Les troubles dépressifs représentent aujourd’hui l’une des causes de handicap et de mortalité précoce les plus fréquentes dans le monde. Les projections établies par l’Organisation Mondiale de la Sante à l’horizon 2020 prévoient qu’ils seront classés second, juste après les maladies cardiovasculaires. De nombreuses études ont montré l’efficacité des antidépresseurs dans la prévention des rechutes, cependant la situation semble moins claire s’agissant de la prévention des récidives. Un certain nombre de travaux de recherche ont été menés visant à évaluer l’impact médico-économique des stratégies thérapeutiques préventives, en recourant à la construction de modèles de simulation, ceux-ci permettant une représentation schématique de l’évolution de la pathologie au cours du temps. Cependant, afin d’être en mesure d’évaluer l’impact économique des stratégies de prévention des troubles dépressifs, un certain nombre de facteurs doivent être pris en considération dans l’élaboration du modèle représentatif de la pathologie. Nous montrons que l’intégration de l’ensemble des facteurs déterminants des récidives, tout en considérant un horizon temporel suffisamment large afin de capter les bénéfices thérapeutiques et (éventuellement) économiques sur le long terme, n’est pas sans poser problème. Nous montrons que les modèles disponibles dans la littérature sont seulement en mesure de proposer une forme partielle d’abstraction de la pathologie dépressive, généralement réduite à un ou deux facteurs de risque principaux, parmi lesquels l’observance du traitement, l’histoire médicale ou encore les caractéristiques sociodémographiques du patient. Nous proposons alors d’envisager les modèles de simulation à événements discrets en tant que réponse possible pour la représentation des facteurs de risque des troubles dépressifs récurrents, et détaillons les principes de la méthode. Nous tentons ensuite de développer un modèle ≪ princeps ≫ à partir de données épidémiologiques. Nous montrons alors que la flexibilité associée à ce type de modélisation permet de proposer un cadre d’analyse au plus près de la réalité de la pathologie dépressive / Depressive disorders represent today one of the most frequent causes of disability and premature death worldwide. Research on the natural history of depressive disorders has shown that it is indeed a chronic rather than an acute disease. Many studies have shown the effectiveness of antidepressants in preventing relapse; however, the situation seems less clear with regard to the prevention of recurrence. A number of research activities have been conducted to evaluate the pharmaco-economic impact of preventive strategies with the help of simulation models. These techniques represent a convenient tool enabling the schematic representation of disease progression over time. However, in order to be able to assess the economic impact of prevention strategies for depressive disorders, a number of factors must be taken into account when developing the model structure. We show that the integration of all determining factors, especially on a wide-enough time horizon in order to capture the therapeutic and possible economic benefits in the long term can be somewhat problematic. We show that the models available in the literature only present a partial framework aiming at depicting disease’s risk factors (medical history, treatment compliance or socio-demographic characteristics) and progression over time. We propose then to consider the use of discrete event simulation models as a possible tool for modelling recurrent depressive disorders, and we provide a detailed description of the principles of this methodology. We then try to develop a core model based on epidemiological evidence. We show that the flexibility associated with this type of modelling method can provide an analytical framework that depicts the characteristics of the depressive pathology in a more realistic fashion

Os transtornos depressivos, a dependência de tabaco e os transtornos relacionados ao uso de álcool (TRUA) são altamente prevalentes e estão associados a diversas comorbidades. Todavia, permanecem subdiagnosticados e subtratados em diversos contextos de saúde. Dessa forma, o presente estudo teve por objetivos: a) avaliar parâmetros de fidedignidade e validade de instrumentos de rastreamento para transtornos depressivos (Patient Health Questionnaire - two itens [PHQ-2] e Well-Being Index - five itens [WHO-5]), dependência de tabaco (Fagerström Test for Nicotine Dependence [FTND] e Heaviness of Smoking Index [HSI]) e de álcool (Fast Alcohol Screening Test [FAST], CAGE, Alcohol Use Disorders Identification Test [AUDIT] e suas versões breves); b) realizar a análise fatorial do WHO-5, FTND e do AUDIT; c) avaliar a comorbidade entre os transtornos supracitados. Participaram dos estudos da fidedignidade teste-reteste 429 universitários e da fidedignidade interavaliadores 41 pacientes do Centro de Atenção Psicossocial - Álcool e Drogas (CAPS-AD). Os estudos da validade preditiva, consistência interna, comorbidade e análise fatorial utilizaram uma amostra de 530 pacientes do Pronto Socorro e do CAPS-AD. A fidedignidade foi estimada por meio do kappa e do coeficiente de correlação intraclasse (CCI). Nos estudos da validade preditiva, a SCID-CV foi a medida diagnóstica comparativa, sendo calculadas as áreas sob a curva ROC (ASC), sensibilidades, especificidades, acurácias, valores preditivos positivos e negativos dos instrumentos. A validade concorrente foi examinada pelo coeficiente de Spearman. O coeficiente alfa de cronbach foi utilizado para aferir a consistência interna. A análise fatorial exploratória foi realizada segundo os critérios de Kaiser. As comorbidades foram avaliadas por meio da regressão logística - odds ratios brutos e ajustados. O nível de significância foi de p<0,05, com intervalo de confiança de 95%. O PHQ-2 e do WHO-5 apresentaram altos índices de fidedignidade (>0,98). Exibiram, também, consistências internas elevadas (0,76 e 0,78, respectivamente). O WHO-5 obteve uma ASC de 0,89; sensibilidade de 0,85 e especificidade de 0,81 no ponto de corte nove. O PHQ-2 apresentou uma ASC de 0,86; sensibilidade de 0,74 e especificidade de 0,87 no ponto de corte três. O WHO-5 exibiu um único fator que explicou 51% da variância dos dados. Os estudos da fidedignidade do FTND resultaram em altos CCI (0,92 no teste-reteste e 0,99 no interavaliadores). Na análise fatorial, o FTND exibiu dois fatores. A consistência interna do FTND foi elevada (0,83), já a do HSI esteve abaixo do recomendado (0,56). O FTND e o HSI apresentaram elevados valores de sensibilidade, especificidade e acurácia. O AUDIT e suas versões abreviadas apresentaram consistências internas entre 0,83 e 0,94. No estudo da validade preditiva, esses instrumentos exibiram ASC entre 0,92 a 0,96, com índices de sensibilidade entre 0,84 e 0,93; e de especificidade de 0,83 a 0,94 para rastrear TRUA. A menor versão, o AUDIT-3 obteve excelentes resultados. No estudo da validade concorrente, observaram-se correlações expressivas entre as versões breves e o AUDIT (0,91 - 0,99). Em todas as avaliações o CAGE apresentou valores satisfatórios, porém inferiores aos das versões breves do AUDIT. Os resultados obtidos confirmam a validade e a confiabilidade das versões brasileiras do WHO-5, PHQ-2, FTND e do HSI, assim como, a eficácia de todas as versões breves do AUDIT, demonstrando que suas propriedades psicométricas são tão satisfatórias quanto às do instrumento completo e superiores as do CAGE. Portanto, o emprego desses instrumentos encontra apoio em sua viabilidade e sua validade, incentivando a sua utilização tanto na prática clínica diária como em pesquisas. Observou-se, neste estudo, que o tabagismo e o abuso e dependência do álcool são importantes preditores de transtornos depressivos e que os dependentes de álcool mostraram quatro vezes mais chance de serem tabagistas. / Depressive disorders, tobacco dependence, and alcohol-related disorders (ARD) are highly prevalent and are associated with several comorbidities. Nonetheless, they are still under-diagnosed and under-treated in many health settings. Therefore, this study was aimed at (1) assessing reliability and validity parameters of screening instruments for depressive disorders (Patient Health Questionnaire 2 [PHQ-2] and Well-Being Index 5 [WHO-5]), tobacco dependence (Fagerström Test for Nicotine Dependence [FTND] and Heaviness of Smoking Index [HSI]), and alcohol dependence (Fast Alcohol Screening Test [FAST], CAGE, Alcohol Use Disorders Identification Test [AUDIT] and their brief versions); (2) performing the factorial analysis of the WHO-5, FTND, and AUDIT; and (3) assessing the comorbidity between the above-mentioned disorders. The test-retest reliability study involved 429 university students and the inter-rater reliability study included 41 patients of a Center for Psychosocial Attention Alcohol and Drugs (CAPS-AD, in the Portuguese acronym). The assessment of the predictive validity, internal consistency, comorbidity, and factorial analysis involved a sample of 530 patients of an emergency unit and the CAPS-AD. Reliability was estimated by means of kappa and interclass correlation (ICC) coefficients. In the predictive validity studies, the SCID-CV was used as the comparison diagnostic measure, with calculation of the areas under the ROC curve (AUC), sensitivity, specificity, accuracy, and positive and negative predictive values of the instruments. Concurrent validity was assessed using Spearmans coefficient. Cronbachs alpha coefficient was used to assess internal consistency. The exploratory factorial analysis was conducted according to Kaisers criteria. Comorbidities were analyzed by logistic regression raw and adjusted odds ratio. The level of statistical significance was set at p < 0.05, with a 95% confidence interval. The PHQ-2 and WHO-5 had high levels of reliability (> 0.98) and internal consistency (0.76 and 0.78, respectively). The WHO-5 had an AUC of 0.89; sensitivity of 0.85; and specificity of 0.81 for a cut-off of 9. The PHQ-2 had an AUC of 0.86; sensitivity of 0.74; and specificity of 0.87 for a cut-off of 3. The WHO-5 yielded one single factor, which explained 51% of the data variance. The reliability study of the FTND provided high ICC coefficients (0.92 for test-retest and 0.99 for inter-rater). In the factorial analysis, the FTND yielded two factors. The internal consistency of the FTND was high (0.83), but that of the HIS was below recommended levels (0.56). The FTND and the HIS had high indices of sensitivity, specificity, and accuracy. The AUDIT and its brief versions had internal consistency values between 0.83 and 0.94. In the study of predictive validity, these instruments had AUC between 0.92 and 0.96, with sensitivity levels between 0.84 and 0.93 and specificity levels ranging from 0.83 and 0.94 for the screening of ARD. The shortest version of the AUDIT (AUDIT-3) had excellent results. In the assessment of concurrent validity, expressive correlations were found between the AUDIT and its brief versions (0.91-0.99). In all analyses, the CAGE had satisfactory results, although inferior to those of the brief versions of the AUDIT. The results confirm the validity and reliability of the Brazilian versions of the WHO-5, PHQ-2, FTND, and HIS, as well as the efficacy of all the brief versions of the AUDIT, demonstrating that their psychometric qualities are as satisfactory as those of the full version of the instrument and superior to those of the CAGE. Therefore, the use of these instruments is supported by their viability and validity, which encourage their use in routine clinical practice and research settings. The results also showed that smoking and alcohol abuse and dependence are important predictors of depressive disorders and that alcoholics had a fourfold higher chance of being smokers.

A depressão tem sido associada a um maior absenteísmo e uso de serviços de saúde e, sua prevalência em pacientes de atenção primária no momento da avaliação é em torno de 10%. Este estudo teve como objetivo, investigar em uma amostra de uma ambulatório de clínica médica de um hospital escola (Ambulatório Geral e Didático do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo), a associação entre: a) transtorno depressivo maior e utilização de serviços de saúde, b) outras depressões e utilização de serviços de saúde, c) transtorno depressivo maior e absenteísmo, d) outras depressões e absenteísmo. MÉTODOS: Dezenove médicos clínicos gerais aplicaram o Primary Care Evaluation of Mental Disorders (Prime-Md) e questões para avaliar o uso de serviços de saúde e absenteísmo no período de 12 meses antes da entrevista, em 414 pacientes. O Prime-Md é uma entrevista para diagnosticar os transtornos mentais mais comuns em atenção primária, desenvolvido para entrevistadores não especialistas. Os transtornos depressivos pesquisados pelo Prime-MD são: transtorno depressivo maior, transtorno depressivo distímico, transtorno depressivo menor, remissão parcial de transtorno depressivo maior, transtorno depressivo bipolar e transtorno depressivo devido a doenças ou uso de substâncias. O diagnóstico segue os critérios do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM) da Associação Psiquiátrica Americana. A análise estatística comparou três grupos: pacientes com transtorno depressivo maior (N=144), pacientes com outras depressões (N=82) e pacientes sem depressão (N=188). As comparações foram feitas pelo teste do Qui-quadrado ou Mann-Whitney. Dois modelos de regressão logística foram gerados com absenteísmo como variável dependente. A variável independente em um modelo foi o transtorno depressivo maior e no outro o grupo com outras depressões. O modelos foram ajustados para: idade, sexo, estado civil e presença de doença clínica. RESULTADOS: Pacientes com transtorno depressivo maior procuram serviços de saúde em um número significativamente maior do que aqueles sem depressão (p=0,0005). O grupo de pacientes com transtorno depressivo maior e o grupo com outras depressões apresentaram mais absenteísmo (sim/não) ao trabalho, atividades domésticas ou à escola, do que aqueles sem depressão, as diferenças também foram significativas para o número de dias perdidos. De acordo com a análise de regressão logística, pacientes com transtorno depressivo maior apresentaram uma razão de chance (odds ratio) de 1,80 (p=0,015; 95% IC, 1,12-2,90) vezes maior de ter absenteísmo quando comparados com aqueles sem depressão; para pacientes com outras depressões a razão de chance em relação àqueles sem depressão foi de 1,89 (p=0,026; 95%IC, 1,05-5,17) vezes maior. Não encontramos diferenças significativas entre os três grupos quanto ao sexo, idade, estado civil, tipo de serviço procurado (pronto-socorro ou ambulatório/posto de saúde), ocorrência de hospitalização ou doenças crônicas. CONCLUSÕES: O transtorno depressivo maior se associou significativamente com uma maior procura por serviços de saúde. Ambos, o transtorno depressivo maior e o grupo com outras depressões se associaram significativamente com absenteísmo. Nosso estudo não é prospectivo, o que restringe conclusões etiológicas. Entretanto, de acordo com dados da literatura, nossos resultados provavelmente indicam que a presença de transtornos depressivos acarreta maior uso do sistema de saúde e maior absenteísmo ao trabalho ou a atividades acadêmicas. Alem disso, o impacto sobre absenteísmo se estende para formas mais leves de depressão e é independente da idade, sexo, estado civil ou presença de doenças clínicas / Depression has been associated with increased absenteeism and use of health care services, and its current prevalence in primary care patients is around 10%. This study aimed to investigate in outpatients at their first visit in a general medical unit of a teaching hospital (Ambulatório Geral Didático do Hospital das Clínicas da Universidade de São Paulo) the association of: a) major depressive disorder and use of health care services, b) other depressive disorders and the use of health care services, c) major depressive disorder and absenteeism, d) other depressive disorders and absenteeism. METHODS: Nineteen clinicians used the Prime-Md and questions to assess absenteeism and the use of health care facilities in the period of 12 months before the study evaluation in 414 outpatients. The Prime-Md is an interview targeted for most common mental disorders in primary care, and developed for non-specialized interviewers. The depressive disorders evaluated by Prime-Md are: major depressive disorder, dysthymic disorder, minor depression, partial remission of a major depressive disorder, depressive disorder in bipolar, and depressive disorder due to general medical conditions or substance use. The diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders-3rd Edition (DSM -III-RAmerican Psychiatric Association). The statistical analysis compared three groups: patients with major depressive disorders (N=144), patients with other depressions (N=82), and patients without depression (N=188). The comparisons were done with the Chi-square or the Mann-Whitney test. Two logistic regression models were generated with absenteeism as the dependent variable. The independent variable in one model was the presence of major depressive disorder and in the other the presence of presence of other depressions. The models were adjusted for age, gender, marital status and presence of general medical condition. RESULTS: Patients with major depressive disorder presented a significantly higher number of visits to health care services compared to those without depression (p=0.0005). The group of patients with major depressive disorder and the group with other depressive disorders presented more absenteeism (yes/no) from work, home duties, or school compared to patients without depression; the differences were also significant for the number of lost days. According to the logistic regression analysis, patients with major depressive disorder presented an odds ratio of 1.80 (p=0.015; 95%CI, 1.12-2.90) to have absenteeism compared to patients without depression; the odds ratio to have absenteeism for patients with other depressions compared to those without depression was 1.89 (p=0.026; 95%CI, 1.05-5.17). We did not find significant differences among the three groups regarding gender, age, marital status, type of visited service (i.e. emergency room or outpatient clinic), hospitalizations, or presence of general medical conditions. CONCLUSIONS: Major depressive disorder was significantly associated with an increased number of visits to health services. Either major depressive disorder or the group with other depressions were significantly associated with increased absenteeism. Our study is not prospective, which restricts etiologic conclusions. However, based on the literature, our results probably indicate that the presence of depressive disorders leads to an increased use of the health system and increased absenteeism from work, home duties or school. Moreover, the impact on absenteeism extends to milder depressive disorders and is independ of age, gender, marital status or the presence of general medical condition

Os transtornos depressivos, a dependência de tabaco e os transtornos relacionados ao uso de álcool (TRUA) são altamente prevalentes e estão associados a diversas comorbidades. Todavia, permanecem subdiagnosticados e subtratados em diversos contextos de saúde. Dessa forma, o presente estudo teve por objetivos: a) avaliar parâmetros de fidedignidade e validade de instrumentos de rastreamento para transtornos depressivos (Patient Health Questionnaire - two itens [PHQ-2] e Well-Being Index - five itens [WHO-5]), dependência de tabaco (Fagerström Test for Nicotine Dependence [FTND] e Heaviness of Smoking Index [HSI]) e de álcool (Fast Alcohol Screening Test [FAST], CAGE, Alcohol Use Disorders Identification Test [AUDIT] e suas versões breves); b) realizar a análise fatorial do WHO-5, FTND e do AUDIT; c) avaliar a comorbidade entre os transtornos supracitados. Participaram dos estudos da fidedignidade teste-reteste 429 universitários e da fidedignidade interavaliadores 41 pacientes do Centro de Atenção Psicossocial - Álcool e Drogas (CAPS-AD). Os estudos da validade preditiva, consistência interna, comorbidade e análise fatorial utilizaram uma amostra de 530 pacientes do Pronto Socorro e do CAPS-AD. A fidedignidade foi estimada por meio do kappa e do coeficiente de correlação intraclasse (CCI). Nos estudos da validade preditiva, a SCID-CV foi a medida diagnóstica comparativa, sendo calculadas as áreas sob a curva ROC (ASC), sensibilidades, especificidades, acurácias, valores preditivos positivos e negativos dos instrumentos. A validade concorrente foi examinada pelo coeficiente de Spearman. O coeficiente alfa de cronbach foi utilizado para aferir a consistência interna. A análise fatorial exploratória foi realizada segundo os critérios de Kaiser. As comorbidades foram avaliadas por meio da regressão logística - odds ratios brutos e ajustados. O nível de significância foi de p<0,05, com intervalo de confiança de 95%. O PHQ-2 e do WHO-5 apresentaram altos índices de fidedignidade (>0,98). Exibiram, também, consistências internas elevadas (0,76 e 0,78, respectivamente). O WHO-5 obteve uma ASC de 0,89; sensibilidade de 0,85 e especificidade de 0,81 no ponto de corte nove. O PHQ-2 apresentou uma ASC de 0,86; sensibilidade de 0,74 e especificidade de 0,87 no ponto de corte três. O WHO-5 exibiu um único fator que explicou 51% da variância dos dados. Os estudos da fidedignidade do FTND resultaram em altos CCI (0,92 no teste-reteste e 0,99 no interavaliadores). Na análise fatorial, o FTND exibiu dois fatores. A consistência interna do FTND foi elevada (0,83), já a do HSI esteve abaixo do recomendado (0,56). O FTND e o HSI apresentaram elevados valores de sensibilidade, especificidade e acurácia. O AUDIT e suas versões abreviadas apresentaram consistências internas entre 0,83 e 0,94. No estudo da validade preditiva, esses instrumentos exibiram ASC entre 0,92 a 0,96, com índices de sensibilidade entre 0,84 e 0,93; e de especificidade de 0,83 a 0,94 para rastrear TRUA. A menor versão, o AUDIT-3 obteve excelentes resultados. No estudo da validade concorrente, observaram-se correlações expressivas entre as versões breves e o AUDIT (0,91 - 0,99). Em todas as avaliações o CAGE apresentou valores satisfatórios, porém inferiores aos das versões breves do AUDIT. Os resultados obtidos confirmam a validade e a confiabilidade das versões brasileiras do WHO-5, PHQ-2, FTND e do HSI, assim como, a eficácia de todas as versões breves do AUDIT, demonstrando que suas propriedades psicométricas são tão satisfatórias quanto às do instrumento completo e superiores as do CAGE. Portanto, o emprego desses instrumentos encontra apoio em sua viabilidade e sua validade, incentivando a sua utilização tanto na prática clínica diária como em pesquisas. Observou-se, neste estudo, que o tabagismo e o abuso e dependência do álcool são importantes preditores de transtornos depressivos e que os dependentes de álcool mostraram quatro vezes mais chance de serem tabagistas. / Depressive disorders, tobacco dependence, and alcohol-related disorders (ARD) are highly prevalent and are associated with several comorbidities. Nonetheless, they are still under-diagnosed and under-treated in many health settings. Therefore, this study was aimed at (1) assessing reliability and validity parameters of screening instruments for depressive disorders (Patient Health Questionnaire 2 [PHQ-2] and Well-Being Index 5 [WHO-5]), tobacco dependence (Fagerström Test for Nicotine Dependence [FTND] and Heaviness of Smoking Index [HSI]), and alcohol dependence (Fast Alcohol Screening Test [FAST], CAGE, Alcohol Use Disorders Identification Test [AUDIT] and their brief versions); (2) performing the factorial analysis of the WHO-5, FTND, and AUDIT; and (3) assessing the comorbidity between the above-mentioned disorders. The test-retest reliability study involved 429 university students and the inter-rater reliability study included 41 patients of a Center for Psychosocial Attention Alcohol and Drugs (CAPS-AD, in the Portuguese acronym). The assessment of the predictive validity, internal consistency, comorbidity, and factorial analysis involved a sample of 530 patients of an emergency unit and the CAPS-AD. Reliability was estimated by means of kappa and interclass correlation (ICC) coefficients. In the predictive validity studies, the SCID-CV was used as the comparison diagnostic measure, with calculation of the areas under the ROC curve (AUC), sensitivity, specificity, accuracy, and positive and negative predictive values of the instruments. Concurrent validity was assessed using Spearmans coefficient. Cronbachs alpha coefficient was used to assess internal consistency. The exploratory factorial analysis was conducted according to Kaisers criteria. Comorbidities were analyzed by logistic regression raw and adjusted odds ratio. The level of statistical significance was set at p < 0.05, with a 95% confidence interval. The PHQ-2 and WHO-5 had high levels of reliability (> 0.98) and internal consistency (0.76 and 0.78, respectively). The WHO-5 had an AUC of 0.89; sensitivity of 0.85; and specificity of 0.81 for a cut-off of 9. The PHQ-2 had an AUC of 0.86; sensitivity of 0.74; and specificity of 0.87 for a cut-off of 3. The WHO-5 yielded one single factor, which explained 51% of the data variance. The reliability study of the FTND provided high ICC coefficients (0.92 for test-retest and 0.99 for inter-rater). In the factorial analysis, the FTND yielded two factors. The internal consistency of the FTND was high (0.83), but that of the HIS was below recommended levels (0.56). The FTND and the HIS had high indices of sensitivity, specificity, and accuracy. The AUDIT and its brief versions had internal consistency values between 0.83 and 0.94. In the study of predictive validity, these instruments had AUC between 0.92 and 0.96, with sensitivity levels between 0.84 and 0.93 and specificity levels ranging from 0.83 and 0.94 for the screening of ARD. The shortest version of the AUDIT (AUDIT-3) had excellent results. In the assessment of concurrent validity, expressive correlations were found between the AUDIT and its brief versions (0.91-0.99). In all analyses, the CAGE had satisfactory results, although inferior to those of the brief versions of the AUDIT. The results confirm the validity and reliability of the Brazilian versions of the WHO-5, PHQ-2, FTND, and HIS, as well as the efficacy of all the brief versions of the AUDIT, demonstrating that their psychometric qualities are as satisfactory as those of the full version of the instrument and superior to those of the CAGE. Therefore, the use of these instruments is supported by their viability and validity, which encourage their use in routine clinical practice and research settings. The results also showed that smoking and alcohol abuse and dependence are important predictors of depressive disorders and that alcoholics had a fourfold higher chance of being smokers.

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Emotional suffering in old age is largely caused by a variety of psychiatric disorders which are often, however, undertreated and underrecognized. This leads to reduced quality of life and functional status and increased morbidity and mortality. Dementia, delirium and depression are common disorders in the very old, and are similar in several ways. All have multiple causes and are diagnosed by means of symptomatic criteria, are challenging to diagnose and difficult to differentiate from each other in the very old. They often coexist in the same individual, and may have common risk factors. The overall aim of this thesis was to add to our knowledge about threats to successful aging, by investigating the prevalences of dementia, depression and delirium, and factors associated with these three disorders. Further aims were to measure change over time in the prevalence of dementia and depression, respectively, and to investigate the risk factors for incident depression. This thesis uses the population-based Umeå85+/GErontological Regional DAtabase (GERDA) material. In 2000-2002, every other 85-year-old, all 90-year-olds and all people ≥95 years living in six municipalities in Västerbotten, Sweden were invited to participate, and in 2005-2007 the process was repeated, with the additional inclusion of the corresponding populations of two municipalities in Österbotten, Finland. A third data collection was carried out in 2010-2012. Trained assessors carried out assessments in the form of structured interviews during one or more home visits, recorded current medication and reviewed medical records obtained from general practitioners and hospitals. In 2000-2002 the prevalence of dementia was 17% among 85-year-olds, 24% among 90-year-olds and 46% among those aged ≥95 years. In 2005-2007 dementia prevalence reached 28% among 85-year-olds, 40% among 90-yearolds and 45% among those aged ≥95 years. The prevalence of dementia in the total sample was 27% in 2000-2002 and 37% in 2005-2007 (p=0.001). In 2000-2002 the prevalence of depressive disorders was 24% among 85-yearolds, 34% among 90-year-olds and 31% among those aged ≥95 years. In 2005-2007 the prevalence of depressive disorders was 33% among 85-year-olds, 39% among 90-year-olds and 38% among those aged ≥95 years. The prevalence of depressive disorders in the total sample was 29% in 2000-2002 and 37% in 2005-2007 (p=0.025). Among participants not depressed at baseline, 26% had developed depression after five years. Factors independently associated with new cases of depression at follow-up were hypertension, a history of stroke and a higher score on the 15-item Geriatric Depression Scale at baseline. The thirtyday prevalence of delirium in 2005-2007 was 17% among 85-year-olds, 21% among 90-year-olds and 39% among participants aged ≥95 years. Delirium prevalence among individuals with dementia was higher than among those without dementia (52% vs. 5%, p&lt;.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression, heart failure, living in an institution and prescribed antipsychotics. There was a high prevalence of dementia, depression and delirium in the papers comprising this thesis, and 55% had at least one of the three disorders. The prevalence of dementia and depression also increased between 2000-2002 and 2005-2007, after controlling for age and sex. Dementia and depression were important associated factors for delirium and half of those with dementia were depressed. The increasing age-specific prevalence of depression seems to be associated with the increasing age-specific prevalence of dementia. The papers presented are among the first to report a significantly increasing age-specific prevalence of dementia and depression among very old people. More knowledge about associated factors and risk factors concerning these disorders may be helpful for carers and decision-makers, as well as providing reference values for studies in other regions. Further efforts are needed in both care and research to better prevent, screen for, diagnose and treat dementia, depression and delirium, especially considering the growing number of very old people. / Umeå85+/GERDA

A depressão tem sido associada a um maior absenteísmo e uso de serviços de saúde e, sua prevalência em pacientes de atenção primária no momento da avaliação é em torno de 10%. Este estudo teve como objetivo, investigar em uma amostra de uma ambulatório de clínica médica de um hospital escola (Ambulatório Geral e Didático do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo), a associação entre: a) transtorno depressivo maior e utilização de serviços de saúde, b) outras depressões e utilização de serviços de saúde, c) transtorno depressivo maior e absenteísmo, d) outras depressões e absenteísmo. MÉTODOS: Dezenove médicos clínicos gerais aplicaram o Primary Care Evaluation of Mental Disorders (Prime-Md) e questões para avaliar o uso de serviços de saúde e absenteísmo no período de 12 meses antes da entrevista, em 414 pacientes. O Prime-Md é uma entrevista para diagnosticar os transtornos mentais mais comuns em atenção primária, desenvolvido para entrevistadores não especialistas. Os transtornos depressivos pesquisados pelo Prime-MD são: transtorno depressivo maior, transtorno depressivo distímico, transtorno depressivo menor, remissão parcial de transtorno depressivo maior, transtorno depressivo bipolar e transtorno depressivo devido a doenças ou uso de substâncias. O diagnóstico segue os critérios do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM) da Associação Psiquiátrica Americana. A análise estatística comparou três grupos: pacientes com transtorno depressivo maior (N=144), pacientes com outras depressões (N=82) e pacientes sem depressão (N=188). As comparações foram feitas pelo teste do Qui-quadrado ou Mann-Whitney. Dois modelos de regressão logística foram gerados com absenteísmo como variável dependente. A variável independente em um modelo foi o transtorno depressivo maior e no outro o grupo com outras depressões. O modelos foram ajustados para: idade, sexo, estado civil e presença de doença clínica. RESULTADOS: Pacientes com transtorno depressivo maior procuram serviços de saúde em um número significativamente maior do que aqueles sem depressão (p=0,0005). O grupo de pacientes com transtorno depressivo maior e o grupo com outras depressões apresentaram mais absenteísmo (sim/não) ao trabalho, atividades domésticas ou à escola, do que aqueles sem depressão, as diferenças também foram significativas para o número de dias perdidos. De acordo com a análise de regressão logística, pacientes com transtorno depressivo maior apresentaram uma razão de chance (odds ratio) de 1,80 (p=0,015; 95% IC, 1,12-2,90) vezes maior de ter absenteísmo quando comparados com aqueles sem depressão; para pacientes com outras depressões a razão de chance em relação àqueles sem depressão foi de 1,89 (p=0,026; 95%IC, 1,05-5,17) vezes maior. Não encontramos diferenças significativas entre os três grupos quanto ao sexo, idade, estado civil, tipo de serviço procurado (pronto-socorro ou ambulatório/posto de saúde), ocorrência de hospitalização ou doenças crônicas. CONCLUSÕES: O transtorno depressivo maior se associou significativamente com uma maior procura por serviços de saúde. Ambos, o transtorno depressivo maior e o grupo com outras depressões se associaram significativamente com absenteísmo. Nosso estudo não é prospectivo, o que restringe conclusões etiológicas. Entretanto, de acordo com dados da literatura, nossos resultados provavelmente indicam que a presença de transtornos depressivos acarreta maior uso do sistema de saúde e maior absenteísmo ao trabalho ou a atividades acadêmicas. Alem disso, o impacto sobre absenteísmo se estende para formas mais leves de depressão e é independente da idade, sexo, estado civil ou presença de doenças clínicas / Depression has been associated with increased absenteeism and use of health care services, and its current prevalence in primary care patients is around 10%. This study aimed to investigate in outpatients at their first visit in a general medical unit of a teaching hospital (Ambulatório Geral Didático do Hospital das Clínicas da Universidade de São Paulo) the association of: a) major depressive disorder and use of health care services, b) other depressive disorders and the use of health care services, c) major depressive disorder and absenteeism, d) other depressive disorders and absenteeism. METHODS: Nineteen clinicians used the Prime-Md and questions to assess absenteeism and the use of health care facilities in the period of 12 months before the study evaluation in 414 outpatients. The Prime-Md is an interview targeted for most common mental disorders in primary care, and developed for non-specialized interviewers. The depressive disorders evaluated by Prime-Md are: major depressive disorder, dysthymic disorder, minor depression, partial remission of a major depressive disorder, depressive disorder in bipolar, and depressive disorder due to general medical conditions or substance use. The diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders-3rd Edition (DSM -III-RAmerican Psychiatric Association). The statistical analysis compared three groups: patients with major depressive disorders (N=144), patients with other depressions (N=82), and patients without depression (N=188). The comparisons were done with the Chi-square or the Mann-Whitney test. Two logistic regression models were generated with absenteeism as the dependent variable. The independent variable in one model was the presence of major depressive disorder and in the other the presence of presence of other depressions. The models were adjusted for age, gender, marital status and presence of general medical condition. RESULTS: Patients with major depressive disorder presented a significantly higher number of visits to health care services compared to those without depression (p=0.0005). The group of patients with major depressive disorder and the group with other depressive disorders presented more absenteeism (yes/no) from work, home duties, or school compared to patients without depression; the differences were also significant for the number of lost days. According to the logistic regression analysis, patients with major depressive disorder presented an odds ratio of 1.80 (p=0.015; 95%CI, 1.12-2.90) to have absenteeism compared to patients without depression; the odds ratio to have absenteeism for patients with other depressions compared to those without depression was 1.89 (p=0.026; 95%CI, 1.05-5.17). We did not find significant differences among the three groups regarding gender, age, marital status, type of visited service (i.e. emergency room or outpatient clinic), hospitalizations, or presence of general medical conditions. CONCLUSIONS: Major depressive disorder was significantly associated with an increased number of visits to health services. Either major depressive disorder or the group with other depressions were significantly associated with increased absenteeism. Our study is not prospective, which restricts etiologic conclusions. However, based on the literature, our results probably indicate that the presence of depressive disorders leads to an increased use of the health system and increased absenteeism from work, home duties or school. Moreover, the impact on absenteeism extends to milder depressive disorders and is independ of age, gender, marital status or the presence of general medical condition

Background: Vietnam suffers consequences of global warming. There is limited data of the relationship between weather, extreme heat and potential mental health problems. It is therefore crucial to study heat-related mental illnesses and to establish good solutions with relevant adaptations to global warming. The adaptation measures should give attention to people that live in areas facing annual extreme weather, and protecting health in general and more specifically mental health of citizens. The study aimed to examine relationships between weather patterns, extreme heat or heatwaves, and mental disorders, and to investigate factors contributing to increased vulnerability and susceptibility. Methods: The thesis includes a systematic review and a hospital-based study using data from the Hanoi Mental Hospital for five years (2008 – 2012), with mental disorders diagnosed by ICD10 (F00-99) to estimate the effects of weather variation, seasonality, increased temperatures, and heatwaves on hospital admissions for depression and other mental disorders. A negative binomial regression model accounting for yearly study period, time trends, and day of the week was used to analyze the relationship between seasonality, heatwaves, and monthly and daily mental disorder hospitalizations. Results: Our findings showed (i) a general tendency for more admissions between May and December, with a seasonal bi-annual high between May-June and November-December, and elevated ambient temperature was significantly related to increasing admissions for depressive disorders; (ii) the number of hospital cases for mental disorders increased in the summer seasone specially in June, and two percent of cases emerged during elevated temperature of one degree Celsius; and (iii) when compared with non-heatwave periods, heatwaves amounted to increasing risks for admission for the whole group of mental disorders (F00-79), and admissions for mental disorders among residents in rural communities and in the elderly population increased significantly during heatwaves. Conclusion: There were associations between hospital admissions for depression and other mental disorders and seasonality, weather patterns, elevated temperatures, and heatwaves. The associations grew stronger with the length of the heatwaves and particularly the elderly appeared more sensitive to seasonality, hot weather and heatwaves.

A importância de algumas abordagens psicoterápicas associadas à farmacoterapia no tratamento do Transtorno Depressivo Maior tem sido bastante destacada, no entanto, existem poucos dados sobre a Psicoterapia Psicodramática. O presente estudo comparou 20 pacientes com diagnóstico de TDM em uso de medicamentos antidepressivos e avaliados pela Escala de Depressão de HAM-D17 (escores entre 7 e 20), divididos em dois grupos: dez pacientes do Grupo Psicoterápico (GP) participaram de 4 sessões individuais de psicoterapia psicodramática e 24 de grupo. Dez pacientes do Grupo Controle (GC) não participaram de sessões psicoterápicas. Os dois grupos foram avaliados pela Escala de HAM-D17 e pela Escala de Adequação Social (EAS) no início e final do processo psicoterápico e o GP também foi avaliado pela Análise Sociométrica, fundamentada no método psicodramático. Em comparação ao GC, o GP apresentou uma melhora significativa quanto aos sintomas depressivos e ao funcionamento social, bem como uma expressiva mudança nos aspectos sociométricos investigados / The importance of several psychotherapic approaches associated to pharmacotherapy on the treatment of Major Depressive Disorder has been quite highlighted, although, there is little information as far as Psychodramatic Psychotherapy is concerned. The present study compared 20 patients diagnosed with MDD in use of antidepressant drugs and evaluated with the Hamilton Depression Scale (scores between 7 and 20), divided into two groups as follows: ten of the patients from the Psychotherapic Group (PG) took part in 4 individual psychodramatic psychotherapy sessions and 24 psychodramatic psychotherapy group sessions. Ten of the patients from the Control Group (CG) did not participate in the psychodramatic psychotherapy sessions. Both groups were evaluated with the HAM-D17 Scale and the Social Adjustment Scale - Self Report (SASSR) at the beginning and at the end of the psychotherapic process, and the PG was also evaluated through Sociometric Analysis, based on the psychodramatic method. In comparison to the CG, the PG presented a significant improvement regarding the symptoms of depression and social functioning, as well as an expressive change on the investigated sociometric aspects

A importância de algumas abordagens psicoterápicas associadas à farmacoterapia no tratamento do Transtorno Depressivo Maior tem sido bastante destacada, no entanto, existem poucos dados sobre a Psicoterapia Psicodramática. O presente estudo comparou 20 pacientes com diagnóstico de TDM em uso de medicamentos antidepressivos e avaliados pela Escala de Depressão de HAM-D17 (escores entre 7 e 20), divididos em dois grupos: dez pacientes do Grupo Psicoterápico (GP) participaram de 4 sessões individuais de psicoterapia psicodramática e 24 de grupo. Dez pacientes do Grupo Controle (GC) não participaram de sessões psicoterápicas. Os dois grupos foram avaliados pela Escala de HAM-D17 e pela Escala de Adequação Social (EAS) no início e final do processo psicoterápico e o GP também foi avaliado pela Análise Sociométrica, fundamentada no método psicodramático. Em comparação ao GC, o GP apresentou uma melhora significativa quanto aos sintomas depressivos e ao funcionamento social, bem como uma expressiva mudança nos aspectos sociométricos investigados / The importance of several psychotherapic approaches associated to pharmacotherapy on the treatment of Major Depressive Disorder has been quite highlighted, although, there is little information as far as Psychodramatic Psychotherapy is concerned. The present study compared 20 patients diagnosed with MDD in use of antidepressant drugs and evaluated with the Hamilton Depression Scale (scores between 7 and 20), divided into two groups as follows: ten of the patients from the Psychotherapic Group (PG) took part in 4 individual psychodramatic psychotherapy sessions and 24 psychodramatic psychotherapy group sessions. Ten of the patients from the Control Group (CG) did not participate in the psychodramatic psychotherapy sessions. Both groups were evaluated with the HAM-D17 Scale and the Social Adjustment Scale - Self Report (SASSR) at the beginning and at the end of the psychotherapic process, and the PG was also evaluated through Sociometric Analysis, based on the psychodramatic method. In comparison to the CG, the PG presented a significant improvement regarding the symptoms of depression and social functioning, as well as an expressive change on the investigated sociometric aspects