Jeffrey S. Eisenberg

Unaffected healthy relatives of patients with major depressive disorder differ from those people without a family history of the disease in neuronal correlates of inhibiting negative stimuli, according to a study in the February issue of the Journal of Psychiatric Research.

Studies have shown that individuals who have a first-degree relative with a major depressive disorder (MDD) are more than three times as likely to develop MDD than are people with no family history of depression.

For this study, Danuta M. Lisiecka of the psychiatry department at Trinity College Dublin, and her colleagues, sought to establish neuronal correlates of familial susceptibility in the process of inhibition of emotional information (J. Psychiatr. Res. 2012;46:181-8).

The study involved 21 unaffected first-degree relatives of patients with MDD and 25 controls. Subjects underwent a functional magnetic resonance imaging procedure with a cognitive-emotional inhibition task, in which they were asked to process visual stimuli, so that the researchers could measure brain activity. Researchers also evaluated blood oxygenated level dependent signal for the two groups during inhibition of positive, negative, and neutral information.

There were no significant differences in the reaction times or accuracy between the two groups, the researchers found. However, a significant difference was found on rating scales between the two groups: the relatives of patients with MDD scored higher on the Hamilton Depression Rating Scale and the Montgomery-Asperg Depression Rating Scale.

In a 2x3 analysis of variance between groups, the researchers compared unaffected healthy relatives of patients with major depressive disorder (UHR-MDD) subjects with healthy controls, jointly and separately for all three levels of emotional valence of the information. They found a statistically significant interaction between the two factors in the right middle cingulate cortex.

On further analysis, the researchers compared both groups for inhibition in each type of emotional valence, and they found that neither group differed in the inhibition of neutral and positive. However, a significant difference was found during emotional inhibition of negative material, with a higher activation in the right middle cingulate cortex and the left caudate nucleus in the UHR-MDD group vs. the control subjects.

"Our findings provide the first evidence that unaffected relatives of patients with MDD [UHR-MDD] differ from healthy controls in terms of neural correlates of inhibition," the researchers wrote.

The effect only by negative stimuli might mean that the UHR-MDD group refers negative information more quickly to personal experiences. So, an environment abundant in negative, unpleasant stimuli might contribute to an individual’s susceptibility to MDD.

There is partial congruence between these results and other studies that examine the neural correlates of inhibition with MDD, namely because of increased activation of the cingulate cortex during the inhibition of negative information by patients who have MDD and the UHR-MDD group. "That suggests that increased activation in the cingulated gyrus may be involved in development of MDD symptoms and jointly with negative environment can be considered as a candidate for a future biomarker of endophenotype vulnerable to MDD.

"Since the cingulate cortex is involved in self-referential processes, its overactivation in a negative environment in individuals susceptible to developing MDD may explain a mechanism of negative self-referential thoughts characteristic for MDD."

The researchers cautioned that conclusions can be drawn only about areas in task processing. Still, the study results suggest that inhibition and self-reference processes are affected in the UHR-MDD group and that those changes might increase susceptibility to MDD. These findings also might have future implications for therapy, they said.

The authors have no conflicts to disclose. Science Foundation Ireland provided funding for the study.

Unaffected healthy relatives of patients with major depressive disorder differ from those people without a family history of the disease in neuronal correlates of inhibiting negative stimuli, according to a study in the February issue of the Journal of Psychiatric Research.

Studies have shown that individuals who have a first-degree relative with a major depressive disorder (MDD) are more than three times as likely to develop MDD than are people with no family history of depression.

For this study, Danuta M. Lisiecka of the psychiatry department at Trinity College Dublin, and her colleagues, sought to establish neuronal correlates of familial susceptibility in the process of inhibition of emotional information (J. Psychiatr. Res. 2012;46:181-8).

The study involved 21 unaffected first-degree relatives of patients with MDD and 25 controls. Subjects underwent a functional magnetic resonance imaging procedure with a cognitive-emotional inhibition task, in which they were asked to process visual stimuli, so that the researchers could measure brain activity. Researchers also evaluated blood oxygenated level dependent signal for the two groups during inhibition of positive, negative, and neutral information.

There were no significant differences in the reaction times or accuracy between the two groups, the researchers found. However, a significant difference was found on rating scales between the two groups: the relatives of patients with MDD scored higher on the Hamilton Depression Rating Scale and the Montgomery-Asperg Depression Rating Scale.

In a 2x3 analysis of variance between groups, the researchers compared unaffected healthy relatives of patients with major depressive disorder (UHR-MDD) subjects with healthy controls, jointly and separately for all three levels of emotional valence of the information. They found a statistically significant interaction between the two factors in the right middle cingulate cortex.

On further analysis, the researchers compared both groups for inhibition in each type of emotional valence, and they found that neither group differed in the inhibition of neutral and positive. However, a significant difference was found during emotional inhibition of negative material, with a higher activation in the right middle cingulate cortex and the left caudate nucleus in the UHR-MDD group vs. the control subjects.

"Our findings provide the first evidence that unaffected relatives of patients with MDD [UHR-MDD] differ from healthy controls in terms of neural correlates of inhibition," the researchers wrote.

The effect only by negative stimuli might mean that the UHR-MDD group refers negative information more quickly to personal experiences. So, an environment abundant in negative, unpleasant stimuli might contribute to an individual’s susceptibility to MDD.

There is partial congruence between these results and other studies that examine the neural correlates of inhibition with MDD, namely because of increased activation of the cingulate cortex during the inhibition of negative information by patients who have MDD and the UHR-MDD group. "That suggests that increased activation in the cingulated gyrus may be involved in development of MDD symptoms and jointly with negative environment can be considered as a candidate for a future biomarker of endophenotype vulnerable to MDD.

"Since the cingulate cortex is involved in self-referential processes, its overactivation in a negative environment in individuals susceptible to developing MDD may explain a mechanism of negative self-referential thoughts characteristic for MDD."

The researchers cautioned that conclusions can be drawn only about areas in task processing. Still, the study results suggest that inhibition and self-reference processes are affected in the UHR-MDD group and that those changes might increase susceptibility to MDD. These findings also might have future implications for therapy, they said.

The authors have no conflicts to disclose. Science Foundation Ireland provided funding for the study.

Unaffected healthy relatives of patients with major depressive disorder differ from those people without a family history of the disease in neuronal correlates of inhibiting negative stimuli, according to a study in the February issue of the Journal of Psychiatric Research.

Studies have shown that individuals who have a first-degree relative with a major depressive disorder (MDD) are more than three times as likely to develop MDD than are people with no family history of depression.

For this study, Danuta M. Lisiecka of the psychiatry department at Trinity College Dublin, and her colleagues, sought to establish neuronal correlates of familial susceptibility in the process of inhibition of emotional information (J. Psychiatr. Res. 2012;46:181-8).

The study involved 21 unaffected first-degree relatives of patients with MDD and 25 controls. Subjects underwent a functional magnetic resonance imaging procedure with a cognitive-emotional inhibition task, in which they were asked to process visual stimuli, so that the researchers could measure brain activity. Researchers also evaluated blood oxygenated level dependent signal for the two groups during inhibition of positive, negative, and neutral information.

There were no significant differences in the reaction times or accuracy between the two groups, the researchers found. However, a significant difference was found on rating scales between the two groups: the relatives of patients with MDD scored higher on the Hamilton Depression Rating Scale and the Montgomery-Asperg Depression Rating Scale.

In a 2x3 analysis of variance between groups, the researchers compared unaffected healthy relatives of patients with major depressive disorder (UHR-MDD) subjects with healthy controls, jointly and separately for all three levels of emotional valence of the information. They found a statistically significant interaction between the two factors in the right middle cingulate cortex.

On further analysis, the researchers compared both groups for inhibition in each type of emotional valence, and they found that neither group differed in the inhibition of neutral and positive. However, a significant difference was found during emotional inhibition of negative material, with a higher activation in the right middle cingulate cortex and the left caudate nucleus in the UHR-MDD group vs. the control subjects.

"Our findings provide the first evidence that unaffected relatives of patients with MDD [UHR-MDD] differ from healthy controls in terms of neural correlates of inhibition," the researchers wrote.

The effect only by negative stimuli might mean that the UHR-MDD group refers negative information more quickly to personal experiences. So, an environment abundant in negative, unpleasant stimuli might contribute to an individual’s susceptibility to MDD.

There is partial congruence between these results and other studies that examine the neural correlates of inhibition with MDD, namely because of increased activation of the cingulate cortex during the inhibition of negative information by patients who have MDD and the UHR-MDD group. "That suggests that increased activation in the cingulated gyrus may be involved in development of MDD symptoms and jointly with negative environment can be considered as a candidate for a future biomarker of endophenotype vulnerable to MDD.

"Since the cingulate cortex is involved in self-referential processes, its overactivation in a negative environment in individuals susceptible to developing MDD may explain a mechanism of negative self-referential thoughts characteristic for MDD."

The researchers cautioned that conclusions can be drawn only about areas in task processing. Still, the study results suggest that inhibition and self-reference processes are affected in the UHR-MDD group and that those changes might increase susceptibility to MDD. These findings also might have future implications for therapy, they said.

The authors have no conflicts to disclose. Science Foundation Ireland provided funding for the study.

The course of depressive and anxiety disorders is worse in patients who also suffer from pain, according to results of a longitudinal study reported in the February 2012 issue of Pain.

Patients with depressive and/or anxiety disorders often report short-term and chronic physical pain. Cross-sectional studies and treatment trials have shown that pain might influence depressive and anxiety disorders, but they have not longitudinally examined the impact of pain on the course of depressive and anxiety disorders.

Marloes M.J.G. Gerrits of the EMGO Institute for Health and Care Research of the VU University Medical Center, Amsterdam, and her colleagues sought to investigate how much pain influences the 2-year course of these disorders and to what extent other psychiatric characteristics mediate them.

This study is part of the Netherlands Study of Depression and Anxiety (NESDA), an 8-year ongoing cohort study monitoring 2,981 participants to investigate the long-term course and consequences of depressive and anxiety disorders. The researchers restricted this study to subjects with a depressive and/or anxiety disorder who were symptomatic in the month prior to baseline. Of 1,456 eligible participants, 1,209 (83%) participated in the 2-year follow-up interview. The mean age of participants was 42.1 years, and 66% were female (Pain 2012;153:429-36).

For this study, Ms. Gerrits, a PhD candidate, and her colleagues assessed pain at baseline according to the specific location (joints, back, neck, abdomen, chest, head, and orofacial area), the number of locations (0-7), and which location had the greatest amount of pain. Additional measures of pain included duration of 90 days or more, use of pain medication within the last 6 months, and how often patients used medication (daily, weekly, monthly, sporadic, or no use). Finally, using the Chronic Pain Grade (CPG), the researchers measured the severity of chronic pain according to intensity and disability caused by the pain.

The researchers also assessed the course of depressive and anxiety disorders by conducting a Composite International Diagnostic Interview (CIDI) at baseline and after 2 years, and a Life Chart Interview.

At baseline, 22.1% of subjects had a depressive disorder only, 40.3% had an anxiety disorder only, and 37.6% had a comorbid disorder, the researchers found. The mean number of pain locations was 3.68, with headache the most often mentioned and orofacial pain the least mentioned. Almost half of the patients (41.4%) had at least 90 days of pain in the past 6 months, and 10.3% used pain medication daily. Also, 27.1% of subjects were highly disabled from chronic pain (grades 3 and 4 on the CPG), indicating severe chronic pain.

Within 6 months after baseline, 24.6% of subjects recovered from their depressive and/or anxiety disorder. Another 13.4% recovered after more than 6 months, 18.5% had at least one relapse during follow-up, and 43.5% had a chronic course for 2 years. At the 2-year follow-up, 61.5% of subjects were diagnosed with depressive and/or anxiety disorder within the previous 6 months.

A higher number of pain locations, joint pain, 90 days or more of pain, daily use of pain medication, and a higher CPG score all were associated with a significantly increased risk of still having a depressive or anxiety disorder after 2 years, the researchers found. Also, longer duration and higher severity of the pain were significantly associated with having a chronic course of depressive and/or anxiety disorders.

"These relationships were largely mediated by a greater severity of the baseline depressive and/or anxiety disorder among those with pain, except for pain of the joints, which remained a significant predictor after considering severity," the researchers reported.

The association between pain and a worse course of depression and/or anxiety may be tied to individuals being disabled regarding daily activities and physical and social roles. Also, chronic pain and depressive and anxiety disorders share pathophysiologic pathways. "That severity of the index depressive and/or anxiety disorder mediated the effects of pain on depression and anxiety course is in line with this, as the most severe depression and anxiety patients will show the largest dysregulations of central stress systems," the researchers noted.

The study’s findings emphasize the importance of asking depressed and anxiety patients about pain. Also, the results suggest that treatment specific for depression and anxiety patients with pain is warranted, the researchers said.

The authors declared that they have no conflict of interest. The infrastructure for the NESDA study is funded through the Netherlands Organization for Health Research and Development and is supported by participating universities and mental health care institutions.

The course of depressive and anxiety disorders is worse in patients who also suffer from pain, according to results of a longitudinal study reported in the February 2012 issue of Pain.

Patients with depressive and/or anxiety disorders often report short-term and chronic physical pain. Cross-sectional studies and treatment trials have shown that pain might influence depressive and anxiety disorders, but they have not longitudinally examined the impact of pain on the course of depressive and anxiety disorders.

Marloes M.J.G. Gerrits of the EMGO Institute for Health and Care Research of the VU University Medical Center, Amsterdam, and her colleagues sought to investigate how much pain influences the 2-year course of these disorders and to what extent other psychiatric characteristics mediate them.

This study is part of the Netherlands Study of Depression and Anxiety (NESDA), an 8-year ongoing cohort study monitoring 2,981 participants to investigate the long-term course and consequences of depressive and anxiety disorders. The researchers restricted this study to subjects with a depressive and/or anxiety disorder who were symptomatic in the month prior to baseline. Of 1,456 eligible participants, 1,209 (83%) participated in the 2-year follow-up interview. The mean age of participants was 42.1 years, and 66% were female (Pain 2012;153:429-36).

For this study, Ms. Gerrits, a PhD candidate, and her colleagues assessed pain at baseline according to the specific location (joints, back, neck, abdomen, chest, head, and orofacial area), the number of locations (0-7), and which location had the greatest amount of pain. Additional measures of pain included duration of 90 days or more, use of pain medication within the last 6 months, and how often patients used medication (daily, weekly, monthly, sporadic, or no use). Finally, using the Chronic Pain Grade (CPG), the researchers measured the severity of chronic pain according to intensity and disability caused by the pain.

The researchers also assessed the course of depressive and anxiety disorders by conducting a Composite International Diagnostic Interview (CIDI) at baseline and after 2 years, and a Life Chart Interview.

At baseline, 22.1% of subjects had a depressive disorder only, 40.3% had an anxiety disorder only, and 37.6% had a comorbid disorder, the researchers found. The mean number of pain locations was 3.68, with headache the most often mentioned and orofacial pain the least mentioned. Almost half of the patients (41.4%) had at least 90 days of pain in the past 6 months, and 10.3% used pain medication daily. Also, 27.1% of subjects were highly disabled from chronic pain (grades 3 and 4 on the CPG), indicating severe chronic pain.

Within 6 months after baseline, 24.6% of subjects recovered from their depressive and/or anxiety disorder. Another 13.4% recovered after more than 6 months, 18.5% had at least one relapse during follow-up, and 43.5% had a chronic course for 2 years. At the 2-year follow-up, 61.5% of subjects were diagnosed with depressive and/or anxiety disorder within the previous 6 months.

A higher number of pain locations, joint pain, 90 days or more of pain, daily use of pain medication, and a higher CPG score all were associated with a significantly increased risk of still having a depressive or anxiety disorder after 2 years, the researchers found. Also, longer duration and higher severity of the pain were significantly associated with having a chronic course of depressive and/or anxiety disorders.

"These relationships were largely mediated by a greater severity of the baseline depressive and/or anxiety disorder among those with pain, except for pain of the joints, which remained a significant predictor after considering severity," the researchers reported.

The association between pain and a worse course of depression and/or anxiety may be tied to individuals being disabled regarding daily activities and physical and social roles. Also, chronic pain and depressive and anxiety disorders share pathophysiologic pathways. "That severity of the index depressive and/or anxiety disorder mediated the effects of pain on depression and anxiety course is in line with this, as the most severe depression and anxiety patients will show the largest dysregulations of central stress systems," the researchers noted.

The study’s findings emphasize the importance of asking depressed and anxiety patients about pain. Also, the results suggest that treatment specific for depression and anxiety patients with pain is warranted, the researchers said.

The authors declared that they have no conflict of interest. The infrastructure for the NESDA study is funded through the Netherlands Organization for Health Research and Development and is supported by participating universities and mental health care institutions.

The course of depressive and anxiety disorders is worse in patients who also suffer from pain, according to results of a longitudinal study reported in the February 2012 issue of Pain.

Patients with depressive and/or anxiety disorders often report short-term and chronic physical pain. Cross-sectional studies and treatment trials have shown that pain might influence depressive and anxiety disorders, but they have not longitudinally examined the impact of pain on the course of depressive and anxiety disorders.

Marloes M.J.G. Gerrits of the EMGO Institute for Health and Care Research of the VU University Medical Center, Amsterdam, and her colleagues sought to investigate how much pain influences the 2-year course of these disorders and to what extent other psychiatric characteristics mediate them.

This study is part of the Netherlands Study of Depression and Anxiety (NESDA), an 8-year ongoing cohort study monitoring 2,981 participants to investigate the long-term course and consequences of depressive and anxiety disorders. The researchers restricted this study to subjects with a depressive and/or anxiety disorder who were symptomatic in the month prior to baseline. Of 1,456 eligible participants, 1,209 (83%) participated in the 2-year follow-up interview. The mean age of participants was 42.1 years, and 66% were female (Pain 2012;153:429-36).

For this study, Ms. Gerrits, a PhD candidate, and her colleagues assessed pain at baseline according to the specific location (joints, back, neck, abdomen, chest, head, and orofacial area), the number of locations (0-7), and which location had the greatest amount of pain. Additional measures of pain included duration of 90 days or more, use of pain medication within the last 6 months, and how often patients used medication (daily, weekly, monthly, sporadic, or no use). Finally, using the Chronic Pain Grade (CPG), the researchers measured the severity of chronic pain according to intensity and disability caused by the pain.

The researchers also assessed the course of depressive and anxiety disorders by conducting a Composite International Diagnostic Interview (CIDI) at baseline and after 2 years, and a Life Chart Interview.

At baseline, 22.1% of subjects had a depressive disorder only, 40.3% had an anxiety disorder only, and 37.6% had a comorbid disorder, the researchers found. The mean number of pain locations was 3.68, with headache the most often mentioned and orofacial pain the least mentioned. Almost half of the patients (41.4%) had at least 90 days of pain in the past 6 months, and 10.3% used pain medication daily. Also, 27.1% of subjects were highly disabled from chronic pain (grades 3 and 4 on the CPG), indicating severe chronic pain.

Within 6 months after baseline, 24.6% of subjects recovered from their depressive and/or anxiety disorder. Another 13.4% recovered after more than 6 months, 18.5% had at least one relapse during follow-up, and 43.5% had a chronic course for 2 years. At the 2-year follow-up, 61.5% of subjects were diagnosed with depressive and/or anxiety disorder within the previous 6 months.

A higher number of pain locations, joint pain, 90 days or more of pain, daily use of pain medication, and a higher CPG score all were associated with a significantly increased risk of still having a depressive or anxiety disorder after 2 years, the researchers found. Also, longer duration and higher severity of the pain were significantly associated with having a chronic course of depressive and/or anxiety disorders.

"These relationships were largely mediated by a greater severity of the baseline depressive and/or anxiety disorder among those with pain, except for pain of the joints, which remained a significant predictor after considering severity," the researchers reported.

The association between pain and a worse course of depression and/or anxiety may be tied to individuals being disabled regarding daily activities and physical and social roles. Also, chronic pain and depressive and anxiety disorders share pathophysiologic pathways. "That severity of the index depressive and/or anxiety disorder mediated the effects of pain on depression and anxiety course is in line with this, as the most severe depression and anxiety patients will show the largest dysregulations of central stress systems," the researchers noted.

The study’s findings emphasize the importance of asking depressed and anxiety patients about pain. Also, the results suggest that treatment specific for depression and anxiety patients with pain is warranted, the researchers said.

The authors declared that they have no conflict of interest. The infrastructure for the NESDA study is funded through the Netherlands Organization for Health Research and Development and is supported by participating universities and mental health care institutions.

More than one in four women who were later diagnosed with breast cancer had a combined state anxiety and depressive symptoms, and this helped predict quality of life, state anxiety, depressive symptoms, and fatigue at 12 and 24 months after surgery, according to a multicenter prospective study reported in the February 2012 issue of the Journal of Affective Disorders.

Incidence of breast cancer in Europe is 88/100,000 individuals, with survival rates of 24.3/100,000. A recent study estimated that 16.3% of cancer patients have clinical depression and 20.7% have all types of depression, respectively. However, few studies address the relationship between baseline anxiety and/or depression and quality of life.

So, Lotje van Esch, a doctoral candidate at the Center of Research on Psychology and Somatic Diseases at Tilburg University in the Netherlands, and her coauthors began to investigate state anxiety (namely, the level of momentary anxiety), depressive symptoms, and combined state anxiety and depressive symptoms (CADS) the relationship to quality of life, fatigue, and mood at 12 and 24 months after surgery in women with breast cancer (J. Affect. Disord. 2012;136:895-901).

They recruited 1,501 women referred by the national screening program or their general practitioners to six hospitals. These women, who had not yet received a diagnosis, completed a set of questionnaires that measured state anxiety, the presence and degree of depressive symptoms over the previous week, fatigue, quality of life, personality trait neuroticism, and trait anxiety.

Among these subjects, 407 women (27% of all subjects) were diagnosed with breast cancer, and 111 (28% of those diagnosed with cancer) had CADS at baseline. These patients completed questionnaires again at 12 and 24 months after surgery, although 75 dropped out between baseline and 12 months, and 24 dropped out between 12 and 14 months. The researchers also gathered demographic data and medical information on disease stage at diagnosis, type of operation and adjuvant treatment, such as chemotherapy, radiotherapy, or hormone treatment.

Of the remaining 332 patients who were in the study at 12 months, 14% had CADS, the results show. And, 10% of the remaining 246 patients had CADS at 24 months, and 10% had CADS at 12 and 24 months, respectively.

And, 10% of the remaining 246 patients at 24 months, 10% had CADS at 12 and 24 months, respectively.

At 12 and 24 months, 21% of the group had elevated depressive symptoms, and 20% had state anxiety. Of the group that had CADS at baseline, a greater percentage had elevated levels of anxiety, depressive symptoms, and CADS at 12 and 24 months than did the group that did not have CADS at baseline.

"[The] CADS group had elevated levels of state anxiety, depressive symptoms, and CADS at all follow-up measure moments in the 2 years after baseline, compared with the non-CADS group," the researchers said. "In both groups, these scores decreased over time but, after 24 months, the CADS, state anxiety, and depressive symptoms scores of the CADS group were still about three times as high as the scores in the non-CADS group. This implies that the CADS group experienced considerably more anxiety and/or depressive symptoms even 24 months after surgery."

On further analysis, the researchers found that CADS and neuroticism were both significant predictors of patients’ quality of life, fatigue, depressive symptoms, and state anxiety at 12 and 24 months after surgery, the researchers found.

The findings in this study suggest that clinicians use questionnaires or screening instruments to identify those women with a higher score on state anxiety and depressive symptom, the researchers say, and that they should do so as soon as possible when diagnosing and treating breast cancer. "Only by identifying this group of patients, tailored psychological care can be accomplished," they add.

The study’s strength was its prospective multicenter and longitudinal design. A limitation, however, was that some data were not available because some patients dropped out, and because some women were included less than 2 years earlier. Also, those who dropped out often cited a high stress level, meaning that anxiety levels might have been higher in the patients who did not participate.

The authors had no conflicts of interest to declare, and there were no study sponsors.

More than one in four women who were later diagnosed with breast cancer had a combined state anxiety and depressive symptoms, and this helped predict quality of life, state anxiety, depressive symptoms, and fatigue at 12 and 24 months after surgery, according to a multicenter prospective study reported in the February 2012 issue of the Journal of Affective Disorders.

Incidence of breast cancer in Europe is 88/100,000 individuals, with survival rates of 24.3/100,000. A recent study estimated that 16.3% of cancer patients have clinical depression and 20.7% have all types of depression, respectively. However, few studies address the relationship between baseline anxiety and/or depression and quality of life.

So, Lotje van Esch, a doctoral candidate at the Center of Research on Psychology and Somatic Diseases at Tilburg University in the Netherlands, and her coauthors began to investigate state anxiety (namely, the level of momentary anxiety), depressive symptoms, and combined state anxiety and depressive symptoms (CADS) the relationship to quality of life, fatigue, and mood at 12 and 24 months after surgery in women with breast cancer (J. Affect. Disord. 2012;136:895-901).

They recruited 1,501 women referred by the national screening program or their general practitioners to six hospitals. These women, who had not yet received a diagnosis, completed a set of questionnaires that measured state anxiety, the presence and degree of depressive symptoms over the previous week, fatigue, quality of life, personality trait neuroticism, and trait anxiety.

Among these subjects, 407 women (27% of all subjects) were diagnosed with breast cancer, and 111 (28% of those diagnosed with cancer) had CADS at baseline. These patients completed questionnaires again at 12 and 24 months after surgery, although 75 dropped out between baseline and 12 months, and 24 dropped out between 12 and 14 months. The researchers also gathered demographic data and medical information on disease stage at diagnosis, type of operation and adjuvant treatment, such as chemotherapy, radiotherapy, or hormone treatment.

Of the remaining 332 patients who were in the study at 12 months, 14% had CADS, the results show. And, 10% of the remaining 246 patients had CADS at 24 months, and 10% had CADS at 12 and 24 months, respectively.

And, 10% of the remaining 246 patients at 24 months, 10% had CADS at 12 and 24 months, respectively.

At 12 and 24 months, 21% of the group had elevated depressive symptoms, and 20% had state anxiety. Of the group that had CADS at baseline, a greater percentage had elevated levels of anxiety, depressive symptoms, and CADS at 12 and 24 months than did the group that did not have CADS at baseline.

"[The] CADS group had elevated levels of state anxiety, depressive symptoms, and CADS at all follow-up measure moments in the 2 years after baseline, compared with the non-CADS group," the researchers said. "In both groups, these scores decreased over time but, after 24 months, the CADS, state anxiety, and depressive symptoms scores of the CADS group were still about three times as high as the scores in the non-CADS group. This implies that the CADS group experienced considerably more anxiety and/or depressive symptoms even 24 months after surgery."

On further analysis, the researchers found that CADS and neuroticism were both significant predictors of patients’ quality of life, fatigue, depressive symptoms, and state anxiety at 12 and 24 months after surgery, the researchers found.

The findings in this study suggest that clinicians use questionnaires or screening instruments to identify those women with a higher score on state anxiety and depressive symptom, the researchers say, and that they should do so as soon as possible when diagnosing and treating breast cancer. "Only by identifying this group of patients, tailored psychological care can be accomplished," they add.

The study’s strength was its prospective multicenter and longitudinal design. A limitation, however, was that some data were not available because some patients dropped out, and because some women were included less than 2 years earlier. Also, those who dropped out often cited a high stress level, meaning that anxiety levels might have been higher in the patients who did not participate.

The authors had no conflicts of interest to declare, and there were no study sponsors.

More than one in four women who were later diagnosed with breast cancer had a combined state anxiety and depressive symptoms, and this helped predict quality of life, state anxiety, depressive symptoms, and fatigue at 12 and 24 months after surgery, according to a multicenter prospective study reported in the February 2012 issue of the Journal of Affective Disorders.

Incidence of breast cancer in Europe is 88/100,000 individuals, with survival rates of 24.3/100,000. A recent study estimated that 16.3% of cancer patients have clinical depression and 20.7% have all types of depression, respectively. However, few studies address the relationship between baseline anxiety and/or depression and quality of life.

So, Lotje van Esch, a doctoral candidate at the Center of Research on Psychology and Somatic Diseases at Tilburg University in the Netherlands, and her coauthors began to investigate state anxiety (namely, the level of momentary anxiety), depressive symptoms, and combined state anxiety and depressive symptoms (CADS) the relationship to quality of life, fatigue, and mood at 12 and 24 months after surgery in women with breast cancer (J. Affect. Disord. 2012;136:895-901).

They recruited 1,501 women referred by the national screening program or their general practitioners to six hospitals. These women, who had not yet received a diagnosis, completed a set of questionnaires that measured state anxiety, the presence and degree of depressive symptoms over the previous week, fatigue, quality of life, personality trait neuroticism, and trait anxiety.

Among these subjects, 407 women (27% of all subjects) were diagnosed with breast cancer, and 111 (28% of those diagnosed with cancer) had CADS at baseline. These patients completed questionnaires again at 12 and 24 months after surgery, although 75 dropped out between baseline and 12 months, and 24 dropped out between 12 and 14 months. The researchers also gathered demographic data and medical information on disease stage at diagnosis, type of operation and adjuvant treatment, such as chemotherapy, radiotherapy, or hormone treatment.

Of the remaining 332 patients who were in the study at 12 months, 14% had CADS, the results show. And, 10% of the remaining 246 patients had CADS at 24 months, and 10% had CADS at 12 and 24 months, respectively.

And, 10% of the remaining 246 patients at 24 months, 10% had CADS at 12 and 24 months, respectively.

At 12 and 24 months, 21% of the group had elevated depressive symptoms, and 20% had state anxiety. Of the group that had CADS at baseline, a greater percentage had elevated levels of anxiety, depressive symptoms, and CADS at 12 and 24 months than did the group that did not have CADS at baseline.

"[The] CADS group had elevated levels of state anxiety, depressive symptoms, and CADS at all follow-up measure moments in the 2 years after baseline, compared with the non-CADS group," the researchers said. "In both groups, these scores decreased over time but, after 24 months, the CADS, state anxiety, and depressive symptoms scores of the CADS group were still about three times as high as the scores in the non-CADS group. This implies that the CADS group experienced considerably more anxiety and/or depressive symptoms even 24 months after surgery."

On further analysis, the researchers found that CADS and neuroticism were both significant predictors of patients’ quality of life, fatigue, depressive symptoms, and state anxiety at 12 and 24 months after surgery, the researchers found.

The findings in this study suggest that clinicians use questionnaires or screening instruments to identify those women with a higher score on state anxiety and depressive symptom, the researchers say, and that they should do so as soon as possible when diagnosing and treating breast cancer. "Only by identifying this group of patients, tailored psychological care can be accomplished," they add.

The study’s strength was its prospective multicenter and longitudinal design. A limitation, however, was that some data were not available because some patients dropped out, and because some women were included less than 2 years earlier. Also, those who dropped out often cited a high stress level, meaning that anxiety levels might have been higher in the patients who did not participate.

The authors had no conflicts of interest to declare, and there were no study sponsors.

Adolescents who had more symptoms of depression in ninth grade were quicker than their peers to engage in smoking cigarettes and use marijuana and hard drugs across the high school years, according to a longitudinal study in the February 2012 issue of the Journal of Adolescent Health.

Depression often has its onset in adolescence, which is also when individuals are more likely to increase risky health behaviors, such as alcohol and marijuana use. In the past, researchers had two divergent hypotheses to explain the relationship between depressive symptoms and risky behaviors in adolescents: the self-medication/acting out hypothesis, which holds that early depressive symptoms predict increases in risky behaviors over time, and the failure hypothesis, which states that early participation in risky behaviors predicts increases in depressive symptoms over time.

© Stockphoto4u/iStockphoto.com

Given a lack of consensus as to which hypothesis is accurate, Setareh Hooshmand, a graduate student in the department of psychology at Brock University, St. Catharines, Ont., and her coinvestigators wanted to examine which of these appeared correct. In a cohort sequential study, they followed 4,412 adolescents (51% male) aged 14-17 from grades 9 to 12 (J. Adolesc. Health 2012;50:140-7). Trained research staff administered a questionnaire to students that asked about depressive symptoms, frequency of alcohol use, number of alcoholic drinks at a time, cigarette smoking, marijuana use, hard drug use, and delinquency rates.

The results indicate support for the self-medication hypothesis, the researchers said. Specifically, those individuals who had more depressive symptoms in ninth grade reported faster increases than their peers in smoking, marijuana, and hard drug use – all of which might be perceived as having mood-enhancing functions – across the high school years.

The self-medication hypothesis, however, was not supported for the relationships between depressive symptoms and alcohol use, and depressive symptoms and delinquency, the researchers say. Alcohol use, though sometimes a form of self-medication, often increases over the high school years, and might represent enhanced social networks and feelings of belonging, the researchers say. Delinquent behaviors often occur in the presence of friends, suggesting heightened arousal rather than depression.

The study results show no support for the failure hypothesis. "The failure hypothesis assumes that depressive symptoms would result from risk behaviors because of an internalization of social rejection," the researchers say. "Participating in substance-related risks, however, may not lead to social rejection from peers for adolescents. In fact, socially-accepted substance use, such as alcohol use, often occurs in social contexts and thus may help alleviate feelings of rejection and low self-esteem."

The study’s limitations are that they cannot infer causality and that other variables, such as genetic and/or environmental influences, might better explain the relationship between depressive symptoms and risky behavior. Also, this relationship might be dynamic and change over adolescent development, suggesting the need for research at different age periods.

Despite these limitations, the researchers say, the results are important. "They suggest that by targeting depressive symptoms during early adolescence, treatment programs may prevent increases in the frequency of health-risk behaviors over the course of high school," the researchers say.

Teena Willoughby, Ph.D., the second author, received funding from the Social Sciences and Humanities Research Council of Canada.

Adolescents who had more symptoms of depression in ninth grade were quicker than their peers to engage in smoking cigarettes and use marijuana and hard drugs across the high school years, according to a longitudinal study in the February 2012 issue of the Journal of Adolescent Health.

Depression often has its onset in adolescence, which is also when individuals are more likely to increase risky health behaviors, such as alcohol and marijuana use. In the past, researchers had two divergent hypotheses to explain the relationship between depressive symptoms and risky behaviors in adolescents: the self-medication/acting out hypothesis, which holds that early depressive symptoms predict increases in risky behaviors over time, and the failure hypothesis, which states that early participation in risky behaviors predicts increases in depressive symptoms over time.

© Stockphoto4u/iStockphoto.com

Given a lack of consensus as to which hypothesis is accurate, Setareh Hooshmand, a graduate student in the department of psychology at Brock University, St. Catharines, Ont., and her coinvestigators wanted to examine which of these appeared correct. In a cohort sequential study, they followed 4,412 adolescents (51% male) aged 14-17 from grades 9 to 12 (J. Adolesc. Health 2012;50:140-7). Trained research staff administered a questionnaire to students that asked about depressive symptoms, frequency of alcohol use, number of alcoholic drinks at a time, cigarette smoking, marijuana use, hard drug use, and delinquency rates.

The results indicate support for the self-medication hypothesis, the researchers said. Specifically, those individuals who had more depressive symptoms in ninth grade reported faster increases than their peers in smoking, marijuana, and hard drug use – all of which might be perceived as having mood-enhancing functions – across the high school years.

The self-medication hypothesis, however, was not supported for the relationships between depressive symptoms and alcohol use, and depressive symptoms and delinquency, the researchers say. Alcohol use, though sometimes a form of self-medication, often increases over the high school years, and might represent enhanced social networks and feelings of belonging, the researchers say. Delinquent behaviors often occur in the presence of friends, suggesting heightened arousal rather than depression.

The study results show no support for the failure hypothesis. "The failure hypothesis assumes that depressive symptoms would result from risk behaviors because of an internalization of social rejection," the researchers say. "Participating in substance-related risks, however, may not lead to social rejection from peers for adolescents. In fact, socially-accepted substance use, such as alcohol use, often occurs in social contexts and thus may help alleviate feelings of rejection and low self-esteem."

The study’s limitations are that they cannot infer causality and that other variables, such as genetic and/or environmental influences, might better explain the relationship between depressive symptoms and risky behavior. Also, this relationship might be dynamic and change over adolescent development, suggesting the need for research at different age periods.

Despite these limitations, the researchers say, the results are important. "They suggest that by targeting depressive symptoms during early adolescence, treatment programs may prevent increases in the frequency of health-risk behaviors over the course of high school," the researchers say.

Teena Willoughby, Ph.D., the second author, received funding from the Social Sciences and Humanities Research Council of Canada.

Adolescents who had more symptoms of depression in ninth grade were quicker than their peers to engage in smoking cigarettes and use marijuana and hard drugs across the high school years, according to a longitudinal study in the February 2012 issue of the Journal of Adolescent Health.

Depression often has its onset in adolescence, which is also when individuals are more likely to increase risky health behaviors, such as alcohol and marijuana use. In the past, researchers had two divergent hypotheses to explain the relationship between depressive symptoms and risky behaviors in adolescents: the self-medication/acting out hypothesis, which holds that early depressive symptoms predict increases in risky behaviors over time, and the failure hypothesis, which states that early participation in risky behaviors predicts increases in depressive symptoms over time.

© Stockphoto4u/iStockphoto.com

Given a lack of consensus as to which hypothesis is accurate, Setareh Hooshmand, a graduate student in the department of psychology at Brock University, St. Catharines, Ont., and her coinvestigators wanted to examine which of these appeared correct. In a cohort sequential study, they followed 4,412 adolescents (51% male) aged 14-17 from grades 9 to 12 (J. Adolesc. Health 2012;50:140-7). Trained research staff administered a questionnaire to students that asked about depressive symptoms, frequency of alcohol use, number of alcoholic drinks at a time, cigarette smoking, marijuana use, hard drug use, and delinquency rates.

The results indicate support for the self-medication hypothesis, the researchers said. Specifically, those individuals who had more depressive symptoms in ninth grade reported faster increases than their peers in smoking, marijuana, and hard drug use – all of which might be perceived as having mood-enhancing functions – across the high school years.

The self-medication hypothesis, however, was not supported for the relationships between depressive symptoms and alcohol use, and depressive symptoms and delinquency, the researchers say. Alcohol use, though sometimes a form of self-medication, often increases over the high school years, and might represent enhanced social networks and feelings of belonging, the researchers say. Delinquent behaviors often occur in the presence of friends, suggesting heightened arousal rather than depression.

The study results show no support for the failure hypothesis. "The failure hypothesis assumes that depressive symptoms would result from risk behaviors because of an internalization of social rejection," the researchers say. "Participating in substance-related risks, however, may not lead to social rejection from peers for adolescents. In fact, socially-accepted substance use, such as alcohol use, often occurs in social contexts and thus may help alleviate feelings of rejection and low self-esteem."

The study’s limitations are that they cannot infer causality and that other variables, such as genetic and/or environmental influences, might better explain the relationship between depressive symptoms and risky behavior. Also, this relationship might be dynamic and change over adolescent development, suggesting the need for research at different age periods.

Despite these limitations, the researchers say, the results are important. "They suggest that by targeting depressive symptoms during early adolescence, treatment programs may prevent increases in the frequency of health-risk behaviors over the course of high school," the researchers say.

Teena Willoughby, Ph.D., the second author, received funding from the Social Sciences and Humanities Research Council of Canada.

Men and women aged 50 years and older who have been diagnosed with schizophrenia are at greater risk of suicide, according to research in the February issue of Schizophrenia Research.

This was especially true for middle-age and older women diagnosed with schizophrenia.

An estimated 1 in 1,000 adults aged 65 years and older are thought to have schizophrenia, previous studies show. Some 7%-17% of older adults who commit suicide have schizophrenia, compared with 8.5% of patients in the general population. Even without schizophrenia, studies have shown that older adults have the highest rate of suicide among all age groups.

The most recent findings come from a team of researchers led by Annette Erlangsen, Ph.D., and William W. Eaton, Ph.D., Dr. Erlangsen, Dr. Eaton, and their colleagues sought to determine whether an elevated risk of suicide associated with schizophrenia exists during the second half of life and which factors might help predict that risk.

Using individual-level register data, the researchers performed a nationwide cohort study of some 2,899,411 individuals (1,382,390 men, 1,517,021 women) aged 50 and older who lived in Denmark between 1990 and 2006 (Schizophr. Res. 2012; 134;111-7). They also gathered historical information on psychiatric hospitalizations since 1970 and obtained gender-specific suicide rates using the exact number of person-days under exposure.

Indeed, there was an excess in mortality because of suicide among older adults with schizophrenia, which declined with decreasing age, when compared with the remainder of the population, reported Dr. Erlangsen of the Mental Health Centre Copenhagen and the Johns Hopkins School of Public Health, Baltimore, and Dr. Eaton of Johns Hopkins.

Since 1970, the researchers learned, 8,893 men (0.64%) and 9,165 women (0.60%) had been diagnosed with schizophrenia during a hospitalization. Also, 5,230 men and 2,911 women died by suicide, including 125 men (2.4%) and 123 women (4.2%) who had been diagnosed with schizophrenia.

Suicide rates per 100,000 person-years were significantly higher among all patients diagnosed with schizophrenia vs. those without the disorder, although the rates did decrease with age. The rates were as follows: 217.7 vs. 31.3 among men aged 50-69 years; 107.2 vs. 51.6 among men aged 70 years and older; 218.1 vs. 15.9 among women aged 50-69 years; and 68.3 vs. 20.0 among women aged 70 years and older.

These findings confirm earlier studies that show excess mortality from suicide among older men with schizophrenia and establish an increased risk among women aged 70 years and older with schizophrenia. Higher suicide rates among women might be tied to the late onset of schizophrenia. In addition, women tend to present more positive symptoms than do men – symptoms that have been linked to suicide risks.

"However, a more plausible explanation might be that men with schizophrenia died earlier in their life course," the researchers said.

Suicide rates might have declined with age as older adults with schizophrenia might have learned to adapt to the disorder.

Among other findings:

• The risk of suicide in older adults hospitalized with schizophrenia was lower than for other psychiatric inpatients. An elevated risk of suicide remained among previously hospitalized individuals vs. those with no psychiatric diagnoses. Also, 62% percent of men and 67% of women diagnosed with schizophrenia and who died by suicide had been admitted to a psychiatric hospital more than six times, "indicating a chronic disease course with several relapses," they said. The risk was elevated for both genders during the first 3 months after admission and the first 3 months after discharge.

• The risk of suicide in older adults diagnosed with mood disorders and schizophrenia was almost as high as those diagnosed only with schizophrenia. Among women with schizophrenia, coexisting personality disorders or substance abuse further elevated the risk of suicide.

• There was a 15-fold increased risk for men and a 22-fold increase for women who attempted suicide within the previous 365 days vs. those who made no recent attempt. This emphasizes the importance of suicide attempts as a risk indicator, the researchers said.

"In terms of implications, both recently discharged, history of several hospitalizations, co-existing psychiatric disorders, and suicide attempts represent well-defined high risk groups with respect to interventions," the researchers said. "Prevention of suicide in older adults should predominantly be aimed at intervening early in the suicidal process. Follow-up during medical treatment and assessment for depression seem to be successful strategies. It is possible that older adults with schizophrenia would profit from similar approaches."

The strength of this study is the complete data collection from the entire population of Denmark, the researchers said. One limitation, however, is that only subjects diagnosed during a psychiatric or somatic hospitalization were considered to have schizophrenia, which might have led to an underestimation.

The authors reported no conflicts of interest. Dr. Erlangsen received a grant from the Danish Ministry of Welfare for the study. Dr. Eaton received a grant from the National Institute of Mental Health at the National Institutes of Health.

Men and women aged 50 years and older who have been diagnosed with schizophrenia are at greater risk of suicide, according to research in the February issue of Schizophrenia Research.

This was especially true for middle-age and older women diagnosed with schizophrenia.

An estimated 1 in 1,000 adults aged 65 years and older are thought to have schizophrenia, previous studies show. Some 7%-17% of older adults who commit suicide have schizophrenia, compared with 8.5% of patients in the general population. Even without schizophrenia, studies have shown that older adults have the highest rate of suicide among all age groups.

The most recent findings come from a team of researchers led by Annette Erlangsen, Ph.D., and William W. Eaton, Ph.D., Dr. Erlangsen, Dr. Eaton, and their colleagues sought to determine whether an elevated risk of suicide associated with schizophrenia exists during the second half of life and which factors might help predict that risk.

Using individual-level register data, the researchers performed a nationwide cohort study of some 2,899,411 individuals (1,382,390 men, 1,517,021 women) aged 50 and older who lived in Denmark between 1990 and 2006 (Schizophr. Res. 2012; 134;111-7). They also gathered historical information on psychiatric hospitalizations since 1970 and obtained gender-specific suicide rates using the exact number of person-days under exposure.

Indeed, there was an excess in mortality because of suicide among older adults with schizophrenia, which declined with decreasing age, when compared with the remainder of the population, reported Dr. Erlangsen of the Mental Health Centre Copenhagen and the Johns Hopkins School of Public Health, Baltimore, and Dr. Eaton of Johns Hopkins.

Since 1970, the researchers learned, 8,893 men (0.64%) and 9,165 women (0.60%) had been diagnosed with schizophrenia during a hospitalization. Also, 5,230 men and 2,911 women died by suicide, including 125 men (2.4%) and 123 women (4.2%) who had been diagnosed with schizophrenia.

Suicide rates per 100,000 person-years were significantly higher among all patients diagnosed with schizophrenia vs. those without the disorder, although the rates did decrease with age. The rates were as follows: 217.7 vs. 31.3 among men aged 50-69 years; 107.2 vs. 51.6 among men aged 70 years and older; 218.1 vs. 15.9 among women aged 50-69 years; and 68.3 vs. 20.0 among women aged 70 years and older.

These findings confirm earlier studies that show excess mortality from suicide among older men with schizophrenia and establish an increased risk among women aged 70 years and older with schizophrenia. Higher suicide rates among women might be tied to the late onset of schizophrenia. In addition, women tend to present more positive symptoms than do men – symptoms that have been linked to suicide risks.

"However, a more plausible explanation might be that men with schizophrenia died earlier in their life course," the researchers said.

Suicide rates might have declined with age as older adults with schizophrenia might have learned to adapt to the disorder.

Among other findings:

• The risk of suicide in older adults hospitalized with schizophrenia was lower than for other psychiatric inpatients. An elevated risk of suicide remained among previously hospitalized individuals vs. those with no psychiatric diagnoses. Also, 62% percent of men and 67% of women diagnosed with schizophrenia and who died by suicide had been admitted to a psychiatric hospital more than six times, "indicating a chronic disease course with several relapses," they said. The risk was elevated for both genders during the first 3 months after admission and the first 3 months after discharge.

• The risk of suicide in older adults diagnosed with mood disorders and schizophrenia was almost as high as those diagnosed only with schizophrenia. Among women with schizophrenia, coexisting personality disorders or substance abuse further elevated the risk of suicide.

• There was a 15-fold increased risk for men and a 22-fold increase for women who attempted suicide within the previous 365 days vs. those who made no recent attempt. This emphasizes the importance of suicide attempts as a risk indicator, the researchers said.

"In terms of implications, both recently discharged, history of several hospitalizations, co-existing psychiatric disorders, and suicide attempts represent well-defined high risk groups with respect to interventions," the researchers said. "Prevention of suicide in older adults should predominantly be aimed at intervening early in the suicidal process. Follow-up during medical treatment and assessment for depression seem to be successful strategies. It is possible that older adults with schizophrenia would profit from similar approaches."

The strength of this study is the complete data collection from the entire population of Denmark, the researchers said. One limitation, however, is that only subjects diagnosed during a psychiatric or somatic hospitalization were considered to have schizophrenia, which might have led to an underestimation.

The authors reported no conflicts of interest. Dr. Erlangsen received a grant from the Danish Ministry of Welfare for the study. Dr. Eaton received a grant from the National Institute of Mental Health at the National Institutes of Health.

Men and women aged 50 years and older who have been diagnosed with schizophrenia are at greater risk of suicide, according to research in the February issue of Schizophrenia Research.

This was especially true for middle-age and older women diagnosed with schizophrenia.

An estimated 1 in 1,000 adults aged 65 years and older are thought to have schizophrenia, previous studies show. Some 7%-17% of older adults who commit suicide have schizophrenia, compared with 8.5% of patients in the general population. Even without schizophrenia, studies have shown that older adults have the highest rate of suicide among all age groups.

The most recent findings come from a team of researchers led by Annette Erlangsen, Ph.D., and William W. Eaton, Ph.D., Dr. Erlangsen, Dr. Eaton, and their colleagues sought to determine whether an elevated risk of suicide associated with schizophrenia exists during the second half of life and which factors might help predict that risk.

Using individual-level register data, the researchers performed a nationwide cohort study of some 2,899,411 individuals (1,382,390 men, 1,517,021 women) aged 50 and older who lived in Denmark between 1990 and 2006 (Schizophr. Res. 2012; 134;111-7). They also gathered historical information on psychiatric hospitalizations since 1970 and obtained gender-specific suicide rates using the exact number of person-days under exposure.

Indeed, there was an excess in mortality because of suicide among older adults with schizophrenia, which declined with decreasing age, when compared with the remainder of the population, reported Dr. Erlangsen of the Mental Health Centre Copenhagen and the Johns Hopkins School of Public Health, Baltimore, and Dr. Eaton of Johns Hopkins.

Since 1970, the researchers learned, 8,893 men (0.64%) and 9,165 women (0.60%) had been diagnosed with schizophrenia during a hospitalization. Also, 5,230 men and 2,911 women died by suicide, including 125 men (2.4%) and 123 women (4.2%) who had been diagnosed with schizophrenia.

Suicide rates per 100,000 person-years were significantly higher among all patients diagnosed with schizophrenia vs. those without the disorder, although the rates did decrease with age. The rates were as follows: 217.7 vs. 31.3 among men aged 50-69 years; 107.2 vs. 51.6 among men aged 70 years and older; 218.1 vs. 15.9 among women aged 50-69 years; and 68.3 vs. 20.0 among women aged 70 years and older.

These findings confirm earlier studies that show excess mortality from suicide among older men with schizophrenia and establish an increased risk among women aged 70 years and older with schizophrenia. Higher suicide rates among women might be tied to the late onset of schizophrenia. In addition, women tend to present more positive symptoms than do men – symptoms that have been linked to suicide risks.

"However, a more plausible explanation might be that men with schizophrenia died earlier in their life course," the researchers said.

Suicide rates might have declined with age as older adults with schizophrenia might have learned to adapt to the disorder.

Among other findings:

• The risk of suicide in older adults hospitalized with schizophrenia was lower than for other psychiatric inpatients. An elevated risk of suicide remained among previously hospitalized individuals vs. those with no psychiatric diagnoses. Also, 62% percent of men and 67% of women diagnosed with schizophrenia and who died by suicide had been admitted to a psychiatric hospital more than six times, "indicating a chronic disease course with several relapses," they said. The risk was elevated for both genders during the first 3 months after admission and the first 3 months after discharge.

• The risk of suicide in older adults diagnosed with mood disorders and schizophrenia was almost as high as those diagnosed only with schizophrenia. Among women with schizophrenia, coexisting personality disorders or substance abuse further elevated the risk of suicide.

• There was a 15-fold increased risk for men and a 22-fold increase for women who attempted suicide within the previous 365 days vs. those who made no recent attempt. This emphasizes the importance of suicide attempts as a risk indicator, the researchers said.

"In terms of implications, both recently discharged, history of several hospitalizations, co-existing psychiatric disorders, and suicide attempts represent well-defined high risk groups with respect to interventions," the researchers said. "Prevention of suicide in older adults should predominantly be aimed at intervening early in the suicidal process. Follow-up during medical treatment and assessment for depression seem to be successful strategies. It is possible that older adults with schizophrenia would profit from similar approaches."

The strength of this study is the complete data collection from the entire population of Denmark, the researchers said. One limitation, however, is that only subjects diagnosed during a psychiatric or somatic hospitalization were considered to have schizophrenia, which might have led to an underestimation.

The authors reported no conflicts of interest. Dr. Erlangsen received a grant from the Danish Ministry of Welfare for the study. Dr. Eaton received a grant from the National Institute of Mental Health at the National Institutes of Health.

Insight into illness, marital status, and employment were the most important factors associated with higher quality of life in patients with schizophrenia, according to a study in Progress in Neuro-Psychopharmacology and Biological Psychology. Neurocognition, however, had no apparent influence on quality of life.

Quality of life (QoL) measurements – including psychological, economic, and vocational status; functional abilities; social interaction; and physical health – help clinicians evaluate whether their treatments and care of patients who have schizophrenia are effective. The factors that predict quality of life, however, remain unclear, and numerous studies show conflicting results.

So, Dr. Laurent Boyer of University of the Mediterranean Aix-Marseille II in Marseille, France, and colleagues undertook a cross-sectional study to determine how insight into illness affects patients’ self-reported quality of life. Insight into illness, including the need to comply with treatment, might help predict outcomes and possibly reduce the risk of relapse and rehospitalization, they say.

"This study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The study took place in the psychiatric department of a French public university teaching hospital (Prog. Neuropsychopharmacol. Biol. Psychiatry 2012;36:271-6). Dr. Boyer and colleagues enrolled 113 outpatients (79 men, 34 women) with a mean age of 38.6 years and a diagnosis of schizophrenia. Also, 8 subjects (7.1%) were married, 51 (45.1%) had 12 or more years of education, 16 (14.2%) were employed, and 54 (47.8%) lived independently.

Besides this sociodemographic information, the researchers gathered information about clinical characteristics, which medications patients used, and cognitive performance on a standardized battery of tests. They interviewed patients using a shortened version of SUMD (Scale to Assess Unawareness of Mental Disease) to determine whether patients understood that they have a mental disease and whether they were aware of its symptoms. Last, they administered the S-QoL 18 questionnaire, which explores 18 items that describe eight dimensions of well-being, including physical and psychological well-being, self-esteem, relationships with family and friends, resilience, autonomy, and sentimental life.

The mean scores on the shortened SUMD were 4.81 for awareness of their mental disorder, 3.42 for level of awareness of positive symptoms, and 3.79 for level of awareness of negative symptoms. Meanwhile, the average index score on the S-QoL 18 was 59.43, with all dimension scores higher than 60, except for scores tied to relationships with friends, physical well-being, and sentimental life.

Univariate and multivariate analysis showed that marital status and employment were associated with a higher quality of life. This finding was consistent with other studies that found a lower quality of life among those who were unemployed, had no reliable friend or daily contact with family, and had few leisure activities, reported Dr. Boyer, who also is affiliated with the department of public health at Hôpital de la Timone in Marseille.

Awareness of symptoms (both positive and negative) also was associated with a higher quality of life. However, better awareness of the disease – including having a mental disorder, needing to take medicine, being restricted in daily living, facing barriers to rehabilitation, and being stigmatized – was associated with a lower quality of life, the researchers found.

"One explanation for the discrepancy with awareness of mental disorders could be that identifying symptoms may require a different form of [judgment] that is unrelated to beliefs about people or minds," the researchers wrote. "A better awareness of symptoms may help to develop personal care skills that mitigate or reduce these symptoms and also help to apply adapted skills necessary for [everyday life], thus enabling success across a variety of domains of QoL."

The analyses showed no direct relationship between neurocognition and quality of life. "Our findings suggest that insight might be a mediator of the relationship between neurocognition and QoL," the researchers said.

Some potential limitations of the study exist. For example, the sample might not represent the entire population of patients who have schizophrenia. Also, the study used just one type of QoL instrument. A study on a larger, more diverse group of patients is needed, as are further studies to investigate the discrepancies in mental awareness of the disease and how that awareness relates to symptoms and quality of life.

Even so, the researchers say, clinicians must consider several facets of a patient’s insight into his or her illness when developing specific interventions to improve quality of life for patients with schizophrenia. "Moreover," they add, "this study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The authors reported no conflicts of interest. The French Ministry of Health provided a national grant for this study.

Insight into illness, marital status, and employment were the most important factors associated with higher quality of life in patients with schizophrenia, according to a study in Progress in Neuro-Psychopharmacology and Biological Psychology. Neurocognition, however, had no apparent influence on quality of life.

Quality of life (QoL) measurements – including psychological, economic, and vocational status; functional abilities; social interaction; and physical health – help clinicians evaluate whether their treatments and care of patients who have schizophrenia are effective. The factors that predict quality of life, however, remain unclear, and numerous studies show conflicting results.

So, Dr. Laurent Boyer of University of the Mediterranean Aix-Marseille II in Marseille, France, and colleagues undertook a cross-sectional study to determine how insight into illness affects patients’ self-reported quality of life. Insight into illness, including the need to comply with treatment, might help predict outcomes and possibly reduce the risk of relapse and rehospitalization, they say.

"This study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The study took place in the psychiatric department of a French public university teaching hospital (Prog. Neuropsychopharmacol. Biol. Psychiatry 2012;36:271-6). Dr. Boyer and colleagues enrolled 113 outpatients (79 men, 34 women) with a mean age of 38.6 years and a diagnosis of schizophrenia. Also, 8 subjects (7.1%) were married, 51 (45.1%) had 12 or more years of education, 16 (14.2%) were employed, and 54 (47.8%) lived independently.

Besides this sociodemographic information, the researchers gathered information about clinical characteristics, which medications patients used, and cognitive performance on a standardized battery of tests. They interviewed patients using a shortened version of SUMD (Scale to Assess Unawareness of Mental Disease) to determine whether patients understood that they have a mental disease and whether they were aware of its symptoms. Last, they administered the S-QoL 18 questionnaire, which explores 18 items that describe eight dimensions of well-being, including physical and psychological well-being, self-esteem, relationships with family and friends, resilience, autonomy, and sentimental life.

The mean scores on the shortened SUMD were 4.81 for awareness of their mental disorder, 3.42 for level of awareness of positive symptoms, and 3.79 for level of awareness of negative symptoms. Meanwhile, the average index score on the S-QoL 18 was 59.43, with all dimension scores higher than 60, except for scores tied to relationships with friends, physical well-being, and sentimental life.

Univariate and multivariate analysis showed that marital status and employment were associated with a higher quality of life. This finding was consistent with other studies that found a lower quality of life among those who were unemployed, had no reliable friend or daily contact with family, and had few leisure activities, reported Dr. Boyer, who also is affiliated with the department of public health at Hôpital de la Timone in Marseille.

Awareness of symptoms (both positive and negative) also was associated with a higher quality of life. However, better awareness of the disease – including having a mental disorder, needing to take medicine, being restricted in daily living, facing barriers to rehabilitation, and being stigmatized – was associated with a lower quality of life, the researchers found.

"One explanation for the discrepancy with awareness of mental disorders could be that identifying symptoms may require a different form of [judgment] that is unrelated to beliefs about people or minds," the researchers wrote. "A better awareness of symptoms may help to develop personal care skills that mitigate or reduce these symptoms and also help to apply adapted skills necessary for [everyday life], thus enabling success across a variety of domains of QoL."

The analyses showed no direct relationship between neurocognition and quality of life. "Our findings suggest that insight might be a mediator of the relationship between neurocognition and QoL," the researchers said.

Some potential limitations of the study exist. For example, the sample might not represent the entire population of patients who have schizophrenia. Also, the study used just one type of QoL instrument. A study on a larger, more diverse group of patients is needed, as are further studies to investigate the discrepancies in mental awareness of the disease and how that awareness relates to symptoms and quality of life.

Even so, the researchers say, clinicians must consider several facets of a patient’s insight into his or her illness when developing specific interventions to improve quality of life for patients with schizophrenia. "Moreover," they add, "this study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The authors reported no conflicts of interest. The French Ministry of Health provided a national grant for this study.

Insight into illness, marital status, and employment were the most important factors associated with higher quality of life in patients with schizophrenia, according to a study in Progress in Neuro-Psychopharmacology and Biological Psychology. Neurocognition, however, had no apparent influence on quality of life.

Quality of life (QoL) measurements – including psychological, economic, and vocational status; functional abilities; social interaction; and physical health – help clinicians evaluate whether their treatments and care of patients who have schizophrenia are effective. The factors that predict quality of life, however, remain unclear, and numerous studies show conflicting results.

So, Dr. Laurent Boyer of University of the Mediterranean Aix-Marseille II in Marseille, France, and colleagues undertook a cross-sectional study to determine how insight into illness affects patients’ self-reported quality of life. Insight into illness, including the need to comply with treatment, might help predict outcomes and possibly reduce the risk of relapse and rehospitalization, they say.

"This study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The study took place in the psychiatric department of a French public university teaching hospital (Prog. Neuropsychopharmacol. Biol. Psychiatry 2012;36:271-6). Dr. Boyer and colleagues enrolled 113 outpatients (79 men, 34 women) with a mean age of 38.6 years and a diagnosis of schizophrenia. Also, 8 subjects (7.1%) were married, 51 (45.1%) had 12 or more years of education, 16 (14.2%) were employed, and 54 (47.8%) lived independently.

Besides this sociodemographic information, the researchers gathered information about clinical characteristics, which medications patients used, and cognitive performance on a standardized battery of tests. They interviewed patients using a shortened version of SUMD (Scale to Assess Unawareness of Mental Disease) to determine whether patients understood that they have a mental disease and whether they were aware of its symptoms. Last, they administered the S-QoL 18 questionnaire, which explores 18 items that describe eight dimensions of well-being, including physical and psychological well-being, self-esteem, relationships with family and friends, resilience, autonomy, and sentimental life.

The mean scores on the shortened SUMD were 4.81 for awareness of their mental disorder, 3.42 for level of awareness of positive symptoms, and 3.79 for level of awareness of negative symptoms. Meanwhile, the average index score on the S-QoL 18 was 59.43, with all dimension scores higher than 60, except for scores tied to relationships with friends, physical well-being, and sentimental life.

Univariate and multivariate analysis showed that marital status and employment were associated with a higher quality of life. This finding was consistent with other studies that found a lower quality of life among those who were unemployed, had no reliable friend or daily contact with family, and had few leisure activities, reported Dr. Boyer, who also is affiliated with the department of public health at Hôpital de la Timone in Marseille.

Awareness of symptoms (both positive and negative) also was associated with a higher quality of life. However, better awareness of the disease – including having a mental disorder, needing to take medicine, being restricted in daily living, facing barriers to rehabilitation, and being stigmatized – was associated with a lower quality of life, the researchers found.

"One explanation for the discrepancy with awareness of mental disorders could be that identifying symptoms may require a different form of [judgment] that is unrelated to beliefs about people or minds," the researchers wrote. "A better awareness of symptoms may help to develop personal care skills that mitigate or reduce these symptoms and also help to apply adapted skills necessary for [everyday life], thus enabling success across a variety of domains of QoL."

The analyses showed no direct relationship between neurocognition and quality of life. "Our findings suggest that insight might be a mediator of the relationship between neurocognition and QoL," the researchers said.

Some potential limitations of the study exist. For example, the sample might not represent the entire population of patients who have schizophrenia. Also, the study used just one type of QoL instrument. A study on a larger, more diverse group of patients is needed, as are further studies to investigate the discrepancies in mental awareness of the disease and how that awareness relates to symptoms and quality of life.

Even so, the researchers say, clinicians must consider several facets of a patient’s insight into his or her illness when developing specific interventions to improve quality of life for patients with schizophrenia. "Moreover," they add, "this study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work."

The authors reported no conflicts of interest. The French Ministry of Health provided a national grant for this study.

Urgent intervention after a transient ischemic attack by an acute care team followed by nurse-conducted health counseling can substantially reduce the risk of new vascular events within the first year, according to results of the Aarhus TIA study.

Careful evaluation and use of preventive measures helped the team lower the cumulative risk of stroke below predicted levels 7 days and 90 days after TIA.

Immediate intervention is important because TIA can increase patients’ risk of ischemic stroke by more than 30% within the first 3 months after the attack. Studies have shown that urgent intervention can substantially reduce this risk, but little is known about stroke risk beyond 90 days. Additional studies have shown poor treatment and compliance rates for preventive measures such as cholesterol and blood pressure reduction and smoking cessation.

Dr. Paul von Weitzel-Mudersbach and his colleagues at Aarhus (Denmark) University Hospital established an acute TIA team that served patients with TIA on the stroke unit and the TIA clinic, and examined all patients with TIA who were referred to the hospital between March 1, 2007, and Feb. 28, 2008. A total of 306 patients (56.2% men) with a median age of 65.8 years met the study’s inclusion criteria. These patients underwent a detailed diagnostic work-up and received 150 mg aspirin immediately after CT/MRI. Patients with symptomatic carotid or intracerebral stenosis also received 300 mg clopidogrel unless carotid endarterectomy was planned within 1 week. A trained nurse discussed lifestyle changes, including smoking cessation, healthy diet, and physical exercise at baseline and during follow-up telephone interviews at 7 days and 90 days (Eur. J. Neurol. 2011;18:1285-90).

Urgent treatment was associated with a reduced risk of adverse clinical outcomes, the researchers found. Within 1 year, 16 (5%) of the 306 patients had a stroke, non-fatal MI, or vascular death. The cumulative stroke risk was 1.3% after 2 days. The intervention resulted in a significantly lower cumulative stroke risk than what was predicted with ABCD² criteria after both 7 days (1.6% vs. 4.5%) and 90 days (2% vs. 7.5%).

At the end of 1 year, the cumulated stroke risk was 4.2% (13 patients, all had ischemic stroke), and the cumulated mortality was 2.9%, or 9 patients; 5 of these deaths were due to vascular causes, and the remainder were caused by cancer and sepsis. TIA recurred in the first year in 10.2% of patients. There were no non-fatal MIs.

The investigators found that 8.1% of patients underwent carotid endarterectomy, with a median time to operation of 11 days after the first contact with the acute TIA team, 12.5 days after the call for attention, and 17.5 days after the index TIA.

The number of patients who achieved the secondary prevention target increased from 34% of patients at baseline to 48% after 1 year. The secondary prevention target was considered attained if a patient fulfilled at least three of the following four criteria: systolic blood pressure 130 mm Hg or less and diastolic 80 mm Hg or less; total cholesterol less than 4.5 mmol/L; no smoking; and self-reported adherence to antithrombotic treatment. At least 95% of patients fulfilled at least one prevention measure after 1 year.

Patients with large artery disease (LAD) had the best compliance: 55% reached the secondary prevention target and 100% were adherent to antithrombotic treatment. LAD was not a predictor for vascular events within the first year, possibly due to good adherence to secondary prevention.

The study was supported by the Danish Heart Foundation and the Research Council in the former Aarhus County. The authors had no disclosures.☐

Urgent intervention after a transient ischemic attack by an acute care team followed by nurse-conducted health counseling can substantially reduce the risk of new vascular events within the first year, according to results of the Aarhus TIA study.

Careful evaluation and use of preventive measures helped the team lower the cumulative risk of stroke below predicted levels 7 days and 90 days after TIA.

Immediate intervention is important because TIA can increase patients’ risk of ischemic stroke by more than 30% within the first 3 months after the attack. Studies have shown that urgent intervention can substantially reduce this risk, but little is known about stroke risk beyond 90 days. Additional studies have shown poor treatment and compliance rates for preventive measures such as cholesterol and blood pressure reduction and smoking cessation.

Dr. Paul von Weitzel-Mudersbach and his colleagues at Aarhus (Denmark) University Hospital established an acute TIA team that served patients with TIA on the stroke unit and the TIA clinic, and examined all patients with TIA who were referred to the hospital between March 1, 2007, and Feb. 28, 2008. A total of 306 patients (56.2% men) with a median age of 65.8 years met the study’s inclusion criteria. These patients underwent a detailed diagnostic work-up and received 150 mg aspirin immediately after CT/MRI. Patients with symptomatic carotid or intracerebral stenosis also received 300 mg clopidogrel unless carotid endarterectomy was planned within 1 week. A trained nurse discussed lifestyle changes, including smoking cessation, healthy diet, and physical exercise at baseline and during follow-up telephone interviews at 7 days and 90 days (Eur. J. Neurol. 2011;18:1285-90).

Urgent treatment was associated with a reduced risk of adverse clinical outcomes, the researchers found. Within 1 year, 16 (5%) of the 306 patients had a stroke, non-fatal MI, or vascular death. The cumulative stroke risk was 1.3% after 2 days. The intervention resulted in a significantly lower cumulative stroke risk than what was predicted with ABCD² criteria after both 7 days (1.6% vs. 4.5%) and 90 days (2% vs. 7.5%).

At the end of 1 year, the cumulated stroke risk was 4.2% (13 patients, all had ischemic stroke), and the cumulated mortality was 2.9%, or 9 patients; 5 of these deaths were due to vascular causes, and the remainder were caused by cancer and sepsis. TIA recurred in the first year in 10.2% of patients. There were no non-fatal MIs.

The investigators found that 8.1% of patients underwent carotid endarterectomy, with a median time to operation of 11 days after the first contact with the acute TIA team, 12.5 days after the call for attention, and 17.5 days after the index TIA.

The number of patients who achieved the secondary prevention target increased from 34% of patients at baseline to 48% after 1 year. The secondary prevention target was considered attained if a patient fulfilled at least three of the following four criteria: systolic blood pressure 130 mm Hg or less and diastolic 80 mm Hg or less; total cholesterol less than 4.5 mmol/L; no smoking; and self-reported adherence to antithrombotic treatment. At least 95% of patients fulfilled at least one prevention measure after 1 year.

Patients with large artery disease (LAD) had the best compliance: 55% reached the secondary prevention target and 100% were adherent to antithrombotic treatment. LAD was not a predictor for vascular events within the first year, possibly due to good adherence to secondary prevention.

The study was supported by the Danish Heart Foundation and the Research Council in the former Aarhus County. The authors had no disclosures.☐

Urgent intervention after a transient ischemic attack by an acute care team followed by nurse-conducted health counseling can substantially reduce the risk of new vascular events within the first year, according to results of the Aarhus TIA study.

Careful evaluation and use of preventive measures helped the team lower the cumulative risk of stroke below predicted levels 7 days and 90 days after TIA.

Immediate intervention is important because TIA can increase patients’ risk of ischemic stroke by more than 30% within the first 3 months after the attack. Studies have shown that urgent intervention can substantially reduce this risk, but little is known about stroke risk beyond 90 days. Additional studies have shown poor treatment and compliance rates for preventive measures such as cholesterol and blood pressure reduction and smoking cessation.

Dr. Paul von Weitzel-Mudersbach and his colleagues at Aarhus (Denmark) University Hospital established an acute TIA team that served patients with TIA on the stroke unit and the TIA clinic, and examined all patients with TIA who were referred to the hospital between March 1, 2007, and Feb. 28, 2008. A total of 306 patients (56.2% men) with a median age of 65.8 years met the study’s inclusion criteria. These patients underwent a detailed diagnostic work-up and received 150 mg aspirin immediately after CT/MRI. Patients with symptomatic carotid or intracerebral stenosis also received 300 mg clopidogrel unless carotid endarterectomy was planned within 1 week. A trained nurse discussed lifestyle changes, including smoking cessation, healthy diet, and physical exercise at baseline and during follow-up telephone interviews at 7 days and 90 days (Eur. J. Neurol. 2011;18:1285-90).

Urgent treatment was associated with a reduced risk of adverse clinical outcomes, the researchers found. Within 1 year, 16 (5%) of the 306 patients had a stroke, non-fatal MI, or vascular death. The cumulative stroke risk was 1.3% after 2 days. The intervention resulted in a significantly lower cumulative stroke risk than what was predicted with ABCD² criteria after both 7 days (1.6% vs. 4.5%) and 90 days (2% vs. 7.5%).

At the end of 1 year, the cumulated stroke risk was 4.2% (13 patients, all had ischemic stroke), and the cumulated mortality was 2.9%, or 9 patients; 5 of these deaths were due to vascular causes, and the remainder were caused by cancer and sepsis. TIA recurred in the first year in 10.2% of patients. There were no non-fatal MIs.

The investigators found that 8.1% of patients underwent carotid endarterectomy, with a median time to operation of 11 days after the first contact with the acute TIA team, 12.5 days after the call for attention, and 17.5 days after the index TIA.

The number of patients who achieved the secondary prevention target increased from 34% of patients at baseline to 48% after 1 year. The secondary prevention target was considered attained if a patient fulfilled at least three of the following four criteria: systolic blood pressure 130 mm Hg or less and diastolic 80 mm Hg or less; total cholesterol less than 4.5 mmol/L; no smoking; and self-reported adherence to antithrombotic treatment. At least 95% of patients fulfilled at least one prevention measure after 1 year.

Patients with large artery disease (LAD) had the best compliance: 55% reached the secondary prevention target and 100% were adherent to antithrombotic treatment. LAD was not a predictor for vascular events within the first year, possibly due to good adherence to secondary prevention.

The study was supported by the Danish Heart Foundation and the Research Council in the former Aarhus County. The authors had no disclosures.☐

Anaphylaxis in children following immunizations is extremely rare, with no events associated with infant and preschool schedule vaccinations and a delayed onset of symptoms in other children, according to a study published online Jan. 23 in Archives of Disease in Childhood.

Anaphylaxis may follow exposure to allergens from many sources, including vaccines made up of a mixture of compounds. Because anaphylaxis is rare, however, it is usually very difficult to pick this up as a potential side effect of a new treatment during clinical trials. Manufacturers have to rely on data collected after the product has come to market.

Dr. Michel Erlewyn-Lajeunesse of Children’s Allergy Clinic, University Hospital Southampton NHS Trust, and colleagues wanted to estimate the incidence and clinical presentation of anaphylaxes as an adverse event following immunization. Pediatricians in the United Kingdom and Ireland were asked to report all cases of suspected anaphylaxis in children younger than age 16 years following an immunization to the British Paediatric Surveillance Unit between September 30, 2008, and September 30, 2009 (Arch. Dis. Child 2012 [doi:10.1136/archdischild-2011-301163]). Reporting physicians also completed an online survey or patient questionnaires on the case presentation, diagnosis, management, and subsequent outcome.

© Yarinca/istockphoto.com

During this time, physicians reported 15 cases of suspected anaphylaxis following vaccination, 7 of which the researchers confirmed. Six children required an injection of adrenaline, three received intravenous fluids, and all seven children fully recovered.

These included 2 cases among more than 16,000 single-component measles vaccines administered, for an incidence of 12 cases per 100,000. [No single-component measles vaccines are currently available in the United States.]

"A higher rate of anaphylaxis following single-component vaccines has been previously observed, although there is no obvious explanation for this," the researchers said. "Measures should be taken to record the use of non-routine vaccines so that the public may be protected." No cases of anaphylaxis occurred among the 5.5 million infants and preschool-age children who received normally scheduled vaccines, including measles, mumps, and rubella (MMR) and influenza. "This is extremely reassuring data for the general public and healthcare workers alike," they said.

There also were three cases of anaphylaxis among more than 2 million doses of human papillomavirus (HPV) vaccine, for an incidence of 1.4 cases per million doses.

Three children already carried injectable adrenaline to treat idiopathic anaphylaxis or multiple food allergies. "We suggest that children with idiopathic anaphylaxis are immunized in a center used to treating anaphylaxis and are observed for at least an hour following the procedure," Dr. Erlewyn-Lajeunesse and associates said.

The onset of symptoms was 15 minutes in three cases and 30 or more minutes in four cases (120 minutes in one case). The latter finding, observed in other studies, "is in keeping with an idiosyncratic non-immunoglobulin E-mediated reaction," they said. Although there is no standard observation time, the researchers said that an observation time of up to 60 minutes may be appropriate in children with a history of idiopathic anaphylaxis.

"Anaphylaxis remains a very rare adverse event following immunization," the researchers said. "There is a clear need for international surveillance using standardized methodologies and case definitions."

The U.S. Vaccine Adverse Event Reporting System (VAERS) recorded 452 reports of "anaphylactoid reactions" in over 1.9 billion doses of vaccine given over a 10-year period, for an estimated incidence of 0.2 cases per million doses.

This study was funded by an unrestricted educational grant from Sanofi Pasteur MSD. Dr. Erlewyn-Lajeunesse reported having received reimbursement from GlaxoSmithKline and Wyeth to attend scientific meetings. Coauthor Dr. Paul T. Heath is an investigator for clinical trials conducted on behalf of St. George’s, University of London, sponsored by vaccine manufacturers. Coauthor Dr. Adam Finn undertakes clinical trails and related research, consulting, lecturing, and chairing for all the major manufacturers and has received reimbursement of travel, accommodation, registration and living expenses relating to these activities. Dr. Pichichero said he had no relevant financial disclosures.

Anaphylaxis in children following immunizations is extremely rare, with no events associated with infant and preschool schedule vaccinations and a delayed onset of symptoms in other children, according to a study published online Jan. 23 in Archives of Disease in Childhood.

Anaphylaxis may follow exposure to allergens from many sources, including vaccines made up of a mixture of compounds. Because anaphylaxis is rare, however, it is usually very difficult to pick this up as a potential side effect of a new treatment during clinical trials. Manufacturers have to rely on data collected after the product has come to market.

Dr. Michel Erlewyn-Lajeunesse of Children’s Allergy Clinic, University Hospital Southampton NHS Trust, and colleagues wanted to estimate the incidence and clinical presentation of anaphylaxes as an adverse event following immunization. Pediatricians in the United Kingdom and Ireland were asked to report all cases of suspected anaphylaxis in children younger than age 16 years following an immunization to the British Paediatric Surveillance Unit between September 30, 2008, and September 30, 2009 (Arch. Dis. Child 2012 [doi:10.1136/archdischild-2011-301163]). Reporting physicians also completed an online survey or patient questionnaires on the case presentation, diagnosis, management, and subsequent outcome.

© Yarinca/istockphoto.com

During this time, physicians reported 15 cases of suspected anaphylaxis following vaccination, 7 of which the researchers confirmed. Six children required an injection of adrenaline, three received intravenous fluids, and all seven children fully recovered.

These included 2 cases among more than 16,000 single-component measles vaccines administered, for an incidence of 12 cases per 100,000. [No single-component measles vaccines are currently available in the United States.]

"A higher rate of anaphylaxis following single-component vaccines has been previously observed, although there is no obvious explanation for this," the researchers said. "Measures should be taken to record the use of non-routine vaccines so that the public may be protected." No cases of anaphylaxis occurred among the 5.5 million infants and preschool-age children who received normally scheduled vaccines, including measles, mumps, and rubella (MMR) and influenza. "This is extremely reassuring data for the general public and healthcare workers alike," they said.

There also were three cases of anaphylaxis among more than 2 million doses of human papillomavirus (HPV) vaccine, for an incidence of 1.4 cases per million doses.

Three children already carried injectable adrenaline to treat idiopathic anaphylaxis or multiple food allergies. "We suggest that children with idiopathic anaphylaxis are immunized in a center used to treating anaphylaxis and are observed for at least an hour following the procedure," Dr. Erlewyn-Lajeunesse and associates said.

The onset of symptoms was 15 minutes in three cases and 30 or more minutes in four cases (120 minutes in one case). The latter finding, observed in other studies, "is in keeping with an idiosyncratic non-immunoglobulin E-mediated reaction," they said. Although there is no standard observation time, the researchers said that an observation time of up to 60 minutes may be appropriate in children with a history of idiopathic anaphylaxis.

"Anaphylaxis remains a very rare adverse event following immunization," the researchers said. "There is a clear need for international surveillance using standardized methodologies and case definitions."

The U.S. Vaccine Adverse Event Reporting System (VAERS) recorded 452 reports of "anaphylactoid reactions" in over 1.9 billion doses of vaccine given over a 10-year period, for an estimated incidence of 0.2 cases per million doses.

This study was funded by an unrestricted educational grant from Sanofi Pasteur MSD. Dr. Erlewyn-Lajeunesse reported having received reimbursement from GlaxoSmithKline and Wyeth to attend scientific meetings. Coauthor Dr. Paul T. Heath is an investigator for clinical trials conducted on behalf of St. George’s, University of London, sponsored by vaccine manufacturers. Coauthor Dr. Adam Finn undertakes clinical trails and related research, consulting, lecturing, and chairing for all the major manufacturers and has received reimbursement of travel, accommodation, registration and living expenses relating to these activities. Dr. Pichichero said he had no relevant financial disclosures.

Anaphylaxis in children following immunizations is extremely rare, with no events associated with infant and preschool schedule vaccinations and a delayed onset of symptoms in other children, according to a study published online Jan. 23 in Archives of Disease in Childhood.

Anaphylaxis may follow exposure to allergens from many sources, including vaccines made up of a mixture of compounds. Because anaphylaxis is rare, however, it is usually very difficult to pick this up as a potential side effect of a new treatment during clinical trials. Manufacturers have to rely on data collected after the product has come to market.

Dr. Michel Erlewyn-Lajeunesse of Children’s Allergy Clinic, University Hospital Southampton NHS Trust, and colleagues wanted to estimate the incidence and clinical presentation of anaphylaxes as an adverse event following immunization. Pediatricians in the United Kingdom and Ireland were asked to report all cases of suspected anaphylaxis in children younger than age 16 years following an immunization to the British Paediatric Surveillance Unit between September 30, 2008, and September 30, 2009 (Arch. Dis. Child 2012 [doi:10.1136/archdischild-2011-301163]). Reporting physicians also completed an online survey or patient questionnaires on the case presentation, diagnosis, management, and subsequent outcome.

© Yarinca/istockphoto.com

During this time, physicians reported 15 cases of suspected anaphylaxis following vaccination, 7 of which the researchers confirmed. Six children required an injection of adrenaline, three received intravenous fluids, and all seven children fully recovered.

These included 2 cases among more than 16,000 single-component measles vaccines administered, for an incidence of 12 cases per 100,000. [No single-component measles vaccines are currently available in the United States.]

"A higher rate of anaphylaxis following single-component vaccines has been previously observed, although there is no obvious explanation for this," the researchers said. "Measures should be taken to record the use of non-routine vaccines so that the public may be protected." No cases of anaphylaxis occurred among the 5.5 million infants and preschool-age children who received normally scheduled vaccines, including measles, mumps, and rubella (MMR) and influenza. "This is extremely reassuring data for the general public and healthcare workers alike," they said.

There also were three cases of anaphylaxis among more than 2 million doses of human papillomavirus (HPV) vaccine, for an incidence of 1.4 cases per million doses.

Three children already carried injectable adrenaline to treat idiopathic anaphylaxis or multiple food allergies. "We suggest that children with idiopathic anaphylaxis are immunized in a center used to treating anaphylaxis and are observed for at least an hour following the procedure," Dr. Erlewyn-Lajeunesse and associates said.

The onset of symptoms was 15 minutes in three cases and 30 or more minutes in four cases (120 minutes in one case). The latter finding, observed in other studies, "is in keeping with an idiosyncratic non-immunoglobulin E-mediated reaction," they said. Although there is no standard observation time, the researchers said that an observation time of up to 60 minutes may be appropriate in children with a history of idiopathic anaphylaxis.

"Anaphylaxis remains a very rare adverse event following immunization," the researchers said. "There is a clear need for international surveillance using standardized methodologies and case definitions."

The U.S. Vaccine Adverse Event Reporting System (VAERS) recorded 452 reports of "anaphylactoid reactions" in over 1.9 billion doses of vaccine given over a 10-year period, for an estimated incidence of 0.2 cases per million doses.

This study was funded by an unrestricted educational grant from Sanofi Pasteur MSD. Dr. Erlewyn-Lajeunesse reported having received reimbursement from GlaxoSmithKline and Wyeth to attend scientific meetings. Coauthor Dr. Paul T. Heath is an investigator for clinical trials conducted on behalf of St. George’s, University of London, sponsored by vaccine manufacturers. Coauthor Dr. Adam Finn undertakes clinical trails and related research, consulting, lecturing, and chairing for all the major manufacturers and has received reimbursement of travel, accommodation, registration and living expenses relating to these activities. Dr. Pichichero said he had no relevant financial disclosures.

Children currently diagnosed with an autism spectrum disorder are more likely to have coexisting psychiatric or neurodevelopmental conditions than are children with a past but not current diagnosis, and these conditions might lead to a change in ASD diagnosis, suggest the findings of a cross-sectional study in the February issue of Pediatrics.

An estimated 1% of 8-year-old children (typically the peak age of prevalence) have an ASD, such as autistic disorder; pervasive developmental disorder, not otherwise specified (PDD-NOS); or Asperger’s syndrome, according to the Centers for Disease Control and Prevention. Co-occurring conditions often include attention-deficit/hyperactivity disorder, learning disability, depression, anxiety, and seizures. Also, more than 10% of children diagnosed with an ASD at age 2 years no longer have the diagnosis by age 9 years.

To provide an appropriate diagnosis and opportunities for early intervention, clinicians must be able to differentiate between the core features of an ASD and any coexisting conditions.

Using cross-sectional data from the National Survey of Children’s Health 2007 (NSCH), Heather A. Close, of the Center for Autism and Developmental Disabilities Epidemiology at Johns Hopkins University, Baltimore, and her colleagues examined the relationship between co-occurring conditions and changes in diagnosis of an ASD (Pediatrics 2012;129:305-16 [doi:10.1542/peds.2011-1217]). This study consisted of 1,366 children from the NSCH with a parent-reported current or a past but not current (PBNC) diagnosis of an ASD.

The study authors found that the type of co-occurring conditions varied by age. For example, 3- to 5-year-old children currently diagnosed with an ASD were 11 times more likely to have a moderate or severe learning disability and 9 times more likely to have a moderate or severe developmental delay than children with a PBNC diagnosis. They were nearly 5 times more likely to have two or more current co-occurring conditions than children with a PBNC diagnosis of an ASD.

Meanwhile, children aged 6-11 years with a current ASD diagnosis were almost 4 times more likely to have had a past speech problem and 3.5 times more likely to have current moderate or severe anxiety than children with a PBNC diagnosis. And, they were more than 3 times as likely to have two or more current co-occurring conditions as those with a PBNC diagnosis.

Finally, adolescents aged 12-17 years with a current ASD diagnosis were almost 4 times more likely to have moderate or severe speech problems and 10 times more likely to have current mild seizures or epilepsy than children with a PBNC diagnosis of ASD.

Children and adolescents with a current ASD diagnosis were more likely to have two or more co-occurring conditions than those with a PBNC diagnosis.

The study results suggest that some co-occurring conditions might, in part, lead to a change in an ASD diagnosis, although the underlying mechanisms for this change are unclear. In this study, the researchers focused on the possible impact that neurodevelopmental and psychiatric conditions could have on the continuation of ASD diagnosis by comparing groups who currently have an ASD diagnosis to groups with a PBNC diagnosis.

"Our results are in line with the few studies that have researched differences between current or past ASD diagnoses in the context of co-occurring conditions," Ms. Close and her colleagues wrote.

Children with ASDs have impaired communication, including delays in speech and acquisition of language, or delays in age-appropriate social skills. With increasing age, these symptoms appear more consistent with ASD than with what might have been considered a speech or hearing problem or a nonspecific developmental delay.

"This can also be true in the opposite direction, in which a child might have been diagnosed with an ASD because of the presence of common ASD co-occurring conditions or diagnoses and then was later reclassified as not having an ASD," the researchers said.

Possible reasons for reclassifying children previously diagnosed with an ASD include developmental improvements as the child ages, such as in IQ or adaptive social abilities, or a child no longer meeting the diagnostic criteria as a result of early intervention. "Improvements leading to a loss of an ASD diagnosis also occur more commonly in children diagnosed at an early age with PDD-NOS rather than with autistic disorder," the researchers said.

The limitations of this study included the fact that information was based on parent-reported diagnoses obtained through one telephone interview; the different outcomes among children and adolescents with autism, Asperger’s syndrome, and PDD-NOS; the small sample size for some variables of interest; and a lack of information on individual interventions for each study. Also, the study investigated children with a current or previous ASD diagnosis but did not specifically look at the change from never having a diagnosis to having a diagnosis.

A prospective, longitudinal, population-based retrospective study of adults that asks similar questions could offer a detailed profile of the ages at which an ASD diagnosis changes, as well as co-occurring conditions and interventions, the researchers said.

The authors had no financial relationships to disclose.

Children currently diagnosed with an autism spectrum disorder are more likely to have coexisting psychiatric or neurodevelopmental conditions than are children with a past but not current diagnosis, and these conditions might lead to a change in ASD diagnosis, suggest the findings of a cross-sectional study in the February issue of Pediatrics.

An estimated 1% of 8-year-old children (typically the peak age of prevalence) have an ASD, such as autistic disorder; pervasive developmental disorder, not otherwise specified (PDD-NOS); or Asperger’s syndrome, according to the Centers for Disease Control and Prevention. Co-occurring conditions often include attention-deficit/hyperactivity disorder, learning disability, depression, anxiety, and seizures. Also, more than 10% of children diagnosed with an ASD at age 2 years no longer have the diagnosis by age 9 years.

To provide an appropriate diagnosis and opportunities for early intervention, clinicians must be able to differentiate between the core features of an ASD and any coexisting conditions.

Using cross-sectional data from the National Survey of Children’s Health 2007 (NSCH), Heather A. Close, of the Center for Autism and Developmental Disabilities Epidemiology at Johns Hopkins University, Baltimore, and her colleagues examined the relationship between co-occurring conditions and changes in diagnosis of an ASD (Pediatrics 2012;129:305-16 [doi:10.1542/peds.2011-1217]). This study consisted of 1,366 children from the NSCH with a parent-reported current or a past but not current (PBNC) diagnosis of an ASD.

The study authors found that the type of co-occurring conditions varied by age. For example, 3- to 5-year-old children currently diagnosed with an ASD were 11 times more likely to have a moderate or severe learning disability and 9 times more likely to have a moderate or severe developmental delay than children with a PBNC diagnosis. They were nearly 5 times more likely to have two or more current co-occurring conditions than children with a PBNC diagnosis of an ASD.

Meanwhile, children aged 6-11 years with a current ASD diagnosis were almost 4 times more likely to have had a past speech problem and 3.5 times more likely to have current moderate or severe anxiety than children with a PBNC diagnosis. And, they were more than 3 times as likely to have two or more current co-occurring conditions as those with a PBNC diagnosis.

Finally, adolescents aged 12-17 years with a current ASD diagnosis were almost 4 times more likely to have moderate or severe speech problems and 10 times more likely to have current mild seizures or epilepsy than children with a PBNC diagnosis of ASD.

Children and adolescents with a current ASD diagnosis were more likely to have two or more co-occurring conditions than those with a PBNC diagnosis.

The study results suggest that some co-occurring conditions might, in part, lead to a change in an ASD diagnosis, although the underlying mechanisms for this change are unclear. In this study, the researchers focused on the possible impact that neurodevelopmental and psychiatric conditions could have on the continuation of ASD diagnosis by comparing groups who currently have an ASD diagnosis to groups with a PBNC diagnosis.

"Our results are in line with the few studies that have researched differences between current or past ASD diagnoses in the context of co-occurring conditions," Ms. Close and her colleagues wrote.

Children with ASDs have impaired communication, including delays in speech and acquisition of language, or delays in age-appropriate social skills. With increasing age, these symptoms appear more consistent with ASD than with what might have been considered a speech or hearing problem or a nonspecific developmental delay.

"This can also be true in the opposite direction, in which a child might have been diagnosed with an ASD because of the presence of common ASD co-occurring conditions or diagnoses and then was later reclassified as not having an ASD," the researchers said.

Possible reasons for reclassifying children previously diagnosed with an ASD include developmental improvements as the child ages, such as in IQ or adaptive social abilities, or a child no longer meeting the diagnostic criteria as a result of early intervention. "Improvements leading to a loss of an ASD diagnosis also occur more commonly in children diagnosed at an early age with PDD-NOS rather than with autistic disorder," the researchers said.

The limitations of this study included the fact that information was based on parent-reported diagnoses obtained through one telephone interview; the different outcomes among children and adolescents with autism, Asperger’s syndrome, and PDD-NOS; the small sample size for some variables of interest; and a lack of information on individual interventions for each study. Also, the study investigated children with a current or previous ASD diagnosis but did not specifically look at the change from never having a diagnosis to having a diagnosis.

A prospective, longitudinal, population-based retrospective study of adults that asks similar questions could offer a detailed profile of the ages at which an ASD diagnosis changes, as well as co-occurring conditions and interventions, the researchers said.

The authors had no financial relationships to disclose.

Children currently diagnosed with an autism spectrum disorder are more likely to have coexisting psychiatric or neurodevelopmental conditions than are children with a past but not current diagnosis, and these conditions might lead to a change in ASD diagnosis, suggest the findings of a cross-sectional study in the February issue of Pediatrics.

An estimated 1% of 8-year-old children (typically the peak age of prevalence) have an ASD, such as autistic disorder; pervasive developmental disorder, not otherwise specified (PDD-NOS); or Asperger’s syndrome, according to the Centers for Disease Control and Prevention. Co-occurring conditions often include attention-deficit/hyperactivity disorder, learning disability, depression, anxiety, and seizures. Also, more than 10% of children diagnosed with an ASD at age 2 years no longer have the diagnosis by age 9 years.

To provide an appropriate diagnosis and opportunities for early intervention, clinicians must be able to differentiate between the core features of an ASD and any coexisting conditions.

Using cross-sectional data from the National Survey of Children’s Health 2007 (NSCH), Heather A. Close, of the Center for Autism and Developmental Disabilities Epidemiology at Johns Hopkins University, Baltimore, and her colleagues examined the relationship between co-occurring conditions and changes in diagnosis of an ASD (Pediatrics 2012;129:305-16 [doi:10.1542/peds.2011-1217]). This study consisted of 1,366 children from the NSCH with a parent-reported current or a past but not current (PBNC) diagnosis of an ASD.

The study authors found that the type of co-occurring conditions varied by age. For example, 3- to 5-year-old children currently diagnosed with an ASD were 11 times more likely to have a moderate or severe learning disability and 9 times more likely to have a moderate or severe developmental delay than children with a PBNC diagnosis. They were nearly 5 times more likely to have two or more current co-occurring conditions than children with a PBNC diagnosis of an ASD.

Meanwhile, children aged 6-11 years with a current ASD diagnosis were almost 4 times more likely to have had a past speech problem and 3.5 times more likely to have current moderate or severe anxiety than children with a PBNC diagnosis. And, they were more than 3 times as likely to have two or more current co-occurring conditions as those with a PBNC diagnosis.

Finally, adolescents aged 12-17 years with a current ASD diagnosis were almost 4 times more likely to have moderate or severe speech problems and 10 times more likely to have current mild seizures or epilepsy than children with a PBNC diagnosis of ASD.

Children and adolescents with a current ASD diagnosis were more likely to have two or more co-occurring conditions than those with a PBNC diagnosis.

The study results suggest that some co-occurring conditions might, in part, lead to a change in an ASD diagnosis, although the underlying mechanisms for this change are unclear. In this study, the researchers focused on the possible impact that neurodevelopmental and psychiatric conditions could have on the continuation of ASD diagnosis by comparing groups who currently have an ASD diagnosis to groups with a PBNC diagnosis.

"Our results are in line with the few studies that have researched differences between current or past ASD diagnoses in the context of co-occurring conditions," Ms. Close and her colleagues wrote.

Children with ASDs have impaired communication, including delays in speech and acquisition of language, or delays in age-appropriate social skills. With increasing age, these symptoms appear more consistent with ASD than with what might have been considered a speech or hearing problem or a nonspecific developmental delay.

"This can also be true in the opposite direction, in which a child might have been diagnosed with an ASD because of the presence of common ASD co-occurring conditions or diagnoses and then was later reclassified as not having an ASD," the researchers said.

Possible reasons for reclassifying children previously diagnosed with an ASD include developmental improvements as the child ages, such as in IQ or adaptive social abilities, or a child no longer meeting the diagnostic criteria as a result of early intervention. "Improvements leading to a loss of an ASD diagnosis also occur more commonly in children diagnosed at an early age with PDD-NOS rather than with autistic disorder," the researchers said.

The limitations of this study included the fact that information was based on parent-reported diagnoses obtained through one telephone interview; the different outcomes among children and adolescents with autism, Asperger’s syndrome, and PDD-NOS; the small sample size for some variables of interest; and a lack of information on individual interventions for each study. Also, the study investigated children with a current or previous ASD diagnosis but did not specifically look at the change from never having a diagnosis to having a diagnosis.

A prospective, longitudinal, population-based retrospective study of adults that asks similar questions could offer a detailed profile of the ages at which an ASD diagnosis changes, as well as co-occurring conditions and interventions, the researchers said.

The authors had no financial relationships to disclose.

A new questionnaire that takes into consideration both patient and physician perspectives is designed to detect rheumatoid arthritis flares in between appointments, and also may enable patients to self-detect flare and immediately seek an appointment, according to a review of the tool published online Nov. 9 in Annals of the Rheumatic Diseases.

There is a lack of consensus about how to define and measure flare. For some, flares happen in the context of RA worsening over a significant period. This definition of flare does not take into consideration transient exacerbations that spontaneously resolve. Others define flare as any exacerbation, whether transient or long lasting.

At the same time, physicians tend to define flare based on objective signs and clinical features, while patients perceive flare according to symptoms and their effects on daily living.

The Flare Assessment in Rheumatoid Arthritis (FLARE) questionnaire melds both patient and physician perspectives, transient and present flares, explained Dr. Jean-Marie Berthelot, of the University of Nantes (France).

The self-administered part of the instrument was based on patient interviews, the findings from which were systematically analyzed to identify attributes patients most commonly used to describe RA flare and the frequency.

In all, 61% of the 99 patients interviewed reported that a flare usually starts with a feeling of swelling in the joints, and 11% mentioned frozen joints. All respondents reported increased pain of varying levels and an increased daily intake of analgesics. Other characteristics included depression (67%), sleep disturbances (77%), and increased fatigue (91%). Also, 96% reported repercussions on daily activities, 88% reported feeling a loss of independence, and 91% reported feeling more fragile emotionally during the flare. Only 9% reported flu-like symptoms.

"From this content analysis, we selected 10 domains to describe RA flare, according to the patient perspective," the researchers explained.

For the physician assessment part of the instrument, 13 rheumatologists participated in a Delphi exercise in which the researchers asked each to list 10 elements that best reflected RA flares. The researchers organized these into domains and eliminated items during a four-round Delphi process in which they selected items only when cited by at least 75% of the participants.

The patients and physicians had four domains in common: joint swelling, pain, sleep disturbance, and intake of analgesics. The common domains were merged, and the remaining domains also were included in the FLARE questionnaire.

However, several issues must be resolved. For example, a threshold of disease worsening is needed to define flare. Also, clarification about the duration of symptom exacerbation is necessary.

The tool needs to be validated in a prospective trial before it can be used to more tightly adjust treatment "based on the overall activity of RA between two visits," the investigators concluded. Once validated "it should be suitable for clinical research and might be for daily clinical practice," they wrote (Ann. Rheum. Dis. 2011 Nov. 9 [doi: 10.1136/ard.2011.150656]).

The study was funded by an unrestricted grant from Sanofi-Aventis France, but the company had no access to the data and was not involved in the study design or data analysis. The authors reported having no conflicts to disclose.

A new questionnaire that takes into consideration both patient and physician perspectives is designed to detect rheumatoid arthritis flares in between appointments, and also may enable patients to self-detect flare and immediately seek an appointment, according to a review of the tool published online Nov. 9 in Annals of the Rheumatic Diseases.

There is a lack of consensus about how to define and measure flare. For some, flares happen in the context of RA worsening over a significant period. This definition of flare does not take into consideration transient exacerbations that spontaneously resolve. Others define flare as any exacerbation, whether transient or long lasting.

At the same time, physicians tend to define flare based on objective signs and clinical features, while patients perceive flare according to symptoms and their effects on daily living.

The Flare Assessment in Rheumatoid Arthritis (FLARE) questionnaire melds both patient and physician perspectives, transient and present flares, explained Dr. Jean-Marie Berthelot, of the University of Nantes (France).

The self-administered part of the instrument was based on patient interviews, the findings from which were systematically analyzed to identify attributes patients most commonly used to describe RA flare and the frequency.

In all, 61% of the 99 patients interviewed reported that a flare usually starts with a feeling of swelling in the joints, and 11% mentioned frozen joints. All respondents reported increased pain of varying levels and an increased daily intake of analgesics. Other characteristics included depression (67%), sleep disturbances (77%), and increased fatigue (91%). Also, 96% reported repercussions on daily activities, 88% reported feeling a loss of independence, and 91% reported feeling more fragile emotionally during the flare. Only 9% reported flu-like symptoms.

"From this content analysis, we selected 10 domains to describe RA flare, according to the patient perspective," the researchers explained.

For the physician assessment part of the instrument, 13 rheumatologists participated in a Delphi exercise in which the researchers asked each to list 10 elements that best reflected RA flares. The researchers organized these into domains and eliminated items during a four-round Delphi process in which they selected items only when cited by at least 75% of the participants.

The patients and physicians had four domains in common: joint swelling, pain, sleep disturbance, and intake of analgesics. The common domains were merged, and the remaining domains also were included in the FLARE questionnaire.

However, several issues must be resolved. For example, a threshold of disease worsening is needed to define flare. Also, clarification about the duration of symptom exacerbation is necessary.

The tool needs to be validated in a prospective trial before it can be used to more tightly adjust treatment "based on the overall activity of RA between two visits," the investigators concluded. Once validated "it should be suitable for clinical research and might be for daily clinical practice," they wrote (Ann. Rheum. Dis. 2011 Nov. 9 [doi: 10.1136/ard.2011.150656]).

The study was funded by an unrestricted grant from Sanofi-Aventis France, but the company had no access to the data and was not involved in the study design or data analysis. The authors reported having no conflicts to disclose.

A new questionnaire that takes into consideration both patient and physician perspectives is designed to detect rheumatoid arthritis flares in between appointments, and also may enable patients to self-detect flare and immediately seek an appointment, according to a review of the tool published online Nov. 9 in Annals of the Rheumatic Diseases.

There is a lack of consensus about how to define and measure flare. For some, flares happen in the context of RA worsening over a significant period. This definition of flare does not take into consideration transient exacerbations that spontaneously resolve. Others define flare as any exacerbation, whether transient or long lasting.

At the same time, physicians tend to define flare based on objective signs and clinical features, while patients perceive flare according to symptoms and their effects on daily living.

The Flare Assessment in Rheumatoid Arthritis (FLARE) questionnaire melds both patient and physician perspectives, transient and present flares, explained Dr. Jean-Marie Berthelot, of the University of Nantes (France).

The self-administered part of the instrument was based on patient interviews, the findings from which were systematically analyzed to identify attributes patients most commonly used to describe RA flare and the frequency.

In all, 61% of the 99 patients interviewed reported that a flare usually starts with a feeling of swelling in the joints, and 11% mentioned frozen joints. All respondents reported increased pain of varying levels and an increased daily intake of analgesics. Other characteristics included depression (67%), sleep disturbances (77%), and increased fatigue (91%). Also, 96% reported repercussions on daily activities, 88% reported feeling a loss of independence, and 91% reported feeling more fragile emotionally during the flare. Only 9% reported flu-like symptoms.

"From this content analysis, we selected 10 domains to describe RA flare, according to the patient perspective," the researchers explained.

For the physician assessment part of the instrument, 13 rheumatologists participated in a Delphi exercise in which the researchers asked each to list 10 elements that best reflected RA flares. The researchers organized these into domains and eliminated items during a four-round Delphi process in which they selected items only when cited by at least 75% of the participants.

The patients and physicians had four domains in common: joint swelling, pain, sleep disturbance, and intake of analgesics. The common domains were merged, and the remaining domains also were included in the FLARE questionnaire.

However, several issues must be resolved. For example, a threshold of disease worsening is needed to define flare. Also, clarification about the duration of symptom exacerbation is necessary.

The tool needs to be validated in a prospective trial before it can be used to more tightly adjust treatment "based on the overall activity of RA between two visits," the investigators concluded. Once validated "it should be suitable for clinical research and might be for daily clinical practice," they wrote (Ann. Rheum. Dis. 2011 Nov. 9 [doi: 10.1136/ard.2011.150656]).

The study was funded by an unrestricted grant from Sanofi-Aventis France, but the company had no access to the data and was not involved in the study design or data analysis. The authors reported having no conflicts to disclose.