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It has been claimed that functional somatic syndromes share a common etiology. This prospective population-based study assessed whether the same variables predict new onsets of irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS) and fibromyalgia (FM).
The study included 152 180 adults in the Dutch Lifelines study who reported the presence/absence of relevant syndromes at baseline and follow-up. They were screened at baseline for physical and psychological disorders, socio-demographic, psycho-social and behavioral variables. At follow-up (mean 2.4 years) new onsets of each syndrome were identified by self-report. We performed separate analyses for the three syndromes including participants free of the relevant syndrome or its key symptom at baseline. LASSO logistic regressions were applied to identify which of the 102 baseline variables predicted new onsets of each syndrome.
There were 1595 (1.2%), 296 (0.2%) and 692 (0.5%) new onsets of IBS, CFS, and FM, respectively. LASSO logistic regression selected 26, 7 and 19 predictors for IBS, CFS and FM, respectively. Four predictors were shared by all three syndromes, four predicted IBS and FM and two predicted IBS and CFS but 28 predictors were specific to a single syndrome. CFS was more distinct from IBS and FM, which predicted each other.
Syndrome-specific predictors were more common than shared ones and these predictors might form a better starting point to unravel the heterogeneous etiologies of these syndromes than the current approach based on symptom patterns. The close relationship between IBS and FM is striking and requires further research.
Background: Research in the West shows that group psychological intervention together with an antidepressant treatment leads to more effective treatment of a depressive disorder. There are no treatment trials from low income countries comparing the efficacy of antidepressant treatment with a group psychological intervention. Aim: To conduct a feasibility trial to compare the efficacy of an antidepressant to a group psychosocial intervention, for low income women attending primary health care in Karachi, Pakistan. Method: This was a preliminary RCT in an urban primary health care clinic in Karachi, Pakistan. Consecutive eligible women scoring >12 on the CIS-R and >18 on Hamilton Depression Rating Scale (HDRS) (n = 66) were randomly assigned to antidepressants or a psychosocial treatment in group settings. The primary outcome measure was HDRS score; secondary outcome measures were disability and quality of life. Results: More than half of the patients in both groups improved (50% reduction in HDRS scores); at end of therapy at 3 months 19 (59.4%) vs 18 (56.2%), and at 6-month follow-up 21(67.7%) vs 20(62.5%) for antidepressants and psychosocial intervention respectively. Although HDRS, BDQ and EQ5-D scores all improved considerably in both groups from start to end of treatment, and these improvements were largely maintained after a further 3 months, the differences between the two treatments were not statistically significant. Conclusion: Psychosocial intervention was as effective as antidepressants in reducing depression and in improving quality of life and disability at the end of therapy. However, these findings need further exploration through a larger trial.
Poverty may moderate the effect of treatment of depression in low-income countries.
To assess poverty and lack of empowerment as moderators of a cognitive-behavioural therapy (CBT)-based intervention for perinatal depression in rural Pakistan.
Using secondary analysis of data from a randomised controlled trial (trial registration: ISRCTN65316374) we identified predictors of depression at 1-year follow-up and moderators of the intervention (n=791).
Predictors of follow-up depression included household debt, the participant not being empowered to manage household finance and the interaction terms for these variables with the trial arm. Effect sizes for women with and without household debt were 0.80 and 0.55 respectively. The effect size for women in debt and not empowered financially was 0.94 compared with 0.50 for women with neither of these factors.
Our findings demonstrate the importance of household debt and lack of financial empowerment of women as important maintaining factors of depression in low-income countries and our locally developed intervention tackled these problems successfully.
This chapter provides an overview of the current state of evidence regarding treatment of medically unexplained symptoms, somatisation and the functional somatic syndromes. Both primary and secondary care studies have been performed to assess the efficacy of psychological interventions, most commonly cognitive behaviour therapy administered by a mental health professional, or antidepressants, prescribed by the patient's usual doctor. Thirteen trials evaluated cognitive behaviour therapy, five evaluated antidepressants, four the effect of a consultation letter to the general practitioner (GP) and three the training of GPs. The chapter reviews psychological treatments and the use of antidepressants. It uses three systematic reviews to provide an overview of the evidence of efficacy of interventions for functional somatic symptoms. The evidence is stronger for some pharmacological treatments than for psychological treatments partly because of the universal use of placebo tablets and the lack of an attention-placebo in psychological treatment trials.
This chapter considers three groups, medically unexplained symptoms, somatoform disorders, and functional somatic syndromes. Describing the nature of these groups, it talks about their prevalence in cross-sectional studies in primary, secondary care and population-based studies. Medically unexplained symptoms are very common both in the general population and in primary and secondary care, but at least in the first two settings most are transient. Systematic reviews of the prevalence of irritable bowel syndrome in population-based samples have indicated that the prevalence varies considerably with the definition of the syndrome. Functional somatic syndromes are also common but only some patients with these syndromes also have numerous somatic symptoms. There is little doubt that somatoform disorders, or bodily distress syndromes, are an important and challenging group of conditions that are expensive in terms of healthcare use and time missed from work.
Medically unexplained symptoms and somatisation are the fifth most common reason for visits to doctors in the USA, and form one of the most expensive diagnostic categories in Europe. The range of disorders involved includes irritable bowel syndrome, chronic widespread pain and chronic fatigue syndrome. This book reviews the current literature, clarifies and disseminates clear information about the size and scope of the problem, and discusses current and future national and international guidelines. It also identifies barriers to progress and makes evidence-based recommendations for the management of medically unexplained symptoms and somatisation. Written and edited by leading experts in the field, this authoritative text defines international best practice and is an important resource for psychiatrists, clinical psychologists, primary care doctors and those responsible for establishing health policy.
Antidepressant drugs are widely used in the treatment of depression in
people with chronic physical health problems.
To examine evidence related to efficacy, tolerability and safety of
antidepressants for people with depression and with chronic physical
Meta-analyses of randomised controlled efficacy trials of antidepressants
in depression in chronic physical health conditions. Systematic review of
Sixty-three studies met inclusion criteria (5794 participants). In
placebo-controlled studies, antidepressants showed a significant
advantage in respect to remission and/or response: selective serotonin
reuptake inhibitors (SSRIs) risk ratio (RR) = 0.81 (95% CI 0.73–0.91) for
remission, RR = 0.83 (95% CI 0.71–0.97) for response; tricyclics RR =
0.70 (95% CI 0.40–1.25 (not significant)) for remission, RR = 0.55 (95%
0.43–0.70) for response. Both groups of drugs were less well tolerated
than placebo (leaving study early due to adverse effects) for SSRIs RR =
1.80 (95% CI 1.16–2.78), for tricyclics RR = 2.00 (95% CI 0.99–3.57).
Only SSRIs were shown to improve quality of life. Direct comparisons of
SSRIs and tricyclics revealed no advantage for either group for
remission, response, effect size or tolerability. Effectiveness studies
suggest a neutral or beneficial effect on mortality for antidepressants
in participants with recent myocardial infarction.
Antidepressants are efficacious and safe in the treatment of depression
occurring in the context of chronic physical health problems. The SSRIs
are probably the antidepressants of first choice given their demonstrable
effect on quality of life and their apparent safety in cardiovascular
British Pakistani women have a high prevalence of depression. There are no reported psychosocial interventions for depression in ethnic minorities in the UK.
To determine the efficacy of a social group intervention compared with antidepressants, and whether the combination of the two is more efficacious than either alone.
A total of 123 women with depression participated in the primary care-based cluster randomised controlled trial (ISRCTN19172148). Outcome measures were severity of depression (Hamilton Rating Scale for Depression), social functioning and satisfaction at 3 and 9 months.
Greater improvement in depression in the social intervention group and the combined treatment group compared with those receiving antidepressants alone fell short of significance. There was significantly greater improvement in social functioning in the social intervention and combined treatment groups than in the antidepressant group at both 3 and 9 months.
Pakistani women with depression found the social groups acceptable and their social function and satisfaction improved if they received social treatment compared with the receipt of antidepressants alone.
Depressive disorder is the most common psychiatric disorder among patients attending primary care worldwide. This chapter indicates the ways in which different definitions and different modes of measurement used in previous research can affect the prevalence of depression. It examines the prevalence of depression in different groups and reviews the few studies that have examined the incidence of depression in the medically ill. In published studies, the prevalence of depression in the medically ill ranges between 15% and 61%. A self-administered questionnaire is required to screen a large population of physically ill patients and may be used as the first stage of a two-phase survey, which includes research interviews to determine the actual cases of depressive disorder. Cross-sectional studies demonstrate a close association between depressive disorders and physical illness in population-based studies. Finally, the chapter explains the effect of depression in terms of health-related quality of life and healthcare costs.
The extent to which depression impairs health-related quality of life (HRQoL) in the physically ill has not been clearly established.
To quantify the adverse influence of depression and anxiety assessed at the time of first myocardial infarction and 6 months later, on the physical aspect of HRQoL 12 months after the infarction.
In all, 260 in-patients, admitted following first myocardial infarction, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study SF–36 assessment before discharge and at 6- and 12-month follow-up.
Depression and anxiety 6 months after myocardial infarction predicted subsequent impairment in the physical aspects of HRQoL (attributable adjusted R2=9%, P<0.0005). These negative effects of depression and anxiety on outcome were mediated by feelings of fatigue. Depression and anxiety present before myocardial infarction did not predict HRQoL 12 months after myocardial infarction.
Detection and treatment of depression and anxiety following myocardial infarction improve the patient's health-related quality of life.