Dissertations / Theses on the topic 'Depression, Mental Diagnosis Australia'

Background: Dissemination of evidence-based mental health clinical practice guidelines had not been studied in Australia prior to the National General Practice Guideline Implementation Program. This naturalistic research reports ten national interventions designed to disseminate the NHMRC 1997 Clinical Practice Guideline Depression in Young People for GPs (GDIYP-GP) through 123 Divisions of General Practice. The guideline covered depression and suicide in young people aged 13 to 20 years. Aim: To evaluate a 'coordinated link agent' and 'enhanced packaged approach' for disseminating a national guideline by engaging 20 Divisions in using 5 dissemination models and to measure Divisions' capacities in performing unfunded local dissemination to GPs. Method: An Implementation Kit was the main national intervention, housing the guidelines and 5 models: Education by the Division; Education by an external provider; 3) Clinical Audit; 4) Segmented Formats and 5) Appraisal. Five studies are reported: 1) an organisational census on guideline-related practices in all topics; 2) a Case Study Database of 3 consecutive interviews of 51 participating Divisions; 3) a Guideline Appraisal study of 9 cohorts of doctors; 4) a Clinical Audit study of 54 doctors involving 1200 patients; and 5) a 'Segmented Formats' documentary analysis of Division communications on GDIYP-GP. Results: Prior dissemination by most Divisions was administrative mail outs rather than planned programs. In all, 70 instead of the pilot 20 organisations participated (57% of the sector) using 10,000 guidelines: 45 participated by 7 weeks and 71 by 35 weeks and the majority used multiple active strategies showing fidelity to the Kit. Education by the Division, Segmented Formats and Appraisal were the most adopted models. GDIYP-GP was acceptable and relevant to the majority of Divisions and to 9 samples of doctors. Conclusion: Divisions are one appropriate system through which evidence-based mental health guidelines can be disseminated to general practitioners. Uptake can be rapid using a flexible enhanced package approach with link-agent support. 3-6 months is needed for organisations to begin effective interventions. Divisions reorient their approach with guidance toward evidence-based dissemination but Division and practice barriers

Background. Diagnosing major depression in the medically ill is difficult because of the overlap of somatic symptoms between the two entities. No studies have examined this issue in advanced HIV disease. Methods. Male subjects with a CD4 count ≤200 were recruited from a specialised outpatient HIV treatment centre. They completed a 30 minute questionnaire and then participated in a diagnostic interview with an HIV psychiatrist. Results. Eight (19.0%) of 42 subjects were diagnosed with major depression. Both inclusive and exclusive approaches to the diagnosis increased the prevalence to 21.4%. Predictive items on the self-report depression scales were inserted in a logistic regression. Four items pertaining to self-worth, discouragement, crying and irritability were left in the model. All somatic items were excluded. Conclusion. This study is an important first step in devising a self-report instrument that would be useful in detecting clinical depression in patients with advanced HIV disease.

Cognitive theory of depression predicts that the illness is associated with an information processing bias that interprets ambiguous information in a mood-congruent or depressive fashion. This negative interpretative bias may serve as a vulnerability factor or maintenance mechanism for a depressive illness. The majority of studies investigating such interpretative biases rely primarily on subjective experimental methodologies (eg., evaluative feedback and self-report) that are vulnerable to experimenter demand effects, response selection biases, and the influence of autobiographical memories. In addition, the results from these studies have been mixed, leading to no firm evidence for the existence of a depression-linked interpretative bias for ambiguous material. In order to avoid the limitations that have plagued subjective research, the present study utilised two of the most promising objective physiological measures of assessing interpretation: the Rapid Serial Viewing Presentation (RSVP) procedure and the affective modulation of the human eye blink reflex. The modified RSVP experiment recorded the reaction time of participants reading a textual scenario that was composed of an opening ambiguous sentence and various emotionally valenced continuations. Interpretation of the ambiguous sentence could be inferred from the reaction time as comprehension latency is inversely related to perceived plausibility. The affective modulation experiment recorded the blink amplitudes of participants startled while performing an imagery task. Blink amplitudes are augmented by negative stimuli and inhibited by hedonic stimuli. Thus, the affective interpretation of ambiguous stimuli could be inferred from the size of the recorded blink response. The results of both experiments did not support the predictions made by cognitive theory. There was no difference in the reaction time responses to the various textual stimuli between 2 depressed outpatients and healthy controls. However, antidepressant medication did have an influence upon the ability of patients to correctly judge the plausibility of the emotionally valenced continuation sentences. With regard to the eye blink experiment, there was also no difference between the depressed outpatients and the controls in terms of size of blink amplitude to the various categories of affective stimuli. Depressive, ambiguous, and distorted stimuli did not augment blink amplitudes in healthy controls or depressed patients without social anxiety disorder. However, depressed patients with a comorbid diagnosis of social anxiety disorder did react to the ambiguous stimuli in an aversive and anxious manner as indicated by increased blink amplitudes. This may be due to the social aspect of the experimental context, which engenders fears of evaluation and performance anxiety. The eye blink procedure can therefore be compromised by group selection, as the comorbidity of anxiety and depression can confound the investigation of depression-linked interpretative biases. In addition, the failure of depressive stimuli to augment blink amplitudes may render the procedure insensitive to the selection of such biases

Thesis (MSc)--University of Stellenbosch, 2000.
ENGLISH ABSTRACT: Malingering is the intentional production or exaggeration of symptoms for personal gain in the context of external incentives. Due to the absence of objective symptoms, depression may represent a relatively attractive option for malingerers. Existing approaches to distinguish between depressive symptoms and possible malingering often use time-consuming psychometric tests or unreliable interview techniques. Short screening tests for malingering may be a practicable alternative and recently South African cut-off scores on tests for malingering were determined for a student sample. The purpose of this study was to establish South African cut-off scores for persons with a diagnosis of depression on screening instruments for malingering. Fifty-one subjects with a diagnosis of depression (measured by the Zung Depression Scale) were randomly ascribed to one of two groups: an experimental group of 25 subjects (instructed to simulate symptoms based on a malingering case scenario) and a control group of 26 subjects (instructed to do their best in the tests). No incentive was provided to the subjects. Each subject completed the 21-item verbal memory forced choice test (FCT), the Rey IS-item test (Rey IS-item), the dot-counting test (DCT), the Word Recognition test (WR) that is part of the Alzheimer Disease Assessment Scale Cognitive Battery (ADAS-Cog) and the Structured Inventory of Malingered Symptomatology (SIMS). The WR test correctly classified 74.5% of subjects with a sensitivity of 93%. The FCT, with a cut-off of> 15.5, correctly classified 72.5% of subjects. A regression equation was computed by combining the FCT, DCT and SIMS. This correctly classified 74.5% of patients with a sensitivity of 69%. The DCT accurately identified 64% of the malingerers using a cut-off score of> 65.57. The Rey15-item test showed poor results and does not seem to be useful as a screening instrument. The WR test shows promise as a screening instrument for malingering. Combining tests when screening for malingering proved to be an effective way to distinguish between malingering of depressive symptoms and real symptoms. The results of this study will help provide guidelines to mental health workers on how to diagnose malingering in patients with depression more objectively.
AFRIKAANSE OPSOMMING: Malingering is die opsetlike nabootsing of oordrywing van simptome vir persoonlike gewin in die konteks van eksterne vergoeding. As gevolg van die subjektiewe aard van simptome, kan depressie 'n relatief aantreklike opsie wees wanneer psigiatriese kondisies gesimuleer word. Bestaande maniere om te onderskei tussen werklike depressiewe simptome en moontlike malingering, gebruik tydrowende psigometriese toetse of onbetroubare onderhoudstegnieke. Kort siftingstoetse vir malingering kan 'n praktiese altenatief wees en onlangse Suid-Afrikaanse afsnypunte op toetse vir malingering is bepaal vir 'n studentesteekproef. Die doel van hierdie studie was om Suid-Afrikaanse afsnypunte te verkry vir malingeringstoetse vir mense met 'n diagnose van depressie. Een en vyftig subjekte met 'n diagnose van depressie (gemeet deur die Zung Depressieskaal) is ewekansig toegewys aan een van twee groepe: 'n eksperimentele groep van 25 subjekte (met die opdrag om simptome te simuleer op grond van 'n malingering-scenario) en 'n kontrolegroep van 26 subjekte (met die opdrag om hulle bes te doen in die toetse). Geen vergoeding is aan proefpersone gebied nie. Elke subjek het die 21-item verbal memory forced choice test (FfC), die Rey 15-item test (Rey IS-item), die dot-counting test (DCT), die Word Recognition test (WR) wat deel vorm van die Alzheimer Disease Assessment Scale Cognitive Battery (ADAS-Cog) en die Structured Inventory of Malingered Symptomatology (SIMS) voltooi. Die WR het 74.5% van die subjekte korrek geklasifiseer met 'n sensitiwiteit van 93%. Die FCT, met 'n afsnypunt van <15.5, het 72.5% van die subjekte korrek geklassifiseer. 'n Regressie-vergelyking is bereken deur 'n kombinering van die FCT, DCT en SIMS. Dit het 74.5% van die subjekte korrek geklassifiseer met 'n sensitiwiteit van 69%. Die DeT kon 64% van die malingeerders akkuraat identifiseer deur gebruik te maak van 'n afsnypunt van> 65.57. Die Rey IS-item toets het swak resultate getoon en blyk nie bruikbaar te wees as 'n siftingstoets nie. Die WR toon potensiaal as In siftingstoets vir malingering. Die kombinering van toetse wanneer pasiënte gesif word vir malingering blyk 'n effektiewe manier te wees om te onderskei tussen die malingering van depressiewe simptome en werklike simptome. Die resultate van hierdie studie kan help om riglyne te skep vir geestesgesondheidswerkers oor hoe om malingering van depressie meer objektief te diagnoseer.

A differential diagnosis between head injury and depression is critical to ensure proper treatment and appropriate interventions. Knowledge about this can only aid counseling psychologists' work with this population and, identifying a measure that can assist in this process is essential. The purpose of this study is to measure the utility of the Dean — Woodcock Neuropsychological Assessment System (D-WNAS) in distinguishing individuals with head injury from those who have a primary diagnosis of depression, and general neurological impairment. Participants included 433 adults (222 males, 211 females) between the ages 20-55 years of age (mean = 35.3 years, SD = 10.97 years) from the Midwestern United States. During the individual's treatment in the neuropsychological laboratory, each person was administered the following: the Dean-Woodcock Structured Interview (Dean & Woodcock, 1999), mental status exam, the Woodcock Johnson — Revised Tests of Cognitive Ability (WJ-R COG; Woodcock & Johnson, 1989b), the Woodcock Johnson — Revised Tests of Achievement (WJ-R ACH; Woodcock & Johnson, 1989a), and the Dean-Woodcock Sensory Motor Battery (DWSMB; Dean & Woodcock, 1999). This study indicates that responses to D-WNAS can be used to reliably classify adults into groups of depression, head injury, and general neuropsychological impairment. In particular, responses to the D-WSMB portion of the D-WNAS can be used to reliably classify adults into groups of depression, head injury, and general neuropsychological impairment. Classification results revealed that the original grouped cases were classified with 62.6 % (p < .001) accuracy and with 73.2% overall accuracy when the head injury and general neurological impairment groups were combined and compared to depression and normative groups. The WJ-R COG and WJ-R ACH were not as reliable as the D-WSMB at predicting group membership.
Department of Counseling Psychology and Guidance Services

The concept of subcortical dementia predicts higher rates of depressive symptomatology in dementia syndromes with predominant subcortical pathology. This hypothesis was evaluated by comparing the frequency and severity of depressive symptomatology in three diagnostic conditions: Alzheimer's disease (AD) (n=30) I subcortical vascular disease (SVD) (n=30), and Parkinson's disease (PD) (n=30). While AD and PD are prototypical exemplars of cortical and subcortical dementia syndromes respectively, SVD provides a test of the generality of the hypothesis as a subcortical neurodegenerative condition whose pathology is not confined to a single subcortical nucleus. A secondary aim of the study was to compare assessment methods for the ascertainment of depressive symptomatology. Assessment methods included the Hamilton Rating Scale for depression derived from interview with the patient's primary caregiver (HRSCG) and from interview with the patient (HRSEX), and the self-report Geriatric Depression Scale. The severity of current depressive symptomatology across the three neurodegenerative disorders followed a consistent pattern across each method of assessment. Specifically, scores on self-report (GDS) , examiner ratings (HRSEX), and caregiver ratings (HRSCG) of depression were most severe in patients with Parkinson's disease (PD) , intermediate in subcortical vascular disease (SVD), and least severe in Alzheimer's the ascertainment of depressive symptomatology. Assessment methods included the Hamilton Rating Scale for depression derived from interview with the patient's primary caregiver (HRSCG) and from interview with the patient (HRSEX), and the self-report Geriatric Depression Scale. The severity of current depressive symptomatology across the three neurodegenerative disorders followed a consistent pattern across each method of assessment. Specifically, scores on self-report (GDS), examiner ratings (HRSEX), and caregiver ratings (HRSCG) of depression were most severe in patients with Parkinson's disease (PD) , intermediate in subcortical vascular disease (SVD), and least severe in Alzheimer's
Ph. D.

The recognition and diagnosis of elderly depression has been the focus of much research over the last 20 years (Brink, 1982; Goodstein, 1985; Klerman, 1983). One problem in diagnosing depression in the elderly has been adequate assessment devices that are sensitive, specific, and predictable with this population (Yesavage et al., 1983). One assessment device developed specifically for the elderly is the Geriatric Depression Scale (GDS) (Brink et al., 1982;Yesavage et al., 1983). This depression scale has yielded high reliability and validity with other self-rating depression scales. In recent research a Short Form Geriatric Depression Scale was produced containing 15 items, all from the original Long Form GDS. A problem with the Short Form involves the lack of research concerning its construct validity. The purpose of the present study was to demonstrate that the Short Form Geriatric Depression Scale does measure depression in the elderly, and therefore, does possess construct validity. To accomplish this task, it was believed that if significant correlations could be identified between various psychosocial variables highly associated with depression in the elderly and the Short Form GDS, validity could be established. The five psychosocial variables chosen: gender differences, physical/health problems, insufficient social support, marital status, and socioeconomic status (finances), have all been shown to be highly related-to depression in the elderly.The information used for this project was gathered from a survey questionnaire developed by the Institute of Gerontology at Ball State University in Muncie, Indiana. The survey questionnaire was sent to over 5,000 randomly selected elderly in the state of Indiana ranging in age from 60 to 85. Of the approximately 5,000 surveys, 2,979 were completed and returned. The survey incorporated questions concerning the five psychosocial variables reviewed and a modification of the Short Form GDS.In order to test the various hypotheses of the study, several analyses were conducted. Based upon the outcome of these analyses, it was concluded that the Short Form Geriatric Depression Scale does possess construct validity. It was also concluded that the Short Form Geriatric Depression scale does assess depression in the elderly and thus is a valid instrument to use in the assessment of depression with the elderly adult.Based upon the information obtained from the survey following hypotheses were supported:a. Elderly individuals with physical disabilities and/or health related problems had higher total GDS scores on the Short Form. b. A positive relationship was found between physiological problems in the elderly and total GDS score.c. Elderly individuals having no social support system had higher total GDS scores on the Short Form.d. A negative relationship existed between an elderly individual's social support system and total GDS score.e. Elderly widows and widowers produced higher total GDS scores than married elderly.f. Elderly individuals with low economic status had higher total GDS scores than elderly individuals with high economic status.
Department of Counseling Psychology and Guidance Services

Early detection of Alzheimer's disease (AD) and related dementias in the elderly is critical for improving treatment methods and is a necessary component for improving public health interventions. One of the earliest and most common behavioral syndromes of AD is apathy and is associated with executive dysfunction. Apathy in AD is often misdiagnosed as depression due to an overlap in symptoms. Studies that have found depression to be associated with executive dysfunction have not always controlled for the presence of apathy. The Geriatric Depression Scale (GDS) is a widely used instrument designed to assess depression in the elderly. This study utilized the GDS and a set of standard neuropsychological instruments to investigate the relationship between apathy, depression, and executive functions in individuals with AD and related dementias. The first objective of this study was to determine if apathy has a greater impact on executive functions compared to depression in AD and related dementias. The second objective was to determine the effectiveness of the GDS as a screen for apathy. The results of the analyses did not support the hypotheses. However, exploratory analyses suggested a possible non-linear relationship with apathy and various levels of dementia severity. Exploratory analysis also suggested mean levels of endorsement for apathy varied by diagnosis. Further research is warranted to investigate this relationship and the GDS endorsement patterns for caregivers regarding their impression of the demented individual.

Thesis (MPhil)--Stellenbosch University, 2011.
ENGLISH ABSTRACT: People diagnosed as being HIV positive or having AIDS develop depression as they attempt to cope with their daily lives. Some studies have indicated the prevalence of depression and anxiety in people living with HIV/AIDS is higher than in the general population. An evaluation of gender related factors that lead to depression after a diagnosis with HIV/AIDS will highlight the incidences and frequency of what individuals experience in their daily lives. The research is a descriptive study in which the factors that cause depression after HIV/AIDS diagnosis were identified and related to gender. Both quantitative and qualitative methods were used to analyse the responses elicited from the participants in the sample. Twenty five PLHAs who had been diagnosed with depression were selected from patients attending both Nthabiseng and Luthando Clinics at Chris Hani Baragwanath Hospital in Soweto, Johannesburg. A questionnaire was designed to gather demographic as well as information regarding family, social and economic history. A short interview was also conducted with selected patients to determine in their own words what causes their depression. The selected patient hospital charts were analysed to gain additional information to complete the equation. A semi structured interview was conducted with 13 selected health care professionals to gather information on how they see depression in the presence of HIV and whether they are adequately equipped to detect and manage this condition. The findings from this study supported the view depression is present or develops after a positive HIV diagnosis and a difference was detected in the causes of depression in women and that of men. Common causes of depression after HIV diagnosis were denial, fear of death and social insecurity. Women were more likely to attribute their depression to denial and worry about work and family responsibility. Men attributed their depression to failure to provide for their family and loss of social status. Recognising the causes of and gender differences in the causes of HIV-related depression may help in designing more effective counselling strategies and improve management and care of PLHAs.
AFRIKAANSE OPSOMMING: Daar is 'n aantal mense wat nie aan depressie ly voordat hulle met HIV gediagnoseer word nie. Meeste studies dui aan dat die voorkoms van depressie en angstigheid by mense wat lewe met MIV en VIGS heelwat hoër is as die algemene MIV populasie. Baie mense, insluitende gesondheidsorgwerkers, neem aan dat depressie 'n onontsnapbare newe-effek is van MIV/VIGS diagnose. Dus mag dit gebeur dat depressie ongesiens verby gaan, onbehandeld, met die gevolg van oneffektiewe behandeling, riskante optrede, swak bestuur van MIV/VIGS en 'n lae lewenskwaliteit vir hierdie pasiënte. Hierdie navorsingsartikel kyk na die geslags-verwante faktore wat lei tot depressie na die diagnosering van MIV/VIGS. Die navorsing is 'n beskrywende studie waarin faktore wat depressie in MIV/VIGS gediagnoseerde pasiënte veroorsaak identifiseer en gedifferensieer word afhangende van geslag. Kwantitatiewe asook kwalitatiewe metodes is gebruik. Dertig PLHAs wat met depressie gediagnoseer is, word behandel in Nthabiseng asook Luthando Kliniek by die Chris Hani Baragwanath Hospitaal in Soweto, Johannesburg. Nthabiseng is die MIV Kliniek en Luthando is die psigiatriese kliniek vir MIV/VIGS pasiënte. 'n Vraelys is saamgestel om demografiese asook familie, sosiologiese en ekonomiese inligting te verkry. 'n Kort onderhoud is ook met sommige pasiënte gehou om in hul eie woorde te hoor wat hul glo hul depressie veroorsaak. Die geselekteerde pasiënte se hospitaal kaarte is geanaliseer, met die doel om die dokter se insette of redes te kry oor die pasiënte se depressie. 'n Semi-gestruktureerde onderhoud was gedoen met gesondheidsorgwerkers in Luthando- en Nthabiseng klinieke om inligting te verkry oor hoe hierdie professionele gesondheidsorgwerkers depressie sien by MIV/VIGS pasiënte en of hul bevoegd is om dit te identifiseer en te behandel. Die studie het bevind dat daar 'n verskil is by oorsake van depressie by vroue en oorsake van depressie by mans. Mees algemene oorsake van depressie by MIV/VIGS pasiënte is ontkenning, vrees van dood en sosiale onstabiliteit. By die vroue het ontkenning en bekommernis oor werk- en familie verantwoordelikhede meestal bygedra tot hierdie depressie, en by die mans was dit meer asof daar 'n algemene terleurstelling geheers het in hul gemoed. 'n Terleurstelling deurdat hul nie vir hul families sal kan sorg nie asook die vernedering in die sosiale netwerk. Om die verskille in MIV-geassosieerde depressie gebasseer op geslag te kan herken mag bydra tot die ontwerp van meer effektiewe beradingstrategië.

Depression is a pervasive mental health disorder worldwide. Although being diagnosed with chronic illness exacerbates susceptibility to depression, detection and subsequent treatment of comorbid depression in primary care settings remain suboptimal because patients with chronic medical disorders are not commonly screened for depression. There is a need to initiate proactive measures by implementing routine screening in primary care settings. The plan-do-study-act (PDSA) model guided an intervention to establish a depression screening practice. This study aimed to determine if the implementation of evidence-based screening for depression using the Patient Health Questionnaire-9 (PHQ-9) tool could increase diagnosis of comorbid depression among patients suffering from chronic diseases. Convenience sampling served as the method for selecting healthcare records that met the predetermined criteria. Two hundred established patients over 18 years of age were screened for depression at a primary care clinic in Maryland within a 10-week period following Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Study participants included 84 (42%) males and 116 (58%) females. Of these, 84 (42%) had minimal depression, 57 (29%) had mild depression, 23 (12%) had moderate depression, 24 (12%) had moderate-severe depression, and 12 (6%) had severe depression. The baseline report from the clinic revealed 0% depression screening practices yet the post-project chart review revealed a surprisingly high rate of depression diagnosis in 34 (17%) of 200 patients suffering from chronic illnesses. Identification of a reliable tool that would be used to screen depression among patients with chronic diseases at primary care clinics to mitigate the deleterious effects of depression and promote the well-being and health of patients and their families is important.

The Beck Depression Inventory (BDI) is a popular screening and research instrument for measuring severity of depression. The instrument was translated to Portuguese for use in Brazil in 1979; however, it was not until recently that its psychometric properties have been tested empirically for the Brazilian population. The purpose of the present study was to explore the BDI's psychometric properties in a northern region of Brazil and to test for possible relationships between certain demographic variables and BDI outcomes. Samples used in this study were from an urban area in Roraima, the northernmost state of Brazil. The BDI showed adequate levels of internal consistency in nonclinical and clinical samples. Female respondents had significantly higher scores than male respondents. Those who had lower levels of education, income, or occupational status had significantly higher scores than those with higher levels of these variables. Adolescents had significantly higher scores than adults from all age groups except those from age 19 to 22. No significant difference was found between those who identified themselves as “indigenous” and those who identified themselves as “non-indigenous.” Regression analysis results showed that the combination of gender, education, and age best accounted for the variance in BDI scores. An ANCOVA revealed that clinically depressed adults had significantly higher BDI scores than nonclinically depressed adults. Factor analysis results showed that there were two main factors in the item structure for both female respondents and male and female respondents combined: one factor of mainly cognitive-affective items and the other factor of mainly somatic items. The results were discussed in terms of the future use of the BDI in Brazil.

Athletic trainers (ATs) are professionals who are most directly responsible for athletes’ health care in a sport environment. ATs work with athletes on prevention, diagnosis, and treatment of athletic injury; it is through these interactions that put ATs in an ideal position to recognize the psychological and emotional distress that athletes may suffer. Consequently, the National Athletic Trainer’s Association (NATA) has called for ATs to be competent in implementing psychosocial strategies and techniques (e.g., goal-setting, imagery, positive self-talk), recognizing basic symptoms of mental disorders, and identifying and referring athletes in need of psychological help. I explored ATs’ ability to recognize, diagnose, and provide a referral for collegiate athletes who were presenting with symptoms of depression across three different scenarios. The study examined factors that may impact ATs’ abilities in these areas, including AT gender, athlete gender, and type of presenting problem (e.g., athletic injury, romantic relationship, or sport performance issue). Overall, female ATs were better at recognizing depressive symptoms than male ATs, though both were equally proficient at diagnosing depression. Regardless of gender of the AT, gender of the athlete, and presenting problem, ATs were most likely to refer the athletes to a counselor/psychologist, and to a lesser extent sport psychology consultant (SPC). ATs viewed referrals to an SPC as most appropriate for presenting problems related to sport (i.e., performance problem or injury). The results highlight a possible bias in referrals to an SPC, in that SPCs may not be considered an appropriate referral source for romantic relationship problems. Implications for ATs and recommendations for future research are discussed.

Utilizing an analogue research design conducted via the Internet, this study assessed athletic trainers' abilities to recognize, diagnose, and intervene with a hypothetical athlete experiencing depression, and examined the impact of their gender, athlete gender, and athlete's presenting problem on their decisions. Athletic trainers' perceived competency in using psychosocial interventions with athletes, history of referring athletes to psychology professionals, and training backgrounds in psychology also were examined. Participants (270 male and 370 female certified athletic trainers) were randomly assigned to one of six conditions (Athlete Gender X Presenting Problem). After reading the appropriate vignette, they completed questions related to the athlete's psychological symptoms and diagnosis, referral recommendations, and use of psychosocial interventions if working with the athlete. The vignettes were identical except for the athlete's gender and problem. Overall, athletic trainers accurately identified the athlete's depressive symptoms/diagnosis and need for psychological referral. They rated the athlete significantly higher in Depressive Symptoms than in Anger/Agitation Symptoms and Compulsive Behavioral Symptoms, and as more likely to be experiencing a depressive disorder compared to an adjustment disorder, anxiety disorder, sleep disorder, or substance abuse disorder. Female athletic trainers provided significantly higher ratings of Depressive Symptoms than males and the injured athlete was rated significantly higher in Anger/Agitation than the performance problem athlete. Diagnosis ratings were not influenced by athlete gender, athletic trainer gender, or type of problem. Athletic trainers were most likely to refer the athlete to a psychology professional compared to an allied health professional, treating the athlete themselves, or doing nothing. Presenting problem significantly impacted referral recommendations. If treating the athlete themselves, athletic trainers were significantly more likely to use supportive interventions than cognitive-behavioral techniques; they felt significantly more competent in providing supportive interventions. Competency in both interventions was significantly enhanced if athletic trainers completed psychology coursework. Findings suggest that athletic trainers are able to accurately identify and intervene with athletes experiencing psychological problems.

This study tested whether participants exposed to a vignette describing an individual experiencing symptoms of depression, which included only the specific diagnosis label of "depression," would report significantly less stigmatized responses than participants exposed to an otherwise identical vignette which included only the non-specific diagnosis label "mental illness." The study is grounded in past research on stigmatization of mental illness and is informed by three theoretical frameworks, the social identity perspective, attribution theory, and labeling theory. Participants were randomly assigned to read one of the two alternate vignettes, then respond to a series of measures testing desire for social distance, negative emotion (affective reaction), beliefs about people with mental illness, and perceived dangerousness of the character in response to the vignette they viewed. The results showed that labelling the character in the vignettes as struggling with "mental illness" did lead to greater perceived dangerousness of the character described, although labelling did not lead to more stigmatization in any of the other measures. This research demonstrated that people tend to consider a character in a vignette as less trustworthy and more of a risk based solely on the label "mental illness." The experiment also tested if people who have had a personal relationship with someone who has experienced mental illness will have less stigmatized responses to mental illness vignettes, but no significant difference was shown. Overall, the results imply that use of specific language in communication labelling an individual as experiencing a mental health condition is less stigmatizing than non-specific language and may improve chances for successful treatment-seeking and future patient outcomes.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol use has been shown to reduce rates of alcohol use across multiple clinical settings, and is routinely recommended by the United States Preventative Services Task Force (USPSTF). In 2005 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended implementing a single item screening question (SISQ) for this purpose. Since then the SISQ has been well validated compared to other tools, such as the Alcohol Use Disorders Identification Test (AUDIT). It has not, however, been well studied in particular populations, such as those with comorbid anxiety and/or depressive disorders. Medicare Annual Wellness Visits present a unique opportunity to study the SISQ because while they do inquire about alcohol use, they do not routinely include a SISQ. Our study seeks to investigate the efficacy of implementation of a SISQ during Medicare Annual Wellness Visits in a residency clinic population with anxiety and/or depressive disorders. Data collection is ongoing and will measure rates of referral to treatment before and after the SISQ is implemented, as well as rates of brief interventions given.

Observational data and alternative estimators with correct interpretations have been used to assess the "right" treatment rates in previous studies. However, no systematic analytical approach has been proposed to examine whether the existing diagnosis rates were right in practice. This study used patients with acute myocardial infarction (AMI) as an example to demonstrate use of observational data to explore the clinical and economic effects of depression diagnosis and the "right" depression diagnosis rates in real-world settings. The objectives of this study were to (1) examine the effects of depression diagnosing on survival, healthcare costs and utilization among elderly patients with AMI; and (2) ascertain bounds on the estimates of the effects of depression diagnosing on survival, healthcare costs and utilization based on chart abstracted data for a subset of patients. Using Medicare claims data, we included a retrospective cohort of all Medicare fee-for-service patients with their first AMI without a depression diagnosis in the previous year during 2007-2008. Depression diagnosis was identified if a patient had a depression diagnosis within 30 days after AMI admission. We also assessed the effects of depression diagnosis within 60 and 90 days after AMI admission. Outcomes were survival, healthcare costs (total costs, Part A, Part B (outpatient, physician fee schedule, and other), and Part D costs), and utilization (hospitalizations, emergency department (ED) visits, outpatient visits, physician visits, and prescription claims) within 1 year after AMI admission. Risk adjustment (RA) and instrumental variables (IV) models were used to estimate the effects of depression diagnosis on AMI patient outcomes. Instruments of local area depression diagnosis styles were created based on area diagnosis ratio (ADR). Using chart abstracted data for a convenience sample, we measured patient physical functional status by difficulties with activities of daily living (ADL) and overall health by adult comorbidity evaluation-27 (ACE-27), AMI severity, and mental illnesses during the index hospitalization. Among 155841 AMI patients in our study sample, 5.9% had a depression diagnosis within 30 days after AMI admission. Our RA estimates showed that depression diagnosis was associated with decreased survival, increased total healthcare costs, Part A costs, Part B outpatient costs, hospitalizations, ED visits, physician visits, and prescription claims in 1 year after AMI admission for patients diagnosed with depression. The ADR-based instruments were strongly related to depression diagnosis (Chow-F values > 10). Our IV estimates showed that higher depression diagnosis rates were associated with increased total healthcare costs, Part A costs, Part B physician fee schedule costs, Part B other costs, Part D costs, and physician visits, but decreased ED visits and prescription claims in 1 year after AMI admission for patients whose depression diagnosis was affected by ADR-based instruments. Since patients diagnosed with depression were more likely to be sicker based on measures in the charts, the RA estimates might be biased toward worse health outcomes and higher healthcare costs and utilization. Across patients grouped by local depression diagnosis styles, the measures in the charts were more evenly distributed across diagnosis groups. However, patients living in areas with stronger preferences of depression diagnosis tended to use more wheelchairs, indicating worse physical function than those living in areas with less stronger preferences. Furthermore, our instruments based on local physician depression diagnosis styles might be correlated with local area practice styles in general (preference to healthcare utilization overall) and local physician supply, and thereby affect healthcare utilization and costs. Therefore, the instruments might not be valid and we could not conclude whether the existing depression diagnosis rates need to be changed.

This study was an investigation into the clinical judgments made by counseling psychologists when faced with a patient who had major depression and AIDS. Two hundred and eighty one counseling psychologists evaluated one of four vignettes depicting an individual with major depression. In three of the vignettes the individual also had AIDS but the vignette varied on how the virus was contracted (unprotected gay sex, IV drug abuse, hemophilia). In the fourth vignette (the control group) the individual did not have AIDS. Results of the study suggested, that the presence of AIDS overshadows the evaluation and treatment decisions made by counseling psychologists when their patient has major depression and AIDS. Three factors-counseling psychologists' general experience with people who have AIDS, their clinical experience with AIDS patients and how the AIDS virus was contracted-were investigated for possible moderating effects of the overshadowing bias. How the AIDS virus was contracted was used as an indirect measure of clinician attitude toward people with AIDS. Neither general or clinical experience with AIDS patients appeared to have an effect on the diagnostic or treatment decisions made by counseling psychologists when evaluating depressed patients with AIDS. As with experience, method of contracting the AIDS virus did not have a moderating effect on the overshadowing bias. Implications of these results for the evaluation and treatment of depression in AIDS patients, as well as future research are discussed.
Department of Counseling Psychology and Guidance Services

Stalking is a complex phenomenon that results in significant harm to victims. For this reason, it is vital that knowledge and understanding of the behaviour be continually advanced. The aim of the present study was to investigate the influence of perpetrator mental disorder diagnosis, target-perpetrator gender, and persistence on perceptions of stalking. Although psychiatric diagnoses are prevalent among clinical stalker populations, little is known about how the presence of a perpetrator mental disorder may influence perceptions of stalking. Both target-perpetrator gender and persistence have been found to have an effect on perceptions of stalking, however it is not understood if or how the presence of mental disorder may interact with these factors. An experimental 2 × 2 × 2 independent factorial design was used to examine the influence of perpetrator mental disorder diagnosis, target-perpetrator gender, and perpetrator persistence on ascriptions of a stalking label, perceptions of behaviour seriousness and perceptions of responsibility. Two-hundred and eighty participants read one of eight vignettes and responded to one categorical item, five scale items, and an open-ended question pertaining to the behaviour described in the scenario. Overall, the majority of participants perceived the behaviour as stalking. Thematic analysis revealed that the repeated and unwanted nature of the behaviour and specific behaviours such as communicating with and following the target were of importance. Only mental disorder influenced ascriptions of a stalking label, with a chi-square analysis indicating that participants were significantly less likely to ascribe a stalking label in the presence of perpetrator mental disorder. Participants who did not ascribe a stalking label in the presence of mental disorder had concerns regarding the perpetrator’s responsibility for the behaviour. With regard to perceptions of behaviour seriousness and perceptions of responsibility, a MANOVA found significant main effects for mental disorder and target-perpetrator gender. A mentally disordered perpetrator was perceived as less responsible for their behaviour than a non-disordered perpetrator. Furthermore, in the presence of mental disorder, the target was perceived to be more responsible for encouraging the perpetrator’s behaviour. In regard to target-perpetrator gender, the behaviour was perceived to be more likely to result in violence and anxiety for the target when the vignette described a man pursuing a woman in comparison to a woman pursuing a man. When no psychiatric history was provided in the vignette, participants were asked to indicate how likely it was that the perpetrator had a mental disorder diagnosis. A MANCOVA including this covariate indicated that when mental disorder was assumed as opposed to stated, responsibility was not significant but behaviour seriousness was. The influence of a perpetrator’s mental disorder diagnosis and targetperpetrator gender on perceptions of stalking have implications for the treatment of perpetrators and victims, both informally and within the criminal justice system. It should be acknowledged that the discrepancy in findings between an explicitly stated and an assumed mental disorder diagnosis may be due to participants imagining different mental disorders, therefore future research should include the manipulation of diagnosis type.

Anxiety and depression are common comorbidities in people with chronic obstructive pulmonary disease (COPD), contributing to greater morbidity and mortality in an already vulnerable population. Despite the prevalence, few recommendations exist in global management guidelines for the detection and treatment of these comorbidities, reflecting the limited literature available on effective strategies for dealing with mental health issues in COPD populations. There is promising evidence that cognitive behavioural therapy (CBT) improves mental health outcomes in people with COPD. However, investigational studies have commonly reported participants’ lack of transport, lack of time and illness as barriers to recruitment and successful completion. This thesis was undertaken in response to a need identified in the literature for an alternative modality of CBT delivery for people with COPD suffering from psychological symptomatology. Thus, a novel home-based self-management CBT learning resource in a DVD format was developed with an accompanying manual. To investigate the primary aim of this thesis, a randomised controlled trial called the ‘Breathing New Life’ study was conducted to determine the efficacy of CBT to treat anxiety and depression in people living with COPD via two formats: group therapy with a reduced number of sessions or this novel home-based self-management DVD resource, compared to usual care. The secondary aim was to investigate the efficacy of these interventions on improvement in health-related quality of life (HRQoL). This thesis is presented as a series of papers (i.e. PhD with publication) from data collected from the Breathing New Life study (ACTRN12616001039471). Study One investigates the risk factors associated with concomitant anxiety and depression and found younger age and having no previous psychological medical history were risk factors for psychological symptomatology compared to those without psychological symptomatology. Study Two investigates the most suitable screening tool for detecting clinically significant anxiety and depression in COPD populations and found simple modifications to the commonly used Hospital Anxiety and Depression Scale (HADS) improved optimal sensitivity and specificity, whilst the Beck Inventories had acceptable sensitivity and specificity without any modifications. Study Three reports the results from the randomised controlled trial investigating the efficacy of CBT delivered in the two different formats. No significant differences over time between those receiving CBT and usual care for anxiety, depression or HRQoL were found in this COPD cohort. However, opinions of benefit expressed in Study Four—a qualitative investigation into the facilitators and barriers COPD participants face when enrolling and completing CBT—provide support that this population find CBT useful, despite being unable to detect any measureable difference. Globally, this thesis adds new knowledge to the body of literature supporting the importance of early screening and treatment for psychological symptomology in people living with COPD. Despite the inability of CBT to improve anxiety and depression, findings from this thesis have important implications towards industry discussion surrounding routine screening for concomitant anxiety and depression, the continued use of the HADS and Beck Inventories as appropriate screening tools in COPD populations and how best to engage and retain COPD participants in CBT.

Australia is experiencing widespread ecosystem degradation, including dryland salinity, erosion and vegetation loss. Approximately 1 million hectares (5.5%) of the south-west agricultural zone of Western Australia is affected by dryland salinity and is predicted to rise to 5.4 million hectares by 2050. Such degradation is associated with many environmental outcomes that may impact on human health, including a decrease in primary productivity, an increase in the number of invasive species, a decrease in the number of large trees, overall decrease in biodiversity, and an increase in dust production. The resulting degradation affects not only farm production but also farm values. This study examines the effects of such severe and widespread environmental degradation on the physical and mental health of residents. Western Australia has an extensive medical record database which links individual health records for all hospital admissions, cancer cases, births and deaths. For the 15 diseases examined in this project, the study area of the south west of Western Australia (excluding the capital city of Perth) contained 1,570,985 morbidity records and 27,627 mortality records for the 15 diseases examined in a population of approximately 460,000. Environmental data were obtained from the Western Australian Department of Agriculture?s soil and landscape mapping database. A spatial Bayesian framework was used to examine associations between these disease and environmental variables. The Bayesian model detected the confounding variables of socio-economic status and proportion of the population identified as Aboriginal or Torres Strait Islander. With the inclusion of these confounders in the model, associations were found between environmental degradation (including dryland salinity) and several diseases with known environmentally-mediated triggers, including asthma, ischaemic heart disease, suicide and depression. However, once records of individuals who had been diagnosed with coexistent depression were removed from the analysis, the effect of dryland salinity was no longer statistically detectable for asthma, ischaemic heart disease or suicide, although the effects of socio-economic status and size of the Aboriginal population remained. The spatial component of this study showed an association between land degradation and human health. These results indicated that such processes are driving the degree of psychological ill-health in these populations, although it remains uncertain whether this 4 is secondary to overall coexisting rural poverty or some other environmental mechanism. To further investigate this complex issue an instrument designed to measure mental health problems in rural communities was developed. Components of the survey included possible triggers for mental health, including environmental factors. The interview was administered in a pilot study through a telephone survey of a small number of farmers in South-Western Australia. Using logistic regression a significant association between the mental health of male farmers and dryland salinity was detected. However, the sample size of the survey was too small to detect any statistically significant associations between dryland salinity and the mental health of women. The results of this study indicate that dryland salinity, as with other examples of ecosystem degradation, is associated with an increased burden of human disease.

Thesis (MEdPsych (Educational Psychology))--Stellenbosch University, 2008.
A depressive mood disorder has been for the past decade the mood disorder with the highest prevalence in the general population. Independent studies done in South Africa indicated a prevalence of depression between 13% to 53%. These results do not concur with official published statistics indicating a prevalence of depression in 16% of the general population over a lifetime. Depression is probably under diagnosed by general practitioners and only a small proportion of adolescents with depression are recognised and even less receive any support for their depression. The aim of this study was to explore the following: the prevalence of symptoms of depression in grade 10 learners in schools in Stellenbosch, gender differences regarding the prevalence of depression symptoms in grade 10 learners, the prevalence of specific symptoms of depression and to explore similarities between symptoms of depression and the adolescent developmental phase. The study was conducted by means of the Beck Depression Inventory. The survey was conducted with 201 grade 10 learners with the necessary permission. The results regarding the prevalence of depression symptoms and gender differences regarding the prevalence of depression correlate with international statistics. This study found that more respondents indicated one or more symptom of depression at the given time than indicated by the literature. It was also found that some adolescent developmental tasks are similar to some symptoms of depression. Further research in South Africa regarding the prevalence of symptoms of depression was recommended.

Major Depressive Disorder (MDD) is exceedingly prevalent and considered to be one of the leading cause of disability worldwide. Depression is also a heterogeneous disorder characterized by complex diagnotic approaches with a lack of diagnostic biomarker, an inconsistent response to treatment, no established mechanism, and affecting multiple physiological systems such as endocrine, immunological and cardiovasular as well.

The growing impact of the analysis of complex signals on biology and medicine is fundamentally changing our view of living organisms, physiological systems, and disease processes. In this endeavour, the basic challenge is to reveal how the coordinated, dynamical behavior of cells and tissues at the macroscopic level, emerges from the vast number of random molecular interactions at the microscopic level. In this way, the fundamental questions could be: (i) how physiological systems function as a whole, (ii) how they transduce and process dynamical information, (iii) how they respond to external stimuli, and mostly (iv), how they change during a pathological processus.

These challenges are of interest from a number of perspectives including basic modeling of physiology and practical bedside approaches to medical and risk stratification.

The general purpose of this thesis, therefore, is to study physiological time series to provide a new understanding of sleep dynamics in health, specifically as they apply to the pathological condition of MDD. More precisely: (1) to quantitatively characterize the complex, nonlinear behaviour of cardiovascular (ECG) and electroencephalographic (EEG) time series during sleep, in health and in MDD. This project will test the hypotheses that both the sleep EEG and ECG detects reorganization in the system dynamics in patient suffering from depression. (2) To develop new diagnostic and prognostic tests for MDD, by detecting and extracting “hidden information” in the ECG and EEG datasets.

Three different methods are introduced in this thesis for the analysis of dynamical systems. The first one, detrended fluctuation analysis, can reveal the presence of long-term correlations ("memory" in the physiological system) even when embedded in non-stationary time series. Graph theoretical measures were then applied to test whether disrupting an optimal pattern ["small-world network"] of functional brain connectivity underlies depression. Finally, multiscale entropy method, which is aimed at quantifying the complexity of the systems' output resulting from the presence of irregular structures on multiple scales, was applied on the ECG signal.

The results indicate that healthy physiologic systems, measured through the EEG and the ECG signals, are the most complex. According to the decomplexification theory, the depressive disease model exhibits a loss of system complexity, with potential important applications in the development and testing of basic physiologic models, of new diagnostic and prognostic tools in psychiatry, and of clinical risk stratification.
Doctorat en Sciences médicales
info:eu-repo/semantics/nonPublished

El término de Patología Dual (PD) hace referencia a la coexistencia o concurrencia de, al menos, un Trastorno por Uso de Sustancias (TUS) y un Trastorno Mental (TM) en una misma persona. Si bien existe una amplia variedad de combinaciones posibles dada la naturaleza heterogénea de esta condición, en este trabajo se ha considerado la comorbilidad de los TM severos esquizofrenia, trastorno bipolar y depresión mayor. La relevancia de la PD se relaciona con su etiología y expresión fenotípica compleja en la que intervienen múltiples factores de riesgo y de protección junto a su elevada prevalencia, gravedad clínica y psicosocial, difícil manejo terapéutico y peor pronóstico funcional. La evidencia científica y la práctica clínica demuestran que en pacientes duales existen variaciones neurocognitivas y de ritmicidad circadiana asociadas al tipo de TM comórbido que derivan en implicaciones clínicas y funcionales de diferente impacto. El objetivo de la presente tesis doctoral consistió en explorar tales diferencias y la interrelación con otras variables sociodemográficas y clínicas atendiendo al tipo de diagnóstico psiquiátrico comórbido. Con ello se pretende contribuir al conocimiento de un perfil cognitivo y circadiano diferencial en pacientes duales que pueda trasladarse al desarrollo de posibles intervenciones preventivas y de estrategias terapéuticas más dirigidas a sus necesidades individuales y recuperación. La investigación abarcó tres áreas de estudio. En la primera se analizaron las variables sociodemográficas y clínicas de los tres grupos de pacientes duales en tratamiento, permitiendo definir y precisar características asociadas al diagnóstico psiquiátrico y su riesgo o influencia en el inicio y desarrollo del trastorno comórbido. La segunda consistió en la evaluación del rendimiento neurocognitivo, el análisis del efecto que la inteligencia premórbida tiene en el mismo y la interrelación de ambos con variables clínicas. Las alteraciones cognitivas se consideran endofenotipos de algunos TM y, en los últimos años, diferencias individuales en la actividad cerebral y un buen funcionamiento premórbido se han relacionado con el mejor rendimiento cognitivo y funcional. Por último, se exploraron las diferencias en la expresión rítmica circadiana ─temperatura corporal periférica (TCP), horarios de sueño-vigilia y tipología circadiana─ incluyendo la comparación con un grupo de controles sanos (CS) y la influencia del tipo de tratamiento ambulatorio o residencial (mayoritariamente en comunidad terapéutica). Se ha señalado que las alteraciones rítmicas circadianas, tanto en pacientes TUS como en algunos TM, podrían ser una característica clínica significativa que afecta la aparición y el curso del trastorno comórbido. Los datos en pacientes duales, aunque muy escasos, apuntan la existencia de recuperación rítmica asociada al tiempo de abstinencia y al tipo de tratamiento. Se evaluó un total de 114 participantes varones de edades comprendidas entre 20 y 50 años. Todos ellos con diagnóstico de PD en tratamiento ambulatorio o residencial (mayoritariamente en comunidad terapéutica). Los participantes fueron divididos en tres grupos atendiendo al diagnóstico psiquiátrico comórbido de esquizofrenia (SZ+=38), bipolar (BP+=37) o depresión mayor (DM+=39). Fueron criterios de inclusión al estudio la vinculación regular al tratamiento y estabilidad clínica, remisión inicial del TUS (no inducido) y abstinencia mínima de tres meses y hasta un año. Los resultados indicaron que los pacientes con SZ+ presentaron indicadores de mayor riesgo para el inicio y mantenimiento del trastorno comórbido así como de mayor gravedad social y clínica, como inactividad laboral por discapacidad/incapacidad, nivel más bajo de estudios, una edad de inicio tanto del TM como del TUS más temprana, más antecedentes familiares de consumo, uso simultáneo de más sustancias y más consumo de nicotina. A diferencia de éstos, los pacientes con DM+ mostraron una edad media superior, mayor probabilidad de estar separado/divorciado y de tener hijos, desempleo por paro o baja laboral, edad de inicio del TM más tardía, pauta más reducida de fármacos y menor consumo de nicotina. Además, la mitad de ellos se encontraba realizando tratamiento intensivo en comunidad terapéutica. Los BP+ se situaron en una posición intermedia en la mayoría de variables, si bien presentaron más años de estudios y menor dependencia de la adicción. Respecto al rendimiento cognitivo, el funcionamiento premórbido estuvo conservado en los tres grupos, así como las habilidades visuoconstructivas y espaciales, y el span atencional. El aprendizaje y memoria verbal estuvieron afectados en SZ+ y relativamente conservados en DM+ y BP+, exceptuando la evocación inmediata. Destacó un buen procesamiento de la información en DM+, con algunas dificultades en SZ+ y BP+. El funcionamiento ejecutivo de los tres grupos fue adecuado excepto en la tarea TMT, donde SZ+ y BP+ mostraron déficits en la inhibición cognitiva de secuencias automáticas y flexibilidad mental. La inteligencia premórbida influyó en casi todos los dominios cognitivos evaluados y, en menor medida, también la edad de los pacientes, la duración de la abstinencia, la estabilidad clínica y la edad de inicio tanto del TUS como del TM. En cuanto a la expresión rítmica circadiana, los pacientes SZ+, seguidos de BP+, mostraron una acrofase más tardía y un mínimo y mesor más elevados que DM+ y CS. Los pacientes DM+ presentaron mayor amplitud y estabilidad del ritmo respecto a los otros grupos de pacientes y a CS. Además, DM+ fueron predominantemente matutinos, dormían menos horas al día y se levantaban más temprano. Todos los grupos diagnóstico aportaron una menor fragmentación del ritmo comparados con CS. El índice de circadianidad fue menor en SZ+ y DM+ que el observado en CS y según el rango normativo. Por otra parte, respecto a los pacientes residenciales, aquellos ambulatorios presentaron un valor mínimo, mesor y L10 más elevado, una acrofase más tardía y un retraso de la hora central del periodo de vigilia. También refirieron mayor duración de sueño diario, horas más tardías de levantarse y acostarse así como una tipología intermedia. Junto al tipo de tratamiento las variables de edad, abstinencia y consumo de nicotina fueron factores indicativos de afectación o recuperación rítmica. Tales hallazgos apuntan la importancia de la preservación o recuperación cognitiva y circadiana en la funcionalidad de los pacientes duales, siendo indicadores la inteligencia premórbida y el tratamiento residencial respectivamente. Entre las implicaciones preventivas y clínicas que se derivan destaca el incluir en primeros episodios y a edades más avanzadas evaluaciones neuropsicológicas y del CI premórbido e incorporar intervenciones para enriquecer la reserva cognitiva en caso necesario. Así mismo, evaluar el estado rítmico circadiano antes y a lo largo del tratamiento, incorporando estrategias cronoterapéuticas en los pacientes ambulatorios. En conclusión, la consideración de las alteraciones neurocognitivas y circadianas y el impacto en ellas del TM comórbido contribuirá a la detección de posibles marcadores de vulnerabilidad y pueden ser predictores de pronóstico y adherencia al tratamiento junto al establecimiento de objetivos y estrategias de tratamiento más precisas orientadas a la prevención o rehabilitación así como a mantener cambios de comportamiento y hábitos saludables a medio y largo plazo para la evitación de recaídas.
The term Dual Pathology (DP) refers to the coexistence or concurrence of at least one Substance Use Disorder (SUD) and a Mental Disorder (MD) in the same person. Although there is a wide variety of possible combinations given the heterogeneous nature of this condition, this work has considered the comorbidity of three very prevalent severe MDs in DP (schizophrenia, bipolar disorder and major depression). The relevance of DP seems to be related to its etiology and complex phenotypic expression in which multiple risk and protection factors are involved. Added to this is the high prevalence, clinical and psychosocial severity, difficult therapeutic management and worse overall functional prognosis. Today, the correct detection, diagnosis and therapeutic intervention in DP is a difficult task and a pending challenge among professionals and researchers in the fields of mental health and addictions. Scientific evidence and clinical practice show that in dual patients there are cognitive and circadian rhythmic variations associated with the type of comorbid MD, which may result in clinical and functional implications of different impact. Therefore, the objective of the present doctoral thesis was to explore such differences and the interrelation with other sociodemographic and clinical variables based on the type of comorbid psychiatric diagnosis. Our purpose is to try to contribute to the knowledge of a differential profile in dual patients according to the comorbid pathology that could be transferred to the development of possible preventive interventions and therapeutic strategies especially directed to their individual needs. This research covered three areas of study. First, the sociodemographic and clinical variables of the three groups of dual patients under treatment were analyzed, allowing to define and specify characteristics associated with the psychiatric diagnosis and their risk or influence on the onset and development of the comorbid disorder. Secondly, was the evaluation of neurocognitive performance, the analysis of the effect that premorbid intelligence has on it and the interrelation of both with clinical variables. Cognitive alterations are considered as endophenotypes of some MD and, in recent years, individual differences in brain activity and good premorbid functioning have been linked to a better cognitive and functional performance. Finally, differences in circadian rhythmic expression - peripheral body temperature (PBT), sleep-wake time and circadian typology- were explored, including a comparison with a group of healthy controls (HC) and the influence of the type of outpatient treatment or residential (mostly in therapeutic community). The evidence indicates the existence of circadian rhythmic alterations in both SUD and in some MD, suggesting that these alterations could be a significant clinical feature that affects the onset and course of comorbid disorder. Data in dual patients, although scarce, suggest the existence of rhythmic recovery associated with withdrawal time and the type of treatment. A total of 114 male participants aged 20 to 50 years were evaluated, all of them with diagnosis of DP in outpatient or residential treatment (most in the therapeutic community). The participants were divided into three groups based on the comorbid psychiatric diagnosis of schizophrenia (SZ+=38), bipolar disorder (BP+=37) or major depression (MD+=39). Inclusion criteria to the study were regular treatment adherence and clinical stability, initial remission of SUD (not induced), and minimum abstinence period of three months and up to one year. The results indicated that patients with SZ+ presented indicators of a greater risk for the onset and maintenance of the comorbid disorder as well as greater social and clinical severity, such as inactivity due to disability, lower level of studies, and an earlier age of onset for both MD and SUD, more family history of substance use, simultaneous use of more substances, and more nicotine consumption. In contrast to these, patients with MD+ exhibited an older average age, greater probability of being separated/divorced and having children, unemployment due to work stoppage or work leave, age of onset of the latest MD, reduced pattern of drugs, and lower consumption of nicotine. In addition, half of them were undergoing an intensive treatment in a therapeutic community. The BP+ patients were placed in an intermediate position in the majority of the variables, although the group highlighted a higher level of education and a lower severity of addiction. Regarding the cognitive performance, premorbid functioning was conserved in the three groups, as well as visoconstructive and spatial skills, and attention span. Learning and verbal memory were affected in SZ+ and relatively conserved in MD+ and BP+, except for immediate memory. Thus, we observed a good processing of information for MD+, and some difficulties for SZ+ and BP+. The executive functioning of the three groups was adequate except in the TMT task, in which SZ+ and BP+ showed deficits in the cognitive inhibition of automatic sequences and mental flexibility. Moreover, premorbid intelligence influenced almost all cognitive domains evaluated and, to a lesser extent also the age of the patients, the abstinence period, clinical stability, and the age of onset for both SUD and MD+. Regarding the circadian rhythmic expression, the SZ+ patients, followed by BP+, showed a late acrophase and a higher mesor than MD+ and HC. The MD+ patients presented greater amplitude and stability of the rhythm compared with the other groups of patients and HC. In addition, patients MD+ were predominantly within a morning typology, slept less hours a day and got up earlier. All the diagnostics groups exhibited less fragmentation of the rhythm compared to HC. The circadianity index was lower in SZ+ and MD+ than that observed for HC, and according to the normative range. On the other hand, regarding residential patients, those outpatients had a higher minimum, mesor and L10 value, a late acrophase and a delay in the central time of the waking period. They also reported a longer duration of daily sleep, later hours of getting up and going to bed, as well as an intermediate typology. Together with the type of treatment, age, abstinence period and nicotine consumption were indicative factors of rhythmic involvement or recovery. Our findings point out the importance of the cognitive preservation and circadian recovery in the functionality of dual patients; being indicators of these aspects the premorbid intelligence and the residential treatment, respectively. Among the preventive and clinical implications that arise from such findings, it is worth mentioning the inclusion of neuropsychological and premorbid IC assessment in early episodes and at older ages, also incorporating interventions to enrich the cognitive reserve if necessary. Likewise, other clinical implications from our observations are to evaluate the circadian rhythmic state before and throughout the SUD treatment, incorporating chronotherapeutic strategies for outpatients. In conclusion, the consideration of neurocognitive and circadian alterations and the posible impact on them of comorbid MD will contribute to the detection of possible markers of vulnerability and can be predictors of prognosis and adherence to treatment together with the establishment of more precise goals and strategies; oriented to prevention or rehabilitation as well as to maintaining changes in behavior and healthy habits in the medium and long term to avoid relapses.

Objectives. Evaluate differences in depressive symptoms, compare sociodemographic and health-related variables associated with depressive symptoms and report level of impact of depressive symptoms on daily activities. Methods. Cross-sectional study using a self-administered questionnaire and Patient Health Questionnaire-9 (PHQ-9) diagnostic survey on 1115 patients aged 60–93 years who attended a primary care clinic in Korea, Russia or USA. Results. At least mild depression (PHQ-9 score of ≥5) occurred in 28% of Koreans, 65% of Russian and 27% of US participants. Russians scored more depressed on all PHQ-9 items (P < 0.01) and more suicidal thoughts (P < 0.001), while Koreans had less feelings of worthlessness (P < 0.001). Depression predictors included poorer self-rated health [odds ratio (OR) 2.47, 95% confidence interval (CI) 1.84–3.33, P < 0.0001], chronic diseases (OR 1.34, CI 1.21–1.48, P < 0.0001), female gender (OR 1.56, CI 1.15–2.12, P = 0.0046) and religious attendance (OR 0.88, CI 0.79–0.97, P = 0.0099) for all subjects. Being employed was protective in Korea (OR 0.41, CI 0.21–0.77, P = 0.0061) and being married (OR 0.42, CI 0.27–0.66, P = 0.0002) and of older age (OR 0.95, CI 0.93–0.98, P = 0.0006) protective in US participants. Vascular disease was associated with depressive symptoms in Russia (OR 3.47, CI 1.23–9.80, P = 0.0187). In regression analyses stratified by country for a given level of depressive symptoms, the Russian sample had less impact on daily activities (Russia R2 = 0.107 versus Korea R2 = 0.211 and US R2 = 0.419) P = 0.029. Conclusions. Depressive symptoms were more common in Russia than in Korea and USA but had less impact on daily functioning. Cultural or environmental factors may account for this finding.

Motor Neurone Disease (MND) is caused by the degeneration and death of motor neurones. It is universally fatal and causes wasting and weakness of the somatic musculature. The disease usually affects those aged between 40 and 70, with 50% of people with MND dying within 3 years and 90 percent within 6 years. Only 10 percent survive 10 years or more While the incidence of MND is much lower than that of Multiple Sclerosis, twice as many people die of MND as die from Multiple Sclerosis and Muscular Dystrophy combined. Once diagnosis is confirmed it appears that the health care service has little to offer in the way of care or a cure. The majority of people with MND are cared for in their home by family members which places enormous stress on both the individual and other family members. The purpose of this study is to examine the factors which influence quality of life (QOL) in people with MND. This remains sadly under-investigated with only one significant report in the last three decades. The present study utilised a self-rated questionnaire, sent to individuals with neurologically confirmed MND, volunteering their participation via requests for help published in the MND Association newsletters throughout Australia. The questionnaire comprised standard measures which allowed the assessment of general well being (Rand 36-item Health Survey), depression (Beck Depression Inventory), coping strategies (Jalowiec Coping Scale), levels of hope (Herth Hope Scale), social support network (Norbeck Social Support Scale). Additional questions were constructed to assess illness-related knowledge, use of alternative therapies, the importance of spirituality and satisfaction with the way the diagnosis was delivered. Demographically the individuals involved with the study differed little from other reports on MND. Psychologically, low mood was evident in over three quarters of the subjects. However, only 10 percent could be described as depressed. Coping strategies most frequently used was a problem solving approach and a dependency mechanism least frequently. Fifty three of the 74 in the study group held favourable levels of hope. For such a terrible diagnosis it was most disturbing that 45 percent of those with MND thought that the information made available at diagnosis was inadequate. Of even greater concern was the fact that three quarters said that the diagnosis was disclosed in a brutal manner, with 61 % saying the manner was officious and factual. Many individuals with MND had a poor knowledge about the disease with 40 percent believing that MND was a disorder of the muscles and one third did not know the median survival in this condition. Twenty three of the 74 admitted to using at least one alternative therapy at some stage. Expectedly, MND had a significant adverse effect on the life style, financial situation, social life, physical disability , psychological state and overall quality of life of many involved in the study. Only family relationships appeared to show little change following the diagnosis of MND. Despite great strains on marital harmony spouses remained the main carers in over half of the individuals with MND. People with MND suffer greatly from the moment that the diagnosis is communicated through the depression of relentless muscle weakness and finally death from aspiration or respiratory failure. This study has highlighted that in general the care available to those suffering from MND is rather a hit or miss affair. Several measures to meet the specific needs of those diagnosed with MND are discussed. Most important of all is the need to better anticipate the rapidly changing needs of such individuals and for the medical and nursing professionals to be aware of the great harm they cause by removing all hope by well meaning frankness and the good they can do by offering support at all stages of the disease.

Mood disorders are often linked with concurrent partner relational distress. The present study compared the cost effectiveness of treating mood disorder alone versus when the condition is comorbid with partner relational distress. Cigna, a leading health insurance management company in the US, provided outpatient data. Participants included patients with solely a mood disorder diagnosis (n = 72,712) and those with both a mood disorder and a comorbid partner relational distress diagnosis (n = 113, including 69 females and 44 males). These participants were treated in outpatient settings throughout the US. These numbers are surprisingly low considering the extensive literature showing a strong relationship between mood disorder and partner relational distress. A multivariate general linear model and binary logistic regressions were used to analyze the data. Results indicate that having a mood disorder present with a partner relational distress disorder significantly increased the average cost of care by about $471 per person compared to having solely a mood disorder. For mood disorders alone, there were also differences in cost effectiveness and readmission for mood disorders by professional license type, age, and gender with counselors being the most cost effective and medical doctors being the least (60% more costly). The treatment modality used impacted readmission rates, with family therapy having the lowest (8.54%) and mixed therapy having the highest (33.54%). Due to the small sample size, we were unable to determine the significance of subsequent analyses for comorbid disorders. Clinical implications and future directions for research will be discussed.

Les données issues de la recherche en neurosciences permettent de considérer la dépression comme une affection invalidante générale, caractérisée par des déficits neurocognitifs et comportementaux, au delà des symptômes dépressifs cliniques définis dans les classifications nosographiques. Ces déficits coexistent à la phase aiguë d’un épisode dépressif caractérisé (EDC) et interfèrent dans la prise de décision et réalisation d’un comportement orienté vers un but, et la sensation d’effort associée. Ils semblent persister en période de rémission clinique, altérant la qualité de la réponse thérapeutique et fonctionnelle et aggravant à terme le pronostic du trouble. L’objectif de ce travail est d’identifier des marqueurs neurocognitifs objectivement mesurables en pratique clinique, et d’étudier leur association au pronostic d’un EDC, afin de mieux prédire les probabilités de rémission et d’optimiser les stratégies de prescription thérapeutique des patients. L’altération des processus neurocognitifs liés à la récompense constitue un premier marqueur de vulnérabilité du trouble dépressif : dans une étude explorant la production d’un effort moteur dans le but d’obtenir une récompense, les patients déprimés présentaient un déficit de production d’effort, à la différence des sujets sains. Ce trouble de la motivation par incitation - processus sous tendu en imagerie fonctionnelle chez le sujet sain par l’activation de circuits cortico-striataux ventraux -pourrait constituer une dimension spécifique de la maladie dépressive. Participant à l’altération des processus de prise de décision et d’action, ce déficit motivationnel est associé, et possiblement secondaire, à des déficits plus spécifiquement cognitifs que nous avons ensuite étudiés. Dans une étude explorant plusieurs fonctions cognitives chez des patients déprimés au sein d’une large cohorte, la présence d’un ralentissement psychomoteur séquellaire après 6 à 8 semaines de traitement – chez des patients pourtant en rémission clinique -, était positivement et de manière indépendante, significativement corrélée au nombre d’épisodes dépressifs passés, constituant ainsi un marqueur d’une sévérité « cumulative » du trouble dépressif. Enfin, dans une revue de la littérature sur le caractère progressivement évolutif des déficits cognitifs dans le trouble dépressif unipolaire, nous avons discuté l’existence d’un effet « neurotoxique » cérébral de l’accumulation d’EDC, à l’origine de troubles neurocognitifs et de conséquences sur le cours évolutif de la maladie (risque majoré de rémission clinique et/ou fonctionnelle partielle, de récurrence, d’évolution démentielle). Un des principaux intérêts de l’identification de marqueurs de vulnérabilité cliniques et cognitifs est de mettre en évidence leur rôle prédictif du cours évolutif d’un épisode -ou d’un trouble- dépressif. Dans une étude menée sur une cohorte de plus de 500 patients déprimés, une variable attentionnelle (d2 test d’attention) était capable de prédire l’évolution ultérieure vers la rémission complète (clinique et fonctionnelle) de façon significative, linéaire, et indépendante des autres variables et de représenter un marqueur-trait de la dépression, aisément utilisable en pratique clinique. D’autres marqueurs cognitifs (tels que les fonctions exécutives) ont montré une valeur prédictive élevée de la réponse thérapeutique, avec une précision proche de celle de marqueurs d’imagerie ou électrophysiologie, selon les résultats d’une méta-analyse récente, justifiant leur emploi dans le suivi des patients
Hese deficits coexist in the acute phase of a depressive episode and interfere with decision-making and goal-directed behaviors, and the associated feeling of effort. They appear to persist in periods of clinical remission, decreasing the quality of the therapeutic and functional response and lately worsening the prognosis of the disorder. The aim of this work is to identify objectively measurable neurocognitive markers in clinical practice, and to study their association with the prognosis of a depressive episode, in order to better predict remission and potentially to optimize therapeutic prescribing strategies for patients accordingly. The impairment of neurocognitive processes related to reward constitutes a first vulnerability marker for major depressive disorder (MDD): in a study assessing the production of motor effort in order to obtain a reward, depressed patients had a deficit in production of effort, unlike healthy subjects. Such deficit in incentive motivation - a process underpinned by the activation of ventral cortico-striatal circuits in healthy subjects - may constitute a specific dimension of MDD. It participates in the decision-making and action processes impairments and is associated with – and possibly a consequence of- more specifically cognitive deficits. In a study assessing several cognitive functions in a large cohort of depressed patients, the persistence of psychomotor retardation after 6 to 8 weeks of treatment - in patients considered as being in clinical remission - was positively and independently correlated with the number of past depressive episodes, thus constituting a marker of "cumulative" marker of past depressive episodes. Finally, in a literature review on the progressive evolution of cognitive deficits in MDD, we discussed the existence of a “neurotoxic” effect of the lifetime accumulation of depressive episodes on neurocognitive deficits and its consequences on disease prognosis (increased risk of incomplete functional/clinical remission, relapses, evolution towards dementia). One of the main interest in identifying clinical and cognitive markers of vulnerability is to highlight their capacity to predict the course of a depressive episode-or disorder. In a study based on a cohort of more than 500 depressed patients, a measurement of attention (d2 attention test) was able to significantly and independently predict the subsequent course towards complete remission (clinical and functional) and to constitute a trait -marker of depression, easy to use in clinical practice. Other cognitive markers (such as executive functions) have shown high predictive values for therapeutic response, comparable to those provided by imaging or electrophysiology markers, according to the results of a recent meta-analysis, that emphasizes the interest of using them in patient’s follow-up. Finally, in order to better assess the prognosis of depressive disorder, we have shown that Seasonal Affective Disorder (SAD) diagnosis criteria - which nevertheless represents a specific depressive disorder with well-known physiopathology substrates (construction validity) - had a low predictive validity, prompting to consider this disorder as a temporary expression of a mood disorder, rather than a specific disorder. The identification of clinical tools measuring motivational and cognitive deficits in clinical routine and predicting the course of a depressive episode or disorder represents a major challenge in the improvement of personalized therapeutic management and the long-term prognosis in depressed patients

Esse estudo propôs-se avaliar presença de transtornos de eixo I, personalidade e caracterizar demograficamente 33 transexuais (masculinos e femininos). Outros objetivos foram comparar Depressão e Transtornos de Personalidade após dois anos de psicoterapia grupal e estruturar um temário específico para ela. Foram aplicados: SCID-I/P, Beck, Hamilton e Entrevista Estruturada para Distúrbios da Personalidade pelo DSM-III-R. As características demográficas gerais não variaram nos grupos. Não houve nenhum diagnóstico psiquiátrico prevalente. Houve predomínio de sintomas depressivos e não de quadros clínicos de depressão. Quanto aos transtornos e traços de personalidade, nenhum dado estatisticamente significativo foi encontrado. Temas para psicoterapia foram estabelecidos.
This study aimed to evaluate the presence of personality disorders of axis I as well as to characterize demographically 33 transsexuals (male and female). Other objectives were to compare depression and personality disorders after two years of group therapy and structure a specific theme list to it. SCID-I/P, Beck, Hamilton and Structured Interview for Personality disorders by the DMS-III-R were applied. General demographic characteristics did not vary among the groups. There was no prevailing psychiatric diagnosis. As for disorders and personality traits, no statistically significant data was found. Psychotherapy themes were established.

Under-utilisation of mental health services is widespread globally and within Australia, especially among culturally and linguistically diverse (CALD) communities. Improving service access is a priority, as is the need to deliver culturally competent services to the CALD communities. Having migrated to Australia in waves for approximately 150 years from China and South East Asia for various social, political and economic reasons, the Chinese population in Sydney is now the fastest growing non-English speaking ethnic group. There is a need to better understand the impact of culture on the emotional experiences of these Chinese in Australia. How do Chinese make sense of their depressive episodes? To address this question, this study explored the ways participants reach out for medical and/or non-medical help. Lay concepts of illness underpin these decisions and were thus unveiled. Mixed-method research design provided the opportunity to bring together multiple vantage points of investigation: population mental health, transcultural psychiatry and medical anthropology. A study combining quantitative survey and qualitative focus groups was undertaken in metropolitan Sydney. Narratives on symptoms, explanatory models and help-seeking strategies were articulated by focus group informants. Surveys covered demographics, symptom-recognition, previous depressive experiences and professional help sought. Depression measurement tools were cross-culturally validated. Self-ratings of ethnic identities and the Suinn-Lew Self-Identity Acculturation Scale were used to quantify Chinese participants' acculturation level. This allowed comparisons between 'low-acculturated' Chinese', highly-acculturated' Chinese and Australians. Survey results showed comparable levels of symptom-recognition in all subgroups. Focus group discussions provided rich data on informants' help-seeking strategies. Highly acculturated Chinese closely resembled the Australians in many study variables, yet qualitative data suggested cultural gaps beyond language barriers in influencing service use. Participants believed that trustful relationships could work as the bridge to link services with those in need. The implications for Australia's mental health policy include recognising the importance of rapport-building and the existence of cultural gaps. The study indicated professionals can benefit from acquiring information about the mental health beliefs both of individual clients and the wider ethnic communities in which they belong, and respecting the cultural differences between helper and helped as the first step towards cultural competency.

The aim of this study was to determine the usefulness of the following instruments for the diagnosis of depression among Africans: The Beck Depression Inventory (2nd Edition) (BDI-II), the Minnesota Multiphasic Personality Inventory (Revised) (MMPI-2) and the Rorschach Inkblot Test (scored in terms of Exner's Comprehensive System). With regard to the MMPI-2, the focus was on the Depressed Suicidal Ideation Critical Item Scale, but the following Critical Item Scales were also examined: Acute Anxiety State, Somatic Symptoms and Family Conflict. With regard to the Rorschach, the Depression Index (DE PI) and the Suicide Constellation (S-CON) were examined. A Structured Questionnaire was used to obtain background information on the patients. The sample consisted of 162 African patients between the ages of 18 and 50 years that were seen in a private practice in Pretoria, Gauteng. All the patients had an educational level of at least Grade 12. The patients were diagnosed according to DSM-IV criteria as suffering from Dysthymia, Major Depression or Adjustment Disorder with Depressed Mood. The personal background information about the patients that was examined included: sources of and reasons for referral, presenting symptoms, views about the causes of depression, and experience of the self. Relevant statistical analyses were done to investigate the reliability and validity of the measurement instruments and to determine if there were any gender or age biases in the results. In contrast to the findings of earlier research that depressed African patients mainly present with physical complaints, the patients who participated in the study predominantly presented with emotional and cognitive symptoms similar to what is found in Western countries. Only a few patients referred to traditional African beliefs such as witchcraft, and most of them interpreted their illness in terms of interpersonal problems, especially in their relationships with other family members. The BDI-II was found to be a reliable and valid instrument that could be used for the diagnosis of depression among African patients. Of the 162 MMPI protocols, 46.3% were invalid. It was especially on the L, F, F(B) and Cs scales that large numbers of patients obtained scores higher than the cut-off scores. The reliabilities of the Critical Item Scales were acceptable, except for the Family Conflict scale, and these scales thus generally appear to be useful for diagnostic purposes in an African context. The mean score on the Depressed Suicidal Ideation Scale was, however, relatively low. The MMPI-2 rendered a large number of misdiagnoses of Schizophrenia and Personality Disorder and only a few of the patients obtained a diagnosis of a depressive disorder. Although the patients found the MMPI-2 too long and the language too complex, they generally experienced the test positively. The DEPI and S-CON rendered a large number of false negatives which indicates that if these indeces are used for assessing depression, it should be done in conjunction with other diagnostic methods. The Rorschach nevertheless proved to be useful for identifying psychodynamic processes that could be used therapeutically. A low and statistically non-significant positive correlation was found between the BDI-II and the DEPI. Both the BDI-II and the DEPI correlated positively with the Depressed Suicidal Ideation scale. The S-CON did not correlate significantly with any of the other scales.
Thesis (DPhil (Psychology))--University of Pretoria, 2006.
Psychology
unrestricted

Thesis (MD (Doctor of Medicine))--Flinders University, School of Medicine, Dept. of Palliative and Supportive Care.
Typescript bound. Includes bibliographical references: (leaves 147-177) Also available online.

Professional Doctorate - Doctor of Clinical Psychology (DCP)
Purpose: To identify variables associated with common mental disorders in an Australian university population. Background: A systematic literature review was conducted to identify research on prevalence and risk factors associated with depression, anxiety, eating and alcohol disorders in university students. The review identified 1200 studies of which 36 met our inclusion criteria. Depression and anxiety disorders were identified as the most prevalent disorders in this group. The main risk factors reported for student mental disorders were: being a woman, being homosexual or bisexual, growing up in a family with low socio-economic status, current financial difficulty and being a man for alcohol disorders. Methods: We invited all Australian based students from a large public university (N=24,209) to participate in a web-based Student Mental Health Survey. Outcome measures included the Primary Health Questionnaire depression, anxiety, and eating disorders modules, and the Alcohol Use Disorders Identification Test. Explanatory variables of interest included gender, age, year of study, degree type, financial means, parental education, domestic/international status and sexual orientation. Multiple logistic regression analysis was used to estimate independent associations with the four outcomes. Results: Complete responses were received from 6044 students (25%). Proportions reporting depression, anxiety, eating disorders and harmful drinking were 8%, 13%, 14% and 8% respectively, while 30% had at least one of these disorders. The groups with the highest rates of disorder were women, 25–34 year olds, students on low income, and homosexual or bisexual students. Parental education was not associated with disorder, and nor was an international/domestic status. Conclusions: This is the first study examining mental disorders in a population-based university sample in Australia. Groups in particular need are women, students on low incomes and homosexual or bisexual students. Given increasing student numbers and participation of students from lower socio-economic backgrounds, policy is urgently needed to promote better mental health in the population, to routinely identify vulnerable students, and to intervene early. A national longitudinal study examining mental health across multiple institutions with oversampling of high risk groups is recommended based on the findings and limitations of this study. There is also need for further research and development of electronic programs which are cost-effective and preventative in nature, as a first response in a stepped care approach to mental health on campuses.

Research Doctorate - Doctor of Philosophy (PhD)
While new motherhood is socially perceived to be a time of great elation and joy, this life stage is also a time of great risk for mental health problems and emotional difficulties. For women, these problems can have long-term impacts including putting them at risk for ongoing mental health problems and dissatisfaction with motherhood. This in turn may reduce infant-mother bonding which can have impacts on the infant’s mental health and intelligence even into childhood. The most common form of mental health morbidity in the perinatal period is postnatal depression, affecting between 10-20% of mothers in Australia (National Health and Medical Research Council 2000). This thesis fills a gap in the current literature by examining both the proximal and distal factors related to postnatal depression in Australia by using longitudinal data collected on a national, broadly representative, sample of women. A longitudinal, multi-methods design was employed to examine the complex associations between risk factors and to also explore the lived experience of new mothers who have experienced postnatal depression. Prior history of mental health conditions were particularly evident as having a significant impact on risk of postnatal depression, as was long-term experience of stressful life events and lack of social support. In addition health and stressful life events in pregnancy and postpartum such as breastfeeding, emotional distress during labour and sleep deprivation had an impact on the occurrence of postnatal depression. The results indicated that understanding a woman’s mental health history is very important in the detection of those who are most vulnerable to postnatal depression. These findings also indicate that treatment and management of depression and anxiety earlier in life may have a positive impact on the incidence of postnatal depression. The findings of this project can direct future mental health clinical guidelines regarding postnatal depression and support the premise of early intervention for mental health problems. By preventing first incidences of mental health problems, recurrences such as those in the perinatal period should be reduced, which in turn will have a positive impact on mother-infant bonding, and on maternal health outcomes and infant outcomes.

At any time, one in three adolescents experiences at least one depressive symptom. There is some evidence that physical activity is associated with reduced depressive symptomatology in adolescents. This study therefore investigated physical activity as a potential preventive intervention for depression in youth. The thesis presents the development, trial, and evaluation of a novel physical activity promotion program, and its effect on symptoms of depression and related health and psychosocial outcomes in adolescents (aged 11-18 years). The first phase of the project involved reviews of the current literature. These reviews, which informed the development of the Intervention to Stay Healthy and Physical Everyday (IN2SHAPE) program, established that few physical activity interventions for adolescent mental health exist. Interventions that were reviewed had substantial methodological limitations. None of the trials employed distal (non-face-to-face) delivery, although distal delivery methods have potential for widespread implementation and may be acceptable to adolescents. A systematic review then identified characteristics of physical activity interventions that have been conducted distally with adolescents, none of which have examined mental health outcomes. The IN2SHAPE program was designed in accordance with this literature, to address many of the methodological flaws of previous programs and for use either with or without face{u00AD}to-face delivery. In the second phase of the project, four empirical studies were conducted. Study 1 was a screening survey of 774 secondary school students from the Australian Capital Territory (ACT). This survey identified participants who met the eligibility criteria for participation in Studies 2 and 3. The study found that lower depression symptoms were associated with higher physical activity participation in this population. In Study 2, focus groups were used to provide adolescent input into the IN2SHAPE program and the planned intervention design. In Study 3, the IN2SHAPE program was administered as part of a three-arm pilot randomised controlled trial (RCT) in a sample of 26 adolescents identified by the screening survey to have elevated, but sub-clinical, depressive symptoms, and less than one hour per day of physical activity. Physical activity interventions with and without face-to-face researcher contact were compared to a nutrition control with researcher contact. Participants were assessed at post-intervention and 4-month follow-up. Physical activity participation significantly increased for both physical activity conditions over the 8-week intervention, as measured by pedometer step counts but not by self-report measures. No significant between-groups effects were found for depressive symptoms, although the effect size for the physical activity group with researcher contact was moderate from pre- to post-intervention (d = .56). The final study involved a participant evaluation of the intervention, using questionnaires and focus groups. It was determined that IN2SHAPE was an acceptable program to adolescent participants. Although there were difficulties recruiting a sample of adolescents with symptoms of depression and limited physical activity, this project highlights the potential utility of physical activity as an intervention to reduce depressive symptoms. Some researcher contact appears necessary to encourage adolescent engagement with the IN2SHAPE program. Further research on the optimal delivery and measurement of physical activity in depression interventions is warranted.

There is growing acceptance of the importance of the consumer viewpoint in mental health research. Previous studies have identified differences in research priorities for researchers and mental health consumers in Australia defined broadly (e.g., Jorm, Griffiths, Christensen & Medway, 2002a). However, little is known about the research priorities of consumers with specific mental health conditions. The aim of the SCOPE for Research project was to inform future directions for research on depression and bipolar disorder in Australia. This was achieved through the qualitative and quantitative exploration of consumer priorities and a comparison of these priorities with published Australian research. Phase 1 comprised focus groups with consumers and individual telephone interviews with consumer advocates. Participants were asked to discuss topics, groups and settings they believed were priorities for depression or bipolar disorder research. They were also asked to describe the factors that influenced their priority-setting and to identify their sources of information on mental health research. A qualitative analysis was conducted to identify major themes and construct a survey for the second phase of the project. In Phase 2, participants were asked to rate the importance of each topic, group or setting on a 5-point scale. Phase 3 of the project consisted of a thematic analysis of Australian published research on depression and bipolar disorder from 1997-2006 and comparison of the consumer survey results with published research. The most frequently cited themes in Phase 1 included the need for research on medication, and lifestyle and psychosocial influences on depression and bipolar disorder. Participants expressed reluctance to prioritise particular subpopulation groups and favoured community-wide research in community settings. They cited personal experience as the strongest influence on their priority-setting and most commonly sourced their information on depression and bipolar disorder research from the Internet. In Phase 2, participants rated research into the topic areas management and treatment as the top priorities. The highest rated target groups for research focused on people most at risk and Phase 2 participants prioritised research conducted in outpatient health settings such as community mental health services. As in Phase 1, the majority of participants were influenced by their own personal experience when setting priorities. The most common sources of information were mental health organisations and the Internet. Most published research identified in Phase 3 concerned lifestyle and psychosocial influences, causes, and description & characteristics of depression and bipolar disorder. Many studies targeted groups based on age and research was primarily conducted in the community. The comparison of the results of the Phase 2 consumer survey with the Phase 3 literature survey revealed more differences than similarities between the priorities of consumers and the current research output. This project represents an important contribution to the process of actively involving consumers in mental health research in Australia. It provides insight into the areas of most concern to the people who are the ultimate beneficiaries of research, the mental health consumers, and the findings can be used as a guide to ensure relevant research.

The common mental disorders (CMDs) which include non-psychotic depression and anxiety-related disorders aggregate mental illnesses commonly seen together without assuming clear diagnostic boundaries. Thus, it provides an excellent platform for a symptom-level investigation of common suffering in regions where the current Western-based diagnostic categories may not apply. This current study investigates the symptom networks of CMDs among adult primary care patients in India, using data from a clinical trial testing the effectiveness of a collaborative stepped-care intervention led by lay health counselors. Network modeling was used to investigate a) symptom centralities, b) boundaries between depression and anxiety-related disorders, and c) baseline differences in network configurations across gender, public versus private health care settings, and treatment response over one-year of follow-up. Intense anxiety/panic and fatigue were the most central symptoms overall. While panic and depressed mood were the most central in public health care settings, fatigue and depressed mood were most central in private settings. Overall, findings indicate central symptoms might differ across cultures and socioeconomic groups. To the knowledge of this current author, this is the first study investigating the symptom networks of CMDs among primary care patients in India.

INTRODUCTION: Conversational agents are of great interest in the field of mental health, often in the news these days as a solution to the problem of a limited number of clinicians per patient. Until very recently, little research was actually done in patients with mental health conditions, but rather, only in healthy controls. Little is actually known if those with mental health conditions would want to use conversational agents, and how comfortable they might feel hearing results they would normally hear from a clinician, instead from a chatbot. OBJECTIVES: We asked patients with mental health conditions to ask a chatbot to read a results document to them and tell us how they found the experience. To our knowledge, this is one of the earliest studies to consider actual patient perspectives on conversational agents for mental health, and would inform whether this avenue of research is worth pursuing in the future. Our specific aims are to first and foremost determine the usability of such conversational agent tools, second, to determine their likely adoption among individuals with mental health disorders, and third, to determine whether those using them would grow a sense of artificial trust with the agent. METHODS: We designed and implemented a conversational agent specific to mental health tracking along with a supporting scale able to measure its efficacy in the selected domains of Adoption, Usability, and Trust. These specific domains were selected based on the phases of interaction during a conversation that patients would have with a conversational agent and adapted for simplicity in measurement. Patients were briefly introduced to the technology, our particular conversational agent, and a demo, before using it themselves and taking the survey with the supporting scale thereafter. RESULTS: With a mean score of 3.27 and standard deviation of 0.99 in the Adoption domain, we see that subjects typically felt less than content with adoption but believe that the conversational agent could become commonplace without complicated technical hurdles. With a mean score of 3.4 and standard deviation of 0.93 in the Usability domain, we see that subjects tended to feel more content with the usability of the conversational agent. With a mean score of 2.65 and standard deviation of 0.95 in the Trust domain, we see that subjects felt least content with trusting the conversational agent. CONCLUSIONS: In summary, though conversational agents are now readily accessible and relatively easy to use, we see there is a bridge to be crossed before patients are willing to trust a conversational agent over speaking directly with a clinician in mental health settings. With increased attention, clinic adoption, and patient experience, however, we feel that conversational agents could be readily adopted for simple or routine tasks and requesting information that would otherwise require time, cost, and effort to acquire. The field is still young, however, and with advances in digital technologies and artificial intelligence, capturing the essence of natural language conversation could transform this currently simple tool with limited use-cases into a powerful one for the digital clinician.

The focus of the research study is to explore chronically ill African American, Latino, and White patients' causal attributions of symptoms of depression and factors that predict depression care treatment preferences among these groups. Research has demonstrated that perception of illness impacts what treatments a person will deem appropriate for their mental health problems and from whom they will seek treatment. Research also indicates that certain ethnic groups are more likely to seek treatment for their symptoms of depression in the primary care setting. Yet, it is unclear how they actually perceive their symptoms and what best predicts the treatments that they are likely to consider acceptable. A convenient sample of 109 HIV+ adults, 79 diabetic adults, and 3 adults with both conditions were recruited for this study. Participants had to be receiving services for either HIV, diabetes, or both conditions in one of the three central Austin facilities and be a representative from one of three racial/ethnic groups: African Americans, Latino, and White. Differences were found across ethnicity with regard to causal beliefs and treatment preferences for the symptoms of depression both among the HIV and the diabetic subgroups. Latinos in both groups were more likely than Whites to prefer counseling or a single form of treatment over combined treatment methods. Diabetic Latinos were more likely to prefer counseling for symptoms of depression. HIV seropositive individuals who reported the least number of symptoms of physical illness were more likely to attribute their symptoms of depression to stressful life events, whereas those who reported the greatest number of symptoms of physical illness were more likely to attribute their symptoms of depression to their medical illness. Additionally among the HIV subgroup, individuals who reported high stress tended to predict the preferences for treatment provided by a psychiatrist/psychologist and Whites scored highest on this factor. Finally, differences in depression scores across race/ethnicity were also revealed. The utility of assessing a patient's understanding of symptoms of depression in order to determine how personal illness models impact treatment preferences and knowledge of patient's causal attributions can aid medical social workers and physicians in collaborative management of chronic illness and depression are discussed.

These original data for this research were documented in the clinical diary records of an army psychiatrist on deployment in Vietnam during 1969–70. This study is unique due to the original battlefield diagnosis data used for foundation comparison analysis and longitudinal retrospective case control paired measurement. In battlefield psychiatric assessment diagnostic data recorded in Vietnam during 1969–70 of 119 Australian military servicemen (Experimental group) who presented battlefield trauma exposure reactions were examined. The research case controls (Control group) are 275 Australian Vietnam veterans selected from data at the Australian War Memorial Research Centre. Case control identified participants did not present with medical symptoms in 1969-70 and presented the same demographic profile as the Experimental group population. This research examined whether initial psychiatric illnesses initiated by battlefield trauma exposure in 1969-70 by a cohort of Vietnam veterans would have long term pernicious effects on their physical and psychological health, relationships and employment status. This research compared, PTSD, delayed onset PTSD, severity of combat exposure and depressive symptoms, quality of dyads, general health and quality of life. The analysis of specific demographic variables determined the means, standard deviations, and medians for those continuous variables for both groups from 1969-70 (n=394) and 2006-07 (n=97). The 2006-07 Experimental group (n=21) represents 17.65% and the Control group (n=76) represents 28.15% of the original groups selected and matched from 1969-70 data. These participants completed a battery of psychometric questionnaires and a follow up telephone interview. Demographic variables were evaluated for inclusion as covariates. These demographic variables were correlated with combat exposure and the presentation of PTSD in 1969-70 and 2006-07. PTSD identified in 2006-07 was modelled as a latent variable with three manifest indicators (re-experiencing, hyper-arousal and avoidance). Categorical variables were determined by frequency tables for respective group participants. Group differences in continuous variables were analysed by t-test or the Wilcoxon signed rank sum test accounting for non-normal distributions. Categorical variables, chi-square tests or Fisher's Exact Tests were performed when assumptions of chi-square tests were violated. Research participants from 1969-70 and 2006-07 did not indicate a significant difference in demographic, categorical or continuous variables. Initial 1969-70 battlefield psychiatric diagnosis TSD did indicate of a causal link to delayed onset PTSD in research participants in 2006-07. The PTSD (2006-07 diagnosis) indicated a descriptive difference, 64 of the 76 Control met the diagnostic criteria, while 19 of the 21 Experimental met the criteria. A significant difference was identified in the 2006-07 presence and severity of depression, two symptoms (intrusion and avoidance) of PTSD and the reported combat exposure. The prevalence of delayed onset PTSD was also highlighted. Obtaining original battlefield psychiatric diagnoses is rare. Comparison with an identifiable Control group after 35 years informs knowledge of how military personnel cope with battlefield exposure. Specifically concluding that; battlefield exposures during 1969-70 for the majority of the research participants have impacted detrimentally on their psychological and physical health, relationships, employment and ongoing overall wellbeing to this day. Delayed onset PTSD is the principal indicator of this current state for these veterans.
Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

These original data for this research were documented in the clinical diary records of an army psychiatrist on deployment in Vietnam during 1969–70. This study is unique due to the original battlefield diagnosis data used for foundation comparison analysis and longitudinal retrospective case control paired measurement. In battlefield psychiatric assessment diagnostic data recorded in Vietnam during 1969–70 of 119 Australian military servicemen (Experimental group) who presented battlefield trauma exposure reactions were examined. The research case controls (Control group) are 275 Australian Vietnam veterans selected from data at the Australian War Memorial Research Centre. Case control identified participants did not present with medical symptoms in 1969-70 and presented the same demographic profile as the Experimental group population. This research examined whether initial psychiatric illnesses initiated by battlefield trauma exposure in 1969-70 by a cohort of Vietnam veterans would have long term pernicious effects on their physical and psychological health, relationships and employment status. This research compared, PTSD, delayed onset PTSD, severity of combat exposure and depressive symptoms, quality of dyads, general health and quality of life. The analysis of specific demographic variables determined the means, standard deviations, and medians for those continuous variables for both groups from 1969-70 (n=394) and 2006-07 (n=97). The 2006-07 Experimental group (n=21) represents 17.65% and the Control group (n=76) represents 28.15% of the original groups selected and matched from 1969-70 data. These participants completed a battery of psychometric questionnaires and a follow up telephone interview. Demographic variables were evaluated for inclusion as covariates. These demographic variables were correlated with combat exposure and the presentation of PTSD in 1969-70 and 2006-07. PTSD identified in 2006-07 was modelled as a latent variable with three manifest indicators (re-experiencing, hyper-arousal and avoidance). Categorical variables were determined by frequency tables for respective group participants. Group differences in continuous variables were analysed by t-test or the Wilcoxon signed rank sum test accounting for non-normal distributions. Categorical variables, chi-square tests or Fisher's Exact Tests were performed when assumptions of chi-square tests were violated. Research participants from 1969-70 and 2006-07 did not indicate a significant difference in demographic, categorical or continuous variables. Initial 1969-70 battlefield psychiatric diagnosis TSD did indicate of a causal link to delayed onset PTSD in research participants in 2006-07. The PTSD (2006-07 diagnosis) indicated a descriptive difference, 64 of the 76 Control met the diagnostic criteria, while 19 of the 21 Experimental met the criteria. A significant difference was identified in the 2006-07 presence and severity of depression, two symptoms (intrusion and avoidance) of PTSD and the reported combat exposure. The prevalence of delayed onset PTSD was also highlighted. Obtaining original battlefield psychiatric diagnoses is rare. Comparison with an identifiable Control group after 35 years informs knowledge of how military personnel cope with battlefield exposure. Specifically concluding that; battlefield exposures during 1969-70 for the majority of the research participants have impacted detrimentally on their psychological and physical health, relationships, employment and ongoing overall wellbeing to this day. Delayed onset PTSD is the principal indicator of this current state for these veterans.
Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

Research Doctorate - Doctor of Philosophy (PhD)
Background: Medication use among older people has received increased attention in recent years because the prevalence of multiple medication use in the older population has increased. There is some evidence that some medications can cause mental illness such as depression, anxiety, and mood disorders. However, there is limited evidence of the association between medication use and mental health outcomes, in older women. Aims: This thesis has six interconnected aims: 1) To describe medications used by women in the ALSWH who were born in 1921-1926 (1921-1926 Cohort). 2) To examine the cross-sectional association between medication use and mental health scores, in women aged 76-81 years, who completed Survey 3 (2002) of the Australian Longitudinal Study on Women’s Health. 3) To examine, longitudinally, the association between medication use and poor mental health, in ALSWH participants who completed Survey 3 (2002), Survey 4 (2005), Survey 5 (2008) and Survey 6 (2011). 4) To assess the association between various classes of medication and mental health among ALSWH participants aged 76-81 years, who completed Survey 3 in 2002. 5) To examine, longitudinally, the association between classes of medication used and poor mental health, across surveys 3-6, clarifying, and expanding upon the findings of aim four. 6) To systematically review current literature of studies assessing the association between selected classes of medication and mental health outcomes, in older adults without mental illness. Methods and Results: To reach these aims, secondary data analyses of ALSWH data and four systematic reviews (in 2014 and 2015) were conducted. Women at greater risk of poor mental health who used medications, had more co-comorbid conditions, more symptoms, were more likely to be obese, and to be a smoker. Two analyses were conducted in order to evaluate aims two and three. First, cross-sectional analyses were undertaken, using a multivariable linear regression, to examine the association between medication use, in terms of two measures, and mental health scores, among women aged 76-81 years, at Survey 3 in 2002. A weak linear association between the number of different medications or number of different therapeutic medication groups used, and mental health scores, was found. A second set of analyses examined longitudinal associations between two measures of medication use and poor mental health, by using Generalized Estimating Equations (GEE) models. From these analyses, it was found that poor mental health was associated with higher medication use (number of different medications and number of different therapeutic medication groups used). However, the association did not persist after adjusting for physical function and bodily pain. Unadjusted univariate analyses, using linear regression to assess the associations between various classes of medication and mental health scores, among similar women who completed Survey 3, showed statistically significant associations between the use of medications for the nervous system (Class N), blood (Class B), alimentary tract and metabolism (Class A), musculoskeletal system (Class M), and cardiovascular system (Class C), and lower mental health scores, among older Australian women, aged 76-81 years. GEE models were then used to explore associations between these four classes of medication (nervous system, alimentary tract and metabolism, musculoskeletal system, and cardiovascular system medications) and poor mental health, during ten years of follow-up and adjusting for other factors. The evidence from these analyses suggests that there is not a clear association between use of these four classes of medications and poor mental health, in older Australian women. Additional analyses (sensitivity analyses) were also conducted, as part of the fifth aim, excluding women who were using psycholeptics (N05) and psychoanaleptics (N06) medications for anxiety and depression, during 2002-2011. These analyses concluded that using Class A, Class M, and Class C medications were associated with lower risk of having poor mental health, for older women, during 2002-2011. While using Class N medications such as analgesics, antiepileptics, anti-Parkinson and other nervous system medications, was not significantly associated with poor mental health. Following these analyses, four systematic reviews considered whether there is any other published evidence to suggest an association between medications in each of these four classes, and mental health outcomes, in adults aged 65 years and over, without mental illness. These reviews indicated that adverse mental health outcomes such as anxiety or depression, were suspected, for some Class N medications (e.g. tiagabine, topiramate, rasagiline), some Class A medications (e.g. esomeprazole lansoprazole, cimetidine), some Class M medications (e.g. celecoxib, rofecoxib, etoricoxib), and some Class C medications (e.g. indapamide, hydrochlorothiazide/amiloride, metoprolol). Conclusion and Implications: This thesis has added to the evidence base examining the associations between medication use and mental health, and provided a comprehensive approach to examining these associations by using six different medication measures. The study findings presented in this thesis provides evidence that the number of different medications or the number of different therapeutic medication groups are not clearly associated with poor mental health after controlling for physical functioning or bodily pain, which themselves are strongly associated with poor mental health. Using Class A, Class M and Class C medications was associated with lower risk of having poor mental health, in older women, after excluding N05 and N06 medications. With a growing proportion of older people in our society, prescribers should be aware of the advantages that these medications have, for improving mental health. Future well designed studies in different population groups are required to confirm and extend these results, and to especially examine the association between using other common classes of medication, and poor mental health, over time. Four reviews provide evidence that some specific medications in Class N, Class A, Class M and Class C, may play a role in the development of mental illness, in older adults. Future research might include well-designed studies, where the aim is to assess the effects of individual medications, and determine their long-term effects on mental health, and whether these effects are different for older women. The results of this thesis contribute insights to the body of existing knowledge and provide justification for on-going research in this area, especially regarding mental health outcomes, for women. The findings enable clinicians and health professionals to be aware of the possible side effects of using various types of prescription medications, so they can better support this population, especially those at risk of poor mental health. It may be informative for other researchers, by providing an understanding of medication use over the life course, and pre-empting the potential long-term hazards of using medications, in terms of compromising mental health.