Mental Health

"Depression and Incident Stroke in Women"
An Pan, PhD; Olivia I. Okereke, MD, SM; Qi Sun, MD, ScD; Giancarlo Logroscino, MD, PhD; JoAnn E. Manson, MD, DrPH; Walter C. Willett, MD, DrPH; Alberto Ascherio, MD, DrPH; Frank B. Hu, MD, PhD; Kathryn M. Rexrode, MD
STROKEAHA.111.617043 Published online before print August 11, 2011, doi: 10.1161/​STROKEAHA.111.617043

Abstract

Background and Purpose—Depression has been associated with an increased risk of coronary heart disease, but prospective data for the association with stroke are limited.

Methods—We followed-up 80 574 women aged 54 to 79 years in Nurses' Health Study without a history of stroke from 2000 to 2006. Depressive symptoms were assessed at multiple time points by a Mental Health Index score (1992, 1996, and 2000), and clinical significant depressive symptoms were defined as a score ≤52. Antidepressant medication use was asked biennially beginning in 1996, and physician-diagnosed depression was reported biennially beginning in 2000. Depression was defined as currently reporting or having a history of any of these 3 conditions.

Results—During 6 years of follow-up, 1033 incident strokes were documented (538 ischemic, 124 hemorrhagic, and 371 unknown strokes). Having a history of depression was associated with a multivariate-adjusted hazard ratio (HR) of 1.29 (95% confidence interval [CI], 1.13–1.48) for total stroke. Women who used antidepressant medications were at increased risk for stroke, whether they also had a Mental Health Index score ≤52 or diagnosed depression (HR, 1.39; 95% CI, 1.15–1.69) or not (HR, 1.31; 95% CI, 1.03–1.67). Furthermore, for each cycle, participants who reported current depression had an increased risk of stroke (HR, 1.41; 95% CI, 1.18–1.67), whereas individuals who only had a history of depression were at nonsignificantly elevated risk (HR, 1.23; 95% CI, 0.97–1.56) compared with women who never reported a diagnosis of depression or antidepressant medication use.

Conclusions—Our results suggest that depression is associated with a moderately increased risk of subsequent stroke.

From Medical News Today summary:

Women who suffer from depression have a 29% higher risk of having a stroke, researchers from Brigham and Women's Hospital in Boston, Mass. and Harvard Medical School wrote in the journal Stroke. Those on SSRIs (selective serotonin reuptake inhibitors), such as Celexa, Zoloft or Prozac, have a 39% higher risk, the authors informed.

The researchers carried out a six-year follow-up in the Nurses' Health Study involving 80,574 women aged 54 to 79 years from 2000 to 2006. None of them had a history of stroke.

Senior author, Dr. Kathryn Rexrode said that anti-depressant drug use could be an indication of depression severity.

Dr. Rexrode stated:

"I don't think the medications themselves are the primary cause of the risk. This study does not suggest that people should stop their medications to reduce the risk of stroke."

In their study, the researchers assessed symptoms of depression several times with a Mental Health Index. Patients' use of anti-depressants was reported every 24 months, starting in 1996, and doctors diagnosed depression starting in 2000. They defined depression as either having a history of depression or a current diagnosis.

22% of the women had depression at baseline. During the six-year follow-up period there were 1,033 cases of stroke.

The investigators found that women with depression were more likely to be smokers, with a higher body mass index, younger, less physically active, and single when compared to those with no history of depression. Women with depression also tended to have more coexisting conditions, such as diabetes, hypertension or heart disease.

...

From the press release: 

Women who reported experiencing gender-based violence, such as rape, sexual assault, intimate partner violence and stalking, had an associated higher lifetime prevalence of mental health disorders, dysfunction and disability, according to a study in the August 3 issue of JAMA, a theme issue on violence and human rights.

Violence against women is a major public health concern, contributing to high levels of illness and death worldwide, according to background information in the article. "In the United States, 17 percent of women report rape or attempted rape and more than one-fifth of women report intimate partner violence (IPV), stalking, or both. There is mounting evidence that each of these forms of gender-based violence (GBV) is associated with mental disorder among women, although methodological shortcomings of existing studies constrain the inferences that can be drawn," the authors write.

Susan Rees, Ph.D., of the University of New South Wales, Sydney, New South Wales, Australia, and colleagues assessed the association of a composite index of GBV (rape, sexual abuse, IPV, and stalking) with a range of lifetime mental disorders, including indices of severity and co-existing illnesses. The researchers analyzed data from the Australian National Mental Health and Well-being Survey of 2007, which included 4,451 women (65 percent response rate), ages 16 to 85 years. Diagnostic criteria from the World Health Organization's World Mental Health Survey Initiative was used to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD).

The researchers found that the lifetime prevalence for any mental disorder was 37.8 percent. A total of 1,218 women (27.4 percent) reported experiencing at least 1 of the types of GBV assessed in this study. The lifetime prevalence rates were 14.7 percent for sexual assault, 10 percent for stalking, 8.1 percent for rape, and 7.8 percent for IPV. Women who had been exposed to 1 form of GBV reported a high rate of lifetime mood disorder (weighted, 30.7 percent), lifetime anxiety disorder (38.5 percent), lifetime substance use disorder (23.0 percent), lifetime PTSD (15.2 percent), and any lifetime mental disorder (57.3 percent).

...

The researchers also found that gender-based violence was associated with more severe current mental disorder, higher rates of 3 or more lifetime disorders, physical disability, mental disability, impaired quality of life, an increase in disability days, and overall disability.

...

Lifetime Prevalence of Gender-Based Violence in Women and the Relationship With Mental Disorders and Psychosocial Function
Susan Rees, Derrick Silove, Tien Chey, Lorraine Ivancic, Zachary Steel, Mark Creamer, Maree Teesson, Richard Bryant, Alexander C. McFarlane, Katherine L. Mills, Tim Slade, Natacha Carragher, Meaghan O'Donnell, David Forbes
JAMA. 2011;306(5):513-521.
doi:10.1001/jama.2011.1098 [[fee]

Context: Intimate partner physical violence, rape, sexual assault, and stalking are pervasive and co-occurring forms of gender-based violence (GBV). An association between these forms of abuse and lifetime mental disorder and psychosocial disability among women needs to be examined.

Objectives: To assess the association of GBV and mental disorder, its severity and comorbidity, and psychosocial functioning among women.

Design, Setting, and Participants: A cross-sectional study based on the Australian National Mental Health and Well-being Survey in 2007, of 4451 women (65% response rate) aged 16 to 85 years.

Main Outcome Measures: The Composite International Diagnostic Interview version 3.0 of the World Health Organization's World Mental Health Survey Initiative was used to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD). Also included were indices of lifetime trauma exposure, including GBV, sociodemographic characteristics, economic status, family history of mental disorder, social supports, general mental and physical functioning, quality of life, and overall disability.

Results: A total of 1218 women (27.4%) reported experiencing at least 1 type of GBV. For women exposed to 3 or 4 types of GBV (n = 139), the rates of mental disorders were 77.3% (odds ratio [OR], 10.06; 95% confidence interval [CI], 5.85-17.30) for anxiety disorders, 52.5% (OR, 3.59; 95% CI, 2.31-5.60) for mood disorder, 47.1% (OR, 5.61; 95% CI, 3.46-9.10) for substance use disorder, 56.2% (OR, 15.90; 95% CI, 8.32-30.20) for PTSD, 89.4% (OR, 11.00; 95% CI, 5.46-22.17) for any mental disorder, and 34.7% (OR, 14.80; 95% CI, 6.89-31.60) for suicide attempts. Gender-based violence was associated with more severe current mental disorder (OR, 4.60; 95% CI, 2.93-7.22), higher rates of 3 or more lifetime disorders (OR, 7.79; 95% CI, 6.10-9.95), physical disability (OR, 4.00; 95% CI, 1.82-8.82), mental disability (OR, 7.14; 95% CI, 2.87-17.75), impaired quality of life (OR, 2.96; 95% CI, 1.60-5.47), an increase in disability days (OR, 3.14; 95% CI, 2.43-4.05), and overall disability (OR, 2.73; 95% CI, 1.99-3.75).

Conclusion: Among a nationally representative sample of Australian women, GBV was significantly associated with mental health disorder, dysfunction, and disability.

T. M. Greer. Coping Strategies as Moderators of the Relation Between Individual Race-Related Stress and Mental Health Symptoms for African American Women.Psychology of Women Quarterly, 2011; 35 (2): 215 DOI:10.1177/0361684311399388 

Abstract

The purpose of this investigation was to examine coping strategies as moderators of the relationship between individual race-related stress and mental health symptoms among a sample of 128 African American women. Coping strategies refer to efforts used to resolve problems and those used to manage, endure, or alleviate distress. Culture-specific strategies were examined in the current study (i.e., efforts that are commonly used by members of a cultural group). Culture-specific efforts were hypothesized to influence the severity of psychological symptoms associated with individual race-related stress, such that frequent use of culture-specific efforts would lessen the strength of the relationship between race-related stress and psychological symptoms. Moderated hierarchical regression analyses revealed that high use of ritual-centered strategies to address race-related stress was related to severe anxiety and interpersonal sensitivity. No moderating effect of coping strategies was found for depression, obsessive-compulsion, and somatization symptoms. The findings suggest that African American women may inadvertently utilize coping efforts that serve to increase the severity of psychological symptoms related to individual race-related stress. Mental health professionals should explore underlying emotions related to coping efforts utilized to address race-related stress among African American women.

From the Winnipeg Free Press:

HALIFAX -- The Canadian military and Veterans Affairs are trying to understand why current and former female personnel in their early 40s were more than twice as likely to die from suicide as their civilian counterparts.

Groundbreaking research by the two departments and Statistics Canada has shown a statistically higher rate in the number of suicide deaths in female former service personnel between the ages of 40 to 44, compared to their civilian counterparts.

The Canadian Forces Cancer and Mortality Study also found a comparative difference in the suicide rate among women of the same age in the military.

There were 37 suicides by women in all age groups who were serving or released from the military, with 29 occurring among females years after they left the Canadian Forces.

Men ages 16 to 44 who had been released from the military also had a higher risk of death by suicide when compared to the same male civilian age group.

The research also found that people who served from 1972 to 1986 had a greater risk of committing suicide.

Gender Differences in Combat-Related Stressors and Their Association With Postdeployment Mental Health in a Nationally Representative Sample of U.S. OEF/OIF Veterans

Abstract

Though the broader literature suggests that women may be more vulnerable to the effects of trauma exposure, most available studies on combat trauma have relied on samples in which women’s combat exposure is limited and analyses that do not directly address gender differences in associations between combat exposure and postdeployment mental health. Female service members’ increased exposure to combat in Afghanistan and Iraq provides a unique opportunity to evaluate gender differences in different dimensions of combatrelated stress and associated consequence for postdeployment mental health. The current study addressed these research questions in a representative sample of female and male U.S. veterans who had returned from deployment to Afghanistan or Iraq within the previous year. As expected, women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). No gender differences were observed in reports of perceived threat in the war zone. Though it was hypothesized that combat-related stressors would demonstrate stronger negative associations with postdeployment mental health for women, only one of 16 stressor
gender interactions achieved statistical significance and an evaluation of the clinical significance of these interactions revealed that effects were trivial. Results suggest that female Operation Enduring Freedom/Operation Iraqi Freedom service members may be as resilient to combat-related stress as men. Future research is needed to evaluate gender differences in the longer-term effects of combat exposure.

Women Warriors Show Resilience Similar to Men

From the press release:

WASHINGTON—Women service members who experience combat are apparently as resilient as the men they serve alongside, according to a study published by the American Psychological Association. 

Men and women deployed to Iraq and Afghanistan in 2007 and 2008 experienced very similar levels of combat-related stress and post-deployment mental health impacts during the first year following return from deployment, researchers reported in the Journal of Abnormal Psychology, published by APA.

The findings are particularly significant given the recent call for the Pentagon to reverse its longstanding policy that bars women from ground combat, Vogt said. As of 2009, more than 750 women had been wounded or killed in action during Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom, the paper states.

The research was based on survey responses from 595 service members drawn from a random sample from the Defense Manpower Data Center roster. It included 340 women and 252 men from active duty, National Guard, and Reserve forces. The women, on average, were three years younger and more likely to belong to a racial/ethnic minority group.  The men were more likely to be married, living with children, have higher incomes and to have served in the Marine Corps during their deployment. 

Researchers used stress measures that included exposure to combat involving firing a weapon, being fired on, and witnessing injury and death; experiencing consequences of combat, such as observing or handling human remains and dealing with detainees; enduring difficult living situations in the war zone; and fearing for one’s safety and well-being.

As expected, men reported more exposure to combat and battle aftermath, as well as difficult living conditions. “The fact that these differences were relatively small, however, suggests that women’s exposure to these stressors in [Iraq and Afghanistan] may be, on average, only slightly lower than men’s exposure on average,” the study states.

Few gender differences were reported in post-deployment mental health. Specifically, levels of post-traumatic stress, mental health functioning, and depression were similar, though scores on substance abuse were higher for men than women.

The findings could reflect improved training of female service members in recent years and that combat duty may equalize risk due to its persistent level of threat, according to the study.

Summary:

Changes in patient demographics present unique challenges for VA in providing safe environments for all veterans treated in Department of Veterans Affairs (VA) facilities. GAO was asked to examine whether or not sexual assault incidents are fully reported and what factors may contribute to any observed underreporting, how facility staff determine sexual assault-related risks veterans may pose in residential and inpatient mental health settings, and precautions facilities take to prevent sexual assaults and other safety incidents. GAO reviewed relevant laws, VA policies, and sexual assault incident documentation from January 2007 through July 2010 provided by VA officials and the VA Office of the Inspector General (OIG). In addition, GAO visited and reviewed portions of selected veterans' medical records at five judgmentally selected VA medical facilities chosen to ensure the residential and inpatient mental health units at the facilities varied in size and complexity. Finally, GAO spoke with the four Veterans Integrated Service Networks (VISN) that oversee these VA medical facilities.

GAO found that many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Specifically, for the four VISNs GAO spoke with, VISN and VA Central Office officials did not receive reports of most sexual assault incidents reported to the VA police. Also, nearly two-thirds of sexual assault incidents involving rape allegations originating in VA facilities were not reported to the VA OIG, as required by VA regulation. In addition, GAO identified several factors that may contribute to the underreporting of sexual assault incidents including unclear guidance and deficiencies in VA's oversight. VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs and inpatient mental health units GAO visited said they examine information about veterans' legal histories along with other personal information as part of a multidisciplinary assessment process. VA clinicians reported that they obtain legal history information directly from veterans, but these self-reported data are not always complete or accurate. In reviewing selected veterans' medical records, GAO found that complete legal history information was not always documented. In addition, VA has not provided clear guidance on how such legal history information should be collected or documented. VA facilities GAO visited used a variety of precautions intended to prevent sexual assaults and other safety incidents; however, GAO found some of these measures were deficient, compromising facilities' efforts to prevent sexual assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans' medical records or increasing staff observation of veterans who posed risks to others. These VA facilities also used physical security precautions--such as closed-circuit surveillance cameras to actively monitor units, locks and alarms to secure key areas, and police assistance when incidents occurred. These physical precautions were intended to prevent a broad range of safety incidents, including sexual assaults, through monitoring patients and activities, securing residential programs and inpatient mental health units, and educating staff about security issues and ways to deal with them. However, GAO found significant weaknesses in the implementation of these physical security precautions at these VA facilities, including poor monitoring of surveillance cameras, alarm system malfunctions, and the failure of alarms to alert both VA police and clinical staff when triggered. Inadequate system installation and testing procedures contributed to these weaknesses. Further, facility officials at most of the locations GAO visited said the VA police were understaffed. Such weaknesses could lead to delayed response times to incidents and seriously erode efforts to prevent or mitigate sexual assaults and other safety incidents. GAO recommends that VA improve both the reporting and monitoring of sexual assault incidents and the tools used to identify risks and address vulnerabilities at VA facilities. VA concurred with GAO's recommendations and provided an action plan to address them.

From the Los Angeles Times article: