Tiago N. Munhoz

Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral

Com o objetivo de estudar a validade do Patient Health Questionnaire-9 (PHQ-9) no rastreio de episodio depressivo maior na populacao geral, conduziu-se um estudo de base populacional em Pelotas, Rio Grande do Sul, Brasil. Os domicilios foram sorteados por amostragem em multiplos estagios, sendo os adultos (> 20 anos) convidados a participar. O padrao ouro foi a entrevista diagnostica estruturada Mini International Neuropsychiatric Interview (MINI) aplicada por psiquiatras e psicologos. Tanto o PHQ-9 quanto o MINI foram aplicados no domicilio. Em um total de 447 participantes (191 homens e 256 mulheres) a analise continua identificou o ponto de corte > 9 como de maxima sensibilidade (77,5%; 61,5-89,2) e especificidade (86,7%; 83,0-89,9). Usando o algoritmo do teste, houve diminuicao da sensibilidade para 42,5% (27,0-59,1), enquanto que a especificidade aumentou para 95,3% (92,8-97,2). O PHQ-9 mostrou-se apropriado para rastreamento de episodio depressivo maior. Pela maior sensibilidade, o PHQ-9 pontuado de forma continua mostrou-se mais adequado do que o algoritmo para rastreamento de episodio depressivo maior na comunidade.Con el objetivo de evaluar la validez del Cuestionario de Salud del Paciente-9 (PHQ-9) en la deteccion de un episodio depresivo mayor en la poblacion general, se llevo a cabo un estudio de base poblacional en la ciudad de Pelotas, Rio Grande do Sul, Brasil. Los hogares se seleccionaron al azar a traves de muestreo multietapico, siendo solo invitados a participar los adultos (> 20 anos). El padron de primer orden fue la Mini Entrevista Neuropsiquiatrica Internacional (MINI), aplicada por psiquiatras y psicologos. Ambos instrumentos fueron aplicados en la casa del participante. De un total de 447 participantes (191 hombres y 256 mujeres), el analisis continuo mostro un punto de corte > 9 como el de maxima sensibilidad (77,5%; 61,5-89,2) y especificidad (86,7%; 83,0-89,9) para la identificacion de un episodio depresivo mayor. Al utilizar el algoritmo del test, la sensibilidad disminuyo a un 42,5% (27,0-59,1), mientras que la especificidad aumento a un 95,3% (92,8-97,2). El PHQ-9 mostro ser adecuado para el cribado de un episodio depresivo mayor. Debido a la sensibilidad mas alta, el PHQ-9 marcado como una variable continua fue mas adecuado que el algoritmo para la deteccion de episodio depresivo mayor en la comunidad.

Sensitivity and specificity of the Patient Health Questionnaire-9 (PHQ-9) among adults from the general population

Com o objetivo de estudar a validade do Patient Health Questionnaire-9 (PHQ-9) no rastreio de episodio depressivo maior na populacao geral, conduziu-se um estudo de base populacional em Pelotas, Rio Grande do Sul, Brasil. Os domicilios foram sorteados por amostragem em multiplos estagios, sendo os adultos (> 20 anos) convidados a participar. O padrao ouro foi a entrevista diagnostica estruturada Mini International Neuropsychiatric Interview (MINI) aplicada por psiquiatras e psicologos. Tanto o PHQ-9 quanto o MINI foram aplicados no domicilio. Em um total de 447 participantes (191 homens e 256 mulheres) a analise continua identificou o ponto de corte > 9 como de maxima sensibilidade (77,5%; 61,5-89,2) e especificidade (86,7%; 83,0-89,9). Usando o algoritmo do teste, houve diminuicao da sensibilidade para 42,5% (27,0-59,1), enquanto que a especificidade aumentou para 95,3% (92,8-97,2). O PHQ-9 mostrou-se apropriado para rastreamento de episodio depressivo maior. Pela maior sensibilidade, o PHQ-9 pontuado de forma continua mostrou-se mais adequado do que o algoritmo para rastreamento de episodio depressivo maior na comunidade.Con el objetivo de evaluar la validez del Cuestionario de Salud del Paciente-9 (PHQ-9) en la deteccion de un episodio depresivo mayor en la poblacion general, se llevo a cabo un estudio de base poblacional en la ciudad de Pelotas, Rio Grande do Sul, Brasil. Los hogares se seleccionaron al azar a traves de muestreo multietapico, siendo solo invitados a participar los adultos (> 20 anos). El padron de primer orden fue la Mini Entrevista Neuropsiquiatrica Internacional (MINI), aplicada por psiquiatras y psicologos. Ambos instrumentos fueron aplicados en la casa del participante. De un total de 447 participantes (191 hombres y 256 mujeres), el analisis continuo mostro un punto de corte > 9 como el de maxima sensibilidad (77,5%; 61,5-89,2) y especificidad (86,7%; 83,0-89,9) para la identificacion de un episodio depresivo mayor. Al utilizar el algoritmo del test, la sensibilidad disminuyo a un 42,5% (27,0-59,1), mientras que la especificidad aumento a un 95,3% (92,8-97,2). El PHQ-9 mostro ser adecuado para el cribado de un episodio depresivo mayor. Debido a la sensibilidad mas alta, el PHQ-9 marcado como una variable continua fue mas adecuado que el algoritmo para la deteccion de episodio depresivo mayor en la comunidad.

Validation of the Edinburgh postnatal depression scale (EPDS) for screening of major depressive episode among adults from the general population

BackgroundStandardized questionnaires designed for the identification of depression are useful for monitoring individual as well as population mental health. The Edinburgh Postnatal Depression Scale (EPDS) has originally been developed to assist primary care health professionals to detect postnatal depression, but several authors recommend its use outside of the postpartum period. In Brazil, the use of the EPDS for screening depression outside the postpartum period and among non-selected populations has not been validated. The present study aimed to assess the validity of the EPDS as a screening instrument for major depressive episode (MDE) among adults from the general population.MethodsThis is a validation study that used a population-based sampling technique to select the participants. The study was conducted in the city of Pelotas, Brazil. Households were randomly selected by two stage conglomerates with probability proportional to size. EPDS was administered to 447 adults (≥20 years). Approximately 17 days later, participants were reinterviewed by psychiatrics and psychologists using a structured diagnostic interview (Mini International Neuropsychiatric Interview, MINI). We calculated the sensitivity and specificity of each cutoff point of EPDS, and values were plotted as a receiver operator characteristic curve.ResultsThe best cutoff point for screening depression was ≥8, with 80.0% (64.4 - 90.9%) sensitivity and 87.0% (83.3 - 90.1%) specificity. Among women the best cutoff point was ≥8 too with values of sensitivity and specificity of 84.4% (67.2 – 94.7%) and 81.3% (75.5 – 86.1%), respectively. Among men, the best cutoff point was ≥7 (75% sensitivity and 89% specificity).ConclusionsThe EPDS was shown to be suitable for screening MDE among adults in the community.

Major depressive episode among Brazilian adults: A cross-sectional population-based study

BACKGROUND Despite the fact that there is extensive scientific research on depression very few population-based studies have been conducted in Brazilian cities. METHODS A sampling design of two-stage conglomerates with probability proportional to size. All adults aged 20 or more living in the selected households were invited to participate in the study. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) with a cutoff ≥9. RESULTS The study sample comprised 2925 respondents. The prevalence of depression in the sample studied was 20.4% (95% CI 18.9;21.8). After adjustment for confounding factors according to a conceptual analysis model the following variables were associated with a higher prevalence of depression: female gender; younger age; white skin color; lower socioeconomic condition; lower education; smoking; being single or separated; being unemployed; and reporting a heart condition. Alcohol use, arterial hypertension, and diabetes mellitus were not found to be associated with depression. LIMITATIONS The difference in the proportion of males among losses and refusals compared to that in the sample analyzed. Another limitation is reverse causality bias that is a problem inherent to cross-sectional studies. CONCLUSIONS Our findings support the relevance of depression as a prevalent condition among adults. It also provided evidence of the factors associated with depression, and that some are potentially modifiable risk factors may have implications for policy and health service planning.

A nationwide population-based study of depression in Brazil

INTRODUCTION The state of mental health of the population is considered to be an important and essential component of public health. Depression is the mental disorder with greatest prevalence in several countries around the world. METHODS This was a nationwide Brazilian survey with household-based interviews. The sampling process was at random and cluster-based, and performed in three stages: census tracts, households and individuals. One inhabitant aged ≥18 years was selected per household. Individuals at greater risk of depression were identified through the Patient Health Questionnaire-9 (PHQ-9) algorithm, which uses internationally accepted diagnostic criteria. All analyses took into account sample weights. RESULTS A total of 60,202 individuals were evaluated and the prevalence of positive screening for depression was 4.1% (95% CI: 3.8-4.4%). After adjustments for potential confounding factors, depression was found to be greater among women, individuals aged either 40-59 years or 80 years or over, individuals living in urban areas, those with lower educational level, smokers, and among individuals with arterial hypertension, diabetes and heart disorders. Skin colour, marital status and alcohol abuse were not associated with depression. LIMITATIONS Characteristics of respondents and non-respondents in the sample could not be compared because data about non-respondents was not available. CONCLUSIONS The prevalence of positive screening for depression in Brazil was similar to other studies conducted worldwide. In Brazil, this proportion reflects a considerable absolute number of people with greater risk of depression (≈5.5 million) that may require adequate management through the health system and services.

Sintomas depressivos em idosos residentes em áreas de abrangência das Unidades Básicas de Saúde da zona urbana de Bagé, RS

OBJECTIVE: To identify the prevalence of depressive symptoms and associated factors in elderly. METHODS: Cross-sectional study of population-based sample of 1,593 individuals aged 60 years or more in the urban area of Bage, Rio Grande do Sul, Brazil, in 2008. Data were collected in household interviews. The prevalence of depressive symptoms was assessed using the Geriatric Depression Scale. The analysis was performed using Poisson regression with robust variance estimation. RESULTS: The prevalence of depressive symptoms was 18.0%, with the 95% confidence interval 16.1 - 19.9. The majority of the sample consisted of women (62.8%). The mean age was 70 years, with a 8.24 standard deviation (SD); 25.1% of seniors aged 60 to 64 years and 31.2% were 75 years or older. In the adjusted analysis, depressive symptoms were significantly associated (p value < 0.05) with the elderly female, yellow, brown or indigenous descendancy, lower economic status, retired, with history of heart problems, incapacity to basic and instrumental activities of daily living, worse self-rated health and dissatisfaction with life in general. Age, marital status, education, self-reported hypertension and diabetes were not associated with depressive symptoms after adjusting for confounders. CONCLUSION: The high prevalence of depressive symptoms in the population requires investment in preventive actions, noting the need for practices that promote active aging with the maintenance of functional activity, improving self-rated health and life satisfaction.OBJECTIVE To identify the prevalence of depressive symptoms and associated factors in elderly. METHODS Cross-sectional study of population-based sample of 1,593 individuals aged 60 years or more in the urban area of Bagé, Rio Grande do Sul, Brazil, in 2008. Data were collected in household interviews. The prevalence of depressive symptoms was assessed using the Geriatric Depression Scale. The analysis was performed using Poisson regression with robust variance estimation. RESULTS The prevalence of depressive symptoms was 18.0%, with the 95% confidence interval 16.1 - 19.9. The majority of the sample consisted of women (62.8%). The mean age was 70 years, with a 8.24 standard deviation (SD); 25.1% of seniors aged 60 to 64 years and 31.2% were 75 years or older. In the adjusted analysis, depressive symptoms were significantly associated (p value < 0.05) with the elderly female, yellow, brown or indigenous descendancy, lower economic status, retired, with history of heart problems, incapacity to basic and instrumental activities of daily living, worse self-rated health and dissatisfaction with life in general. Age, marital status, education, self-reported hypertension and diabetes were not associated with depressive symptoms after adjusting for confounders. CONCLUSION The high prevalence of depressive symptoms in the population requires investment in preventive actions, noting the need for practices that promote active aging with the maintenance of functional activity, improving self-rated health and life satisfaction.

Gender differences in the effects of childhood maltreatment on adult depression and anxiety: A systematic review and meta-analysis

Child maltreatment has well-documented long-term, adverse effects on mental health, but it is not clear whether there are gender differences in these effects. We conducted a systematic review to investigate whether there are gender differences in the effects of maltreatment on adult depression and anxiety. Medline, PsycINFO, Web of Science, and Lilacs were searched for relevant studies published up to May 2016. Eligible studies included population-based studies (with a cohort, case-control or cross-sectional design) which assessed maltreatment during childhood or adolescence (≤18 years) and its association with major depression or generalized anxiety disorder (DSM/ICD diagnostic criteria) in adulthood (>18 years) separately for females and males. Meta-analysis was performed to estimate the association between each exposure and outcome using fixed and random effects models. Pooled odds ratios (OR) were estimated separately for women and men and compared. Five studies of physical and sexual abuse were included in the meta-analyses. These provided twenty-two effects sizes estimates (11 for men, 11 for women) for associations between physical/sexual abuse and depression/anxiety. Exposure to each kind of abuse increased the odds of depression/anxiety. Associations were larger for women than for men, however, these gender differences were not statistically significant. Physical and sexual abuse in childhood/adolescence are risk factors for depression/anxiety in adulthood and the effect could be larger for women; however, currently there is insufficient evidence to definitively identify gender differences in the effects of maltreatment.

Perinatal and postnatal risk factors for disruptive mood dysregulation disorder at age 11: 2004 Pelotas Birth Cohort Study

Background To date, there have been few studies of DMDD examining the risk factors during gestation and during the first years of life. We assessed the perinatal and postnatal risk factors associated with the occurrence of disruptive mood dysregulation disorder (DMDD) by 11 years of age. Methods Prospective longitudinal study. Mothers completed a standardized questionnaire shortly after childbirth. We used the Development and Well-Being Assessment, administered to the mothers or legal guardians, to identify DMDD among the 11-year-old subjects. We also employed logistic regression to perform bivariate and multivariate analyses, using a theoretical model of conceptual analysis. Results We evaluated data related to 3563 subjects at 11 years of age. The prevalence of DMDD was 2.5% (95% CI=2.0–3.0). After adjusting for potential confounders, we found that the early risk factors for the development of DMDD by 11 years of age were maternal mood symptoms during pregnancy, maternal depression during the first years after childbirth, and low maternal level of education. Limitations We were unable to evaluate the genetic characteristics of the family at the birth of each subject, and there were no data available regarding the prenatal or postnatal mental health of the fathers. Conclusions The prevalence of DMDD in early adolescence is low and its risk factors are related to potentially modifiable maternal characteristics. Scientific evidence indicates that DMDD is a major predictor of other psychiatric disorders, especially depression and anxiety. Effective prenatal and postnatal mental health care could prevent mental disorders in offspring.

Depression among Brazilian adolescents: a cross-sectional population-based study.

BACKGROUND Depression is the most common mental disorder during adolescence. Mental disorders often begin between infancy and adolescence, persisting throughout the rest of life and even affecting the well-being of subsequent generations. METHODS This was a cross-sectional population-based study, with two-stage, probability-proportional-to-size cluster sampling, conducted in the city of Pelotas, in southern Brazil. All individuals aged 10-19 years and living in the selected dwellings were invited to participate in the study. To identify depression, we applied the Patient Health Questionnaire-9. We defined minor depression as the presence of two or more depressive symptoms, at least one of which is depressed mood or anhedonia. The symptoms were considered valid only if reported to persist for a week or more or to occur nearly every day, the exception being suicidal thoughts, which was considered valid regardless of frequency. RESULTS We interviewed 743 adolescents, among whom the prevalence of minor depression was 17.0% (95% confidence interval, 14.0-20.0), being higher among girls than among boys, as well as among individuals aged 14-15 years, those self-identifying as an ethnic minority, those who were smokers and those who lived with a depressed individual. LIMITATIONS The reverse causality bias that is a problem inherent to cross-sectional studies, which precluded the establishment of temporal relationships between exposures and the outcome of interest. CONCLUSIONS Our results illustrate the relevance of depression in adolescents, underscoring the need for mental health policies targeting this population, with the objective of minimising the short- and long-term effects of early-onset depression.

Mother-child bed-sharing trajectories and psychiatric disorders at the age of 6 years

Background Little is known about the effect of bed-sharing with the mother over the child mental health. Methods Population-based birth cohort conducted in Pelotas, Brazil. Children were enrolled at birth (n=4231) and followed-up at 3 months and at 1, 2, 4, and 6 years of age. Bed-sharing was defined as “habitual sharing of the bed between the child and the mother, for sleeping, for part of the night or the whole night”. Trajectories of bed sharing between 3 months and 6 years of age were calculated. Mental health was assessed at the age of 6 years using the Development and Well-Being Assessment instrument that generates psychiatric diagnosis according to ICD-10 and DSM-IV criteria. Odds ratios (OR) with 95% confidence intervals were obtained by multivariate logistic regression. Results 3583 children were analyzed. Four trajectories were identified: non bed-sharers (44.4%), early-only (36.2%), late-onset (12.0%), and persistent bed-sharers (7.4%). In the adjusted analyses persistent bed-sharers were at increased odds of presenting any psychiatric disorder (OR=1.7; 1.2–2.5) and internalizing problems (OR=2.1; 1.4–3.1), as compared to non bed-sharers. Among the early-only bed-sharers OR for any psychiatric disorder was 1.4 (1.1–1.8) and for internalizing problems 1.6 (1.2–2.1). Limitations Although the effect of bed-sharing was adjusted for several covariates including the family socio-economic status, maternal mental health and excessive crying, there was no information on maternal personal reasons for bed-sharing. Mothers that bed-share intentionally and those that bed-share in reaction to a child sleep problem may have a different interpretation of their children behavior that may bias the study results. Conclusion Bed-sharing is a common practice in our setting and is associated with impaired child mental health at the age of six years.