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Saturday, September 1, 2018

Depression and Death

Depression is known to be associated with increased mortality. This has little to do with the well-known impact of depression on suicide risk. The risk of suicide, usually in the range of 10-15 per 100,000 person-years, it not enough to make have a big impact on life-expectancy. The bigger effect is due to an elevated frequency of deaths due to the most common causes: cardiovascular disease in particular. However, the treatment of depression has not been shown to diminish cardiovascular mortality in most studies that have looked at this. We've recently explored this association in an epidemiological study in Canada: available here. We found that there was an elevated risk of death in people with depression, but that this was largely due to other features that are associated with depression such as chronic diseases (e.g. diabetes, hypertension) and other risk factors such as smoking. Of course, this doesn't mean that depression is not at the root of the problem, since depression can increase the risk of chronic disease (see a Canadian study here), and can also modify other risk factor exposures, e.g. people with depression are more likely to start and less likely to quit smoking. The bottom line seems to be that physical health should be a big priority for people living with depression.

Wednesday, April 11, 2018

Medical Assistance in Dying (MAID)

This is an especially controversial topic in psychiatry and in the area of depression, where a wish to die may be a symptom of the illness (thoughts of death or suicide are one of the nine symptoms that comprise the A criteria for major depressive episode in DSM-5) or a response, particularly in treatment resistant depression, to the suffering that is associated with this condition. An interesting discussion of this issue was published in the Canadian Journal of Psychiatry - click HERE to read the piece.

Sunday, February 4, 2018

Melancholy and Depression in Paintings

University of Calgary Professor Peter Toohey has produced a fascinating collection images of depression and melancholy in art, which is available to see at his blog, which you can see by clicking here. He is also interested in other emotions, such as boredom and has collections of images for those too. This gallery presents many themes connected to depression through art, including geometry, which is interesting, but there are also religious and musical themes. It is a very interesting experience to scroll through these images.

There are several other interesting collections on this same theme:  click here.

Wednesday, December 13, 2017

Major Depression Epidemiology in Canada

Traditionally, information about psychiatric epidemiology (including the patterns of major depression in Canada) has come from national surveys, such as the two major surveys conducted by Statistics Canada on mental health. One of these was conducted in 2002 and another in 2012. However, a lot of information is available from general health surveys too - and of course from other data sources. The challenge when there are bits and pieces of information available from different sources is to be able to synthesize this information in a meaningful way. Fortunately, there are good statistical tools available for this task. Many of the posts in this blog have described specific results from these data synthesis strategies. In 2015 I presented an update of some of these results at a conference sponsored by Canada's Research Data Centres. The presentation is available on Youtube, if you would like to see it, please click here.

This supplements early summaries (including an earlier one that is recorded on Youtube also, to see it click here). A more formal summary of some of the basic descriptive epidemiology has been published in the Canadian Journal of Psychiatry, here.

Monday, August 21, 2017

Major Depression and Secondhand Smoke Exposure

Epidemiologically, the association between smoking and common mental disorders is well characterized, it has been consistently observed in population-based studies. I don't think that the association has been taken very seriously. This is a shame because the settings in which the common mood and anxiety disorders are managed are well situated to help people quit smoking. A recent meta-analysis of studies of smoking cessation that included mental health outcome measures indicated that improvements that follow smoking cessation resemble those of antidepressant medications (when quantified as effect sizes) [1]. This challenges the perceptions that are gained by mental health professionals and people who smoke - which is that smoking makes them feel better, something that is undoubtedly true in the short term during nicotine withdrawal. Over the longer term, it appears that smoking cessation leads to improvements in mental health. Mental health professionals may have a tendency to assume that people smoke to self-medicate their symptoms and because of this assumption may have neglected to energetically tackle smoking cessation. Another angle is that of secondhand smoke exposure. Secondhand smoke inhalation has many of the adverse biological effects of smoking, which include things like increased markers of inflammation [2] but it is unlikely that people would inhale secondhand smoke for self-medication purposes. We recently looked at whether secondhand smoke exposure is associated with major depression in the general population of Canada - and found that it is strongly and consistently associated [3].

There is increasing evidence that smoking cessation should be a component of psychiatric treatments, and clinicians should be aware that secondhand smoke exposure may be something that contributes to poor outcomes among their patients. People who've struggled with depression should seek to quit - it is short term pain for long-term gain. They should also avoid secondhand smoke "like the plague."

1.  Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., Aveyard, P., 2014. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 348, pp. g1151

2.  Jefferis, B.J., Lowe, G.D., Welsh, P., Rumley, A., Lawlor, D.A., Ebrahim, S., Carson, C., Doig, M., Feyerabend, C., McMeekin, L., Wannamethee, S.G., Cook, D.G., Whincup, P.H., 2010. Secondhand smoke (SHS) exposure is associated with circulating markers of inflammation and endothelial function in adult men and women. Atherosclerosis 208, pp. 550-556

3. http://www.sciencedirect.com/science/article/pii/S0165032717300551

Friday, March 17, 2017

Decision Support Tools for People with Depression

For years decision support tools have been available for certain diseases, but not usually for mental health. However, there has recently been an emergence of some on-line calculators for supporting important clinical decisions such as "should I take an antidepressant" and "should I stop my antidepressant." The extent of evidence underpinning the decision support is difficult to discern, but these tools are interesting because they walk a person though a decision making process, soliciting ratings from the decision-maker to inform the final decision.

Saturday, November 19, 2016

Chronic Conditions and Major Depression

When I was training (many years ago) in Psychiatry, all of the textbooks used to have long lists of medical conditions that could "cause" depression. The idea was that such lists would serve as a reminder that physical causes should be considered when assessing patients. For example, if there was a reason to suspect hypothyroidism, then that patient's thyroid should be checked. However, in current times this way of thinking - that depression would be distinguished as being "caused" by a physical OR a psychological cause seems very simplistic. Certainly, there are physical mechanisms that could link some chronic conditions to depression, but every chronic condition can have psychological and social implications too. Depression likely arises as a result of the multiple contributing causes in every case, not a different single cause in different cases. We recently conducted an analysis of national survey data to look at patterns of association between major depressive episodes and various chronic medical conditions. The meta-analysis (published here) uncovered three previously undescribed patterns of association. First, we found that most conditions are more strongly associated with depression in younger people. This effect was most prominent for high blood pressure and cancer. I believe that this probably indicates that developing such a condition is more stressful and threatening for a younger than older person. This is of course mere speculation. This was not a universal pattern. Migraine was an exception: the strength of association increased with age, especially in men. Second, especially for conditions predominantly affecting older age groups (arthritis, diabetes, back pain, cataracts, effects of stroke and heart disease) an epidemiological occurrence called confounding (by age) was evident. Because depression prevalence diminishes with age, and because these conditions affect older people, statistical adjustments were needed to see the true association. Finally, a surprising result was that thryoid disease, long considered the "classical" physical cause of depression, was only weakly associated with depression, and only in women. Epilepsy, had a unique pattern than didn't depend on age or sex.