Suicidal Ideation and Suicide Attempts in Anxious or Depressed Family Caregivers of Patients with Cancer: A Nationwide Survey in Korea

Purpose

To describe the prevalence of suicidal ideation and suicide attempts in family caregivers (FCs) of patients with cancer and to identify the factors associated with suicidal ideation and suicide attempts in FCs with anxiety or depression.

Methods

A national, multicenter survey administered to 897 FCs asked questions concerning suicidal ideation and suicide attempts during the previous year and assessed anxiety, depression, socio–demographic factors, caregiving burden, patient factors, and quality of life (QOL).

Results

A total of 17.7% FCs reported suicidal ideation, and 2.8% had attempted suicide during the previous year. Among FCs with anxiety, 31.9% had suicidal ideation and 4.7% attempted suicide; the corresponding values for FCs with depression were 20.4% and 3.3%, respectively. Compared with FCs without anxiety and depression, FCs with anxiety or depression showed a higher adjusted odds ratios (aOR) for suicidal ideation (aOR  = 4.07 and 1.93, respectively) and attempts (OR  = 3.00 and 2.43, respectively). Among FCs with anxiety or depression, being female, unmarried, unemployed during caregiving, and having a low QOL were associated with increased odds of suicidal ideation. FCs with anxiety who became unemployed during caregiving constituted a high-risk group for suicide. Being unmarried and having a low QOL with respect to financial matters were associated with increased suicide attempts among FCs with depression.

Conclusion

FCs with anxiety or depression were at high risk of suicide. Interventions to enhance social support and to improve perceived QOL may help prevent suicide and manage suicidal ideation in FCs with anxiety or depression.     

Association between non-suicidal self-injuries and suicide attempts in Chinese adolescents and college students: a cross-section study

Purpose

This study examined the association between non-suicidal self-injury (NSSI) and suicide attempts among Chinese adolescents and college students.

Methods

A total sample of 2013 Chinese students were randomly selected from five schools in Wuhan, China, including 1101 boys and 912 girls with the age ranging between 10 and 24 years. NSSI, suicidal ideation, suicide attempts and depressive symptoms were measured by self-rated questionnaires. Self-reported suicide attempts were regressed on suicidal ideation and NSSI, controlling for participants'' depressive symptoms, and demographic characteristics.

Results

The self-reported prevalence rates of NSSI, suicidal ideation, suicide attempts were 15.5%, 8.8%, and 3.5%, respectively. Logistic regression analyses indicated that NSSI was significantly associated with self-reported suicide attempts. Analyses examining the conditional association of NSSI and suicidal ideation with self-reported suicide attempts revealed that NSSI was significantly associated with greater risk of suicide attempts in those not reporting suicidal ideation than those reporting suicidal ideation in the past year.

Conclusions

These findings highlight the importance of NSSI as a potentially independent risk factor for suicide attempts among Chinese/Han adolescents and college students.     

Genomewide association scan of suicidal thoughts and behaviour in major depression

Background

Suicidal behaviour can be conceptualised as a continuum from suicidal ideation, to suicidal attempts to completed suicide. In this study we identify genes contributing to suicidal behaviour in the depression study RADIANT.

Methodology/Principal Findings

A quantitative suicidality score was composed of two items from the SCAN interview. In addition, the 251 depression cases with a history of serious suicide attempts were classified to form a discrete trait. The quantitative trait was correlated with younger onset of depression and number of episodes of depression, but not with gender. A genome-wide association study of 2,023 depression cases was performed to identify genes that may contribute to suicidal behaviour. Two Munich depression studies were used as replication cohorts to test the most strongly associated SNPs. No SNP was associated at genome-wide significance level. For the quantitative trait, evidence of association was detected at GFRA1, a receptor for the neurotrophin GDRA (p = 2e-06). For the discrete trait of suicide attempt, SNPs in KIAA1244 and RGS18 attained p-values of <5e-6. None of these SNPs showed evidence for replication in the additional cohorts tested. Candidate gene analysis provided some support for a polymorphism in NTRK2, which was previously associated with suicidality.

Conclusions/Significance

This study provides a genome-wide assessment of possible genetic contribution to suicidal behaviour in depression but indicates a genetic architecture of multiple genes with small effects. Large cohorts will be required to dissect this further.     

Barriers to Advance Care Planning in Cancer,Heart Failure and Dementia Patients: A Focus Group Study on General Practitioners' Views and Experiences

Background

The long-term and often lifelong relationship of general practitioners (GPs) with their patients is considered to make them the ideal initiators of advance care planning (ACP). However, in general the incidence of ACP discussions is low and ACP seems to occur more often for cancer patients than for those with dementia or heart failure.

Objective

To identify the barriers, from GPs'' perspective, to initiating ACP and to gain insight into any differences in barriers between the trajectories of patients with cancer, heart failure and dementia.

Method

Five focus groups were held with GPs (n = 36) in Flanders, Belgium. The focus group discussions were transcribed verbatim and analyzed using the method of constant comparative analysis.

Results

Three types of barriers were distinguished: barriers relating to the GP, to the patient and family and to the health care system. In cancer patients, a GP''s lack of knowledge about treatment options and the lack of structural collaboration between the GP and specialist were expressed as barriers. Barriers that occured more often with heart failure and dementia were the lack of GP familiarity with the terminal phase, the lack of key moments to initiate ACP, the patient''s lack of awareness of their diagnosis and prognosis and the fact that patients did not often initiate such discussions themselves. The future lack of decision-making capacity of dementia patients was reported by the GPs as a specific barrier for the initiation of ACP.

Conclusion

The results of our study contribute to a better understanding of the factors hindering GPs in initiating ACP. Multiple barriers need to be overcome, of which many can be addressed through the development of practical guidelines and educational interventions.     

Drugs Associated with More Suicidal Ideations Are also Associated with More Suicide Attempts

Context

In randomized controlled trials (RCTs), some drugs, including CB1 antagonists for obesity treatment, have been shown to cause increased suicidal ideation. A key question is whether drugs that increase or are associated with increased suicidal ideations are also associated with suicidal behavior, or whether drug–induced suicidal ideations are unlinked epiphenomena that do not presage the more troubling and potentially irrevocable outcome of suicidal behavior. This is difficult to determine in RCTs because of the rarity of suicidal attempts and completions.

Objective

To determine whether drugs associated with more suicidal ideations are also associated with more suicide attempts in large spontaneous adverse event (AE) report databases.

Methodology

Generalized linear models with negative binomial distribution were fitted to Food and Drug Administration (FDA) Adverse Event (AE) Reporting System (AERS) data from 2004 to 2008. A total of 1,404,470 AEs from 832 drugs were analyzed as a function of reports of suicidal ideations; other non-suicidal adverse reactions; drug class; proportion of reports from males; and average age of subject for which AE was filed. Drug was treated as the unit of analysis, thus the statistical models effectively had 832 observations.

Main Outcome Measures

Reported suicide attempts and completed suicides per drug.

Results

832 drugs, ranging from abacavir to zopiclone, were evaluated. The 832 drugs, as primary suspect drugs in a given adverse event, accounted for over 99.9% of recorded AERS. Suicidal ideations had a significant positive association with suicide attempts (p<.0001) and had an approximately 131-fold stronger magnitude of association than non-suicidal AERs, after adjusting for drug class, gender, and age.

Conclusions

In AE reports, drugs that are associated with increased suicidal ideations are also associated with increased suicidal attempts or completions. This association suggests that drug-induced suicidal ideations observed in RCTs plausibly represent harbingers that presage the more serious suicide attempts and completions and should be a cause for concern.     

Characteristics of suicide attempts in anorexia and bulimia nervosa: a case-control study

Objective

Compared to other eating disorders, anorexia nervosa (AN) has the highest rates of completed suicide whereas suicide attempt rates are similar or lower than in bulimia nervosa (BN). Attempted suicide is a key predictor of suicide, thus this mismatch is intriguing. We sought to explore whether the clinical characteristics of suicidal acts differ between suicide attempters with AN, BN or without an eating disorders (ED).

Method

Case-control study in a cohort of suicide attempters (n = 1563). Forty-four patients with AN and 71 with BN were compared with 235 non-ED attempters matched for sex, age and education, using interview measures of suicidal intent and severity.

Results

AN patients were more likely to have made a serious attempt (OR = 3.4, 95% CI 1.4–7.9), with a higher expectation of dying (OR = 3.7,95% CI 1.1–13.5), and an increased risk of severity (OR = 3.4,95% CI 1.2–9.6). BN patients did not differ from the control group. Clinical markers of the severity of ED were associated with the seriousness of the attempt.

Conclusion

There are distinct features of suicide attempts in AN. This may explain the higher suicide rates in AN. Higher completed suicide rates in AN may be partially explained by AN patients'' higher desire to die and their more severe and lethal attempts.     

Hostility, physical aggression and trait anger as predictors for suicidal behavior in Chinese adolescents: a school-based study

Purpose

This study explored the extent to which trait aggression is associated with suicidal behavior in a nationwide school-based sample of adolescents.

Methods

A nationwide sample of 14,537 high school students in urban areas of China was recruited. Information concerning suicide ideation, plans, attempts, trait aggression and other risk factors was collected by a self-reported questionnaire. Multivariate regression analyses were employed to predict suicidal behavior.

Results

Approximately 18.5% of students reported suicide ideation, 8.7% reported suicide plans, and 4.1% reported attempts during the past one year. Hostility and trait anger had a significant positive association with suicidal ideation. Hostility and physical aggression were positively related to suicide plans. Hostility had a positive correlation with suicide attempts, while trait anger was inversely associated with suicide attempts.

Conclusions

This study suggests that hostility, physical aggression and trait anger may be able to be used to predict suicidal behavior among adolescents. Suicide prevention programs should target at attenuating the severity of hostility, anger and physical aggression. But teachers and parents should also give close attention to students with low trait anger.     

Suicidal behavior and depression in smoking cessation treatments

Background

Two treatments for smoking cessation—varenicline and bupropion—carry Boxed Warnings from the U.S. Food and Drug Administration (FDA) about suicidal/self-injurious behavior and depression. However, some epidemiological studies report an increased risk in smoking or smoking cessation independent of treatment, and differences between drugs are unknown.

Methodology

From the FDA''s Adverse Event Reporting System (AERS) database from 1998 through September 2010 we selected domestic, serious case reports for varenicline (n = 9,575), bupropion for smoking cessation (n = 1,751), and nicotine replacement products (n = 1,917). A composite endpoint of suicidal/self-injurious behavior or depression was defined as a case with one or more Preferred Terms in Standardized MedDRA Query (SMQ) for those adverse effects. The main outcome measure was the ratio of reported suicide/self-injury or depression cases for each drug compared to all other serious events for that drug.

Results

Overall we identified 3,249 reported cases of suicidal/self-injurious behavior or depression, 2,925 (90%) for varenicline, 229 (7%) for bupropion, and 95 (3%) for nicotine replacement. Compared to nicotine replacement, the disproportionality results (OR (95% CI)) were varenicline 8.4 (6.8–10.4), and bupropion 2.9 (2.3–3.7). The disproportionality persisted after excluding reports indicating concomitant therapy with any of 58 drugs with suicidal behavior warnings or precautions in the prescribing information. An additional antibiotic comparison group showed that adverse event reports of suicidal/self-injurious behavior or depression were otherwise rare in a healthy population receiving short-term drug treatment.

Conclusions

Varenicline shows a substantial, statistically significant increased risk of reported depression and suicidal/self-injurious behavior. Bupropion for smoking cessation had smaller increased risks. The findings for varenicline, combined with other problems with its safety profile, render it unsuitable for first-line use in smoking cessation.     

Prevalence of Depression,Suicidal Ideation,Alcohol Intake and Nicotine Consumption in Rural Central India. The Central India Eye and Medical Study

Background

To investigate the prevalence of depression, suicidal ideations, alcohol and nicotine consumption in adults in an agrarian society mostly unchanged by the effects of urbanization.

Methods

The Central India Eye and Medical Study is a population-based study in rural Central India close to the tribal belt and included 4711 subjects (aged 30+ years). Depression was assessed by the Center for Epidemiologic Studies Depression Scale (CESD), suicidal ideation by six standardized questions, nicotine use by the Fagerstroem Nicotine Tolerance Questionnaire (FTNQ), and alcohol consumption by the Alcohol Use Disorders Identification Test (AUDIT).

Results

Mild to moderate depression (CESD sum score: 15–21) was detected in 1862 (39.6%) individuals (33.5% of men, 44.8 of women), and major depression (CESD sum score >21) in 613 (13.0%) individuals (8.1 of men, 17.3% of women). Suicide attempt was reported by 199 (4.2%) participants and suicidal thoughts during the last 6 months by 238 (5.1%) individuals. There were 887 (18.9%) smokers and smokeless tobacco was consumed by 1968 (41.8%) subjects. Alcohol consumption was reported by 1081 (23.0%) participants; 283 (6.0%) subjects had an AUDIT score ≥8 (hazardous drinking), and 108 (4.63%) subjects a score ≥13 (women) or ≥15 (men) (alcohol dependence).

Conclusions

In rural Central India, prevalence of major depression was comparable to figures reported from other developing countries. Prevalence of smoking and hazardous alcohol consumption was higher than as reported from urban regions. Measures should be taken to address the relatively high prevalence of suicide attempts and thoughts on suicide in rural Central India.     

Psychological Factors as Predictors of Suicidal Ideation among Adolescents in Malaysia

Background

There has been a drastic increase in the rate of suicides over the past 45 years in Malaysia. The statistics show that adolescents aged between 16 and 19 years old are at high risk of committing suicide. This could be attributed to issues relating to the developmental stage of adolescents. During this stage, adolescents face challenges and are exposed to various stressful experiences and risk factors relating to suicide.

Method

The present study examined psychological factors (i.e., depression, anxiety and stress) as predictors for suicidal ideation among adolescents. A cross-sectional study was conducted on 190 students (103 males and 87 females), aged 15 to 19 years old from two different schools in Kuala Lumpur. The Depression Anxiety Stress Scale 21-item version (DASS-21) was used to measure depression, anxiety and stress among the students, and the Beck Scale for Suicide Ideation (BSS) to measure suicidal ideation. The data were analysed using Pearson''s correlation and multiple regression analysis.

Results

The results show that 11.10%, 10.00%, and 9.50% of the students reported that they were experiencing severe depression, anxiety and stress, respectively. There were significant correlations between depression, anxiety, and stress with suicidal ideation. However, only depression was identified as a predictor for suicidal ideation.

Conclusion

Hence, this study extends the role of depression in predicting suicidal ideation among adolescents in the Malaysian context. The findings imply that teenagers should be assisted in strengthening their positive coping strategies in managing distress to reduce depression and suicidal ideation.     

Temperament Traits and Chronic Pain: The Association of Harm Avoidance and Pain-Related Anxiety

Objective

Anxiety symptoms are common in chronic pain patients. High levels of anxiety are associated with increased pain experience and disability. Proneness to anxiety has a large interindividual variation. The aim of the study was to determine whether the anxiety-related temperament trait Harm Avoidance (HA), is associated with pain-related anxiety.

Methods

One hundred chronic pain patients in a multidisciplinary pain clinic participated in the study. The patients were assessed using the HA scale of the Temperament and Character Inventory (TCI) of Cloninger and Pain Anxiety Symptoms Scale-20 (PASS-20). Both the HA total score and the four subscales of HA were analyzed. Current pain intensity was measured using the Visual Analogue Scale (VAS). The Beck Depression Inventory (BDI) was used to control for the influence of depression on the personality measurement.

Results

The HA total score was associated with PASS-20, but the association became non-significant after controlling for depression. The HA4 Fatigability subscale was associated with the PASS scales. Depression did not influence this association. Pain intensity was not correlated with HA or the PASS scales. However, the association between HA4 Fatigability and PASS was influenced by pain intensity. Higher pain intensity was associated with stronger association between the scales.

Conclusion

Harm Avoidance, representing temperament and trait-related anxiety, has relevance in pain-related anxiety. Assessing personality and temperament may deepen the clinician''s understanding of the pain experience and behavior in chronic pain patients.     

Psychiatric Diagnoses and Risk of Suicidal Behaviour in Young Disability Pensioners: Prospective Cohort Studies of All 19-23 Year Olds in Sweden in 1995, 2000, and 2005, Respectively

Objective

Increasing rates of disability pension (DP) have been observed among young adults. We studied specific psychiatric DP diagnoses and subsequent risk of suicidal behaviour in a series of three cohorts of young adult in Sweden.

Method

In a nationwide register study, we included all young adults who in 1995, 2000, and 2005, respectively, were 19–23 years old and lived in Sweden (n≈500,000 per cohort). Rates of DP and specific psychiatric DP diagnoses were recorded in each cohort. Hazard ratios (HRs) and 95% confidence intervals (CIs) for suicidal behaviour during the following five years, with the corresponding age group as reference, were calculated by Cox proportional hazard regression, adjusted for demographic variables and previous own and parental suicidal behaviour.

Results

The overall proportion with DP in this age group increased from 0.92% in 1995 to 2.29% in 2005, with particularly large increases in psychiatric diagnoses such as hyperkinetic disorders, pervasive developmental disorders, and depression/anxiety. The overall proportion of young disability pensioners attempting suicide during the five-year follow-up increased from 2.21% in the 1995 cohort to 3.81% in the 2005 cohort. Within most psychiatric DP diagnoses, the risk of attempted suicide did not change significantly over time, whereas suicide attempts increased in the reference group. Accordingly, the HRs for suicide attempt decreased in some psychiatric DP diagnoses. The highest adjusted HRs were observed for depression/anxiety (16.41; CI: 9.06 to 29.74) and schizophrenia (9.37; 6.13 to 14.31) in the 1995 cohort. The rate of suicide among young disability pensioners during follow-up ranged from 0.19% in 1995 to 0.37% in 2005, mainly occurring in individuals with psychiatric diagnoses.

Conclusion

Suicidal behaviour has become more prevalent among young disability pensioners, which co-occurred with an increased tendency to grant DP in psychiatric diagnoses with a known high risk of suicidal behaviour. Preventive measures are warranted.     

Predictive Validity of the Suicide Trigger Scale (STS-3) for Post-Discharge Suicide Attempt in High-Risk Psychiatric Inpatients

Background

The greatly increased risk of suicide after psychiatric hospitalization is a critical problem, yet we are unable to identify individuals who would attempt suicide upon discharge. The Suicide Trigger Scale v.3 (STS-3), was designed to measure the construct of an affective ‘suicide trigger state’ hypothesized to precede a suicide attempt (SA). This study aims to test the predictive validity of the STS-3 for post-discharge SA on a high-risk psychiatric-inpatient sample.

Methods

The STS-3, and a psychological test battery measuring suicidality, mood, impulsivity, trauma history, and attachment style were administered to 161 adult psychiatric patients hospitalized following suicidal ideation (SI) or SA. Receiver Operator Characteristic and logistic regression analyses were used to assess prediction of SA in the 6-month period following discharge from hospitalization.

Results

STS-3 scores for the patients who made post-discharge SA followed a bimodal distribution skewed to high and low scores, thus a distance from median transform was applied to the scores. The transformed score was a significant predictor of post-discharge SA (AUC 0.731), and a subset of six STS-3 scale items was identified that produced improved prediction of post-discharge SA (AUC 0.814). Scores on C-SSRS and BSS were not predictive. Patients with ultra-high (90^th percentile) STS-3 scores differed significantly from ultra-low (10^th percentile) scorers on measures of affective intensity, depression, impulsiveness, abuse history, and attachment security.

Conclusion

STS-3 transformed scores at admission to the psychiatric hospital predict suicide attempts following discharge among the high-risk group of suicidal inpatients. Patients with high transformed scores appear to comprise two clinically distinct groups; an impulsive, affectively intense, fearfully attached group with high raw STS-3 scores and a low-impulsivity, low affect and low trauma-reporting group with low raw STS-3 scores. These groups may correspond to low-plan and planned suicide attempts, respectively, but this remains to be established by future research.     

Reliability and validity of the Ethiopian version of the hospital anxiety and depression scale (HADS) in HIV infected patients

Background

The hospital anxiety and depression scale (HADS) is a widely used instrument for evaluating psychological distress from anxiety and depression. HADS has not yet been validated in Ethiopia. The aim of this study was to evaluate the reliability and validity of the Amharic (Ethiopian language) version of HADs among HIV infected patients.

Methods

The translated scale was administered to 302 HIV/AIDS patients on follow up for and taking anti-retroviral treatment. Consistency assessment was conducted using Cronbach''s alpha, test-retest reliability using intra-class correlation coefficients (ICC). Construct validity was examined using principal components analysis (PCA). Parallel analysis, Kaiser''s criterion and the scree test were used for factor extraction.

Results

The internal consistency was 0.78 for the anxiety, 0.76 for depression subscales and 0.87 for the full scale of HADS. The intra-class correlation coefficient (ICC) was 80%, 86%, and 84% for the anxiety and depression subscales, and total score respectively. PCA revealed a one dimensional scale.

Conclusion

This preliminary validation study of the Ethiopian version of the HADs indicates that it has promising acceptability, reliability and validity. The adopted scale has a single underlying dimension as indicated by Razavi''s model. The HADS can be used to examine psychological distress in HIV infected patients. Findings are discussed and recommendations made.     

Rural/urban Background,Depression and Suicidal Ideation in Chinese College Students: A Cross-Sectional Study

Objectives

The objective of this study was to examine, first, the relationship of having a rural vs. urban background with suicidal ideation in Chinese college students, and second, whether a potential relationship was mediated by depression.

Methods

A survey was conducted among 1,145 undergraduate students at a university in China. Suicidal ideation and depressive symptoms were measured by the revised Hopkins’ Symptom checklist (SCL-90-R). Associations between rural vs. urban background, depression and suicidal ideation were estimated by multivariable linear regression-based β coefficients, logistic regression-based odds ratios (ORs), and corresponding 95% confidence intervals (CIs). The magnitude of indirect effect and bias-corrected 95% CIs were obtained through bootstrap techniques.

Results

Rural background was positively associated with depression, which was in turn associated with suicidal ideation. The OR for rural status and suicidal ideation equaled 2.15 (95% CI = 1.36–3.41). This OR was slightly, though significantly (p<0.05) attenuated by additional adjustment for depressive symptoms (OR = 1.99, 95% CI = 1.15–3.44).

Conclusion

Having a rural background is a determinant of suicidal ideation in Chinese college students. Depression may only marginally mediate this association.     

A Study of Remitted and Treatment-Resistant Depression Using MMPI and Including Pessimism and Optimism Scales

Background

The psychological aspects of treatment-resistant and remitted depression are not well documented.

Methods

We administered the Minnesota Multiphasic Personality Inventory (MMPI) to patients with treatment-resistant depression (n = 34), remitted depression (n = 25), acute depression (n = 21), and healthy controls (n = 64). Pessimism and optimism were also evaluated by MMPI.

Results

ANOVA and post-hoc tests demonstrated that patients with treatment-resistant and acute depression showed similarly high scores for frequent scale (F), hypochondriasis, depression, conversion hysteria, psychopathic device, paranoia, psychasthenia and schizophrenia on the MMPI compared with normal controls. Patients with treatment-resistant depression, but not acute depression registered high on the scale for cannot say answer. Using Student''s t-test, patients with remitted depression registered higher on depression and social introversion scales, compared with normal controls. For pessimism and optimism, patients with treatment-resistant depression demonstrated similar changes to acutely depressed patients. Remitted depression patients showed lower optimism than normal controls by Student''s t-test, even though these patients were deemed recovered from depression using HAM-D.

Conclusions

The patients with remitted depression and treatment-resistant depression showed subtle alterations on the MMPI, which may explain the hidden psychological features in these cohorts.     

Tracking Functional Brain Changes in Patients with Depression under Psychodynamic Psychotherapy Using Individualized Stimuli

Objective

Neurobiological models of depression posit limbic hyperactivity that should normalize after successful treatment. For psychotherapy, though, brain changes in patients with depression show substantial variability. Two critical issues in relevant studies concern the use of unspecific stimulation experiments and relatively short treatment protocols. Therefore changes in brain reactions to individualized stimuli were studied in patients with depression after eight months of psychodynamic psychotherapy.

Methods

18 unmedicated patients with recurrent major depressive disorder were confronted with individualized and clinically derived content in a functional MRI experiment before (T1) and after eight months (T2) of psychodynamic therapy. A control group of 17 healthy subjects was also tested twice without intervention. The experimental stimuli were sentences describing each participant''s dysfunctional interpersonal relationship patterns derived from clinical interviews based on Operationalized Psychodynamic Diagnostics (OPD).

Results

At T1 patients showed enhanced activation compared to controls in several limbic and subcortical regions, including amygdala and basal ganglia, when confronted with OPD sentences. At T2 the differences in brain activity between patients and controls were no longer apparent. Concurrently, patients had improved significantly in depression scores.

Conclusions

Using ecologically valid stimuli, this study supports the model of limbic hyperactivity in depression that normalizes after treatment. Without a control group of untreated patients measured twice, though, changes in patients'' brain activity could also be attributed to other factors than psychodynamic therapy.     

Prevalence of Chronic Conditions in Australia

Objectives

To estimate prevalence of chronic conditions among patients seeing a general practitioner (GP), patients attending general practice at least once in a year, and the Australian population.

Design, setting and participants

A sub-study of the BEACH (Bettering the Evaluation and Care of Health) program, a continuous national study of general practice activity conducted between July 2008 and May 2009. Each of 290 GPs provided data for about 30 consecutive patients (total 8,707) indicating diagnosed chronic conditions, using their knowledge of the patient, patient self-report, and patient''s health record.

Main outcome measures

Estimates of prevalence of chronic conditions among patients surveyed, adjusted prevalence in patients who attended general practice at least once that year, and national population prevalence.

Results

Two-thirds (66.3%) of patients surveyed had at least one chronic condition: most prevalent being hypertension (26.6%), hyperlipidaemia (18.5%), osteoarthritis (17.8%), depression (13.7%), gastro-oesophageal reflux disease (11.6%), asthma (9.5%) and Type 2 diabetes (8.3%). For patients who attended general practice at least once, we estimated 58.8% had at least one chronic condition. After further adjustment we estimated 50.8% of the Australian population had at least one chronic condition: hypertension (17.4%), hyperlipidaemia (12.7%), osteoarthritis (11.1%), depression (10.5%) and asthma (8.0%) being most prevalent.

Conclusions

This study used GPs to gather information from their knowledge, the patient, and health records, to provide prevalence estimates that overcome weaknesses of studies using patient self-report or health record audit alone. Our results facilitate examination of primary care resource use in management of chronic conditions and measurement of prevalence of multimorbidity in Australia.     

Variability in Vulnerability Assessment of Older People by Individual General Practitioners: A Cross-Sectional Study

Background

In clinical practice, GPs appeared to have an internalized concept of “vulnerability.” This study investigates the variability between general practitioners (GPs) in their vulnerability-assessment of older persons.

Methods

Seventy-seven GPs categorized their 75-plus patients (n = 11392) into non-vulnerable, possibly vulnerable, and vulnerable patients. GPs personal and practice characteristics were collected. From a sample of 2828 patients the following domains were recorded: sociodemographic, functional [instrumental activities in daily living (IADL), basic activities in daily living (BADL)], somatic (number of diseases, polypharmacy), psychological (Mini-Mental State Examination, 15-item Geriatric Depression Scale; GDS-15) and social (De Jong-Gierveld Loneliness Scale; DJG). Variability in GPs'' assessment of vulnerability was tested with mixed effects logistic regression. P-values for variability (p_var) were calculated by the log-likelihood ratio test.

Results

Participating GPs assessed the vulnerability of 10,361 patients. The median percentage of vulnerable patients was 32.0% (IQR 19.5 to 40.1%). From the somatic and psychological domains, GPs uniformly took into account the patient characteristics ‘total number of diseases’ (OR 1.7, 90% range  = 0, p_var = 1), ‘polypharmacy’ (OR 2.3, 90% range  = 0, p_var = 1) and ‘GDS-15’ (OR 1.6, 90% range  = 0, p_var = 1). GPs vary in the way they assessed their patients'' vulnerability in the functional domain (IADL: median OR 2.8, 90% range 1.6, p_var<0.001, BADL: median OR 2.4, 90% range 2.9, p_var<0.001) and the social domain (DJG: median OR 1.2, 90% range  = 1.2, p_var<0.001).

Conclusions

GPs seem to share a medical concept of vulnerability, since they take somatic and psychological characteristics uniformly into account in the vulnerability-assessment of older persons. In the functional and social domains, however, variability was found. Vulnerability assessment by GPs might be a promising instrument to select older people for geriatric care if more uniformity could be achieved.

Trial Registration

Netherlands Trial Register NTR1946