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1.  Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies 
PLoS Medicine  2013;10(5):e1001439.
Karen Devries and colleagues conduct a systematic review of longitudinal studies to evaluate the direction of association between symptoms of depression and intimate partner violence.
Please see later in the article for the Editors' Summary
Background
Depression and suicide are responsible for a substantial burden of disease globally. Evidence suggests that intimate partner violence (IPV) experience is associated with increased risk of depression, but also that people with mental disorders are at increased risk of violence. We aimed to investigate the extent to which IPV experience is associated with incident depression and suicide attempts, and vice versa, in both women and men.
Methods and Findings
We conducted a systematic review and meta-analysis of longitudinal studies published before February 1, 2013. More than 22,000 records from 20 databases were searched for studies examining physical and/or sexual intimate partner or dating violence and symptoms of depression, diagnosed major depressive disorder, dysthymia, mild depression, or suicide attempts. Random effects meta-analyses were used to generate pooled odds ratios (ORs). Sixteen studies with 36,163 participants met our inclusion criteria. All studies included female participants; four studies also included male participants. Few controlled for key potential confounders other than demographics. All but one depression study measured only depressive symptoms. For women, there was clear evidence of an association between IPV and incident depressive symptoms, with 12 of 13 studies showing a positive direction of association and 11 reaching statistical significance; pooled OR from six studies = 1.97 (95% CI 1.56–2.48, I2 = 50.4%, pheterogeneity = 0.073). There was also evidence of an association in the reverse direction between depressive symptoms and incident IPV (pooled OR from four studies = 1.93, 95% CI 1.51–2.48, I2 = 0%, p = 0.481). IPV was also associated with incident suicide attempts. For men, evidence suggested that IPV was associated with incident depressive symptoms, but there was no clear evidence of an association between IPV and suicide attempts or depression and incident IPV.
Conclusions
In women, IPV was associated with incident depressive symptoms, and depressive symptoms with incident IPV. IPV was associated with incident suicide attempts. In men, few studies were conducted, but evidence suggested IPV was associated with incident depressive symptoms. There was no clear evidence of association with suicide attempts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression and suicide are responsible for a substantial proportion of the global disease burden. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—affects more than 350 million people worldwide. It is the eleventh leading cause of global disability-adjusted life-years (a measure of overall disease burden), and it affects one in six people at some time during their lives. Globally, about a million people commit suicide every year, usually because they have depression or some other mental illness. Notably, in cross-sectional studies (investigations that look at a population at a single time point), experience of intimate partner violence (IPV, also called domestic violence) is strongly and consistently associated with both depressive disorders and suicide. IPV, like depression and suicide, is extremely common—in multi-country studies, 15%–71% of women report being physically assaulted at some time during their lifetime. IPV is defined as physical, sexual, or psychological harm by a current or former partner or spouse; men as well as women can be the victims of IPV.
Why Was This Study Done?
It may seem obvious to assume that IPV is causally related to subsequent depression and suicidal behavior. However, cross-sectional studies provide no information about causality, and it is possible that depression and/or suicide attempts cause subsequent IPV or that there are common risk factors for IPV, depression, and suicide. For example, individuals with depressive symptoms may be more accepting of partners with characteristics that predispose them to use violence, or early life exposure to violence may predispose individuals to both depression and choosing violent partners. Here, as part of the Global Burden of Disease Study 2010, the researchers investigate the extent to which experience of IPV is associated with subsequent depression and suicide attempts and vice versa in both men and women by undertaking a systematic review and meta-analysis of longitudinal studies that have examined IPV, depression, and suicide attempts. A systematic review uses predefined criteria to identify all the research on a given topic, meta-analysis combines the results of several studies, and longitudinal studies track people over time to investigate associations between specific characteristics and outcomes.
What Did the Researchers Do and Find?
The researchers identified 16 longitudinal studies involving a total of 36,163 participants that met their inclusion criteria. All the studies included women, but only four also included men. All the studies were undertaken in high- and middle-income countries. For women, 11 studies showed a statistically significant association (an association unlikely to have occurred by chance) between IPV and subsequent depressive symptoms. In a meta-analysis of six studies, experience of IPV nearly doubled the risk of women subsequently reporting depressive symptoms. In addition, there was evidence of an association in the reverse direction. In a meta-analysis of four studies, depressive symptoms nearly doubled the risk of women subsequently experiencing IPV. IPV was also associated with subsequent suicide attempts among women. For men, there was some evidence from two studies that IPV was associated with depressive symptoms but no evidence for an association between IPV and subsequent suicide attempt or between depressive symptoms and subsequent IPV.
What Do These Findings Mean?
These findings suggest that women who are exposed to IPV are at increased risk of subsequent depression and that women who are depressed are more likely to be at risk of IPV. They also provide evidence of an association between IPV and subsequent suicide attempt for women. The study provides little evidence for similar relationships among men, but additional studies are needed to confirm this finding. Moreover, the accuracy of these findings is likely to be affected by several limitations of the study. For example, few of the included studies controlled for other factors that might have affected both exposure to IPV and depressive symptoms, and none of the studies considered the effect of emotional violence on depressive symptoms and suicide attempts. Nevertheless, these findings have two important implications. First, they suggest that preventing violence against women has the potential to reduce the global burden of disease related to depression and suicide. Second, they suggest that clinicians should pay attention to past experiences of violence and the risk of future violence when treating women who present with symptoms of depression.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001439.
This study is further discussed in a PLOS Medicine Perspective by Alexander Tsai
The US National Institute of Mental Health provides information on all aspects of depression and of suicide and suicide prevention (in English and Spanish)
The UK National Health Service Choices website provides detailed information about depression, including personal stories about depression, and information on suicide and its prevention; it has a webpage about domestic violence, which includes descriptions of personal experiences
The World Health Organization provides information on depression, on the global burden of suicide and on suicide prevention, and on intimate partner violence (some information in several languages)
MedlinePlus provides links to other resources about depression, suicide, and domestic violence (in English and Spanish)
The charity Healthtalkonline has personal stories about depression and about dealing with suicide
doi:10.1371/journal.pmed.1001439
PMCID: PMC3646718  PMID: 23671407
2.  Sex Differences in Response to Citalopram: A STAR*D Report 
Journal of psychiatric research  2008;43(5):503-511.
Objective
Controversy exists as to whether women with depression respond better to selective serotonin reuptake inhibitors (SSRIs) than men. The purpose of this report was to determine whether men and women differ in their responses to treatment with the SSRI citalopram using a large sample of real world patients from primary and psychiatric specialty care settings.
Method
As part of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, 2876 participants were treated with citalopram for up to 12-14 weeks. Baseline demographic and clinical characteristics and outcomes were gathered and compared between men and women.
Results
At baseline, women were younger, had more severe depressive symptoms and were more likely to have: early onset; previous suicide attempt(s); a family history of depression, alcohol abuse or drug abuse; atypical symptom features; and one or more of several concurrent psychiatric disorders. Despite greater baseline severity and more Axis I comorbidities, women were more likely to reach remission and response with citalopram than men.
Conclusions
Women have a better response to the SSRI citalopram than men, which may be due to sex-specific biological differences particularly in serotonergic systems.
doi:10.1016/j.jpsychires.2008.07.002
PMCID: PMC2681489  PMID: 18752809
antidepressants; gender differences; estradiol; women's health; depression
3.  Irritability is associated with anxiety and greater severity, but not bipolar spectrum features, in major depressive disorder 
Acta Psychiatrica Scandinavica  2009;119(4):282-289.
Objective
Irritability is common during major depressive episodes, but its clinical significance and overlap with symptoms of anxiety or bipolar disorder remains unclear. We examined clinical correlates of irritability in a confirmatory cohort of Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study participants with major depressive disorder (MDD).
Method
Logistic regression was used to identify features associated with presence of irritability on the clinician-rated Inventory of Depressive Symptomatology.
Results
Of 2,307 study participants, 1067(46%) reported irritability at least half the time during the preceding week; they were more likely to be female, to be younger, to experience greater depression severity and anxiety, and to report poorer quality of life, prior suicide attempts, and suicidal ideation. Bipolar spectrum features were not more common among those with irritability.
Conclusion
Irritable depression is not a distinct subtype of MDD, but irritability is associated with greater overall severity, anxiety comorbidity, and suicidality.
doi:10.1111/j.1600-0447.2008.01298.x
PMCID: PMC3312008  PMID: 19207123
major depressive disorder; bipolar disorder; diagnosis; irritability; anger; suicide
4.  Gender Differences in Anxiety Disorders: Prevalence, Course of Illness, Comorbidity and Burden of Illness 
Journal of psychiatric research  2011;45(8):1027-1035.
Women have consistently higher prevalence rates of anxiety disorders, but less is known about how gender affects age of onset, chronicity, comorbidity, and burden of illness. Gender differences in DSM-IV anxiety disorders were examined in a large sample of adults (N = 20,013) in the United States using data from the Collaborative Psychiatric Epidemiology Studies (CPES). The lifetime and 12-month male:female prevalence ratios of any anxiety disorder were 1:1.7 and 1:1.79, respectively. Women had higher rates of lifetime diagnosis for each of the anxiety disorders examined, except for social anxiety disorder which showed no gender difference in prevalence. No gender differences were observed in the age of onset and chronicity of the illness. However, women with a lifetime diagnosis of an anxiety disorder were more likely than men to also be diagnosed with another anxiety disorder, bulimia nervosa, and major depressive disorder. Furthermore, anxiety disorders were associated with a greater illness burden in women than in men, particularly among European American women and to some extend also among Hispanic women. These results suggest that anxiety disorders are not only more prevalent but also more disabling in women than in men.
doi:10.1016/j.jpsychires.2011.03.006
PMCID: PMC3135672  PMID: 21439576
Sex; Gender; Anxiety; Prevalence; Comorbidity
5.  Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010 
PLoS Medicine  2013;10(11):e1001547.
In this paper, Ferrari and colleagues analyzed the burden of depressive disorders in GBD 2010 and identified depressive disorders as a leading cause of burden. The authors present severity proportions; burden by country, region, age, sex, and year; as well as burden of depressive disorders as a risk factor for suicide and ischemic heart disease.
Please see later in the article for the Editors' Summary
Background
Depressive disorders were a leading cause of burden in the Global Burden of Disease (GBD) 1990 and 2000 studies. Here, we analyze the burden of depressive disorders in GBD 2010 and present severity proportions, burden by country, region, age, sex, and year, as well as burden of depressive disorders as a risk factor for suicide and ischemic heart disease.
Methods and Findings
Burden was calculated for major depressive disorder (MDD) and dysthymia. A systematic review of epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data quantified the severity of health loss from depressive disorders. These weights were used to calculate years lived with disability (YLDs) and disability adjusted life years (DALYs). Separate DALYs were estimated for suicide and ischemic heart disease attributable to depressive disorders.
Depressive disorders were the second leading cause of YLDs in 2010. MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and dysthymia for 1.4% (0.9%–2.0%). Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause. MDD accounted for 2.5% (1.9%–3.2%) of global DALYs and dysthymia for 0.5% (0.3%–0.6%). There was more regional variation in burden for MDD than for dysthymia; with higher estimates in females, and adults of working age. Whilst burden increased by 37.5% between 1990 and 2010, this was due to population growth and ageing. MDD explained 16 million suicide DALYs and almost 4 million ischemic heart disease DALYs. This attributable burden would increase the overall burden of depressive disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.
Conclusions
GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden allocated to suicide and ischemic heart disease. These findings emphasize the importance of including depressive disorders as a public-health priority and implementing cost-effective interventions to reduce its burden.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depressive disorders are common mental disorders that occur in people of all ages across all world regions. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—can make people feel that life is no longer worth living. People affected by depression lose interest in the activities they used to enjoy and can also be affected by physical symptoms such as disturbed sleep. Major depressive disorder (MDD, also known as clinical depression) is an episodic disorder with a chronic (long-term) outcome and increased risk of death. It involves at least one major depressive episode in which the affected individual experiences a depressed mood almost all day, every day for at least 2 weeks. Dysthymia is a milder, chronic form of depression that lasts for at least 2 years. People with dysthymia are often described as constantly unhappy. Both these subtypes of depression (and others such as that experienced in bipolar disorder) can be treated with antidepressant drugs and with talking therapies.
Why Was This Study Done?
Depressive disorders were a leading cause of disease burden in the 1990 and 2000 Global Burden of Disease (GBD) studies, collaborative scientific efforts that quantify the health loss attributable to diseases and injuries in terms of disability adjusted life years (DALYs; one DALY represents the loss of a healthy year of life). DALYs are calculated by adding together the years of life lived with a disability (YLD, a measure that includes a disability weight factor reflecting disease severity) and the years of life lost because of disorder-specific premature death. The GBD initiative aims to provide data that can be used to improve public-health policy. Thus, knowing that depressive disorders are a leading cause of disease burden worldwide has helped to prioritize depressive disorders in global public-health agendas. Here, the researchers analyze the burden of MDD and dysthymia in GBD 2010 by country, region, age, and sex, and calculate the burden of suicide and ischemic heart disease attributable to depressive disorders (depression is a risk factor for suicide and ischemic heart disease). GBD 2010 is broader in scope than previous GBD studies and quantifies the direct burden of 291 diseases and injuries and the burden attributable to 67 risk factors across 187 countries.
What Did the Researchers Do and Find?
The researchers collected data on the prevalence, incidence, remission rates, and duration of MDD and dysthymia and on the excess deaths caused by these disorders from published articles. They pooled these data using a statistical method called Bayesian meta-regression and calculated YLDs for MDD and dysthymia using disability weights collected in population surveys. MDD accounted for 8.2% of global YLDs in 2010, making it the second leading cause of YLDs. Dysthymia accounted for 1.4% of global YLDs. MDD and dysthymia were also leading causes of DALYs, accounting for 2.5% and 0.5% of global DALYs, respectively. The regional variation in the burden was greater for MDD than for dysthymia, the burden of depressive disorders was higher in women than men, the largest proportion of YLDs from depressive disorders occurred among adults of working age, and the global burden of depressive disorders increased by 37.5% between 1990 and 2010 because of population growth and ageing. Finally, MDD explained an additional 16 million DALYs and 4 million DALYs when it was considered as a risk factor for suicide and ischemic heart disease, respectively. This “attributable” burden increased the overall burden of depressive disorders to 3.8% of global DALYs.
What Do These Findings Mean?
These findings update and extend the information available from GBD 1990 and 2000 on the global burden of depressive disorders. They confirm that depressive disorders are a leading direct cause of the global disease burden and show that MDD also contributes to the burden allocated to suicide and ischemic heart disease. The estimates of the global burden of depressive disorders reported in GBD 2010 are likely to be more accurate than those in previous GBD studies but are limited by factors such as the sparseness of data on depressive disorders from developing countries and the validity of the disability weights used to calculate YLDs. Even so, these findings reinforce the importance of treating depressive disorders as a public-health priority and of implementing cost-effective interventions to reduce their ubiquitous burden.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001547.
The US National Institute of Mental Health provides information on all aspects of depression
The UK National Health Service Choices website also provides detailed information about depression and includes personal stories about depression
More personal stories about depression are available from healthtalkonline.org
MedlinePlus provides links to other resources about depression (in English and Spanish)
The World Health Organization provides information on depression and on the global burden of disease (in several languages)
Information about the Global Burden of Disease initiative is available
beyondblue provides many resources on depression
The Queensland Centre for Mental Health Research provides information on epidemiology and the global burden of disease specifically for mental disorders
doi:10.1371/journal.pmed.1001547
PMCID: PMC3818162  PMID: 24223526
6.  Gender differences in suicidal expressions and their determinants among young people in Cambodia, a post-conflict country* 
BMC Psychiatry  2011;11:47.
Background
Suicide among young people is a global public health problem, but adequate information on determinants of suicidal expression is lacking in middle and low income countries. Young people in transitional economies are vulnerable to psychosocial stressors and suicidal expressions. This study explores the suicidal expressions and their determinants among high school students in Cambodia, with specific focus on gender differences.
Methods
A sample of 320 young people, consisting of 153 boys and 167 girls between 15-18 years of age, was randomly selected from two high schools in Cambodia. Their self-reported suicidal expressions, mental health problems, life-skills dimensions, and exposure to suicidal behavior in others were measured using the Youth Self-Report (YSR), Life-Skills Development Scale (LSDS)-Adolescent Form, and Attitude Towards Suicide (ATTS) questionnaires.
Results
Suicidal plans were reported more often by teenage boys than teenage girls (M = 17.3%, F = 5.6%, p = 0.001), whereas girls reported more attempts (M = 0.6%, F = 7.8%, p = 0.012). Young men scored significantly higher on rule-breaking behavior than young women (p = 0.001), whereas young women scored higher on anxious/depression (p = 0.000), withdrawn/depression (p = 0.002), somatic complaints (p = 0.034), social problems (p = 0.006), and internalizing syndrome (p = 0.000). Young men exposed to suicide had significantly higher scores for internalizing syndrome compared to those unexposed (p = 0.001), while young women exposed to suicide scored significantly higher on both internalizing (p = 0.001) and externalizing syndromes (p = 0.012). Any type of exposure to suicidal expressions increased the risk for own suicidal expressions in both genders (OR = 2.04, 95% CI = 1.06-3.91); among young women, however, those exposed to suicide among friends and partners were at greater risk for the serious suicidal expressions (OR = 2.79, 95% CI = 1.00-7.74). Life skills dimension scores inversely correlated with externalizing syndrome in young men (p = 0.026) and internalizing syndrome in young women (p = 0.001).
Conclusions
The significant gender differences in suicidal expressions and their determinants in Cambodian teenagers highlight the importance of culturally appropriate and gender-specific suicide prevention programs. School-based life skills promotion may indirectly influence the determinants for suicidal expressions, particularly among young women with internalizing syndrome in Cambodia.
doi:10.1186/1471-244X-11-47
PMCID: PMC3073893  PMID: 21418649
7.  PREVALENCE AND CLINICAL CHARACTERISTICS OF PSYCHOTIC VERSUS NONPSYCHOTIC MAJOR DEPRESSION IN A GENERAL PSYCHIATRIC OUTPATIENT CLINIC 
Depression and anxiety  2009;26(1):54-64.
Background
Psychotic major depression (PMD) is a severe mental disorder characterized by high levels of illness severity, chronicity, impairment, and treatment resistance. However, most past research on PMD has been conducted in inpatient hospital samples, and relatively little is known about PMD patients presenting for treatment in the community specifically.
Methods
In this study, we examined the prevalence and clinical characteristics of PMD in a large sample (n = 2,500) of treatment-seeking outpatients who were administered structured clinical interviews by trained diagnosticians.
Results
Of the patients diagnosed with major depression, 5.3% had psychotic features. PMD patients were more likely to be members of a racial/ethnic minority and to have lower educational attainment compared to those with nonpsychotic major depression. In addition, PMD patients were found to have greater current depression severity, suicidal ideation, and social and work impairment. These patients also were more likely to have histories of suicide attempts and psychiatric hospitalizations, to report an earlier age of illness onset, and to meet criteria for chronic depression. In terms of psychiatric comorbidity, PMD patients had higher rates of certain anxiety disorders as well as more somatoform and cluster A personality disorders.
Conclusions
Results indicated that PMD was present in a relatively small percentage of treatment-seeking outpatients but was associated with disproportionately high levels of severity and impairment. Similarities and differences between the current findings and those from past research are discussed, including clinical implications for the identification and treatment of PMD in routine practice settings.
doi:10.1002/da.20470
PMCID: PMC3111977  PMID: 18781658
major depression; psychotic depression; hallucinations; delusions; outpatient psychiatry
8.  Do Major Depressive Disorder and Dysthymic Disorder confer differential risk for suicide? 
Journal of affective disorders  2008;115(1-2):69-78.
Background
Although there has been a tremendous amount of research examining the risk conferred for suicide by depression in general, relatively little research examines the risk conferred by specific forms of depressive illness (e.g., dysthymic disorder, single episode versus recurrent major depressive disorder [MDD]). The purpose of the current study was to examine differences in suicidal ideation, clinician-rated suicide risk, suicide attempts, and family history of suicide in a sample of outpatients diagnosed with various forms of depressive illness.
Methods
To accomplish this aim, we conducted a cluster analysis using the aforementioned suicide-related variables in a sample of 494 outpatients seen between January 2001 and July 2007 at the Florida State University Psychology Clinic. Patients were diagnosed using DSM-IV criteria.
Results
Two distinct clusters emerged that were indicative of lower and higher risk for suicide. After controlling for the number of comorbid Axis I and Axis II diagnoses, the only depressive illness that significantly predicted cluster membership was recurrent MDD, which tripled an individual’s likelihood of being assigned to the higher risk cluster.
Limitations
The use of a cross-sectional design; the relatively low suicide risk in our sample; the relatively small number of individuals with double depression.
Conclusions
Our results demonstrate the importance of both chronicity and severity of depression in terms of predicting increased suicide risk. Among the various forms of depressive illness examined, only recurrent MDD appeared to confer greater risk for suicide.
doi:10.1016/j.jad.2008.09.003
PMCID: PMC2674849  PMID: 18842304
Suicide; Depression; Dysthymia
9.  Influences of Hormone-Based Contraception on Depressive Symptoms in Premenopausal Women with Major Depression 
Psychoneuroendocrinology  2007;32(7):843-853.
Summary
Objective
Hormone-based contraceptives affect mood in healthy women or in women with Premenstrual Dysphoric Disorder. No study has yet examined their association with mood in women with major depressive disorder (MDD). The purpose of this study was to determine whether estrogen-progestin combination or progestin-only contraceptives are associated with depression severity, function and quality of life, or general medical or psychiatric comorbidity in women with MDD.
Methods
This analysis focused on a large population of female outpatients less than 40 years of age with non-psychotic MDD who were treated in 18 primary and 23 psychiatric care settings across the United States, using data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Baseline demographic and clinical information was gathered and compared between three groups based on hormonal use: combination (estrogen-progestin)(N=232), progestin-only (N=58), and no hormone treatment (N=948).
Results
Caucasians were significantly more likely to use combined hormone contraception. Women on progestin-only had significantly more general medical comorbidities; greater hypersomnia, weight gain and gastrointestinal symptoms; and worse physical functioning than women in either of the other groups. Those on combined hormone contraception were significantly less depressed than those with no hormone treatment by the 16-item Quick Inventory of Depressive Symptomatology - Self-Rated. The combined hormone group also demonstrated better physical functioning and less obsessive-compulsive disorder comorbidity than either of the other groups.
Conclusions
Synthetic estrogen and progestins may influence depressive and physical symptoms in depressed women.
doi:10.1016/j.psyneuen.2007.05.013
PMCID: PMC2100423  PMID: 17629629
Estradiol; Progesterone; Major Depression; Mood symptoms; Oral contraceptives; Norplant
10.  Eating Disorders 
BMC Women's Health  2004;4(Suppl 1):S21.
Health Issue
Eating disorders are an increasing public health problem among young women. Anorexia and bulimia may give rise to serious physical conditions such as hypothermia, hypotension, electrolyte imbalance, endocrine disorders, and kidney failure.
Key Issues
Eating disorders are primarily a problem among women. In Ontario in 1995, over 90% of reported hospitalized cases of anorexia and bulimia were women. In addition to eating disorders, preoccupation with weight, body image and self-concept disturbances, are more prevalent among women than men.
Women with eating disorders are also at risk for long-term psychological and social problems, including depression, anxiety, substance abuse and suicide. For instance, in 2000, the prevalence of depression among women who were hospitalized with a diagnosis of anorexia (11.5%) or bulimia (15.4 %) was more than twice the rate of depression (5.7 %) among the general population of Canadian women. The highest incidence of depression was found in women aged 25 to 39 years for both anorexia and bulimia.
Data Gaps and Recommendations
Hospitalization data are the most recent and accessible information available. However, this data captures only the more severe cases. It does not include the individuals with eating disorders who may visit clinics or family doctors, or use hospital outpatient services or no services at all. Currently, there is no process for collecting this information systematically across Canada; consequently, the number of cases obtained from hospitalization data is underestimated. Other limitations noted during the literature review include the overuse of clinical samples, lack of longitudinal data, appropriate comparison groups, large samples, and ethnic group analysis.
doi:10.1186/1472-6874-4-S1-S21
PMCID: PMC2096691  PMID: 15345084
11.  HIGHER BURDEN OF DEPRESSION AMONG OLDER WOMEN: THE EFFECT OF ONSET, PERSISTENCE AND MORTALITY OVER TIME 
Archives of general psychiatry  2008;65(2):172-178.
CONTEXT
The prevalence of depression is disproportionately higher in older women than men, yet the reasons for this gender difference are not clear.
OBJECTIVE
We sought to determine whether the higher burden of depression among older women than men might be attributable to gender differences in the onset, i.e., first or recurrent episodes, or persistence of depression and/or to differential mortality among those who are depressed.
DESIGN
Prospective cohort study.
SETTING
General community in greater New Haven, Connecticut from March 1998 to August 2005.
PARTICIPANTS
754 persons, aged 70 years or older, who were evaluated at 18-month intervals for 72 months.
MAIN OUTCOME MEASURES
The three outcome states were depressed, non-depressed and death, with scores ≥20 and <20 on the Centers for Epidemiologic Studies-Depression scale denoting depressed and non-depressed, respectively. The association between gender and the likelihood of six possible transitions, namely from non-depressed or depressed to non-depressed, depressed, or death was evaluated over time.
RESULTS
The prevalence of depression was substantially higher among women than men at each of the five time points (p<0.001). In most cases, transitions between the non-depressed and depressed states were characterized by moderate to very large absolute changes in depression scores, i.e., at least 10 points. Adjusting for other demographic characteristics, women had a higher likelihood of transitioning from non-depressed to depressed (odds ratio=2.02; 95% Confidence Interval 1.39, 2.94) and lower likelihood of transitioning from depressed to non-depressed (odds ratio=0.27; 95% confidence interval 0.13, 0.56) or death (odds ratio=0.24; 95% confidence interval 0.09–0.60).
CONCLUSIONS
Among older persons, the higher burden of depression in women than men appears to be attributable to a greater susceptibility to depression and, once depressed, to more persistent depression and a lower probability of death.
doi:10.1001/archgenpsychiatry.2007.17
PMCID: PMC2793076  PMID: 18250255
depression; gender differences; older persons; mortality
12.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Background
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
Conclusions
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Background
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000123.
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
doi:10.1371/journal.pmed.1000123
PMCID: PMC2717212  PMID: 19668361
13.  Alcohol Use Disorders in Primary Care 
OBJECTIVE
To describe how alcohol use disorders (AUDs) affect women, focusing on gender-specific implications for primary care physicians (PCPs).
DESIGN
An overview of literature from 1966 to 2000 identified by a medline, PsychINFO and HealthSTAR/Ovid Healthstar database search using key words “women,”“alcohol” and “alcoholism.”
MEASUREMENTS AND MAIN RESULTS
Although the prevalence of AUDs is greater in men than in women, women with AUDs are more likely to seek help, but less likely to be identified by their physicians. Psychiatric comorbidities (especially depression and eating disorders) are more common in women with AUDs than in men with AUDs. A past history of sexual and/or physical abuse places a woman at increased risk for AUDs. Women have a greater sensitivity to alcohol, have an accelerated progression from alcohol toxicity, and have increased mortality at lower levels of consumption compared to men. Women and men who are light-to-moderate drinkers have lower coronary artery disease mortality than do abstainers or heavy drinkers. Risk of breast cancer is increased in women who drink ≥1 drinks daily. Common barriers to treatment include: fear of abandonment by partner; fear of loss of children; and financial dependency. Brief interventions have been shown to be effective in reduction of alcohol consumption in women with at-risk drinking. It is unclear if women-only treatment programs improve outcomes.
CONCLUSION
PCPs should be alert to gender-specific differences for women with AUDs.
doi:10.1046/j.1525-1497.2002.10617.x
PMCID: PMC1495039  PMID: 12047738
alcoholism; female; primary care; gender effects
14.  Suicide after Leaving the UK Armed Forces —A Cohort Study 
PLoS Medicine  2009;6(3):e1000026.
Background
Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996–2005).
Methods and Findings
We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30–49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20–24 y).
Conclusions
Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.
Navneet Kapur and colleagues find that young men who leave the United Kingdom Armed Forces are at increased risk of suicide.
Editors' Summary
Background.
Leaving any job can be hard but for people leaving the armed forces the adjustment to their new circumstances can sometimes be particularly difficult. For example, ex-military personnel may face obstacles to getting a new job, particularly if they were injured in action. Some become homeless. Others turn to alcohol or drugs or suffer mental illnesses such as depression. These things probably aren't common but those who leave the armed forces might also be at higher risk of suicide than the general population.
Why Was This Study Done?
Serving members of the UK Armed Forces (the British Army, the Naval Service, and the Royal Air Force) have a lower rate of suicide than the general UK population. The lower rate is probably due to “the healthy worker effect” (i.e., workers tend to be healthier than the general population, since the latter includes people unable to work due to illness or disability). However, there are anecdotal reports that ex-military personnel are more likely to die by suicide than are members of the general population. If these reports are correct, then measures should be put into place to prepare people for leaving the Armed Forces and to provide more support for them once they have left the military. The authors of this new study say that no previous studies had systematically examined suicide risk in individuals leaving the Armed Forces. In this new study, therefore, the researchers examine the suicide rate, timing, and risk factors for suicide in a large group (cohort) of former members of the UK Armed Forces.
What Did the Researchers Do and Find?
The researchers linked data on everyone who left the UK Armed Forces between 1996 and 2005 with information on suicides collected by the National Confidential Inquiry into Suicide and Homicide. Since 1996, the Inquiry has been collecting information about all suicides (defined as cases where the coroner has given a verdict of suicide or of “undetermined death”) in the UK, including information about whether the deceased used mental health services in the year before they died. The aim of the Inquiry is to reduce the risk of suicides (and homicides) in the UK by improving the country's mental health services. Between 1996 and 2005, 233,803 people left the Armed Forces and 224 (nearly all men) died by suicide. The researchers' statistical analysis of these data indicates that the overall suicide rate in the ex-military personnel was similar to that in the general population. However, the risk of suicide in men aged 24 y or younger who had left the military was 2–3 times greater than that in the same age group in both the general male population and in men serving in the Armed Forces. The risk of dying by suicide was highest in the first 2 y after leaving the military but remained raised for several years. Risk factors for suicide among ex-military personnel included being male, serving in the Army, having a short length of service, and being of lower rank. Only a fifth of the ex-military personnel who committed suicide had been in contact with mental health services in the year before they died, and the rate of contact with these services was lowest among individuals in the age groups at the highest risk of suicide.
What Do These Findings Mean?
These findings indicate that young men leaving the UK Armed Forces are at increased risk of suicide, particularly shortly after leaving. The study was not able to prove the reason for this increased risk, but the authors suggest three main possibilities: (1) the stress of transitioning to civilian life, (2) exposure to adverse experiences while in the military, or (3) a vulnerability to suicide before entering the military. The study provides some evidence to support the third hypothesis—untrained personnel with short lengths of service have a particularly high risk of dying by suicide after leaving the military, suggesting that the increased suicide risk may reflect a pre-military vulnerability. The researchers suggest that practical and psychological preparation might be helpful for people leaving the Armed Forces and that appropriate help-seeking behavior could be encouraged in these individuals. In the UK, the National Health Service is currently piloting a community-based mental health service for military veterans, characterized by regional clinical networks involving partnerships of relevant experts.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000026.
This study is further discussed in a PLoS Medicine Perspective by Jitender Sareen and Shay-Lee Belik
The Manchester University Centre for Suicide Prevention provides information about the National Confidential Inquiry into Suicide and Homicide and about other research into suicide, and a list of useful Web sites and help lines for people going through crises
A recent article in the Observer newspaper by Mark Townsend discusses the problems facing UK military personnel when they leave the Armed Forces
Information about suicides among serving members of the UK Armed Forces is published by the Defence Analytical Services Agency
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
MedlinePlus also provides links to further information and advice about suicide
The World Health Organization provides information on the global burden of suicide
doi:10.1371/journal.pmed.1000026
PMCID: PMC2650723  PMID: 19260757
15.  Sex Differences in Clinical Predictors of Suicidal Acts After Major Depression: A Prospective Study 
The American journal of psychiatry  2007;164(1):134-141.
Objective
Whether sex differences exist in clinical risk factors associated with suicidal behavior is unknown. The authors postulated that among men with a major depressive episode, aggression, hostility, and history of substance misuse increase risk for future suicidal behavior, while depressive symptoms, childhood history of abuse, fewer reasons for living, and borderline personality disorder do so in depressed women.
Method
Patients with DSM-III-R major depression or bipolar disorder seeking treatment for a major depressive episode (N=314) were followed for 2 years. Putative predictors were tested with Cox proportional hazards regression analysis.
Results
During follow-up, 16.6% of the patients attempted or committed suicide. Family history of suicidal acts, past drug use, cigarette smoking, borderline personality disorder, and early parental separation each more than tripled the risk of future suicidal acts in men. For women, the risk for future suicidal acts was sixfold greater for prior suicide attempters; each past attempt increased future risk threefold. Suicidal ideation, lethality of past attempts, hostility, subjective depressive symptoms, fewer reasons for living, comorbid borderline personality disorder, and cigarette smoking also increased the risk of future suicidal acts for women.
Conclusions
These findings suggest that the importance of risk factors for suicidal acts differs in depressed men and women. This knowledge may improve suicide risk evaluation and guide future research on suicide assessment and prevention.
doi:10.1176/appi.ajp.164.1.134
PMCID: PMC3785095  PMID: 17202555
16.  Mental Illness and Co-morbid Conditions: BioSense 2008 – 2011 
Objective
The purpose of this paper was to analyze the associated burden of mental illness and medical comorbidity using BioSense data 2008–2011.
Introduction
Understanding the relationship between mental illness and medical comorbidity is an important aspect of public health surveillance. In 2004, an estimated one fourth of the US adults reported having a mental illness in the previous year (1). Studies showed that mental illness exacerbates multiple chronic diseases like cardiovascular diseases, diabetes and asthma (2). BioSense is a national electronic public health surveillance system developed by the Centers for Disease Control and Prevention (CDC) that receives, analyzes and visualizes electronic health data from civilian hospital emergency departments (EDs), outpatient and inpatient facilities, Veteran Administration (VA) and Department of Defense (DoD) healthcare facilities. Although the system is designed for early detection and rapid assessment of all-hazards health events, BioSense can also be used to examine patterns of healthcare utilization.
Methods
We used 4 years (2008 – 2011) of BioSense civilian hospitals’ EDs visit data to perform the analysis. We searched final diagnoses for ICD-9 CM codes related to mental illness (290 – 312), schizophrenia (295), major depressive disorder (296.2 – 296.3), mood disorder (296, 300.4 and 311) and anxiety, stress & adjustment disorders (300.0, 300.2, 300.3, 308, and 309). We used BioSense syndromes/sub-syndromes based on chief complaints and final diagnoses for comorbidity. For the purpose of this study, comorbidity was defined broadly as the co-occurrence of mental and physical illness in the same person regardless of the chronological order. The proportion was calculated as the number of mental health visits associated with comorbidity divided by the total number of mental illness relevant visits. We ranked the top 10 proportions of comorbidity for adult mental illness by year.
Results
From 2008–2011, there were 4.6 million visits where mental illness was reported in the EDs visits. Average age of those reported mental illness was 44 years, 55% were women and 45% were men. More women were reported with anxiety (67%), mood (66%), and major depressive disorders (59%) than men; while men were reported more with schizophrenia (56%) than women (44%). The most common comorbid condition was hypertension, followed by chest pain, abdominal pain, diabetes, nausea & vomiting and dyspnea (Table 1). Ranks of injury, falls, headache and asthma were slightly variant by year.
Conclusions
This study supports prior findings that adult mental illness is associated with substantial medical burden. We identified 10 most common comorbid condition associated with mental illness. The major limitation of this work was that electronic data does not allow determination of the causal pathway between mental illness and some medical comorbidity. In addition, data represents only those who have access to healthcare or those with health seeking behaviors. Familiarity with comorbid conditions affecting persons with adult mental illness may assist programs aimed at providing medical care for the mentally ill.
PMCID: PMC3692905
ED visits; Adult mental illness; Medical comorbidity
17.  Social inequalities in depressive symptoms and physical functioning in the Whitehall II study: exploring a common cause explanation 
Study objective: This study investigated which risk factors might explain social inequalities in both depressive symptoms and physical functioning and whether a common set of risk factors might account for the association between depressive symptoms and physical functioning.
Design: A longitudinal prospective occupational cohort study of female and male civil servants relating risk factors at baseline (phase 1: 1985–8) to employment grade gradients in depressive symptoms and physical functioning at follow up (phase 5: 1997–9). Analyses include the 7270 men and women who participated at phase 5.
Setting: Whitehall II Study: 20 London based white collar civil service departments.
Participants: Male and female civil servants, 35–55 years at baseline.
Main results: Depressive symptoms were measured by a subscale of items from the 30 item General Health Questionnaire. Physical functioning was measured by a subscale of the SF-36. Employment grade was used as a measure of socioeconomic position as it reflects both income and status. The grade gradient in depressive symptoms was entirely explained by risk factors including work characteristics, material disadvantage, social supports, and health behaviours. These risk factors only partially explained the gradient in physical functioning. The correlation between depressive symptoms and physical functioning was reduced by adjustment for risk factors and baseline health status but not much of the association was explained by adjustment for risk factors. Among women, the association between depression and physical functioning was significantly stronger in the lower grades both before and after adjustment for risk factors and baseline health. For women, there was only a significant grade gradient in depressive symptoms among those reporting physical ill health.
Conclusions: Some risk factors contribute jointly to the explanation of social inequalities in mental and physical health although their relative importance differs. Work is most important for inequalities in depressive symptoms in men, and work and material disadvantage are equally important in explaining inequalities in depressive symptoms in women while health behaviours are more important for explaining inequalities in physical functioning. These risk factors did not account for the association between mental health and physical health or the greater comorbidity seen in women of lower socioeconomic status. The risk of secondary psychological distress among those with physical ill health is greater in the low employment grades.
doi:10.1136/jech.57.5.361
PMCID: PMC1732450  PMID: 12700221
18.  Prevalence of Depression–PTSD Comorbidity: Implications for Clinical Practice Guidelines and Primary Care-based Interventions 
BACKGROUND
Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment.
OBJECTIVE
To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD).
DESIGN
Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients.
PARTICIPANTS
Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states.
MEASUREMENTS
The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics.
RESULTS
Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity.
CONCLUSIONS
PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.
doi:10.1007/s11606-006-0101-4
PMCID: PMC2219856  PMID: 17503104
depression; PTSD; primary care; clinical practice guidelines
19.  Sex-Specific Differences in Hemodialysis Prevalence and Practices and the Male-to-Female Mortality Rate: The Dialysis Outcomes and Practice Patterns Study (DOPPS) 
PLoS Medicine  2014;11(10):e1001750.
In this study, Port and colleagues describe hemodialysis prevalence and patient characteristics by sex, compare men-to-women mortality rate with data from the general population, and evaluate sex interactions with mortality. The results show that women's survival advantage was markedly diminished in hemodialysis patients.
Please see later in the article for the Editors' Summary
Background
A comprehensive analysis of sex-specific differences in the characteristics, treatment, and outcomes of individuals with end-stage renal disease undergoing dialysis might reveal treatment inequalities and targets to improve sex-specific patient care. Here we describe hemodialysis prevalence and patient characteristics by sex, compare the adult male-to-female mortality rate with data from the general population, and evaluate sex interactions with mortality.
Methods and Findings
We assessed the Human Mortality Database and 206,374 patients receiving hemodialysis from 12 countries (Australia, Belgium, Canada, France, Germany, Italy, Japan, New Zealand, Spain, Sweden, the UK, and the US) participating in the international, prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) between June 1996 and March 2012. Among 35,964 sampled DOPPS patients with full data collection, we studied patient characteristics (descriptively) and mortality (via Cox regression) by sex. In all age groups, more men than women were on hemodialysis (59% versus 41% overall), with large differences observed between countries. The average estimated glomerular filtration rate at hemodialysis initiation was higher in men than women. The male-to-female mortality rate ratio in the general population varied from 1.5 to 2.6 for age groups <75 y, but in hemodialysis patients was close to one. Compared to women, men were younger (mean = 61.9±standard deviation 14.6 versus 63.1±14.5 y), were less frequently obese, were more frequently married and recipients of a kidney transplant, more frequently had coronary artery disease, and were less frequently depressed. Interaction analyses showed that the mortality risk associated with several comorbidities and hemodialysis catheter use was lower for men (hazard ratio [HR] = 1.11) than women (HR = 1.33, interaction p<0.001). This study is limited by its inability to establish causality for the observed sex-specific differences and does not provide information about patients not treated with dialysis or dying prior to a planned start of dialysis.
Conclusions
Women's survival advantage was markedly diminished in hemodialysis patients. The finding that fewer women than men were being treated with dialysis for end-stage renal disease merits detailed further study, as the large discrepancies in sex-specific hemodialysis prevalence by country and age group are likely explained by factors beyond biology. Modifiable variables, such as catheter use, showing significant sex interactions suggest interventional targeting.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Throughout life, the kidneys filter waste products (from the normal breakdown of tissues and from food) and excess water from the blood to make urine. Chronic kidney disease—an increasingly common condition globally—gradually destroys the kidney's filtration units (the nephrons). As the nephrons stop working, the rate at which the blood is filtered (the glomerular filtration rate) decreases, and waste products build up in the blood, eventually leading to life-threatening end-stage kidney (renal) disease. Symptoms of chronic kidney disease, which rarely occur until the disease is advanced, include tiredness, swollen feet and ankles, and frequent urination, particularly at night. Chronic kidney disease cannot be cured, but its progression can be slowed by controlling diabetes and other conditions that contribute to its development. End-stage kidney disease is treated by regular hemodialysis (a process in which blood is cleaned by passing it through a filtration machine) or by kidney transplantation.
Why Was This Study Done?
Like many other long-term conditions, the prevalence (the proportion of the population that has a specific disease) of chronic kidney disease and of end-stage renal disease, and treatment outcomes for these conditions, may differ between men and women. Some of these sex-specific differences may arise because of sex-specific differences in normal biological functions. Other sex-specific differences may be related to sex-specific differences in patient care or in patient awareness of chronic kidney disease. A comprehensive analysis of sex-specific differences among individuals with end-stage renal disease might identify both treatment inequalities and ways to improve sex-specific care. Here, in the Dialysis Outcomes and Practice Patterns Study (DOPPS), the researchers investigate sex-specific differences in the prevalence and practices of hemodialysis and in the characteristics of patients undergoing hemodialysis, and investigate the adult male-to-female mortality (death) rate among patients undergoing hemodialysis. The DOPPS is a prospective cohort study that is investigating the characteristics, treatment, and outcomes of adult patients undergoing hemodialysis in representative facilities in 19 countries (12 countries were available for analysis at the time of the current study).
What Did the Researchers Do and Find?
To investigate sex-specific differences in hemodialysis prevalence, the researchers compared data from the Human Mortality Database, which provides detailed population and mortality data for 37 countries, with data collected by the DOPPS. Forty-one percent of DOPPS patients were women, compared to 52% of the general population in 12 of the DOPPS countries. Next, the researchers used data collected from a randomly selected subgroup of patients to examine sex-specific differences in patient characteristics and mortality. The average estimated glomerular filtration rate at hemodialysis initiation was higher in men than women. Moreover, men were more frequently recipients of a kidney transplant than women. Notably, although in the general population in a given age group women were less likely to die than men, among hemodialysis patients, women were as likely to die as men. Finally, the researchers investigated which patient characteristics were associated with the largest sex-specific differences in mortality risk. The use of a hemodialysis catheter (a tube that is inserted into a patient's vein to transfer their blood into the hemodialysis machine) was associated with a lower mortality risk in men than in women.
What Do These Findings Mean?
These findings show that, among patients treated with hemodialysis for end-stage renal disease, women differ from men in many ways. Although some of these sex-specific differences may be related to biology, others may be related to patient care and to patient awareness of chronic kidney disease. Because this is an observational study, these findings cannot prove that the reported differences in hemodialysis prevalence, treatment, and mortality are actually caused by being a man or a woman. Importantly, however, these findings suggest that hemodialysis may abolish the survival advantage that women have over men in the general population and that fewer women than men are being treated for end-stage-renal disease, even though chronic kidney disease is more common in women than in men. Finally, the finding that the use of hemodialysis catheters for access to veins is associated with a higher mortality risk among women than among men suggests that, where possible, women should be offered a surgical process called arteriovenous fistula placement, which is recommended for access to veins during long-term hemodialysis but which may, in the past, have been underused in women.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001750.
More information about the DOPPS program is available
The US National Kidney and Urologic Diseases Information Clearinghouse provides information about all aspects of kidney disease; the US National Kidney Disease Education Program provides resources to help improve the understanding, detection, and management of kidney disease (in English and Spanish)
The UK National Health Service Choices website provides information for patients on chronic kidney disease and about hemodialysis, including some personal stories
The US National Kidney Foundation, a not-for-profit organization, provides information about chronic kidney disease and about hemodialysis (in English and Spanish)
The not-for-profit UK National Kidney Federation provides support and information for patients with kidney disease and for their carers, including information and personal stories about hemodialysis
World Kidney Day, a joint initiative between the International Society of Nephrology and the International Federation of Kidney Foundations, aims to raise awareness about kidneys and kidney disease
MedlinePlus has pages about chronic kidney disease and about hemodialysis
doi:10.1371/journal.pmed.1001750
PMCID: PMC4211675  PMID: 25350533
20.  Comparing Impulsiveness, Hostility, and Depression in Borderline Personality Disorder and Bipolar II Disorder 
The Journal of clinical psychiatry  2007;68(10):1533-1539.
Objective
To determine whether borderline personality disorder (BPD) and bipolar II disorder can be differentiated from each other and from major depressive disorder (MDD) by comparing depression severity, impulsiveness, and hostility in mood disorder patients with and without BPD.
Method
One hundred seventy-three patients with either MDD or bipolar II disorder were enrolled from a larger sample admitted to a multisite project on mood disorders and suicidal behavior conducted from June 1996 through June 2006. Patients were divided into 4 groups: MDD with BPD, MDD without an Axis II diagnosis, bipolar II disorder with BPD, and bipolar II disorder without an Axis II diagnosis. All diagnoses were based on DSM-IV criteria. Depression was assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D) and the self-rated Beck Depression Inventory (BDI). Impulsiveness was assessed using the Barratt Impulsiveness Scale, and hostility was assessed using the Buss-Durkee Hostility Inventory.
Results
Patients with BPD reported higher levels of impulsiveness (p = .004) and hostility (p = .001), independent of Axis I diagnosis. Bipolar II patients reported greater attentional impulsiveness (p = .008) than MDD patients, independent of BPD status, while BPD patients reported greater nonplanning impulsiveness than patients without BPD, independent of Axis I diagnosis (p = .02). For motor impulsiveness, there was a main effect for Axis I diagnosis (p = .05) and Axis II diagnosis (p = .002). The bipolar II + BPD group scored the highest, suggesting a compound effect of comorbidity. There were no differences in depression severity when measured with the HAM-D, although the BPD groups reported more severe depression on the BDI, independent of their Axis I diagnosis (p = .05). The BPD groups scored higher on the cognitive factor (p = .01) and anxiety factor (p = .03) of the HAM-D.
Conclusion
Results suggest that there is a unique symptom and trait profile associated with BPD that distinguishes the diagnosis from bipolar II disorder. Results also suggest that impulsiveness is an important aspect of both disorders and that there is a compounding effect associated with a diagnosis of bipolar II disorder with comorbid BPD.
PMCID: PMC3775654  PMID: 17960968
21.  Effect of Dysthymia on Receipt of HAART by Minority HIV-infected Women 
Journal of General Internal Medicine  2006;21(12):1235-1241.
BACKGROUND
Receipt of highly active antiretroviral therapy (HAART) differs by gender and racial/ethnic group and may reflect an effect of mood disorders.
OBJECTIVE
We examined the effects of dysthymia and major depression on HAART use by 6 groups defined by gender and race/ethnicity (white, black, Hispanic).
MAIN OUTCOME MEASURE
Self-reported HAART use in the past 6 months.
DATA SOURCE
Interview data from the HIV Cost and Services Utilization Study (HCSUS). Independent variables measured in or before the first half of 1997, and HAART use measured in the second half of 1997.
ANALYSES
Multivariate logistic regression of depression and dysthymia on HAART use by 6 patient groups.
PARTICIPANTS
One thousand nine hundred and eighty-two HIV-infected adults in HIV care in 1996 and with a CD4 count <500 in 1997.
RESULTS
Highly active antiretroviral therapy receipt was the highest for white men (68.6%) and the lowest for Hispanic women (52.7%) and black women (55.4%). Dysthymia was more prevalent in women (Hispanic, 46%; black, 27%; white, 31%) than men (Hispanic, 23%; black, 18%; white, 15%). The prevalence of major depression was greater in whites (women, 35%; men, 31%) than minorities (women, 26%; men, 21%). Compared with white men without dysthymia, the adjusted odds ratios (AORs) of HAART were significantly lower for black women (0.50 [95% confidence interval [95% CI] 0.29 to 0.87]) and Hispanic women (0.45 [95% CI 0.25, 0.79]). Among patients with depression and no dysthymia, minority women had HAART use (AOR=1.28 [95% CI 0.48 to 3.43]) similar to white men.
LIMITATIONS
Self-report data from the early era of HAART use; causation cannot be proven; mental health diagnoses may not meet full DSM IV criteria.
CONCLUSIONS
Dysthymia is highly prevalent in minority women and associated with a 50% reduction in the odds of receiving HAART. This underrecognized condition may contribute more than depression to the “gender disparity” in HAART use.
doi:10.1111/j.1525-1497.2006.00597.x
PMCID: PMC1924745  PMID: 17105522
HIV; AIDS; HAART; dysthymia; disparities; women
22.  Depression- and anxiety-related sick leave and the risk of permanent disability and mortality in the working population in Germany: a cohort study 
BMC Public Health  2013;13:145.
Background
Anxiety and depression are the most common psychiatric disorders and are the cause of a large and increasing amount of sick-leave in most developed countries. They are also implicated as an increasing mortality risk in community surveys. In this study we addressed, whether sick leave due to anxiety, depression or comorbid anxiety and depression was associated with increased risk of retirement due to permanent disability and increased mortality in a cohort of German workers.
Methods
128,001 German workers with statutory health insurance were followed for a mean of 6.4 years. We examined the associations between 1) depression/anxiety-related sick leave managed on an outpatient basis and 2) anxiety/depression-related psychiatric inpatient treatment, and later permanent disability/mortality using Cox proportional hazard regression models (stratified by sex and disorder) adjusted for age, education and job code classification.
Results
Outpatient-managed depression/anxiety-related sick leave was significantly associated with higher permanent disability (hazard ratio (95% confidence interval)) 1.48 (1.30, 1.69) for depression, 1.25 (1.07, 1.45) for anxiety, 1.91 (1.56, 2.35) for both). Among outpatients, comorbidly ill men (2.59 (1.97,3.41)) were more likely to retire early than women (1.42 (1.04,1.93)). Retirement rates were higher for depressive and comorbidly ill patients who needed inpatient treatment (depression 3.13 (2,51, 3,92), both 3.54 (2.80, 4.48)). Inpatient-treated depression was also associated with elevated mortality (2.50 (1.80, 3.48)). Anxiety (0.53 (0.38, 0.73)) and female outpatients with depression (0.61 (0.38, 0.97)) had reduced mortality compared to controls.
Conclusions
Depression/anxiety diagnoses increase the risk of early retirement; comorbidity and severity further increase that risk, depression more strikingly than anxiety. Sickness-absence diagnoses of anxiety/depression identified a population at high risk of retiring early due to ill health, suggesting a target group for the development of interventions.
doi:10.1186/1471-2458-13-145
PMCID: PMC3698165  PMID: 23413800
Anxiety; Depression; Treatment; Invalidity; Mortality; Occupational disability; Protection
23.  Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(1):e1001581.
Lucy Chappell and colleagues conduct a systematic review and meta analysis to investigate a possible association between intimate partner violence and termination of pregnancy.
Please see later in the article for the Editors' Summary
Background
Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.
Methods and Findings
A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I2>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.
Conclusions
IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Intimate partner violence (sometimes referred to as domestic violence) is one of the commonest forms of violence against women and is a global health problem. The World Health Organization defines intimate partner violence as any act of physical, psychological, or sexual aggression or any controlling behavior (for example, restriction of access to assistance) perpetrated by the woman's current or past intimate partner. Although men also experience it, intimate partner violence is overwhelmingly experienced by women, particularly when repeated or severe. Studies indicate that the prevalence (the percentage of a population affected by a condition) of intimate partner violence varies widely within and between countries: the prevalence of intimate partner violence among women ranges from 15% in Japan to 71% in Ethiopia, and the lifetime prevalence of rape (forced sex) within intimate relationships ranges from 5.9% to 42% across the world, for example. Overall, a third of women experience intimate partner violence at some time during their lifetimes. The health consequences of such violence include physical injury, depression, suicidal behavior, and gastrointestinal disorders.
Why Was This Study Done?
Intimate partner violence can also lead to gynecological disorders (conditions affecting the female reproductive organs), unwanted pregnancy, premature labour and birth, and sexually transmitted infections. Because violence may begin or intensify during pregnancy, some countries recommend routine questioning about intimate partner violence during antenatal care. However, women seeking termination of pregnancy (induced abortion) are not routinely asked about intimate partner violence. Every year, many women worldwide terminate a pregnancy. Nearly half of these terminations are unsafe, and complications arising from unsafe abortions are responsible for more than 10% of maternal deaths (deaths from pregnancy or childbirth-related complications). It is important to know whether intimate partner violence and termination of pregnancy are associated in order to develop effective strategies to deal with both these global health concerns. Here, the researchers conducted a systematic review and meta-analysis to investigate the associations between intimate partner violence and termination or pregnancy. A systematic review identifies all the research on a given topic using predefined criteria; meta-analysis combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 74 studies that provided information about experiences of intimate partner violence among women who had had a termination of pregnancy. Data in these studies indicated that, worldwide, intimate partner violence rates among women undergoing termination ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. In the meta-analysis, the lifetime prevalence of intimate partner violence was 24.9% among termination-seeking populations. The identified studies provided evidence that intimate partner violence was associated with termination and with repeat termination. In one study, for example, women presenting for a third termination were more than two and a half times more likely to have a history of physical or sexual violence than women presenting for their first termination. Moreover, according to the meta-analysis, women in violent relationships were three times as likely to conceal a termination from their partner as women in non-violent relationships. Finally, the studies indicated that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help.
What Do These Findings Mean?
These findings indicate that intimate partner violence is associated with termination of pregnancy and that a woman's partner not knowing about the termination is a risk factor for intimate partner violence among women seeking termination. Overall, the researchers' findings support the concept that violence can lead to pregnancy and to subsequent termination of pregnancy, and that there may be a repetitive cycle of abuse and pregnancy. The accuracy of these findings is limited by heterogeneity (variability) among the included studies, by the likelihood of underreporting of both intimate partner violence and termination in the included studies, and by lack of validation of reports of violence through, for example, police reports. Nevertheless, health-care professionals should consider the possibility that women seeking termination of pregnancy may be experiencing intimate partner violence. In trying to prevent repeat terminations, health-care professionals should be aware that while focusing on preventing conception may reduce the chances of a woman becoming pregnant, she may still be vulnerable to abuse. Finally, given the clear associations between intimate partner violence and termination of pregnancy, the researchers suggest that termination services represent an appropriate setting in which to test interventions designed to reduce intimate partner violence.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001581.
The World Health organization provides detailed information about intimate partner violence and about termination of pregnancy (some information available in several languages)
MedlinePlus provides links to other resources about intimate partner violence and about termination of pregnancy (in English and Spanish)
The World Bank has a webpage that discusses the role of the health sector in preventing gender-based violence and a webpage with links to other resources about gender-based violence
The Gender and Health Research Unit of the South African Medical Research Council provides links to further resources about intimate partner violence (research briefs/policy briefs/fact sheets/research reports)
DIVERHSE (Domestic & Interpersonal Violence: Effecting Responses in the Health Sector in Europe) is a European forum for health professionals, nongovernmental organizations, policy-makers, and academics to share their expertise and good practice in developing and evaluating interventions to address violence against women and children in a variety of health-care settings
London School of Hygiene & Tropical Medicine's Gender Violence and Health Centre also has a number of research resources
The UK National Health Service Choices website provides personal stories of intimate partner violence during pregnancy
The March of Dimes provides information on identifying intimate partner violence during pregnancy and making a safety plan
doi:10.1371/journal.pmed.1001581
PMCID: PMC3883805  PMID: 24409101
24.  Gender Differences in Comorbid Disorders among Offenders in Prison Substance Abuse Treatment Programs 
Behavioral sciences & the law  2008;26(4):403-412.
This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.
doi:10.1002/bsl.831
PMCID: PMC2648970  PMID: 18683199
25.  Eating Disorders and Trauma History in Women with Perinatal Depression 
Journal of Women's Health  2011;20(6):863-870.
Abstract
Objective
Although the prevalence of perinatal depression (depression occurring during pregnancy and postpartum) is 10%, little is known about psychiatric comorbidity in these women. We examined the prevalence of comorbid eating disorders (ED) and trauma history in women with perinatal depression.
Methods
A research questionnaire was administered to 158 consecutive patients seen in a perinatal psychiatry clinic during pregnancy (n=99) or postpartum (n=59). Measures included Structured Clinical Interview for DSM (SCID) IV-based questions for lifetime eating psychopathology and assessments of comorbid psychiatric illness including the State/Trait Anxiety Inventory (STAI), Patient Health Questionnaire (PHQ-9), Edinburgh Postnatal Depression Scale (EPDS), and Trauma Inventory.
Results
In this cohort, 37.1% reported a putative lifetime ED history; 10.1% reported anorexia nervosa (AN), 10.1% reported bulimia nervosa (BN), 10.1% reported ED not otherwise specified-purging subtype (EDNOS-P), and 7.0% reported binge eating disorder (BED). Women with BN reported more severe depression (EPDS score, 19.1, standard deviation [SD 4.3], p=0.02; PHQ-severity 14.5, SD 7.4, p=0.02) than the referent group of women with perinatal depression and no ED history (EPDS 13.3, SD=6.1; PHQ 9.0, SD=6.2). Women with AN were more likely to report sexual trauma history than the referent group (62.5% vs. 29.3%, p<0.05), and those with BN were more likely report physical (50.0%, p<0.05) and sexual (66.7%, p<0.05) trauma histories.
Conclusions
ED histories were present in over one third of admissions to a perinatal psychiatry clinic. Women with BN reported more severe depression and histories of physical and sexual trauma. Screening for histories of eating psychopathology is important in women with perinatal depression.
doi:10.1089/jwh.2010.2360
PMCID: PMC3113417  PMID: 21671774

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