Robertas Bunevicius

Validation of the Edinburgh Depression Scale during pregnancy

BACKGROUND Untreated depression during pregnancy may have adverse outcomes for the mother and her child. Screening for depression in the general pregnant population is thus recommended. The Edinburgh Depression Scale (EDS) is widely used for postpartum depression screening. There is no consensus on which EDS cutoff values to use during pregnancy. The aim of the current study was to examine the predictive validity and concurrent validity of the EDS for all three trimesters of pregnancy. METHODS In a large unselected sample of 845 pregnant women, the sensitivity, specificity, and validity of the EDS were evaluated. The Composite International Diagnostic Interview (depression module) was used to examine the predictive validity of the EDS. The anxiety and somatization subscales of the Symptom Checklist 90 (SCL-90) were used to examine its concurrent validity. Only women with a major depressive episode were considered as cases. RESULTS The prevalence of depression decreased toward end term: 5.6%, 5.4%, and 3.4%. The EDS scores also decreased toward end term, while the SCL-90 subscale anxiety scores increased. The EDS showed high test-retest reliability and high concurrent validity with the SCL-90 anxiety and somatization subscales. The area under the receiver operating characteristic curve was high and varied between 0.93 and 0.97. A cutoff value of 11 in the first trimester and that of 10 in the second and third trimesters gave the most adequate combination of sensitivity, specificity, and positive predictive value. CONCLUSIONS The EDS is a reliable instrument for screening depression during pregnancy. A lower cutoff than commonly applied in the postpartum period is recommended.

Guidelines for the pharmacological treatment of anxiety disorders, obsessive - compulsive disorder and posttraumatic stress disorder in primary care

Abstract Objective. Anxiety disorders are frequently under-diagnosed conditions in primary care, although they can be managed effectively by general practitioners. Methods. This paper is a short and practical summary of the World Federation of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety disorders, obsessive–compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) for the treatment in primary care. The recommendations were developed by a task force of 30 international experts in the field and are based on randomized controlled studies. Results. First-line pharmacological treatments for these disorders are selective serotonin reuptake inhibitors (for all disorders), serotonin-norepinephrine reuptake inhibitors (for some) and pregabalin (for generalized anxiety disorder only). A combination of medication and cognitive behavior/exposure therapy was shown to be a clinically desired treatment strategy. Conclusions. This short version of an evidence-based guideline may improve treatment of anxiety disorders, OCD, and PTSD in primary care.

Psychosocial risk factors for depression during pregnancy

Objective. To assess the prevalence of antenatal depressive disorder in different trimesters and to evaluate the relation of psychosocial risk factors to antenatal depressive disorder. Design. Cohort follow‐up. Setting. University Hospital, Kaunas, Lithuania. Sample. Two hundred and thirty pregnant women consecutively admitted. Methods. At 12–16 weeks, 22–26 weeks, and 32–36 weeks of pregnancy, participants were screened for depression using the World Health Organizations Composite International Diagnostic Interview Short Form (CIDI‐SF). Women who gave at least one positive answer to the CIDI‐SF depression‐screening question were evaluated for depressive disorder using the non‐patient version of the Structured Clinical Interview for DSM‐III‐R (SCID‐NP). Psychosocial stressors and two Big Five Personality dimensions, neuroticism and extraversion, were also evaluated. Main outcome measures. Prevalence of depressive disorder. Results. The prevalence of the antenatal depressive disorder at 12–16 weeks’ gestation was 6.1%, at 22–26 weeks 3.5%, and at 32–36 weeks 4.4%. In the first trimester, a greater prevalence of current depressive disorder was independently associated with unplanned and unwanted pregnancy, high neuroticism, low education, and a previous history of depression; in the second trimester with unplanned and unwanted pregnancy and high neuroticism; in the third trimester with unplanned and unwanted pregnancy, high neuroticism, and the occurrence of psychosocial stressors during the last year. Conclusions. The highest prevalence of depressive disorders was found in the first trimester, the lowest in mid‐pregnancy. Several determinants (unwanted and unplanned pregnancy, high neuroticism) were independent predictors of antenatal depressive disorders throughout whole pregnancy, while other determinants (low education, previous history of depression, the occurrence of psychosocial stressors at the end of pregnancy) were trimester specific.

Symptoms of Anxiety and Depression in Medical Students and in Humanities Students: Relationship With Big-Five Personality Dimensions and Vulnerability To Stress

Aims: To evaluate the prevalence of anxiety and depression in medical students and in humanities students. To assess the relationship between symptoms of anxiety, symptoms of depression and Big-Five personality dimensions and vulnerability to stress in medical students. Methods: Randomly selected 338 medical students and 73 humanities students were evaluated for symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), for Big-Five personality dimensions using the Ten-Item Personality Inventory (TIPI), and for vulnerability to stress using the Stress Vulnerability Scale (SVS). Results: Symptoms of anxiety and symptoms of depression were prevalent in medical students (43% and 14%, respectively) and in humanities students (52% and 12%, respectively). In medical students the score on the HADS anxiety subscale and the score on the HADS depression subscale correlated negatively with the score on the TIPI Emotional Stability scale (r = —0.39, p < 0.01 and r = —0.2, p < 0.01, respectively) and correlated positively with the score on the SVS (r = 0.38, p < 0.01 and r = 0.44, p < 0.01, respectively). Conclusions: Symptoms of anxiety and depression are prevalent in medical students and in humanities students. Severity of symptoms of anxiety and symptoms of depression in medical students is negatively related to emotional stability and positively related to stress vulnerability.

Thyroxine vs thyroxine plus triiodothyronine in treatment of hypothyroidism after thyroidectomy for graves’ disease

It was recently demonstrated that treatment with levorotatory thyroxine (T4) plus triodotthyronine (T3) compared with treatment with T4 alone improves psychologic functioning in hypothyroid patients with thyroid cancer or autoimmune thyroiditis. In the present double-blind crossover study, we again compared the effects of combined thyroid replacement vs monotherapy on psychologic function, endocrine function, cardiovascular function, and body composition. The patients were women who were hypothyroid after thyroidectomy for Graves’ disease. The substitution of 10 µg of T3 for 50 µg of T4 caused a statistically significant decrease in free T4 concentration but no significant change in T3 or thyroid-stimulating hormone concentration. Symptoms of hypothyroidism and of hyperthyroidism tended to decrease on a standard symptom scale after combined treatment. With combined hormone replacement, mental state tended to improve on some mood scales but not on cognitive tests. We found alterations in left ventricular diastolic function but no change in body composition after the combined treatment regimen. These preliminary findings in a small group of patients with Graves’ disease are consistent with earlier findings that thyroid replacement with T4-T3 combination improves mental functioning.

Screening for antenatal depression with the Edinburgh Depression Scale

This study aimed to evaluate how precise the Edinburgh Depression Scale (EDS) is in screening for major depressive disorder (MDD) during different periods of pregnancy. A random sample of 230 pregnant women was interviewed in the first, second, and third trimesters of pregnancy using the EDS and not-patient version of the Structured Clinical Interview for DSM-III-R (SCID-NP). We evaluated test-retest reliability of the EDS; area under the ROC curve (AUC), sensitivity, specificity, and positive predictive value (PPV) of the EDS against the SCID-NP diagnoses in the first, second, and third trimesters of pregnancy. Test–retest reliability of the EDS was 0.81 (p < 0.001). An optimal cutoff score of the EDS for screening current SCID-NP diagnosis of MDD was 12 and higher in the first trimester of pregnancy (AUC 0.94, sensitivity 92%, specificity 95%, and PPV 52%) and 11 and higher in the second and third trimesters of pregnancy (AUC 0.96 and 0.90, respectively; sensitivity 100% and 88%, respectively; specificity 92% and 92%, respectively; PPV 25% and 29%, respectively). The EPDS is a reliable instrument for repeated evaluations of depressive symptoms during pregnancy. It has a good sensitivity and specificity for detecting antenatal MDD with optimal cutoff of 11/12 or higher.

Mental improvement after replacement therapy with thyroxine plus triiodothyronine: relationship to cause of hypothyroidism

We treated 26 hypothyroid women - 11 with autoimmune thyroiditis and 15 who had been treated for thyroid cancer - with their usual dose of thyroxine (T4) or with a regimen in which 50 &mgr;g of T4 had been replaced by 12.5 &mgr;g of triiodothyronine (T3). Patients were first randomly assigned to one regimen for 5 wk and then to a second regimen for an additional 5 wk. The substitution of T3 for a portion of T4 caused expected changes in concentrations of thyroid hormones and thyroid-stimulating hormone (TSH). After combined hormone treatment there were clear improvements in both cognition and mood, the latter changes being greater. The patients who had been treated for thyroid cancer showed more mental improvement than the women with autoimmune thyroiditis, perhaps because they were more dependent on exogenous hormone. Some mood improvements correlated positively with changes in TSH while others correlated negatively with changes in free T4.

Psychiatric manifestations of Graves' hyperthyroidism: pathophysiology and treatment options.

Graves’ disease is an autoimmune disorder that is the most common cause of hyperthyroidism. Other symptoms associated with the disease are goitre, ophthalmopathy, and psychiatric manifestations such as mood and anxiety disorders and, sometimes, cognitive dysfunction. Graves’ hyperthyroidism may result in these latter manifestations via the induction of hyperactivity of the adrenergic nervous system.This review addresses the psychiatric presentations, and their pathophysiology and treatment, in patients with hyperthyroidism, based on literature identified by a PubMed/MEDLINE database search. Although the focus is on mental symptoms associated with Graves’ disease, it is not always clear from the literature whether patients had Graves’ disease: in some studies, the patients were thought to have Graves’ disease based on clinical findings such as diffuse goitre or ophthalmopathy or on measurements of thyroid antibodies in serum; however, in other studies, no distinction was made between Graves’ hyperthyroidism and hyperthyroidism from other causes.Antithyroid drugs combined with β-adrenoceptor antagonists are the treatments of choice for hyperthyroidism, as well as for the psychiatric disorders and mental symptoms caused by hyperthyroidism. A substantial proportion of patients have an altered mental state even after successful treatment of hyperthyroidism, suggesting that mechanisms other than hyperthyroidism, including the Graves’ autoimmune process per se and ophthalmopathy, may also be involved. When psychiatric disorders remain after restoration of euthyroidism and after treatment with β-adrenoceptor antagonists, specific treatment for the psychiatric symptoms, especially psychotropic drugs, may be needed.

Diagnostic accuracy of self-rating scales for screening of depression in coronary artery disease patients

OBJECTIVE We evaluated the internal consistency and psychometric properties of the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory-II (BDI-II) for screening of major depressive episodes (MDE) in coronary artery disease (CAD) patients undergoing rehabilitation. METHODS Five-hundred and twenty-two consecutive CAD patients (72% men; mean age 58±9 years) attending a rehabilitation program 2 weeks after inpatient treatment for acute ischemic cardiac events completed the HADS depression subscale (HADS-D), HADS anxiety subscale (HADS-A) and the BDI-II. Interview outcome using the Mini International Neuropsychiatric Interview (MINI) for current MDE according to the DSM-IV-TR criteria was considered as the gold standard. RESULTS Fifty-six (11%) patients had a current MDE. The HADS-D, HADS-A, HADS-total and BDI-II had high internal consistency. Area under the ROC curve was the highest for the BDI-II followed by the HADS. Optimal cut-off values for screening of MDE were ≥5 for the HADS-D, ≥8 for the HADS-A and ≥14 for the HADS-total and for the BDI-II. At optimal cut-off values the BDI-II had slightly superior psychometric properties when compared to the HADS. However, positive predictive values were low for the HADS and for the BDI-II. CONCLUSIONS In CAD patients undergoing rehabilitation, the HADS and BDI-II had high internal consistency. Screening for MDE at optimal cut-off values the BDI-II was slightly superior when compared to the HADS. Positive predictive values for the BDI-II and for the HADS were low indicating that a large proportion of patients with positive screening results did not meet criteria for MDE.

Thyroid disease and mental disorders: cause and effect or only comorbidity?

Purpose of review To discuss the effects of thyroid dysfunction and thyroid autoimmunity on mental symptoms and disorders in patients with thyroid disease with reference to recent epidemiological, clinical, and genetic findings. Recent findings During brain development, iodine deficiency, maternal thyroid dysfunction, and neonatal thyroid malformations together with genetic factors contribute to neurological deficit. Most adults with thyroid dysfunction will develop mental symptoms. In hyperthyroidism, adrenergic hyperactivity is a major cause of psychiatric symptoms, and beta-adrenergic antagonists are effective treatment. Most patients with severe hypothyroidism will also demonstrate mental symptoms; however, causality is not so evident as in hyperthyroidism. Polymorphism in deiodinase genes and in transporter genes appears to make an important contribution to the presentation of mental symptoms as well as to the outcome of treatment of hypothyroidism. A thyroid autoimmunity process may by itself contribute to mental symptoms in vulnerable patients. Data from epidemiological studies provide conflicting evidence as to associations between thyroid disorders and mental symptoms. Summary In the adult brain, compared with the developing brain, brain–thyroid relationships are less apparent but still important. Adrenergic hyperactivity is a major cause of psychiatric symptoms in hyperthyroidism. Genetic factors contribute to the development and treatment outcome of mental disorder in hypothyroidism.