Dissertation (Ph.D.)--University of South Florida, 2006. / Includes vita. Includes bibliographical references (leaves 91-99). Also available online.

Introdução: A associação entre qualidade de vida e depressão já está bem estabelecida na literatura. A presença de sintomas depressivos afeta todos domínios de qualidade de vida e quando comparada com outras condições clinicas é o que traz mais prejuízos para a vida dos sujeitos. Apesar da forte correlação entre estas duas medidas, ainda existem muitas dificuldades metodológicas para a definição do conceito de qualidade de vida, assim como para a confirmação se depressão e qualidade de vida são construtos distintos, ou semelhantes. Além da qualidade de vida, outro desfecho clínico relevante na avaliação destes indivíduos é a remissão dos sintomas depressivos. Os dados encontrados ainda demonstram resultados contraditórios não permitindo conclusões sobre o assunto. Objetivo: O presente estudo teve como objetivo geral avaliar a qualidade de vida bem como fatores preditores de remissão de sintomas depressivos em sujeitos com transtorno depressivo maior que foram acompanhados ao longo de um ano, provenientes de unidades de cuidados primários.Metodologia: Foram incluídos 179 sujeitos com transtorno depressivo maior atual. Foram realizadas visitas na entrada do estudo 6 semanas, 3 meses, 9 meses e 12 meses. Os principais instrumentos utilizados foram WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D e Condições concorrentes. Foram realizados Teste qui-quadrado para comparações de variáveis categóricas, e Teste T-student, como ANOVA para variáveis contínuas. Para avaliação dos construtos de depressão e qualidade de vida utilizou-se análise fatorial exploratória através da análise de componentes principais. Um modelo de Regressão Linear Hierárquica foiproposto para análise da variável dependente qualidade de vida, assim como um modelo através de Regressão Logística Hierárquica para análise da variável dependente remissão de sintomas depressivos. Para avaliação do seguimento dos sujeitos ao longo de 9 meses foi utilizado a análise de Mixed model. Resultados: Esta tese originou quatro artigos. O primeiro artigo apresentou como resultado principal o impacto da depressão subsindrômica na qualidade de vida, sendo semelhante aos sujeitos com depressão maior. O segundo artigo sugeriu que qualidade de vida e depressão são construtos diferentes, apesar de estarem correlacionados. O terceiro artigo demonstrou que os pacientes acompanhados ao longo de 9 meses apresentaram pequenas mudanças nos escores de qualidade de vida aferidos por diversos instrumentos e que estas mudanças não ocorreram rapidamente. A maioria dos sujeitos persistiu com sintomas depressivos, não recebendo tratamento adequado para o trastorno depressivo maior. O quarto artigo demonstrou baixo índice de remissão dos sintomas depressivos ao final do estudo, assim como a presença de ansiedade com um preditor negativo de remissão de sintomas. Conclusões: Sujeitos com transtorno depressivo maior em cuidados primários de saúde não recebem tratamento adequado, adquirindo baixos índices de remissão como importantes prejuízos na qualidade de vida. Estes dados ressaltam a importância da detecção e do tratamento precoce do transtorno depressivo nessa população.Uma vez que há uma carência de recursos para o tratamento especializado no Brasil, é fundamental a implementação de medidas de treinamento entre os profissionais de cuidados primários para o reconhecimento e instituição de medidas terapêuticas eficazes para reduzir a morbidade causada pela depressão. / Introduction: The association between quality of life and depression is already a well discussed topic in literature. The presence of depressive symptoms affects all dimensions of quality of life and, when compared to other clinic conditions, is the one that presents more impairments in the subjects’ lives. Although there is a strong correlation between these two measures, there are still many methodological difficulties to define the quality of life concept, as well as to confirm if depression and quality of life are distinctive constructs, or similar ones. Besides quality of life, another relevant outcome to evaluate these individuals is remission of depressive symptoms. The data found demonstrates contradictory results, not enabling any conclusions concerning this matter. Objective: The present study had as general objective to evaluate quality of life, as well as predicting factors of remission of depressive symptoms in subjects with major depressive disorder who were followed for a year. These subjects have been selected from primary care units. Methodology: There were included 179 subjects with major depressive disorder. There were follow-ups at the beginning of the study, 6 weeks later, 3 months later, 9 months later and 12 moths later. The main instruments used were WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D, as well as co-comordid conditions. We performed Chi- Square Test, to compare categorical variables, and T-student Test, such as ANOVA, for continuous variables. To evaluate the depression and quality of life constructs, we used exploratory factor analysis by analyzing the principal components. A Hierarchic Linear Regression model has been proposed to analyze the dependent 14 variable “quality of life”, as well as a model through Hierarchic Logistic Regression to analyze the dependent “depressive symptoms’ remission”. To evaluate the subjects’ follow-up during 9 months the Mix Model Analysis was used. Results: This thesis originated four articles. The first one presented as main result the impact of subsyndromic depression in quality of life,wich was to major depression subjects. The second article suggested that quality of life and depression are different constructs, although correlated. The third article demonstrated that patients followed during 9 months presented small differences in quality of life scores measured by several instruments and that these changes did not happen quickly. Most of the subjects continued having depressive symptoms, and did not receive adequate treatment for major depressive disorder. The fourth article demonstrated low level of remission of depressive symptom at the end of the study, as well as the presence of anxiety as a negative predictor of symptoms’ remission. Conclusions: Subjects with major depressive disorder in primary health care do not receive proper treatment, thus they reach low levels of remission. This is very prejudicial to the subjects’ quality of life. The data presented here highlight the importance of detecting and treating depressive disorder in its early stage for this population. Since there is a lack of resources for specialized treatment in Brazil, it is fundamental to implement training policies among primary care professionals in order to recognize and provide effective therapeutic measures to reduce morbidity caused by depression.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / The main aim of this dissertation is to analyse the concept of sense in Being and Time, in the context of comprehension. From an initial characterization of the notion of sense presented by Heidegger, we make explicit the conceptual net in which this concept is caught, proceeding by an explanation of it. Locating the central point of this conceptual net in the context of comprehension and interpretation, we proceed by an analysis of such notions, but confining ourselves to the context of explanation of the comprehension of entities, as a matter of our copying with the things in the world and by means of a fore-predicative and predicative structure. In this sense, we present an approach which points out the notion of relation as a central issue, presenting in this sense a sort of typology of relations in Being and Time, and showing the importance of this notion regarding the explanation of the senses of being. We pay special attention to the notion of sign, for it means a exemplar type of relation, named by remission, which is fundamental to the comprehension of the entities senses of being, in special the sense of being of the present-at-hand, as well to a better understand of the Heidegger s notion of to signify. Following this path, we discuss a critical argument against Heidegger s concept of sense, whose central point lies in the notions of sign and remission, understood as analogous of the Frege s pair of concepts Sinn and Bedeutung . Assisted by our previous analysis, we show how this analogy between Frege and Heidegger fails, and in a single point: in considering sign as linguistic designator. By the end, we point out some considerations about the fruitfulness of the Heidegger s notion of sense (if it was taken together another notions treated in this work as, for example, relation and sign) to think in a broader way matters about intentionality and related issues. / O presente trabalho tem como objetivo promover uma análise acerca do conceito de sentido no âmbito de Ser e Tempo no contexto da temática da compreensão. A partir de uma caracterização inicial da noção de sentido apresentada por Heidegger, depreendemos a rede conceitual em torno dessa noção procedendo com uma explicitação da mesma. Localizando o ponto nodal dessa rede conceitual em torno da temática da compreensão e interpretação, seguimos com uma análise destas noções restringindo-nos ao contexto da explicitação da compreensão dos entes, com uma questão do modo como lidamos com os entes no mundo, por meio de uma estrutura pré-predicativa e predicativa. Nesse contexto, apresentamos uma leitura cujo foco incide sobre a noção de relação, revelando desse modo uma tipologia de relações presente em Ser e Tempo e mostrando a importância dessa noção no tocante à explicitação dos sentidos de ser. Dedicamos uma atenção especial à noção de signo por expressar um caso exemplar de relação, denominada de remissão, fundamental para a compreensão dos sentidos de ser dos entes, em especial, do ser disponível, bem como para entender a noção heideggeriana de significar. Seguindo esse mesmo fio condutor, discutimos uma crítica à concepção heideggeriana de sentido, cujo ponto principal versa sobre as noções de signo e remissão em Ser e Tempo, interpretadas como análogas aos conceitos de sentido e referência de Frege. Amparados em nossa análise, mostramos como essa analogia entre Frege e Heidegger fracassa justamente num ponto crucial: em tomar signo como um designador linguistico. Por fim, tecemos algumas considerações acerca da proficuidade da noção heideggeriana de sentido (se tomada em consonância com as noções de relações analisadas no trabalho) para se pensar, por exemplo, algo como comportamento intencional ou intencionalidade de um ponto de vista mais geral.

Introdução: A associação entre qualidade de vida e depressão já está bem estabelecida na literatura. A presença de sintomas depressivos afeta todos domínios de qualidade de vida e quando comparada com outras condições clinicas é o que traz mais prejuízos para a vida dos sujeitos. Apesar da forte correlação entre estas duas medidas, ainda existem muitas dificuldades metodológicas para a definição do conceito de qualidade de vida, assim como para a confirmação se depressão e qualidade de vida são construtos distintos, ou semelhantes. Além da qualidade de vida, outro desfecho clínico relevante na avaliação destes indivíduos é a remissão dos sintomas depressivos. Os dados encontrados ainda demonstram resultados contraditórios não permitindo conclusões sobre o assunto. Objetivo: O presente estudo teve como objetivo geral avaliar a qualidade de vida bem como fatores preditores de remissão de sintomas depressivos em sujeitos com transtorno depressivo maior que foram acompanhados ao longo de um ano, provenientes de unidades de cuidados primários.Metodologia: Foram incluídos 179 sujeitos com transtorno depressivo maior atual. Foram realizadas visitas na entrada do estudo 6 semanas, 3 meses, 9 meses e 12 meses. Os principais instrumentos utilizados foram WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D e Condições concorrentes. Foram realizados Teste qui-quadrado para comparações de variáveis categóricas, e Teste T-student, como ANOVA para variáveis contínuas. Para avaliação dos construtos de depressão e qualidade de vida utilizou-se análise fatorial exploratória através da análise de componentes principais. Um modelo de Regressão Linear Hierárquica foiproposto para análise da variável dependente qualidade de vida, assim como um modelo através de Regressão Logística Hierárquica para análise da variável dependente remissão de sintomas depressivos. Para avaliação do seguimento dos sujeitos ao longo de 9 meses foi utilizado a análise de Mixed model. Resultados: Esta tese originou quatro artigos. O primeiro artigo apresentou como resultado principal o impacto da depressão subsindrômica na qualidade de vida, sendo semelhante aos sujeitos com depressão maior. O segundo artigo sugeriu que qualidade de vida e depressão são construtos diferentes, apesar de estarem correlacionados. O terceiro artigo demonstrou que os pacientes acompanhados ao longo de 9 meses apresentaram pequenas mudanças nos escores de qualidade de vida aferidos por diversos instrumentos e que estas mudanças não ocorreram rapidamente. A maioria dos sujeitos persistiu com sintomas depressivos, não recebendo tratamento adequado para o trastorno depressivo maior. O quarto artigo demonstrou baixo índice de remissão dos sintomas depressivos ao final do estudo, assim como a presença de ansiedade com um preditor negativo de remissão de sintomas. Conclusões: Sujeitos com transtorno depressivo maior em cuidados primários de saúde não recebem tratamento adequado, adquirindo baixos índices de remissão como importantes prejuízos na qualidade de vida. Estes dados ressaltam a importância da detecção e do tratamento precoce do transtorno depressivo nessa população.Uma vez que há uma carência de recursos para o tratamento especializado no Brasil, é fundamental a implementação de medidas de treinamento entre os profissionais de cuidados primários para o reconhecimento e instituição de medidas terapêuticas eficazes para reduzir a morbidade causada pela depressão. / Introduction: The association between quality of life and depression is already a well discussed topic in literature. The presence of depressive symptoms affects all dimensions of quality of life and, when compared to other clinic conditions, is the one that presents more impairments in the subjects’ lives. Although there is a strong correlation between these two measures, there are still many methodological difficulties to define the quality of life concept, as well as to confirm if depression and quality of life are distinctive constructs, or similar ones. Besides quality of life, another relevant outcome to evaluate these individuals is remission of depressive symptoms. The data found demonstrates contradictory results, not enabling any conclusions concerning this matter. Objective: The present study had as general objective to evaluate quality of life, as well as predicting factors of remission of depressive symptoms in subjects with major depressive disorder who were followed for a year. These subjects have been selected from primary care units. Methodology: There were included 179 subjects with major depressive disorder. There were follow-ups at the beginning of the study, 6 weeks later, 3 months later, 9 months later and 12 moths later. The main instruments used were WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D, as well as co-comordid conditions. We performed Chi- Square Test, to compare categorical variables, and T-student Test, such as ANOVA, for continuous variables. To evaluate the depression and quality of life constructs, we used exploratory factor analysis by analyzing the principal components. A Hierarchic Linear Regression model has been proposed to analyze the dependent 14 variable “quality of life”, as well as a model through Hierarchic Logistic Regression to analyze the dependent “depressive symptoms’ remission”. To evaluate the subjects’ follow-up during 9 months the Mix Model Analysis was used. Results: This thesis originated four articles. The first one presented as main result the impact of subsyndromic depression in quality of life,wich was to major depression subjects. The second article suggested that quality of life and depression are different constructs, although correlated. The third article demonstrated that patients followed during 9 months presented small differences in quality of life scores measured by several instruments and that these changes did not happen quickly. Most of the subjects continued having depressive symptoms, and did not receive adequate treatment for major depressive disorder. The fourth article demonstrated low level of remission of depressive symptom at the end of the study, as well as the presence of anxiety as a negative predictor of symptoms’ remission. Conclusions: Subjects with major depressive disorder in primary health care do not receive proper treatment, thus they reach low levels of remission. This is very prejudicial to the subjects’ quality of life. The data presented here highlight the importance of detecting and treating depressive disorder in its early stage for this population. Since there is a lack of resources for specialized treatment in Brazil, it is fundamental to implement training policies among primary care professionals in order to recognize and provide effective therapeutic measures to reduce morbidity caused by depression.

Introdução: A associação entre qualidade de vida e depressão já está bem estabelecida na literatura. A presença de sintomas depressivos afeta todos domínios de qualidade de vida e quando comparada com outras condições clinicas é o que traz mais prejuízos para a vida dos sujeitos. Apesar da forte correlação entre estas duas medidas, ainda existem muitas dificuldades metodológicas para a definição do conceito de qualidade de vida, assim como para a confirmação se depressão e qualidade de vida são construtos distintos, ou semelhantes. Além da qualidade de vida, outro desfecho clínico relevante na avaliação destes indivíduos é a remissão dos sintomas depressivos. Os dados encontrados ainda demonstram resultados contraditórios não permitindo conclusões sobre o assunto. Objetivo: O presente estudo teve como objetivo geral avaliar a qualidade de vida bem como fatores preditores de remissão de sintomas depressivos em sujeitos com transtorno depressivo maior que foram acompanhados ao longo de um ano, provenientes de unidades de cuidados primários.Metodologia: Foram incluídos 179 sujeitos com transtorno depressivo maior atual. Foram realizadas visitas na entrada do estudo 6 semanas, 3 meses, 9 meses e 12 meses. Os principais instrumentos utilizados foram WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D e Condições concorrentes. Foram realizados Teste qui-quadrado para comparações de variáveis categóricas, e Teste T-student, como ANOVA para variáveis contínuas. Para avaliação dos construtos de depressão e qualidade de vida utilizou-se análise fatorial exploratória através da análise de componentes principais. Um modelo de Regressão Linear Hierárquica foiproposto para análise da variável dependente qualidade de vida, assim como um modelo através de Regressão Logística Hierárquica para análise da variável dependente remissão de sintomas depressivos. Para avaliação do seguimento dos sujeitos ao longo de 9 meses foi utilizado a análise de Mixed model. Resultados: Esta tese originou quatro artigos. O primeiro artigo apresentou como resultado principal o impacto da depressão subsindrômica na qualidade de vida, sendo semelhante aos sujeitos com depressão maior. O segundo artigo sugeriu que qualidade de vida e depressão são construtos diferentes, apesar de estarem correlacionados. O terceiro artigo demonstrou que os pacientes acompanhados ao longo de 9 meses apresentaram pequenas mudanças nos escores de qualidade de vida aferidos por diversos instrumentos e que estas mudanças não ocorreram rapidamente. A maioria dos sujeitos persistiu com sintomas depressivos, não recebendo tratamento adequado para o trastorno depressivo maior. O quarto artigo demonstrou baixo índice de remissão dos sintomas depressivos ao final do estudo, assim como a presença de ansiedade com um preditor negativo de remissão de sintomas. Conclusões: Sujeitos com transtorno depressivo maior em cuidados primários de saúde não recebem tratamento adequado, adquirindo baixos índices de remissão como importantes prejuízos na qualidade de vida. Estes dados ressaltam a importância da detecção e do tratamento precoce do transtorno depressivo nessa população.Uma vez que há uma carência de recursos para o tratamento especializado no Brasil, é fundamental a implementação de medidas de treinamento entre os profissionais de cuidados primários para o reconhecimento e instituição de medidas terapêuticas eficazes para reduzir a morbidade causada pela depressão. / Introduction: The association between quality of life and depression is already a well discussed topic in literature. The presence of depressive symptoms affects all dimensions of quality of life and, when compared to other clinic conditions, is the one that presents more impairments in the subjects’ lives. Although there is a strong correlation between these two measures, there are still many methodological difficulties to define the quality of life concept, as well as to confirm if depression and quality of life are distinctive constructs, or similar ones. Besides quality of life, another relevant outcome to evaluate these individuals is remission of depressive symptoms. The data found demonstrates contradictory results, not enabling any conclusions concerning this matter. Objective: The present study had as general objective to evaluate quality of life, as well as predicting factors of remission of depressive symptoms in subjects with major depressive disorder who were followed for a year. These subjects have been selected from primary care units. Methodology: There were included 179 subjects with major depressive disorder. There were follow-ups at the beginning of the study, 6 weeks later, 3 months later, 9 months later and 12 moths later. The main instruments used were WHOQOL-BREF, SF-12, MHI5, CIDI, CES-D, as well as co-comordid conditions. We performed Chi- Square Test, to compare categorical variables, and T-student Test, such as ANOVA, for continuous variables. To evaluate the depression and quality of life constructs, we used exploratory factor analysis by analyzing the principal components. A Hierarchic Linear Regression model has been proposed to analyze the dependent 14 variable “quality of life”, as well as a model through Hierarchic Logistic Regression to analyze the dependent “depressive symptoms’ remission”. To evaluate the subjects’ follow-up during 9 months the Mix Model Analysis was used. Results: This thesis originated four articles. The first one presented as main result the impact of subsyndromic depression in quality of life,wich was to major depression subjects. The second article suggested that quality of life and depression are different constructs, although correlated. The third article demonstrated that patients followed during 9 months presented small differences in quality of life scores measured by several instruments and that these changes did not happen quickly. Most of the subjects continued having depressive symptoms, and did not receive adequate treatment for major depressive disorder. The fourth article demonstrated low level of remission of depressive symptom at the end of the study, as well as the presence of anxiety as a negative predictor of symptoms’ remission. Conclusions: Subjects with major depressive disorder in primary health care do not receive proper treatment, thus they reach low levels of remission. This is very prejudicial to the subjects’ quality of life. The data presented here highlight the importance of detecting and treating depressive disorder in its early stage for this population. Since there is a lack of resources for specialized treatment in Brazil, it is fundamental to implement training policies among primary care professionals in order to recognize and provide effective therapeutic measures to reduce morbidity caused by depression.

Previous magnetic resonance imaging (MRI) studies have demonstrated brain atrophy in major depressive disorder (MDD) that is progressive with continuing illness and may be reversible with antidepressant treatment. What remains unclear is whether brain structure can be positively affected by pharmacological intervention even if patients fail to remit on the treatment. The primary aim of this thesis was to prospectively track changes in brain structure in patients with treatment-resistant depression while they underwent pharmacotherapy with the goal of attaining remission. There is evidence that gene variants associated with poorer antidepressant response also confer greater risk of volume reduction in the hippocampus. A secondary aim of the thesis was to investigate the effects of monoaminergic-related gene variants on hippocampal volume in patients and controls at baseline imaging. Outpatients with treatment-resistant MDD underwent structural MRI scans at baseline and after either 6-months of sustained remission or 12-months of failure to remit. Matched controls were scanned once to provide comparison data for patients’ baseline scans. Participants also provided blood samples for genetic analyses. Imaging outcome measures included longitudinal changes in whole-brain volume, and gray matter volume and mean cortical thickness within specific cortico-limbic regions of interest (ROIs). Over follow-up, remitted patients had an increase in whole-brain volume, while nonremitted patients lost brain volume despite receiving more treatment strategies. Remitters and nonremitters also showed subtle changes in volume and thickness over time in several ROIs in opposing directions, with increasing hippocampal volume and cortical thickness in the rostral middle frontal gyrus and orbitofrontal cortex in remitters, and decreasing volume or thickness in these regions in nonremitters. Genetic imaging analyses revealed that polymorphisms in certain norepinephrine- and serotonin-related genes have similar effects on hippocampal volume in patients and controls, while the serotonin transporter polymorphism differentially affects hippocampal volume in the presence of depression. Given the observations of volume increase in remitted patients and continuing atrophy in nonremitters, pharmacotherapy in the absence of sustained remission is likely insufficient to elicit structural recovery in depression. This finding is important since the restoration of brain structure in patients with treatment-resistant depression may have positive implications for their future prognosis.

Objectif : L’objectif principal de ce travail était d’évaluer les facteurs de risque d’incidence et de rémission de l’incontinence urinaire (IU) au sein d’une cohorte de femmes de la cinquantaine en prenant en compte le type d’IU (Incontinence urinaire d’effort - IUE -, Incontinence par argenture - IUU- et Incontinence urinaire mixte – IUM) et la gravité des symptômes.Matériel et Méthodes : Les données sont issues des questionnaires de l’enquête « les femmes et leur santé », des questionnaires annuels de la cohorte GAZEL et du questionnaire spécifique « les troubles urinaires » posé en 2000 et 2008. Un modèle de Cox a été utilisé entre 1990 et 2008 à partir des données de la question « Avez-vous des difficultés à retenir vos urines ? ». Des modèles de régression logistiques ont été utilisés entre 2000 et 2008 à partir de la question validée de l’IU « Au cours des 12 derniers mois, vous est-il arrivé d’avoir des fuites involontaires d’urine ? ».Résultats : Au sein de notre population, le taux annuel d’incidence de l’IU est de 5,5 % et le taux annuel de rémission est de 6,2 %, confirmant que l’IU est un phénomène dynamique avec des périodes possibles d’aggravation et d’amélioration partielle ou totale. Ces taux sont variables avec le type d’IU : entre 2000 et 2008, les taux d’incidence étaient respectivement de 14,9 % pour l’IUE, de 3,2 % pour l’IUU et de 3.1% pour l’IUM. L’IUE est le type le plus enclin à connaître une rémission de l’IU en comparaison à l’IUU et l’IUM. Les facteurs associés à l’apparition d’une IU sont des facteurs sociaux (le niveau d’études élevé), obstétricaux (la parité), hormonaux (la ménopause), et en rapport avec l’état de santé, physique ou mentale (la prise de poids, l’apparition de symptômes dépressifs, la dégradation de la qualité de vie - dans les dimensions tonus et isolement social du score NHP). La rémission complète est d’autant moins fréquente que les femmes vieillissent et qu’elles prennent du poids. Pour chaque type d’IU, l’influence des facteurs de risque semble différente. Ainsi, le niveau d’étude (être titulaire du baccalauréat), l’IMC (à l’inclusion, et au cours du suivi) et un syndrome dépressif à l’inclusion sont associés à l’apparition d’une IUE. Un antécédent de prise en charge chirurgicale de l’IU est associé à l’apparition d’une IUU et d’une IUM. La correction chirurgicale de l’IU pendant le suivi est, comme attendu, associée à une rémission des symptômes d’IUE, mais en revanche la rééducation périnéale et un antécédent d’accouchement par voie vaginale, sont associés à une persistance des symptômes d’IUE. L’accouchement par voie vaginale était également associé à la persistance de l’IUM. L’IUU et l’IUM sont les types d’IU les plus graves à l’inclusion. De plus, l’aggravation est plus marquée en cas d’IUU ou d’IUM que d’IUE. Hormis le type, les facteurs associés à une aggravation des symptômes sont une operation pour une IU (à l’inclusion) et l’apparition d’un syndrome dépressif. L’aggravation des symptômes est négativement associée à la consommation d’alcool à l’inclusion et une chirurgie de l’incontinence pendant la période d’étude. Le rôle des facteurs sociaux, comme l’obtention du baccalauréat par exemple, est associé à l’apparition d’un IU légère, alors que des facteurs obstétricaux comme un antécédent d’accouchement par voie basse est associé à une apparition de l’IU grave.Conclusion : L’IU est un phénomène dynamique avec des périodes possibles d’aggravation et d’amélioration partielle ou totale. L’analyse des facteurs de risque associés à l’IU doit intégrer une différentiation du type et de la gravité. Les données concernant l’épidémiologie de l’IU chez les femmes entre 45 et 60 ans sont encore trop peu nombreuses. D'autres enquêtes longitudinales incluant un nombre plus important de femmes sont essentielles afin de confirmer nos résultats et mieux conseiller les femmes en présentant les symptômes. / Objective: The main objective of this work was to evaluate the risk factors of incidence and remission of urinary incontinence (UI) in a cohort of women at midlife, taking into account the type of UI (Stress urinary incontinence - SUI – Urge urinary incontinence – IUU - and mixed urinary incontinence - IUM) and the severity of symptoms.Material and Methods: Data were obtained from the survey questionnaires "women and their health," the annual questionnaires cohort GAZEL and specific questionnaire "urinary problems" posed in 2000 and 2008. A Cox model was used between 1990 and 2008 from the data of the question "Have you trouble holding your urine? ". Logistic regression models were used between 2000 and 2008 from the issue validated UI "Over the last 12 months, did you have any involuntary loss of urine ? ".Results: In our population, the annual rate of incidence of UI was 5.5% and the annual rate of remission was 6.2%, confirming that the UI is a dynamic condition with possible periods of worsening and of improvement. These rates vary with the type of UI: between 2000 and 2008, incidence rates were 14.9% for SUI, 3.2% for UUI and 3.1% for the MUI. SUI is the most likely type to experience a possible remission of the UI compared to UUI and MUI. Factors associated with the occurrence of UI are social factors (high educational level), obstetrical (parity), hormonal (menopause), and factors in relation with physical or mental health status (weight gain, onset of depressive symptoms, impairment in health-related quality of life - energy dimension and social isolation dimension of NHP score). Complete remission is even less common as women gain in age and in weight. For each type of UI, the influence of risk factors seems different. Thus, educational level (baccalaureate), BMI (at baseline and during follow-up) and a depressive syndrome at baseline are associated with the onset of SUI. An antecedent of surgical procedure for UI is associated with the occurrence of UUI and MUI. Surgical correction of the UI during follow-up is, as expected, associated with remission of symptoms of SUI. By contrast, pelvic floor muscle training exercises and vaginal childbirth, are associated with persistence of symptoms of SUI. The vaginal delivery was also associated with the persistence of MUI. MUI and UUI are the more severe types of UI at baseline. Furthermore, the aggravation is more pronounced in case of UUI or MUI that for SUI. Aside from the type, the factors associated with worsening symptoms are a prior surgery for a UI (at baseline) and the onset of a depressive syndrome. A worsening of UI is negatively associated with alcohol consumption at baseline and incontinence surgery during the study period. The role of social factors, such as the baccalaureate for example, is associated with the appearance of a slight UI, while obstetric factors such as a vaginal childbirth is associated with the appearance of a severe UI.Conclusion: The UI is a dynamic condition with possible periods of worsening and of partial or total improvement. The analysis of risk factors associated with the UI must incorporate a differentiation of the type and severity. Data on the epidemiology of UI in women between 45 and 60 years are still too few. Other longitudinal studies including a larger number of women are essential to confirm our results and to better counselling women with UI symptoms.

This study explores how cancer patients in remission derive meaning in their lives. A need for social work intervention was identified with cancer survivors, especially those patients who are in remission and who have to continue their lives, in spite of the incurable status of their cancer. In line with literature, the researcher, in her role as social worker at a radiation oncology clinic, observed that patients often report that they find benefit in the cancer experience. The framework for conducting this study is based on the existential theory and the ultimate concern of human existence, that life has meaning under all circumstances. Meaning and meaning-centeredness is described. The role of a meaning-centered approach to oncology social work was argued. The Meaning-Centered Counselling and Therapy (MCCT) model was described from a literature perspective, and proposed as an intervention model. MCCT offers a model that includes the existential domain in interventions. Within the context of this study, remission refers to the period that the cancer is under control. It may be that there is no indication of the cancer, but the cancer is expected to recur, or that some of the symptoms have disappeared, or that the progression of the cancer has slowed down. During remission, patients are under surveillance only, or on maintenance treatment. Thus, they do not have regular contact with the oncology team. Patients live with uncertainty and ambiguity, resuming activities, responsibilities, careers and relationships that were influenced by the cancer diagnosis and treatments. The demands of living in remission are described. This research study explores the quest for meaning in patients who are living with incurable, recurrent cancer. The goal of this research study was to explore meaning-centeredness in adult cancer patients who are in remission. This research study was guided by the following research question: “Does meaning-centeredness play a role in adult cancer patients’ coping with remission?” The research population included oncology patients who are in remission, and have experienced one or more recurrences, and where the cancer has metastasised. A qualitative approach was followed, using the collective case study design. The research was conducted at the Radiation Clinic, Sandton Oncology Centre in Morningside, Johannesburg. Data was collected using an interview schedule to guide 4 focus group interviews, totalling 21 participants, who were selected by means of purposive sampling. All participants gave voluntary and informed consent to take part, and the focus group interviews were voice-recorded, with their permission. The researcher transcribed these recordings. Creswell’s steps for qualitative data analysis were implemented. From the findings, the following themes and sub-themes were identified, demonstrating the search for meaning amongst these participants who are in remission and answering the research question: Theme 1: Meaning-construal associated with attribution with the sub-themes of hope, spirituality, and death awareness and a foreshortened future. Theme 2: Meaning-construal associated with appraisal, with the sub-themes of benefit finding, growth, relationships, and an increased appreciation of life, and prioritising. Theme 3: Meaning-construal associated with reappraisals, with sub-themes of sense of self, sense of coherence, assumptive world, adapting to new normal, and transcendence. The findings demonstrated that a perspective that provided the participants with the means to explore their unique meanings, purposes, and life tasks helped them to cope with remission and the fear or reality of recurrence or metastases. Participants were able to derive meaning in their lives despite living with incurable cancer. Participants, who had integrated the knowledge that their cancer is incurable and recurrent into their meaning-system, were able to adapt and adjust to living in remission. They had a sense of purpose and maintained realistic hope. Their hopes were proportional to the prognosis. They did not dwell on their own death, but focused on what life offers them each day. They developed a new normal that incorporates the knowledge of a foreshortened future, coping with side effects and late effects of treatment, and the uncertainty that the cancer is expected to recur or metastasise again. They were aware of their life tasks, and embraced life to the full. Intervention strategies, based on the existential oriented proposition that life has meaning under all circumstances, were recommended. This included the Meaning-Centered Counselling and Therapy (MCCT) model for integration in oncology social work. Recommendations in this study include enhancing the understanding of members of the trans-disciplinary team regarding the needs and experiences of patients in remission. Furthermore, a better understanding of the role of meaning-centeredness intervention amongst oncology social workers can improve interventions, specifically for patients in remission. / Dissertation (MSW)--University of Pretoria, 2014. / Social Work and Criminology / MSW

The aim of this study is to examine which individual and surrounding factors that are of importance for maintaining drug-freedom after treatment. The study is based on scientific papers found through a scoping review. The result of the study is thematized and analysed with the labelling theory, sense of coherence and the transtheoretical model stages of change. The results show that the individual factors involve occupation (employment, education and activities), health, thoughts and behaviour, network and aftertreatment, and emphasises the inner process and resources one by themselves can develop. The surrounding factors include occupation (employment, education and activities), network, aftertreatment and demographic factors. Here with the perspective on the support that comes from other groups, organisations and people. In the discussion there is a reasoning on the need for a view on relapse as something natural, and sometimes, part of the process. The path to a stable abstinence is not always a straight line or desirable goal, therefore the support should exist in every phase. Another central conclusion is that the Alcoholics Anonymous and Narcotics Anonymous gives a big support but is not used by everyone for different reasons. There should be similar support from public services. Future research could search factors for maintaining drug-freedom outside of the AA and NA community. The factors for stable abstinence could also differ depending on the type of abuse, which can be the subject for a possible future study.

Major depressive disorder (MDD) is considered the current leading cause of disability worldwide (Friedrich, 2017), yet the recovery process in MDD, including neurobiological underpinnings, clinical features and optimal approaches to treatment remains ambiguous. Current definitions of recovery are disputed and involve measures considered subjective in nature, such as thresholds for questionnaires and clinical interviews of symptoms and their duration (De Zwart and Jeronimus, 2019; Fava et al., 2007; Keller, 2003, 2004). Symptom-based measures, although informative of clinical presentation, are not informative of neurobiological underpinnings that may persist even when symptoms are reduced. Indeed, even after treatment, persistent residual symptoms, impairments in quality of life, and vulnerabilities for future return to more severe psychopathology persist (Gotlib and Hammen, 2008; IsHak et al., 2011; Judd et al., 1998a; Kennedy et al., 2004; Kennedy and Foy, 2005; Kennedy and Paykel, 2004). Without assessment of neural mechanisms of recovery in MDD, efforts toward developing novel treatment approaches that are able to address neural processes of illness and to provide sustained remission are slowed. The following collection of studies provide neural and clinical insights into MDD recovery and relate findings to potential treatment approaches that are optimized to individual differences in symptoms and neural functioning and able to address neural vulnerabilities to provide sustained remission. In pursuit of individualized treatment selection in MDD, study one involved a meta-analysis of prior prognostic fMRI studies of response to cognitive behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI) in MDD. Study one also reported on the application of resulting meta-analytic regions (subgenual and perigenual anterior cingulate cortex) in a confirmatory MDD sample. Although regions showed some predictive potential in the confirmatory sample, when predicting SSRI response, effects were inconsistent with prior studies, suggesting methodological confounds may hinder ready translation. In an assessment of the course of MDD, the second study documented depression symptoms and quality of life across 9-14 years after acute treatment (CBT or SSRI) and found that persistent residual depression symptoms and quality of life deficits were common. In light of the normality of chronic symptoms and impairment, the third study evaluated neural features of treatment (CBT) resistance in MDD within the context of neural mechanisms of change. The third study found a vermis-centered cerebellar cluster that was unresponsive to CBT, whereas prefrontal and parietal cortical regions were responsive, providing support of prior theories that CBT directly affects cognitive control and cortical regulatory processes in contrast to salience-driven subcortical functioning (Clark and Beck, 2010; DeRubeis et al., 2008; Frewen et al., 2008; Mayberg, 2003). In consideration of findings, clinical recommendations that pertain to treating residual symptoms and associated neural features toward asymptomatic remission are provided. Future research directions are also provided regarding neuroscience informed precision medicine, current therapy and medication practices, and the larger picture of MDD chronicity broadly. / Doctor of Philosophy / Major depressive disorder (MDD) is considered the leading cause of disability worldwide (Friedrich, 2017), yet there are many aspects of MDD recovery that are unclear such as neural and clinical features and optimal treatment approaches. Current definitions of recovery involve questionnaires and interviews, which may not accurately represent all aspects of recovery (De Zwart and Jeronimus, 2019; Fava et al., 2007; Keller, 2003, 2004). For example, they do not assess neural or biological features of recovery that may continue even if symptoms improve. Indeed, even after treatment, often some minimal depression symptoms, impairments in quality of life, and risks for future more severe symptoms continue (Gotlib and Hammen, 2008; IsHak et al., 2011; Judd et al., 1998a; Kennedy et al., 2004; Kennedy and Foy, 2005; Kennedy and Paykel, 2004). Without assessing neural features of MDD and recovery, developing treatments that can address illness- related neural features and provide sustained recovery are slowed. The following studies report on neural and clinical features of MDD recovery to approach treatment and sustained recovery with consideration of individual differences in symptoms and neural functioning. Pursuing neuroimaging measures of individual differences to inform treatment selection, study one involved a statistical review of prior neuroimaging prediction studies of MDD treatment. Study one also reported on whether the regions suggested by the statistical review to inform treatment selection would be useful when applied to a prior MDD treatment study. Findings suggested functioning of the identified brain regions can help inform treatment selection, but method differences among studies included in the review hinder application of resulting regions. In an assessment of the course of MDD, the second study documented depression symptoms and quality of life across 9-14 years after treatment and found at least minimal depression symptoms as well as impairments in quality life commonly continued after treatment. In light of persistent symptoms and impairment, the third study aimed to identify neural features of MDD that did not respond to treatment, as well as neural features that were responsive to treatment. The third study found that therapy directly affects cognitive control processes, but may not affect brain regions associated more with emotion-driven processes. Clinical recommendations pertain to treating depression symptoms that continue after treatment toward asymptomatic recovery. Future research directions pertain to neuroscience informed treatment selection, current therapy and medication practices, and the larger picture of persistent depression symptoms broadly.