Péter Torzsa

Association between restless legs syndrome and depression in patients with chronic kidney disease.

Restless legs syndrome (RLS) is reportedly associated with depression. This association may be mediated by both sleep-dependent and sleep-independent mechanisms. Here we analyze the association between RLS and depressive symptoms in patients with chronic kidney disease (CKD). We also assessed whether the relationship is independent of insomnia. In a cross-sectional study, socio-demographic parameters, laboratory data, and medical history were collected from 788 kidney transplant patients and 161 dialyzed patients. Insomnia, depression, and the presence of RLS symptoms were assessed with standard questionnaires. Patients with probable RLS had a higher prevalence of depressive symptoms than those without RLS (56% vs. 22% with vs. without RLS, respectively; P<.001). Patients presenting RLS symptoms had higher Athens Insomnia Scale (AIS) scores than patients without RLS [median AIS score (interquartile range): 7 (6) vs. 3 (4) with vs. without RLS, respectively; P<.001]. The AIS score correlated with the CES-D score (Spearmans rho=0.54, P<.001). In multivariate analysis, the presence of RLS symptoms was independently associated with depressive symptoms (OR=3.96, 95% CI 2.21-7.1, P<.001). This relationship remained significant even after including insomnia in the model (OR=2.9, CI 1.55-5.43, P<.001). The presence of RLS symptoms is associated with depression in patients with CKD. This relationship remained significant even after accounting for insomnia. Sleep-independent mechanisms may also contribute to the association between RLS and depression in patients with CKD.

Affective temperament, history of suicide attempt and family history of suicide in general practice patients

BACKGROUND Untreated major affective disorders are strongly associated with suicidal behaviour; however, clinical, psychological and psycho-social risk factors also play a contributory role. Personal history and family history of suicide are also important predictors of suicidal behaviours, and are also a powerful marker of current major depressive episode in general practice patients. Affective temperaments, which can be considered the subaffective manifestations of major mood disorders also show a specific pattern of association with suicidal behaviour. In the present study our aim was to investigate the association between affective temperaments, personal history of suicide attempts and family history of completed suicide in primary practice patients. METHODS Five hundred and nine patients from 6 primary care practices completed the TEMPS-A, and were assessed concerning self-reported history of personal or family suicide. RESULTS We found that among those answering questions concerning suicide, 9.1% reported a family history of suicide in first and second degree relatives and 4.8% had at least one prior suicide attempt. Among those giving a positive answer to both questions, those who had a positive family history had significantly more frequent suicide attempts (15.4% vs. 4.0%). Patients with prior suicide attempts had a significantly higher score on the cyclothymic and depressive, and those with positive family history of suicide had on cyclothymic and anxious subscales. LIMITATIONS In the present study, personal and family history of suicide was assessed retrospectively and in a self-report way. The cross-sectional nature of this study and the facts that no current psychiatric morbidity has been investigated and only the documented history of depressive and anxiety disorders have been detected limit the generalisability of this study. DISCUSSION We found a significant relationship between depressive and cyclothymic affective temperament and personal history of suicide attempts, and between cyclothymic and anxious temperament and family history of completed suicide in first and second degree relatives. This is in line with previous findings showing a strong relationship between these affective temperaments and major mood episodes and that these temperaments are overrepresented among suicide attempters. Our findings also suggest that the presence of cyclothymic (and to lesser extent depressive) affective temperament in a patient with family history of completed suicide indicates a very high risk of suicidal behaviour.

Primary-care physicians' views about the use of home/self blood pressure monitoring: nationwide survey in Hungary.

Objective To obtain unbiased views of primary-care physicians about home blood pressure monitoring (HBPM). Methods A mail survey was conducted in a random sample (n = 700) of all Hungarian primary-care physicians (n = 5112). Items in the questionnaire related to the extent and indications for use of HBPM, to the significance attributed to its results, to the methods of its use, and to concerns physicians had with HBPM. Results Of the 700 questionnaires, 405 (58%) could be analysed. HBPM was popular among the respondents: 60% of them had more then 50 patients on HBPM, 90% of them were recommending its use either ‘often’ or ‘almost all the time’, and 75% of them considered the results of HBPM of either ‘considerable’ or of ‘extreme importance’. The most frequent indications for use were white-coat hypertension (97%), assessing 24-h drug effects (87%), improving compliance (82%), suspicion of hypotension (63%), and resistant hypertension (61%). Physicians actively recommended devices with an upper-arm cuff (83%), equipped with a built in memory (63%). Most respondents (67%) had someone in their offices to teach the patient the correct measurement technique. Surprisingly, 65% of the physicians only reviewed the data to obtain a ‘general picture’ and did not analyse the data. Most of the respondents (78%) encouraged their patients to call their offices, and 90% of them did receive a call. Main concerns with HBPM were the use of non-validated devices (75%), and patient preoccupation with blood pressure (55%). Areas for suggested improvements were the need for patient training facilities (48%), established measurement protocols (44%) and better methods of displaying readings (30%). Conclusions We found an unexpected popularity in the use of HBPM among primary-care physicians. In order to fully exploit the benefits of HBPM, the concerns raised (validated devices, patient preoccupation) and areas to be improved upon (patient training, better methods of displaying results) will have to be addressed by researchers, societies and the industry.

The effect of low-dose carvedilol, nebivolol, and metoprolol on central arterial pressure and its determinants: a randomized clinical trial.

In this prospective, open‐label, randomized, controlled clinical trial the effects of low‐dose carvedilol, nebivolol, and metoprolol on central arterial pressure and augmentation index (AIx) and its heart rate–corrected value (AIx@75) were assessed. The authors randomized 75 hypertensive patients (18–70 years) to carvedilol 12.5/25 mg, metoprolol 50/100 mg, or nebivolol 2.5/5 mg daily and followed them up for 3 months. Central arterial pressure and AIx were measured with applanation tonometry at baseline and at the end of follow‐up. Analyses were restricted to 60 completers. Central systolic pressure decreased equally in all 3 treatment arms. AIx remained unchanged, while AIx@75 decreased significantly by 5.4%±2.5% in the nebivolol group. According to general linear models, individual change in heart rate was a strong predictor of change in AIx in the carvedilol group (r2=0.23, P=.03) although no similar association was found in the nebivolol group (r2=0.09). The impact of β‐blockers with vasodilator effects on pressure augmentation seems to be different with nebivolol having the largest potential of decreasing AIx@75. While AIx changes associated with carvedilol treatment are strongly driven by heart rate changes, those associated with nebivolol treatment seem to be the result of other mechanisms.

Primary care obesity management in Hungary: evaluation of the knowledge, practice and attitudes of family physicians

BackgroundObesity, a threatening pandemic, has an important public health implication. Before proper medication is available, primary care providers will have a distinguished role in prevention and management. Their performance may be influenced by many factors but their personal motivation is still an under-researched area.MethodsThe knowledge, attitudes and practice were reviewed in this questionnaire study involving a representative sample of 10% of all Hungarian family physicians. In different settings, 521 practitioners (448 GPs and 73 residents/vocational trainees) were questioned using a validated questionnaire.ResultsThe knowledge about multimorbidity, a main consequence of obesity was balanced.Only 51% of the GPs were aware of the diagnostic threshold for obesity; awareness being higher in cities (60%) and the highest among residents (90%). They also considered obesity an illness rather than an aesthetic issue.There were wider differences regarding attitudes and practice, influenced by the the doctors’ age, gender, known BMI, previous qualification, less by working location.GPs with qualification in family medicine alone considered obesity management as higher professional satisfaction, compared to physicians who had previously other board qualification (77% vs 68%). They measured their patients’ waist circumference and waist/hip ratio (72% vs 62%) more frequently, provided the obese with dietary advice more often, while this service was less frequent among capital-based doctors who accepted the self-reported body weight dates by patients more commonly. Similar reduced activity and weight-measurement in outdoor clothing were more typical among older doctors.Diagnosis based on BMI alone was the highest in cities (85%). Consultations were significantly shorter in practices with a higher number of enrolled patients and were longer by female providers who consulted longer with patients about the suspected causes of developing obesity (65% vs 44%) and offered dietary records for patients significantly more frequently (65% vs 52%). Most of the younger doctors agreed that obesity management was a primary care issue.Doctors in the normal BMI range were unanimous that they should be a model for their patients (94% vs 81%).ConclusionMore education of primary care physicians, available practical guidelines and higher community involvement are needed to improve the obesity management in Hungary.

Socio-demographic characteristics, health behaviour, co-morbidity and accidents in snorers: a population survey

ObjectiveWe assessed the socio-demographic correlates of snoring and also the patterns of health behaviour and co-morbidity associated with different types of snoring in the Hungarian population. We wanted to study whether different types of snoring are associated with high-risk health behaviour, chronic illnesses, daytime consequences of poor sleep, and with frequent accidents compared with non-snoring individuals.MethodThis is a cross-sectional study. Interviews were carried out in the homes of 12,643 people. This was the largest nationally representative study in Central Europe about health behaviour. In the Athens Insomnia Scale, questions about snoring and sleep behaviour, life-style factors and health behaviour, as well as questions on their history and current medical treatment were included in the questionnaire.ResultsThirty-seven percent of males and 21% of females reported loud snoring with breathing pauses. We found a significant increasing trend for the consumption of alcohol and coffee as well as smoking among non-snorers, habitual snorers and loud snorers, respectively. In an ordinal regression model male gender, the presence of smoking, the presence of three or more co-morbid conditions and alcohol consumption were independent predictors of snoring (OR [95% CI], 1.99 [1.85–2.1], 1.76 [1.60–1.92], 1.45 [1.30–1.62] and 1.22 [1.04–1.43], respectively, P < 0.001) after controlling for multiple socio-demographic and clinical variables. The frequency of accidents was higher in the loud snoring group than among non-snoring individuals (24% vs 17%, P < 0.0001).ConclusionsSnoring is common in the Hungarian adult population. Snoring, especially loud snoring with breathing pauses, is strongly associated with high-risk health behaviour, higher co-morbidity and a higher frequency of accidents.

Gyakori a magas fokú kiégés a háziorvosok és háziorvosi rezidensek körében

UNLABELLED General practitioners (GPs) play a central role in patient care and are exposed to high levels of work strain and consequent burnout due to the large number of stressful patient-doctor relationships. Despite the high likelihood of burnout among GPs, limited information is available about this topic. AIMS To explore the prevalence of burnout among GPs and residents in Hungary. METHODS Exploratory/descriptive, cross-sectional study with self-administered questionnaires among 453 GPs and 43 residents. To assess burnout, the Maslach Burnout Inventory (MBI-GS) was used. To evaluate the level of burnout, mean (+/- SD) scores on the emotional exhaustion, cynicism/depersonalization, and personal accomplishment dimensions of the MBI were determined among male and female GPs and residents. Differences in the level or degree of burnout (high, intermediate and low) in all three burnout dimensions between male and female GPs and residents were examined by independent samples t -test and chi 2 -tests. Socio-demographic antecedents to burnout were assessed by linear regression analyses. RESULTS Residents reported significantly lower cynicism/depersonalization [ t (df): 2.8 (476); p < 0.01] and personal accomplishment [ t (df): 2.0 (485); p < 0.05] compared to GPs. No gender differences were identified in the level of burnout. Significantly more GPs then residents reported high [chi 2 (df) = 5.9 (1); p < 0.05] or intermediate [chi 2 (df) = 4.6 (1); p < 0.05] degree of depersonalization. Emotional exhaustion, depersonalization, and low personal accomplishment were reported by around 30%, 60%, and 100% of the physicians, respectively. Being a resident emerged as the strongest negative predictor of depersonalization (beta = -0.09, 95% CI -0.22 - -0.002). CONCLUSIONS The prevalence of burnout is high among GPs, and almost all GPs report low degree of personal accomplishment. Residency emerged as a significant protective correlate of depersonalization. These findings provide further data for cross-cultural burnout research.

Family history of suicide: A clinical marker for major depression in primary care practice?

BACKGROUND The aim of this study was to investigate the family history of suicide among primary care patients with or without current major depressive episode (MDE). METHODS This study was performed in 2 GP practices in Budapest on 255 consecutively investigated primary care attendees. The diagnosis of current MDE (symptomatic MDE or MDE in partial remission) was made by the Hungarian version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Family history of suicide was rated as positive where the patients reported at least one first or second degree relative with completed suicide. RESULTS Out of the 255 consecutively investigated patients 45 (17.6%) have had current MDE and 24 (9.4%) have had positive family history of suicide. The family history of suicide was significantly more common among patients with current MDE than among those without it (26.6% vs 5.7%, p=0.0001). Fifty percent of patients with, and 14.3% of patients without family history of suicide have had current MDE (p=0.0001). LIMITATION Small sample size, and lacking data on fully remitted major depressives as well as on comorbid psychiatric and medical disorders. CONCLUSION History of completed suicide among first or second degree relatives could be a good and simple clinical marker for current and lifetime MDE in primary care patients.

Personality and cardiovascular risk: association between hypertension and affective temperaments-a cross-sectional observational study in primary care settings.

Abstract Background: Affective temperaments can be considered the subclinical manifestations of affective disorders, which have a bidirectional relationship with cardiovascular diseases. Objectives: Aim of this study was to assess the role of affective temperaments in primary hypertension, which is the leading risk factor of cardiovascular morbidity and mortality. Methods: In total, 251 consecutive patients, including 179 patients being treated for primary hypertension with anti-hypertensives, with chronic disorders without diagnosed depression were enrolled in a primary care setting. Patients completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A). Lifestyle-related risk factors, chronic diseases including cardiovascular complications were also recorded. Logistic regression analysis was used to determine the relationship of affective temperaments and lifestyle-related risk factors on hypertension. Results: Dominant cyclothymic temperament—with instability and rapid mood swings as main characteristics—had a significant association with hypertension (P = 0.006) even after the adjustment of correlation for known risk factors such as age, diabetes mellitus and obesity (OR: 11.88, 95%CI: 1.27–111.17). This association remained significant after controlling for the family wise error rate. The obtained adjusted P value was 0.024 at a 0.05 error rate. Conclusion: Results indicate that dominant cyclothymic affective temperament may be an additional risk factor in cardiovascular morbidity, and it may be worthy of further assessment to identify patients at risk and formulate a more individualized treatment approach.

Affective Temperaments Contribute to Cardiac Complications in Hypertension Independently of Depression

We used a subsample of a larger database [7, 8] for the purposes of the analysis. Consecutively investigated patients of 4 primary care practices with primary hypertension and regular monthly visits of the primary care physician were included. Patients with secondary hypertension were excluded. Data on CC diagnosed by cardiologists, cardiovascular disorders and psychiatric anamnesis (ICD-10 depressive and/or anxiety disorders, diagnosed by psychiatrists) were provided by the general practitioners simultaneously with the latest (within 3 months) laboratory test results on cholesterol levels. Information on lifestyle-related cardiovascular risk factors as well as family history of cardiovascular disorder were collected from the patients. Hypertension, height, weight and waist circumference were recorded at the entry. All patients gave their written informed consent. The study was approved by the competent ethical committee and was carried out in accordance with the tenets of the Declaration of Helsinki. There were 93 males out of 228 patients. The mean age was 64 (SD ±14) years; the mean duration of hypertension was 14 (SD ±7) years. CC was found in 16 cases (acute coronary syndrome or acute myocardial infection in 8 cases, respectively). Table 1 shows the demographic and clinical characteristics of patients with and without CC. Except the serum cholesterol level (which was lower in the CC+ group), we did not find any significant difference in demographic characteristics, cardiovascular risk factors and depression between the two groups. However, patients with CC scored markedly higher on the cyclothymic temperament scale (p = 0.027) than those without CC. We conducted binary logistic regression (step forward) to establish the role of cyclothymic temperament, ICD-10 depression, BDI score, age, gender and smoking on the development of CC. The final model was statistically significant (χ 2 = 7.56; p = 0.006, Cox and Schnell R 2 = 0.035). Cyclothymic temperament predicted CC [β = 0.152, SE = 0.054; Wald χ 2 (1) = 0.79, p = 0.005] independently of other predictor variables, increasing the odds of CC by 16% (odds ratio = 1.16, 95% confidence interval = 1.047– 1.295). Analysing negative attitude, performance difficulty and somatic element subscales of the BDI, performance difficulty and somatic element scores, but not the negative attitude subscale revealed significantly higher scores in the CC+ group. We found in this exploratory study that cyclothymic temperament predicted CC independently of depression (either ICD10-diagnosed or depressive symptoms), age, gender and smoking in hypertensive outpatients. Our results support the proposal of Rafanelli et al. [1] to consider personality as marker for a higher cardiovascular disorder risk and carry additional information as affective temperaments represent the biologically stable core of personality determining its emotional domain [9] . Moreover, cyclothymic temperament with rapid cycles of hyperthymic and deMajor depression and coronary heart disease have a strong, bidirectional relationship. Recently Rafanelli et al. [1] provided a detailed summary of research efforts to improve cardiac morbidity and mortality by treating concurrent depression. They found that antidepressant treatment is more effective on cardiac end points in severe depression; however, mild depressive symptoms without major depressive disorder also increase the cardiovascular risk. It was also revealed that antidepressant treatment does not result in significant cardiovascular improvement in the subpopulation of cardiac patients refractory to dose increase, those with relapses after long-term antidepressant use and those with bipolar disorder. A type A behavioural pattern – as well as cyclothymic disorder [2] – is a subclinical manifestation of bipolar illness, and mood improvement of depressed patients in this group may result in hypomania [1] , leading to extreme behavioural changes detrimental to cardiac prognosis [1] . To further characterize this most vulnerable group, based upon the suggestion of Rafanelli et al. [1] , we examined the affective temperamental traits (Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire, TEMPS-A [3, 4] ) on depressive, cyclothymic, hyperthymic, irritable and anxious subscales, ICD-10-diagnosed depression and depressive symptoms (Beck Depression Inventory, BDI [5, 6] ) in relation to cardiac complications (CC) requiring acute hospitalization (acute coronary syndrome, acute myocardial infarction) in a primary hypertensive outpatient population. Received: November 4, 2013 Accepted after revision: November 15, 2013 Published online: April 17, 2014