclusions: Depression is a common problem in palliative care settings. The quality of much of the available research is poor, based on small samples of patients with very high nonparticipation rates. The clinical importance of depression is described in subsequent papers.

Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London

Objective Despite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth. Method People who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007–09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007–09, using a life table method. Results A total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007–09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). Conclusion The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.

Why do children have chronic abdominal pain, and what happens to them when they grow up? Population based cohort study

Abstract Objective: To test the hypotheses that children with abdominal pain have anxious parents and come from families with high rates of physical illness and that they grow up to suffer from high rates of medically unexplained symptoms and psychiatric disorders. Design: Population based birth cohort study. Setting: General population. Subjects: Participants in the Medical Research Council (MRC) national survey of health and development, a population based birth cohort study established in 1946. Main outcome measures: Abdominal pain present throughout childhood in the absence of defined organic disease, and measures of physical symptoms and psychiatric disorder at age 36 years. Results: There were high rates of complaints about physical health among the parents of children with persistent abdominal pain, and the mothers had higher neuroticism scores. Children with persistent abdominal pain were more likely to suffer from psychiatric disorders in adulthood (odds ratio 2.72 (95% confidence interval 1.65 to 4.49)) but were not especially prone to physical symptoms once psychiatric disorder was controlled for (odds ratio 1.39 (0.83 to 2.36)). Conclusions: Persistent abdominal pain is associated with poor health and emotional disorder in the parents. Children with abdominal pain do not necessarily continue to experience physical symptoms into adulthood but are at increased risk of adult psychiatric disorders. Key messages Persistent abdominal pain in childhood is more common in families with high rates of reported physical illness and psychological symptoms The outcome for persistent abdominal pain is good in terms of mortality Children with persistent abdominal pain are not at greatly increased risk of developing physical symptoms in adulthood Abdominal pain in childhood is associated with considerably increased risk of psychiatric disorders in adulthood

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

BACKGROUND Although mental incapacity is becoming increasingly important in clinical practice, little information is available on its frequency in medical inpatients. We aimed to estimate the prevalence of mental incapacity in acutely admitted medical inpatients; to determine the frequency that medical teams recognised patients who did not have mental capacity; and to identify factors associated with mental incapacity. METHODS Over an 18-month period, we recruited 302 consecutive acute medical inpatients. Participants were assessed with the MacArthur competence tool for treatment and by clinical interview. Cognitive impairment was measured by the mini-mental state examination. FINDINGS 72 (24%) patients were severely cognitively impaired, unconscious, or unable to express a choice and were automatically assigned to the incapacity group. 71 (24%) refused to participate or could not speak English. Thus, 159 patients were interviewed. Of these, 31% (95% CI 24-38) were judged not to have mental capacity. For the total sample (n=302), we estimated that at least 40% did not have mental capacity. Clinical teams rarely identified patients who did not have mental capacity: of 50 patients interviewed, 12 (24%) were rated as lacking capacity. Factors associated with mental incapacity were increasing age and cognitive impairment. INTERPRETATION Mental incapacity is common in acutely ill medical inpatients, and clinicians tend not to recognise it. Screening methods for cognitive impairment could be useful in detecting those with doubtful capacity to consent.

The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis

Objective. There is substantial uncertainty regarding the prevalence of depression in RA. We conducted a systematic review aiming to describe the prevalence of depression in RA. Methods. Web of Science, PsycINFO, CINAHL, Embase, Medline and PubMed were searched for cross-sectional studies reporting a prevalence estimate for depression in adult RA patients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and a meta-analysis was performed. Results. A total of 72 studies, including 13 189 patients, were eligible for inclusion in the review. Forty-three methods of defining depression were reported. Meta-analyses revealed the prevalence of major depressive disorder to be 16.8% (95% CI 10%, 24%). According to the PHQ-9, the prevalence of depression was 38.8% (95% CI 34%, 43%), and prevalence levels according to the HADS with thresholds of 8 and 11 were 34.2% (95% CI 25%, 44%) and 14.8% (95% CI 12%, 18%), respectively. The main influence on depression prevalence was the mean age of the sample. Conclusion. Depression is highly prevalent in RA and associated with poorer RA outcomes. This suggests that optimal care of RA patients may include the detection and management of depression.

Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study

Abstract Objective: To elucidate the associations between frequent headache and psychosocial factors in childhood and to determine whether such children are at an increased risk of headache, multiple physical symptoms, and psychiatric symptoms in adulthood. Design: Population based birth cohort study. Setting: General population. Participants: People participating in the national child development study, a population based birth cohort study established in 1958. Main outcome measures: Headache, multiple physical symptoms, and psychiatric morbidity at age 33. Results: Headache in childhood was associated with several psychosocial factors. Prospectively, children with frequent headache had an increased risk in adulthood of headache (odds ratio 2.22, 95% confidence interval 1.62 to 3.06), multiple physical symptoms (1.75, 1.46 to 2.10), and psychiatric morbidity (1.41, 1.20 to 1.66). The outcomes of headache and multiple physical symptoms were not accounted for by psychiatric morbidity. Conclusion: Children with headache are at an increased risk of recurring headache in adulthood and may complain of other physical and psychiatric symptoms. Strategies for coping with psychosocial adversity in childhood may improve the prognosis in adulthood. What is already known on this topic Common somatic symptoms in childhood are associated with psychosocial factors and may increase the risk of physical and psychiatric symptoms in adulthood No study has yet examined at the general population level the outcome as an adult of headache, the commonest somatic complaint in childhood What this study adds Children who mention headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical symptoms and psychiatric symptoms

A Systematic Review and Meta-Analysis of the Pharmacological Treatment of Cancer-Related Fatigue

BACKGROUND Cancer-related fatigue is an important clinical problem. It is common, distressing, and often difficult to treat. There is a role for drug treatment of cancer-related fatigue, but no consensus has been reached on which drugs are useful. This systematic review and meta-analysis aims to review the available evidence and make recommendations for practice and research. METHODS We searched the Cochrane register of controlled trials (through the second quarter 2007), Medline (January 1, 1966, through August 1, 2007), and EMBASE (January 1, 1980, through August 1, 2007) by use of a predetermined list of search terms. Cochrane Collaboration meta-analysis review methodology was used for this study. The change in fatigue score on the instrument used in each study and other outcomes of interest (adverse events and withdrawal rates) were compared between treatment and control arms by use of the standardized mean difference (SMD) with 95% confidence intervals (CIs). All statistical tests were two-sided. RESULTS We identified 27 eligible trials of drug treatments for cancer-related fatigue (with a total of 6746 participants). The overall effect size for all drug classes was small. A meta-analysis of two studies (n = 264 patients) indicated that methylphenidate (a psychostimulant) was superior to placebo (standardized mean difference [SMD] in change in fatigue score = -0.30, 95% confidence interval [CI] = -0.54 to -0.05; P = .02) for treating cancer-related fatigue. A meta-analysis of 10 studies (n = 2226 patients) evaluating erythropoietin in anemic cancer patients who were undergoing chemotherapy indicated that erythropoietin was superior to placebo (SMD = -0.30, 95% CI = -0.46 to -0.29; P = .008). Among anemic patients (four studies with n = 964 patients), improvement in fatigue was associated with darbepoetin treatment compared with placebo treatment (SMD = -0.13, 95% CI = -0.27 to 0.00; P = .05). Progestational steroids and paroxetine were no better than placebo in the treatment of cancer-related fatigue. CONCLUSIONS There is some evidence that treatment of cancer-related fatigue with methylphenidate appears to be effective. More robust evidence indicates that treatment with hematopoietic agents appears to relieve cancer-related fatigue caused by chemotherapy-induced anemia. Further confirmatory trials are required for both observations.