Richard Neugebauer

Depressive symptoms in women in the six months after miscarriage

This study, the first systematic investigation of the psychiatric impact of miscarriage, tests whether miscarriage markedly increases depressive symptoms in the 6 months after loss. We interviewed 382 miscarrying women entering the study at 2 weeks, 6 weeks, or 6 months after loss and, for comparison, 283 pregnant women and 318 community women not recently pregnant. Among women interviewed 2 weeks after miscarriage the proportion highly symptomatic on the Center for Epidemiologic Studies-Depression scale was 3.4 times that of pregnant women (95% confidence limits 2.0 and 5.0) and 4.3 times that of community women (95% confidence limits 3.0 and 5.8). Among women first interviewed 6 weeks and 6 months after miscarriage the proportion highly symptomatic was three times that of the community women. Women reinterviewed at 6 weeks and 6 months did not have elevated symptom levels, a result attributed to the unintended therapeutic and test effects of study interviews. Interviews were fully structured, readily administered by telephone by nonmedical personnel. The possibility that such interviews afford miscarrying women substantial psychologic benefits merits future investigation.

Prevalence of depression in rural Rwanda based on symptom and functional criteria.

The authors’ objective was to estimate the prevalence of major depressive disorder among Rwandans 5 years after the 1994 genocidal civil war. They interviewed a community-based random sample of adults in a rural part of Rwanda using the Hopkins Symptom Checklist and a locally developed functional impairment instrument. The authors estimated current rates of major depression using an algorithm based on the DSM-IV symptom criteria (A), distress/functional impairment criteria (C), and bereavement exclusionary criteria (E). They also examined the degree to which depressive symptoms compromise social and occupational functioning. Three hundred sixty-eight adults were interviewed, of whom 15.5% met Criteria A, C, and E for current major depression. Depressive symptoms were strongly associated with functional impairment in most major roles for men and women. The authors conclude that a significant part of this population has seriously disabling depression. Work on appropriate, feasible, safe, and effective mental health interventions should be a priority for this population.

Determinants of depressive symptoms in the early weeks after miscarriage.

OBJECTIVES We tested whether and under what conditions miscarriage increases depressive symptoms in the early weeks following loss. METHODS We interviewed 232 women within 4 weeks of miscarriage and 283 pregnant women and 318 community women who had not recently been pregnant. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression (CES-D) Scale. RESULTS Among women who had miscarried, the proportion who were highly symptomatic on the CES-D was 3.4 times that of pregnant women and 4.3 times that of community women. Among childless women, the proportion of women who had miscarried who were highly symptomatic was 5.7 times that of pregnant women and 11.0 times that of community women. Women who had miscarried were equally depressed regardless of length of gestation; among pregnant women, depressive symptoms declined with length of gestation. Among women who had miscarried, symptom levels did not vary with attitude toward the pregnancy; among pregnant women, depressive symptoms were elevated in those with unwanted pregnancies. Prior reproductive loss and advanced maternal age (35+ years) were not associated with symptom levels in any cohort. CONCLUSIONS Depressive symptoms are markedly increased in the early weeks following miscarriage. This effect is substantially modified by number of living children, length of gestation at loss, and attitude toward pregnancy.

Illness in Children After International Travel: Analysis From the GeoSentinel Surveillance Network

OBJECTIVE: By using a large, multicenter database, we investigated the characteristics and morbidities of 1591 children returning from 218 global destinations and presenting for care in 19 countries. METHODS: Data reported to the GeoSentinel Surveillance Network between January 1997 and November 2007 were analyzed, to assess demographic features, travel characteristics, and clinical diagnoses of ill pediatric travelers. Data were compared between children and adults and among 3 pediatric age groups (0–5 years, 6–11 years, and 12–17 years). RESULTS: Children were predominantly tourist travelers returning from Asia, sub-Saharan Africa, or Latin America. Compared with adults, children disproportionately presented within 7 days after return, required hospitalization, lacked pretravel health advice, and had traveled for the purpose of visiting friends and relatives. Diarrhea (28%), dermatologic conditions (25%), systemic febrile illnesses (23%), and respiratory disorders (11%) accounted for the majority of diagnoses reported for children. No fatalities were reported. Diarrhea occurred disproportionately among children after exposure to the Middle East/North Africa, dermatologic conditions after exposure to Latin America, systemic febrile illnesses after exposure to sub-Saharan Africa or Asia, and respiratory disorders after exposure to Europe or North America. The proportionate morbidity rates of travel-associated diseases differed among the pediatric age groups and between children and adults. CONCLUSIONS: The health care utilization patterns before and after travel and the profiles of travel-associated health problems differed between children and adults. Health professionals providing pretravel advice need to consider destination- and age-specific susceptibility to travel-related morbidities and develop prevention strategies accordingly.

Differential recall as a source of bias in epidemiologic research

Differential recall between compared groups is discussed most often in the context of case-control studies. Cases, compared to controls, are suspected of providing a more complete report of their true exposure to an hypothesized risk factor, thereby biasing upwards the estimate of its effect. The present paper describes how differential recall can arise with any observational design in epidemiology; with any class of study variable, not only exposures; and may inflate or deflate the true value of the estimate of effect size. We list a variety of study designs and questionnaire tactics that aim to remedy these problems. The scope and magnitude of the bias created by differential recall and the efficacy of proposed remedies require further study.

Minor depressive disorder in the context of miscarriage

BACKGROUND Although minor depressive disorder is of considerable clinical and public health importance, it has received limited research attention relative to major depressive disorder. This study examines the incidence rate and relative risk for minor depressive disorder following miscarriage. METHODS Using a cohort design we tested whether miscarrying women are at increased risk for an episode of minor depression (diagnosed based on research criteria proposed in Appendix B of DSM-IV) in the 6 months following loss. The miscarriage cohort consisted of women attending a medical center for spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230). RESULTS Among miscarrying women, 5.2% experienced an episode of minor depression, compared with 1.0% of community women. The overall relative risk for an episode of minor depression for miscarrying women was 5.2 (95% confidence interval, 1.2-23.6). Relative risk did not vary by length of gestation at the time of loss or attitude toward the pregnancy. The majority of episodes in miscarrying women began within 1 month following loss. LIMITATIONS Minor depression was relatively rare in both study cohorts. The resulting limits on statistical power reduced our ability to identify factors, such as sociodemographic or reproductive history variables that might moderate the effect of miscarriage on risk for minor depression. CONCLUSIONS These results, in the context of prior work showing increased risks of major depression and depressive symptoms following miscarriage, lend some support to the conceptualization of minor depressive disorder as part of a continuum of symptom severity. Miscarrying women should be evaluated for depression at their follow-up medical visits.

Group Interpersonal Psychotherapy for depressed youth in IDP camps in Northern Uganda: adaptation and training.

This article reviews the use of Interpersonal Psychotherapy (IPT) with depressed youth living in Internally Displaced Persons (IDP) camps in North Uganda. This youth has been exposed to severe losses and disruptions in relationships with caregivers, family, and community members; limited access to formal education; exposure to malnutrition and infections; and pressure to prematurely assume adult family roles. The process of adaptation to the content and training of IPT for these youth is presented and illustrated with case examples.

Perinatal Bereavement Grief Scale Distinguishing Grief From Depression Following Miscarriage

The study evaluated the Perinatal Bereavement Grief Scale (PBGS), the first scale designed to measure grief following reproductive loss in terms of yearning for the lost pregnancy and lost baby. Participants included 304 women interviewed by telephone 1 to 3 times within 6 months after miscarriage. The PBGS had high internal consistency and test-retest reliability. It showed convergent validity with measures of attachment and investment in the child and divergent validity against measures of social desirability and depressive symptoms, supporting the conceptual distinction between grief and depression. Cross-cultural validity was acceptable whether tested by language (Spanish vs. English) or ethnicity (Hispanic vs. other). This measure of yearning enables study of the epidemiology and prognostic value of this key feature of mourning.

Functional impairment in adults with past posttraumatic stress disorder: findings from primary care

Background: Although many patients with posttraumatic stress disorder (PTSD) experience a reduction in posttraumatic symptoms over time, little is currently known about the extent of their residual functional impairment. This study examines functional impairment in primary care patients with a history of PTSD as compared to patients with current PTSD, and those who never developed PTSD following exposure to trauma. Methods: The sample consisted of 321 trauma‐exposed low‐income, predominantly Hispanic adults attending a large urban primary care practice. PTSD was assessed with the Lifetime Composite International Diagnostic Interview and other psychiatric disorders with the SCID‐I. Physical and mental health‐related quality of life was assessed with the Medical Outcome Health Survey (SF‐12), and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self‐Report. Results: Logistic regression analyses controlling for gender, psychiatric comorbidity, and interpersonal traumas showed that although patients with past PTSD function significantly better than patients with current PTSD, they experience persisting deficits in mental health‐related quality of life compared to trauma‐exposed patients who never developed PTSD. Overall, results revealed a continuum of severity in psychiatric comorbidity, functioning, and quality of life, with current PTSD associated with the most impairment, never having met criteria for PTSD with the least impairment, and history of PTSD falling in between. Conclusions: In this primary care sample, adults with a history of past PTSD but no current PTSD continued to report enduring functional deficits, suggesting a need for ongoing clinical attention. Depression and Anxiety, 2011.© 2011 Wiley‐Liss, Inc.

National General Practice Study of Epilepsy and Epileptic Seizures: Objectives and Study Methodology of the Largest Reported Prospective Cohort Study of Epilepsy

Most available data on the prognosis of epileptic seizures come from hospital-based clinics in which patients with chronic or severe disease are over-represented. The National General Practice Study of Epilepsy and Epileptic Seizures is a large prospective community-based study of people with newly diagnosed seizures which aims to address questions related to the early prognosis of epilepsy. 275 general practitioners throughout the United Kingdom have registered a total of 1,195 patients. In this paper we discuss the background to the study and the methodology used.