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Increased risk of depressive disorder within 1 year after diagnosis with urinary calculi in Taiwan
Psychiatry Research 198 (2012) 332–333
Contents lists available at SciVerse ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Increased risk of depressive disorder within 1 year after diagnosis with urinary calculi in Taiwan Shiu-Dong Chung a, b, c, d, e, Joseph J. Keller f, Herng-Ching Lin e,⁎ a
Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Department of Urology, National Taiwan University Hospital, Taipei, Taiwan d Department of Electronic Engineering, Oriental Institute of Technology, Ban Ciao, Taipei, Taiwan e School of Health Care Administration, Taipei Medical University, Taipei, Taiwan f School of Medical Laboratory Sciences and Biotechnology, Taipei Medical University, Taipei, Taiwan b c
a r t i c l e
i n f o
Article history: Received 12 July 2011 Received in revised form 7 December 2011 Accepted 6 January 2012 Keywords: Urinary calculi Depressive disorder Epidemiology
a b s t r a c t This study investigated the risk of subsequent depressive disorders (DD) following a diagnosis of urinary calculi (UC) in Taiwan. In total, 67,917 adult patients newly diagnosed with UC were recruited, along with 153,951 age-matched enrollees who were used as a comparison group. A stratified Cox proportional hazard regression analysis revealed that the adjusted hazard of DD within a 1-year period following diagnosis with UC was 1.75 times greater for patients with UC than for comparison patients. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction A diagnosis of urinary calculi (UC), characterized by the existence of solid deposits in the urinary tract (Hesse et al., 2003), has a high prevalence worldwide. There is limited information concerning the association between depressive disorders and stone diseases. The only study conducted to date was a case–control study of 200 stone formers and 200 matched controls which demonstrated that there was an increased frequency of stressful events in the 2 years preceding stone diagnosis (Najem et al., 1997). The present study investigated the risk of subsequent depressive disorders following a diagnosis of UC in Taiwan using nationwide population-based data.
2. Methods 2.1. Database The data used in this study were obtained from the “Longitudinal Health Insurance Database (LHID2000)”, which was derived from the Taiwan National Health Insurance (NHI) program. The LHID2000 consists of the registration files and original medical claims of 1,000,000 enrollees randomly selected from all the enrollees (n = 23.72 million) listed
⁎ Corresponding author at: School of Health Care Administration, Taipei Medical University, 250 Wu-Hsing St., Taipei 110, Taiwan. Tel.: + 886 2 2736 1661x3613; fax: + 886 2 2378 9788. E-mail address: [email protected] (H.-C. Lin). 0165-1781/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2012.01.007
in the 2000 Registry of Beneficiaries under the NHI program. The LHID2000 has been used by many researchers in their research and publications. 2.2. Study sample This investigation analyzed a study group and a comparison group. A total of 67,917 patients were identified who received a diagnosis of UC (ICD-9-CM codes 592 (calculus of kidney and ureter), 592.0 (calculus of kidney), 592.1 (calculus of ureter) or 592.9 (urinary calculus, unspecified)) in their ambulatory care visits (outpatient department of hospitals or clinics) between January 1, 2001 and December 31, 2007. The first ambulatory care visit with a diagnosis of UC occurring during the period between 2001 and 2007 was assigned as the index date. We excluded patients aged below 18 years (n = 793), and anyone who received either a diagnosis of UC (n = 12,761) or depressive disorder (n = 3,046) (ICD-9-CM codes 296.2, 296.3, 300.4, and 311) before their index date. As a result, 51,317 patients with UC were included in the study group. A total of 153,951 comparison subjects (three for every patient with UC) were extracted to match the study cohort on sex, age group (b30, 30–39, 40–49, 50–59, 60–69, and >69), and year of index date. The first ambulatory care visit occurring in the index year was assigned as the index date. All selected subjects were aged 18 years or over and never received any diagnosis of UC between 1996 and 2008. Neither had any selected subjects in the comparison group received a diagnosis of depressive disorder before the index date. 2.3. Statistical analysis Pearson χ2 tests were used to compare differences in monthly income, geographic location, and urbanization level of patients' residences between the study group and comparison group. Stratified Cox proportional hazard regression analysis (stratified by sex, age group, and year of index ambulatory care visit) was performed to investigate the risk of subsequent depressive disorder during the 1-year follow-up period for patients with and without UC.
S.-D. Chung et al. / Psychiatry Research 198 (2012) 332–333
333
Table 1 Crude and covariate-adjusted hazard ratios for depressive disorder among the sampled patients during the 1-year follow-up, starting from the index date. Development of depression
5-year follow-up period Yes No Crude HR (95% CI) Adjusteda HR (95% CI)
Total sample
Patients with urinary calculi
Comparison patients
N = 205,268
N = 51,317
N = 153,951
No.
%
No.
%
No.
%
2050 203,218 –
1.00 99.00
751 50,566 1.74⁎(1.59–1.91) 1.75⁎(1.60–1.92)
1.46 98.54
1299 152,652 1.00 1.00
0.84 99.16
Note: HR = hazard ratio; HR was calculated by stratified Cox proportional hazard regression, which was stratified by sex, age group, and the year of index ambulatory care visit. a Adjustments were made for patients' geographical location, urbanization level, and monthly income. ⁎ p b 0.001.
3. Results The total study population included 205,268 subjects with a mean age of 47.3 (±15.6 years). Table 1 presents the incidence of depressive disorder within the 1-year period following diagnosis with UC. Of the 205,268 patients in the study sample, 2050 (1.00%) received a diagnosis of depressive disorder during the 1-year follow-up period. These included 751 (1.46% of patients with UC) from the study group and 1299 (0.84% of patients without UC) from the comparison group. After adjustment for the patients' monthly income, geographic location and urbanization level, stratified Cox proportional analysis (stratified by age group, gender, and year of index ambulatory care visit) revealed that the hazard of depressive disorder during the 1year period following diagnosis with UC was 1.75 (95% confidence interval = 1.60–1.92, p = 0.010) times greater for patients with UC than for patients in the comparison group. 4. Discussion This is the first study to demonstrate a significantly increased risk of depressive disorder during the first year following a new diagnosis with UC. Cox proportional hazard analysis, stratified by age group, gender, and year of index date, revealed that the hazard of depressive disorder during the 1-year follow-up period was 1.75 times greater for patients with UC than for those without UC. UC most commonly presents with pain, usually with episodes of renal stone colic (Tiselius, 2003). Diseases characterized by recurrent episodes of pain, including nephrolothiasis, headache, musculoskeletal pain, fibromyalgia, rheumatoid arthritis, chronic pancreatitis, and coronary artery disease, have been shown to be strongly associated with poor physical and mental health (Bingefors and Isacson, 2004; Diniz et al., 2007). A recent study also reported that there is an association between chronic migraine or painkiller overuse and major depression and anxiety disorders (Curone et al., 2011). The results of the present study partly support the concept proposed by Diniz et al. that there is an association between recurrent renal colic and symptoms of both anxiety and depression (Diniz et al., 2007). Another case–control study examined stressful life events in patients with recurrent renal stones by calculating the mean score on the Social Readjustment Rating Scale and demonstrated that stone formers had significantly higher ratings than controls (Diniz et al., 2006). This evidence suggests that relapsed UC is associated with depressive mood and/or depression. The study's strengths include the use of a population-based dataset, which enabled the tracing of UC cases and identification of depressive disorder diagnoses during the study period. The dataset's large sample size also afforded a considerable statistical advantage for detecting real differences between the two groups. However,
this study also suffered from a few limitations. First, the diagnosis of UC and depressive disorders relied on administrative claims data reported by physicians and hospitals. This may have been less accurate than diagnoses made according to standardized criteria. Second, patient information, such as a history of physical inactivity, smoking, alcohol consumption, family history, body mass index, and medication use, all of which may have contributed to depression, was not available through the administrative dataset. Thus, the association between UC and depressive disorders may be partially explained by the residual confounding of these factors. Third, there may have been a surveillance bias, as those patients with UC would have been more likely to have frequent outpatient clinic visits, which would in turn have led to an earlier detection of depressive disorders. Finally, as this study was limited to a Han Chinese population, caution should be exercised before extrapolating these results to other ethnicities. The present study demonstrated an association between UC and an increased risk of subsequent depressive disorders during a 1year follow-up period. Health care workers in both primary and urologic settings should be alert to the increased prevalence of symptoms of clinical depression in this population. Acknowledgments This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, Taiwan and managed by the National Health Research Institutes. The interpretations and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or the National Health Research Institutes. References Bingefors, K., Isacson, D., 2004. Epidemiology, comorbidity, and impact on healthrelated quality of life of self-reported headache and musculoskeletal pain: a gender perspective. European Journal of Pain 8, 435–450. Curone, M., Tullo, V., Mea, E., Proietti-Cecchini, A., Peccarisi, C., Bussone, G., 2011. Psychopathological profile of patients with chronic migraine and medication overuse: study and findings in 50 cases. Italian Journal of Neurological Sciences 32, S177–S179. Diniz, D.H., Schor, N., Blay, S.L., 2006. Stressful life events and painful recurrent colic of renal lithiasis. The Journal of Urology 176, 2483–2487. Diniz, D.H., Blay, S.L., Schor, N., 2007. Anxiety and depression symptoms in recurrent painful renal lithiasis colic. Brazilian Journal of Medical and Biological Research 40, 949–955. Hesse, A., Brändle, E., Wilbert, D., Köhrmann, K.U., Alken, P., 2003. Study on the prevalence and incidence of urolithiasis in Germany comparing the years 1979 vs 2000. European Urology 44, 709–713. Najem, G.R., Seebode, J.J., Samady, A.J., Feuerman, M., Friedman, L., 1997. Stressful life events and risk of symptomatic kidney stones. International Journal of Epidemiology 26, 1017–1023. Tiselius, A.G., 2003. Epidemiology and medical management of stone disease. BJU International 91, 758–767.
Contents lists available at SciVerse ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Increased risk of depressive disorder within 1 year after diagnosis with urinary calculi in Taiwan Shiu-Dong Chung a, b, c, d, e, Joseph J. Keller f, Herng-Ching Lin e,⁎ a
Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Department of Urology, National Taiwan University Hospital, Taipei, Taiwan d Department of Electronic Engineering, Oriental Institute of Technology, Ban Ciao, Taipei, Taiwan e School of Health Care Administration, Taipei Medical University, Taipei, Taiwan f School of Medical Laboratory Sciences and Biotechnology, Taipei Medical University, Taipei, Taiwan b c
a r t i c l e
i n f o
Article history: Received 12 July 2011 Received in revised form 7 December 2011 Accepted 6 January 2012 Keywords: Urinary calculi Depressive disorder Epidemiology
a b s t r a c t This study investigated the risk of subsequent depressive disorders (DD) following a diagnosis of urinary calculi (UC) in Taiwan. In total, 67,917 adult patients newly diagnosed with UC were recruited, along with 153,951 age-matched enrollees who were used as a comparison group. A stratified Cox proportional hazard regression analysis revealed that the adjusted hazard of DD within a 1-year period following diagnosis with UC was 1.75 times greater for patients with UC than for comparison patients. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction A diagnosis of urinary calculi (UC), characterized by the existence of solid deposits in the urinary tract (Hesse et al., 2003), has a high prevalence worldwide. There is limited information concerning the association between depressive disorders and stone diseases. The only study conducted to date was a case–control study of 200 stone formers and 200 matched controls which demonstrated that there was an increased frequency of stressful events in the 2 years preceding stone diagnosis (Najem et al., 1997). The present study investigated the risk of subsequent depressive disorders following a diagnosis of UC in Taiwan using nationwide population-based data.
2. Methods 2.1. Database The data used in this study were obtained from the “Longitudinal Health Insurance Database (LHID2000)”, which was derived from the Taiwan National Health Insurance (NHI) program. The LHID2000 consists of the registration files and original medical claims of 1,000,000 enrollees randomly selected from all the enrollees (n = 23.72 million) listed
⁎ Corresponding author at: School of Health Care Administration, Taipei Medical University, 250 Wu-Hsing St., Taipei 110, Taiwan. Tel.: + 886 2 2736 1661x3613; fax: + 886 2 2378 9788. E-mail address: [email protected] (H.-C. Lin). 0165-1781/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2012.01.007
in the 2000 Registry of Beneficiaries under the NHI program. The LHID2000 has been used by many researchers in their research and publications. 2.2. Study sample This investigation analyzed a study group and a comparison group. A total of 67,917 patients were identified who received a diagnosis of UC (ICD-9-CM codes 592 (calculus of kidney and ureter), 592.0 (calculus of kidney), 592.1 (calculus of ureter) or 592.9 (urinary calculus, unspecified)) in their ambulatory care visits (outpatient department of hospitals or clinics) between January 1, 2001 and December 31, 2007. The first ambulatory care visit with a diagnosis of UC occurring during the period between 2001 and 2007 was assigned as the index date. We excluded patients aged below 18 years (n = 793), and anyone who received either a diagnosis of UC (n = 12,761) or depressive disorder (n = 3,046) (ICD-9-CM codes 296.2, 296.3, 300.4, and 311) before their index date. As a result, 51,317 patients with UC were included in the study group. A total of 153,951 comparison subjects (three for every patient with UC) were extracted to match the study cohort on sex, age group (b30, 30–39, 40–49, 50–59, 60–69, and >69), and year of index date. The first ambulatory care visit occurring in the index year was assigned as the index date. All selected subjects were aged 18 years or over and never received any diagnosis of UC between 1996 and 2008. Neither had any selected subjects in the comparison group received a diagnosis of depressive disorder before the index date. 2.3. Statistical analysis Pearson χ2 tests were used to compare differences in monthly income, geographic location, and urbanization level of patients' residences between the study group and comparison group. Stratified Cox proportional hazard regression analysis (stratified by sex, age group, and year of index ambulatory care visit) was performed to investigate the risk of subsequent depressive disorder during the 1-year follow-up period for patients with and without UC.
S.-D. Chung et al. / Psychiatry Research 198 (2012) 332–333
333
Table 1 Crude and covariate-adjusted hazard ratios for depressive disorder among the sampled patients during the 1-year follow-up, starting from the index date. Development of depression
5-year follow-up period Yes No Crude HR (95% CI) Adjusteda HR (95% CI)
Total sample
Patients with urinary calculi
Comparison patients
N = 205,268
N = 51,317
N = 153,951
No.
%
No.
%
No.
%
2050 203,218 –
1.00 99.00
751 50,566 1.74⁎(1.59–1.91) 1.75⁎(1.60–1.92)
1.46 98.54
1299 152,652 1.00 1.00
0.84 99.16
Note: HR = hazard ratio; HR was calculated by stratified Cox proportional hazard regression, which was stratified by sex, age group, and the year of index ambulatory care visit. a Adjustments were made for patients' geographical location, urbanization level, and monthly income. ⁎ p b 0.001.
3. Results The total study population included 205,268 subjects with a mean age of 47.3 (±15.6 years). Table 1 presents the incidence of depressive disorder within the 1-year period following diagnosis with UC. Of the 205,268 patients in the study sample, 2050 (1.00%) received a diagnosis of depressive disorder during the 1-year follow-up period. These included 751 (1.46% of patients with UC) from the study group and 1299 (0.84% of patients without UC) from the comparison group. After adjustment for the patients' monthly income, geographic location and urbanization level, stratified Cox proportional analysis (stratified by age group, gender, and year of index ambulatory care visit) revealed that the hazard of depressive disorder during the 1year period following diagnosis with UC was 1.75 (95% confidence interval = 1.60–1.92, p = 0.010) times greater for patients with UC than for patients in the comparison group. 4. Discussion This is the first study to demonstrate a significantly increased risk of depressive disorder during the first year following a new diagnosis with UC. Cox proportional hazard analysis, stratified by age group, gender, and year of index date, revealed that the hazard of depressive disorder during the 1-year follow-up period was 1.75 times greater for patients with UC than for those without UC. UC most commonly presents with pain, usually with episodes of renal stone colic (Tiselius, 2003). Diseases characterized by recurrent episodes of pain, including nephrolothiasis, headache, musculoskeletal pain, fibromyalgia, rheumatoid arthritis, chronic pancreatitis, and coronary artery disease, have been shown to be strongly associated with poor physical and mental health (Bingefors and Isacson, 2004; Diniz et al., 2007). A recent study also reported that there is an association between chronic migraine or painkiller overuse and major depression and anxiety disorders (Curone et al., 2011). The results of the present study partly support the concept proposed by Diniz et al. that there is an association between recurrent renal colic and symptoms of both anxiety and depression (Diniz et al., 2007). Another case–control study examined stressful life events in patients with recurrent renal stones by calculating the mean score on the Social Readjustment Rating Scale and demonstrated that stone formers had significantly higher ratings than controls (Diniz et al., 2006). This evidence suggests that relapsed UC is associated with depressive mood and/or depression. The study's strengths include the use of a population-based dataset, which enabled the tracing of UC cases and identification of depressive disorder diagnoses during the study period. The dataset's large sample size also afforded a considerable statistical advantage for detecting real differences between the two groups. However,
this study also suffered from a few limitations. First, the diagnosis of UC and depressive disorders relied on administrative claims data reported by physicians and hospitals. This may have been less accurate than diagnoses made according to standardized criteria. Second, patient information, such as a history of physical inactivity, smoking, alcohol consumption, family history, body mass index, and medication use, all of which may have contributed to depression, was not available through the administrative dataset. Thus, the association between UC and depressive disorders may be partially explained by the residual confounding of these factors. Third, there may have been a surveillance bias, as those patients with UC would have been more likely to have frequent outpatient clinic visits, which would in turn have led to an earlier detection of depressive disorders. Finally, as this study was limited to a Han Chinese population, caution should be exercised before extrapolating these results to other ethnicities. The present study demonstrated an association between UC and an increased risk of subsequent depressive disorders during a 1year follow-up period. Health care workers in both primary and urologic settings should be alert to the increased prevalence of symptoms of clinical depression in this population. Acknowledgments This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, Taiwan and managed by the National Health Research Institutes. The interpretations and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or the National Health Research Institutes. References Bingefors, K., Isacson, D., 2004. Epidemiology, comorbidity, and impact on healthrelated quality of life of self-reported headache and musculoskeletal pain: a gender perspective. European Journal of Pain 8, 435–450. Curone, M., Tullo, V., Mea, E., Proietti-Cecchini, A., Peccarisi, C., Bussone, G., 2011. Psychopathological profile of patients with chronic migraine and medication overuse: study and findings in 50 cases. Italian Journal of Neurological Sciences 32, S177–S179. Diniz, D.H., Schor, N., Blay, S.L., 2006. Stressful life events and painful recurrent colic of renal lithiasis. The Journal of Urology 176, 2483–2487. Diniz, D.H., Blay, S.L., Schor, N., 2007. Anxiety and depression symptoms in recurrent painful renal lithiasis colic. Brazilian Journal of Medical and Biological Research 40, 949–955. Hesse, A., Brändle, E., Wilbert, D., Köhrmann, K.U., Alken, P., 2003. Study on the prevalence and incidence of urolithiasis in Germany comparing the years 1979 vs 2000. European Urology 44, 709–713. Najem, G.R., Seebode, J.J., Samady, A.J., Feuerman, M., Friedman, L., 1997. Stressful life events and risk of symptomatic kidney stones. International Journal of Epidemiology 26, 1017–1023. Tiselius, A.G., 2003. Epidemiology and medical management of stone disease. BJU International 91, 758–767.