Samuli I. Saarni

The impact of 29 chronic conditions on health-related quality of life: a general population survey in Finland using 15D and EQ-5D.

BackgroundHealth-related quality of life (HRQoL) is an essential outcome of health care, but there is no gold standard of HRQoL measurement. We investigated the impact of major chronic conditions on HRQoL using 15D and EQ-5D in a representative sample of Finns.MethodsInformation on chronic somatic conditions was obtained by interviews. Psychiatric disorders were diagnosed using a structured interview (M-CIDI). Tobit and CLAD regression analysis was used to estimate the impact of conditions on HRQoL at the individual and population level.Main resultsAdjusted for other conditions and sociodemographic variables, Parkinson’s disease had the largest negative impact on HRQoL at the individual level, followed by anxiety disorders, depressive disorders and arthrosis of the hip and knee. Based on prevalence, arthrosis of the hip or knee, depression, back problems and urinary incontinence caused the greatest loss of HRQoL at the population level. The results obtained with the two HRQoL measures differed markedly for some conditions and the EQ-5D results also varied with the regression method used.ConclusionsMusculoskeletal disorders are associated with largest losses of HRQoL in the Finnish population, followed by psychiatric conditions. Different HRQoL measures may systematically emphasize different conditions.

Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders

BACKGROUND Health utility and quality of life (QoL) are increasingly important outcome measures in healthcare and health economics. AIMS To compare the loss of subjective QoL and utility-based health-related quality of life (HRQoL) associated with psychotic disorders. METHOD A representative sample of 8028 Finns was screened for psychotic disorders and bipolar I disorder. Lifetime psychotic disorders were diagnosed using the Structured Clinical Interview for DSM-IV and/or case records. Health-related quality of life was measured with EQ-5D and 15D, and QoL was measured with a 10-point scale. RESULTS Schizoaffective disorder was associated with the largest losses of QoL and HRQoL, with bipolar I disorder associated with similar or smaller losses than schizophrenia. Current depressive symptoms explained most of the losses. CONCLUSIONS Depressive symptoms are the strongest predictors of poor QoL/HRQoL in psychotic disorders. Subjective loss of QoL associated with psychotic disorders may be smaller than objective loss of functioning suggests. The EQ-5D is problematic as an outcome measure in psychotic disorders.

Infertility, mental disorders and well-being – a nationwide survey

Objective. Earlier studies suggest that infertility and mental health problems are related and that infertility is a different experience for women and men. The aim of this population‐based study is to examine mental disorders, depressivity, psychological distress, perceived health and quality of life among women and men who have experienced infertility. Design. Cross‐sectional nationwide Health 2000 Survey. Setting. Population‐based. Population. A representative random sample of Finnish people aged 30–44 years (n = 2291). Methods. Outcomes were compared between those who had experienced infertility (n = 338) and the rest of the population. Age, marital status, education, income, body mass index, and smoking were controlled for using logistic and linear regressions. Main outcome measures. Mental disorders (composite international diagnostic interview, CIDI), depressivity (beck depression inventory, BDI), psychological distress (general health questionnaire, GHQ‐12), perceived health, and subjective quality of life. Results. Approximately 20% of women and 9% of men reported having experienced infertility. Childless women with infertility experience had increased adjusted risks for dysthymia (OR 3.41, 95% CI; 1.01–11.5) and anxiety disorders (2.67, 1.00–7.12) compared to women who had not experienced infertility. Women with infertility experience but with a current child had an increased risk for panic disorder (2.58, 1.11–6.01). Childless men with infertility experience had a significantly poorer quality of life compared to men without infertility. Conclusions. Infertility was associated with mental health, especially dysthymia and anxiety. The results differed by gender and the permanency of infertility. Gender‐specific psychosocial support and follow‐up for infertile people is warranted.

Mental disorders in young adulthood

BACKGROUND The effect of mental disorders may be particularly detrimental in early adulthood, and information on mental disorders and their correlates in this age group is important. METHOD A questionnaire focusing on mental health was sent to a nationally representative two-stage cluster sample of 1863 Finns aged 19 to 34 years. Based on a mental health screen, all screen-positives and a random sample of screen-negatives were asked to participate in a mental health assessment, consisting of the Structured Clinical Interview for DSM-IV (SCID-I) interview and neuropsychological assessment. We also obtained case-notes from all lifetime mental health treatments. This paper presents prevalences, sociodemographic associations and treatment contacts for current and lifetime mental disorders. RESULTS Forty percent of these young Finnish adults had at least one lifetime DSM-IV Axis I disorder, and 15% had a current disorder. The most common lifetime disorders were depressive disorders (17.7%) followed by substance abuse or dependence (14.2%) and anxiety disorders (12.6%). Of persons with any lifetime Axis I disorder, 59.2% had more than one disorder. Lower education and unemployment were strongly associated with current and lifetime disorders, particularly involving substance use. Although 58.3% of persons with a current Axis I disorder had received treatment at some point, only 24.2% had current treatment contact. However, 77.1% of persons with a current Axis I disorder who felt in need of treatment for mental health problems had current treatment contact. CONCLUSIONS Mental disorders in young adulthood are common and often co-morbid, and they may be particularly harmful for education and employment in this age group.

The HTA Core Model: A novel method for producing and reporting health technology assessments

OBJECTIVES The aim of this study was to develop and test a generic framework to enable international collaboration for producing and sharing results of health technology assessments (HTAs). METHODS Ten international teams constructed the HTA Core Model, dividing information contained in a comprehensive HTA into standardized pieces, the assessment elements. Each element contains a generic issue that is translated into practical research questions while performing an assessment. Elements were described in detail in element cards. Two pilot assessments, designated as Core HTAs were also produced. The Model and Core HTAs were both validated. Guidance on the use of the HTA Core Model was compiled into a Handbook. RESULTS The HTA Core Model considers health technologies through nine domains. Two applications of the Model were developed, one for medical and surgical interventions and another for diagnostic technologies. Two Core HTAs were produced in parallel with developing the model, providing the first real-life testing of the Model and input for further development. The results of formal validation and public feedback were primarily positive. Development needs were also identified and considered. An online Handbook is available. CONCLUSIONS The HTA Core Model is a novel approach to HTA. It enables effective international production and sharing of HTA results in a structured format. The face validity of the Model was confirmed during the project, but further testing and refining are needed to ensure optimal usefulness and user-friendliness. Core HTAs are intended to serve as a basis for local HTA reports. Core HTAs do not contain recommendations on technology use.

Antidepressant utilisation patterns and determinants of short-term and non-psychiatric use in the Finnish general adult population

BACKGROUND The aim was to study utilisation patterns and determinants of antidepressant use in the general population >30 years, especially short-term use or use not related to known psychiatric morbidity. METHODS Participants from a cross-sectional population-based Finnish Health 2000 Study (2000--2001) were linked with the National Prescription Register and National Care Register for Health Care. Within a representative sample (N=7112) of the adult population (>30 years), 12-month DSM-IV depressive, anxiety, and alcohol use disorders were assessed with the M-CIDI. Utilisation patterns of antidepressants were categorised to short-term, intermittent and continuous use. Factors predicting short-term use or use not related to known psychiatric morbidity were investigated. RESULTS Of Finnish adults 7.1% had used antidepressants in 2000, of which two-thirds reported a physician-diagnosed mental disorder; a third (35%) had major depressive or anxiety disorder during the previous 12 months. In terms of utilisation pattern, 43% were long-term users, 32% intermittent users and 26% short-term users. Short-term use was related to care by a general practitioner and having no known mental disorder. A quarter of all users had no known psychiatric morbidity. This type of user was most common among the older age groups, and inversely related to being single, on disability pension and using mental health services. LIMITATIONS Not all psychiatric indications for antidepressant use could be explored. CONCLUSIONS Depression remains the main indication for antidepressant use. About a quarter of users had no known psychiatric indication and the indication remained unclear. Short-term and non-psychiatric use are more commonly prescribed for the elderly.

Cognitive functioning in a population-based sample of young adults with a history of non-psychotic unipolar depressive disorders without psychiatric comorbidity

BACKGROUND There is evidence for cognitive dysfunction in unipolar depression among middle-aged and elderly patients, but cognitive functioning among depressed young adults has scarcely been systematically investigated. The aims of the present study were to examine cognitive functioning among depressed young adults identified from the general population and to determine whether cognitive deficits vary as a function of different disorder characteristics, such as severity and age at onset. METHODS Performance in verbal and visual short-term memory, verbal long-term memory and learning, attention, processing speed, and executive functioning was compared between a population-based sample of 21-35-year-olds with a lifetime history of non-psychotic unipolar depressive disorders without psychiatric comorbidity (n=68) and healthy controls derived from the same population (n=70). RESULTS Depressed young adults were not found to be impaired in any of the assessed cognitive functions, except for some suggestion of mildly compromised verbal learning. Nevertheless, younger age at depression onset was associated with more impaired executive functioning. LIMITATIONS The results may slightly underestimate of the true association between depression and cognitive impairments in the young adult population due to possible dropout of participants. Additionally, the problem of multiple testing was not entirely corrected. CONCLUSION The findings from this study indicate that a lifetime history of non-psychotic unipolar depressive disorders among young adults without psychiatric comorbidity may be associated only with minimal cognitive deficits, even when some residual depressive symptoms are prevalent. However, early-onset depression may represent a more severe form of the disorder, associated with more cognitive dysfunction.

Ethical analysis to improve decision-making on health technologies

Health technology assessment (HTA) is the multidisciplinary study of the implications of the development, diffusion and use of health technologies. It supports health-policy decisions by providing a joint knowledge base for decision-makers. To increase its policy relevance, HTA tries to extend beyond effectiveness and costs to also considering the social, organizational and ethical implications of technologies. However, a commonly accepted method for analysing the ethical aspects of health technologies is lacking. This paper describes a model for ethical analysis of health technology that is easy and flexible to use in different organizational settings and cultures. The model is part of the EUnetHTA project, which focuses on the transferability of HTAs between countries. The EUnetHTA ethics model is based on the insight that the whole HTA process is value laden. It is not sufficient to only analyse the ethical consequences of a technology, but also the ethical issues of the whole HTA process must be considered. Selection of assessment topics, methods and outcomes is essentially a value-laden decision. Health technologies may challenge moral or cultural values and beliefs, and their implementation may also have significant impact on people other than the patient. These are essential considerations for health policy. The ethics model is structured around key ethical questions rather than philosophical theories, to be applicable to different cultures and usable by non-philosophers. Integrating ethical considerations into HTA can improve the relevance of technology assessments for health care and health policy in both developed and developing countries.

Alcohol consumption, abstaining, health utility, and quality of life – a general population survey in finland

AIMS To examine the associations between alcohol consumption and utility-based health-related quality of life (HRQoL), subjective quality of life (QoL), self-rated health (SRH), and mental distress. METHODS Representative general population survey in Finland, with 5871 persons aged 30-64 years. HRQoL was measured with two health utility instruments (15D and EQ-5D), QoL and SRH were measured with RATING scales, and mental distress with a General Health Questionnaire (GHQ-12). Past alcohol problems were diagnosed with a structured psychiatric interview known as the composite international diagnostic interview (CIDI). Alcohol consumption was examined with a self-report questionnaire. RESULTS Negative associations between alcohol and well-being were observed on several measures for women consuming more than 173 g and men more than 229 g per week. Former drinkers scored worst on most measures, even in comparison to the highest drinking decile. For men, all statistically significant associations between moderate drinking and well-being disappeared when sociodemographic factors and former drinkers were controlled for. For women, moderate alcohol use associated with better SRH and EQ-5D as compared to abstainers. However, the possible health utility benefits associated with moderate alcohol consumption were of clinically insignificant magnitude. CONCLUSIONS Failure to separate former drinkers and other abstainers produces a significant bias favoring moderate drinkers. As the possible health utility benefits of moderate alcohol use were clinically insignificant, it suffices to investigate mortality, when estimating the public health impact of moderate alcohol consumption using quality-adjusted life years.

Body composition in psychotic disorders: a general population survey.

BACKGROUND The literature suggests an association between obesity and schizophrenia but fat mass and fat-free mass, which have been shown to be more predictive of all-cause mortality than only waist circumference and obesity [body mass index (BMI) 30 kg/m2], have not been reported in psychotic disorders. We examined the detailed body composition of people with different psychotic disorders in a large population-based sample. METHOD We used a nationally representative sample of 8082 adult Finns aged 30 years with measured anthropometrics (height, weight, waist circumference, fat percentage, fat-free mass and segmental muscle mass). Psychiatric diagnoses were based on a consensus procedure utilizing the Structured Clinical Interview for DSM-IV (SCID)-interview, case-notes and comprehensive register data. RESULTS Schizophrenia (including schizo-affective disorder) was associated with obesity [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.5-3.6], abdominal obesity (waist circumference 88 cm for women, 102 cm for men) (OR 2.2, 95% CI 1.3-3.6) and with higher fat percentage (mean difference 3.8%, 95% CI 2.0-5.7%), adjusted for age and gender, than in the remaining sample. The associations between schizophrenia and low fat-free mass and decreased muscle mass on trunk and upper limbs became statistically significant after adjusting for BMI. After further adjusting for current antipsychotic medication, education, diet and smoking, schizophrenia remained associated with obesity (OR 1.9, 95% CI 1.1-3.6) and abdominal obesity (OR 3.8, 95% CI 1.5-9.4). Participants with affective psychoses did not differ from the general population. CONCLUSIONS Individuals with schizophrenia have metabolically unfavorable body composition, comprising abdominal obesity, high fat percentage and low muscle mass. This leads to increased risk of metabolic and cardiovascular diseases.