1. Översiktlig projektbeskrivning

Engelsk titel

Mental stress – health effects and health care interventions.
Translational research from population studies to primary care interventions

Sammanfattning av projektet

Den övergripande frågeställningen för projektet är att få ökad kunskap om hälsoeffekter av stress och upplevelsen av stress. Det specifika syftet med projektet är att studera långsiktiga hälsoeffekter av upplevd stress hos kvinnor och män och att också studera effekterna av interventionsprojekt, genomförda i primärvård, vars syften är att minska upplevelsen av stress samt att öka individens egen förmåga att hantera stress och därigenom ha en positiv effekt på depression, metabola störningar och kronisk smärta. Vi kommer att hämta data från två stora longitudinella befolkningsstudier (Populationsundersökningen av Kvinnor i Göteborg samt H70-studierna) för att studera långtids-hälsoeffekter av upplevd stress vad gäller morbiditet, mortalitet och livskvalitet. Interventionseffekter kommer att studeras genom flera interventionsprojekt i primärvården - två randomiserade kontrollerade studier av behandling av mild till måttlig depression samt en randomiserad studie av kognitiv gruppbehandling av kronisk smärta, och slutligen en observationsstudie om långtidsuppföljning av patientcentrerad behandling av depression hos aldre. Forskargruppens breda förankring både i epidemiologisk populationsforskning och primärvårdens kliniska miljö ger unik möjlighet till direkt överföring av forskningsresultat från den epidemiologiska forskningen till intervention i kliniken för klinisk testning av hypoteser som genererats via de epidemiologiska studierna.

Typ av projekt

Forskningsprojekt

MeSH-termer för att beskriva ämnesområdet

Inlagda MeSH-termer

Cardiovascular Diseases

Pathological conditions involving the CARDIOVASCULAR SYSTEM including the HEART; the BLOOD VESSELS; or the PERICARDIUM.

Mental Disorders

Psychiatric illness or diseases manifested by breakdowns in the adaptational process expressed primarily as abnormalities of thought, feeling, and behavior producing either distress or impairment of function.

Behavioral Disciplines and Activities

The specialties in psychiatry and psychology, their diagnostic techniques and tests, their therapeutic methods, and psychiatric and psychological services.

Projektets delaktighet i utbildning

Avhandling
D-uppsats / Magisterexamen
C-uppsats / Kandidatexamen
ST-läkarutbildning
Annan utbildning
Ej del i utbildning

2. Projektorganisation och finansiering

Ekonomiska stöd till projektet

3. Processen och projektets redovisning

Pågående aktiviteter

Planering och förberedelse före datainsamling
Datainsamling pågår
Analys av insamlade data pågår
Författande av skriftlig redovisning / publikation pågår
En eller flera publikationer från projektet är publicerade
Slutfört och inget mer görs inom ramen för detta projekt

Projektstart (när planeringen påbörjas och börjar dokumenteras skriftligt)

2007-01-01

Datum för påbörjande av datainsamling

2007-01-01

Datum då projektet är slutrapporterat

2016-12-31

Publikationer från detta projekt

1. Daily activities mediate the relationship between personality and quality of life in middle-aged women.

   Eklund Mona, Bäckström Martin, Lissner Lauren, Björkelund Cecilia, Sonn Ulla.

   Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2010

   [Links: PMID: 20640517 | DOI länk][Source: PubMed®]
2. Cohort differences in personality in middle-aged women during a 36-year period. Results from the Population Study of Women in Gothenburg.

   André Malin, Lissner Lauren, Bengtsson Calle, Hällström Tore, Sundh Valter, Björkelund Cecilia.

   Scand J Public Health 2010:38(5):457-64.

   [Links: PMID: 20576674 | DOI länk][Source: PubMed®]
3. Thirty-six-year secular trends in sleep duration and sleep satisfaction, and associations with mental stress and socioeconomic factors - results of the Population Study of Women in Gothenburg, Sweden.

   Rowshan Ravan Andishe, Bengtsson Calle, Lissner Lauren, Lapidus Leif, Björkelund Cecilia.

   Journal of sleep research 2010

   [Links: PMID: 20477952 | DOI länk][Source: PubMed®]
4. Effects of leisure-time physical activity on well-being among women: a 32-year perspective.

   Blomstrand Ann, Björkelund Cecilia, Ariai Nashmil, Lissner Lauren, Bengtsson Calle.

   Scandinavian journal of public health 2009:37(7):706-12.

   [Links: PMID: 19622547 | DOI länk][Source: PubMed®]
5. Association between periodontal disease and ischemic heart disease among Swedish women. A cross-sectional study.

   Stenman Ulrika, Wennstrom Anette, Ahlqwist Margareta, Bengtsson Calle, Bjorkelund Cecilia, Lissner Lauren, Hakeberg Magnus.

   Acta Odontol Scand. 2009:1-7.

   [Links: PMID: 19301159 | DOI länk][Source: PubMed®]
6. The prevalence of work-related stress, and its association with self-perceived health and sick-leave, in a population of employed Swedish women.

   Holmgren Kristina, Dahlin-Ivanoff Synneve, Björkelund Cecilia, Hensing Gunnel.

   BMC public health 2009:9:73.

   [Links: PMID: 19254367 | DOI länk][Source: PubMed®]
7. Engagement in patterns of daily occupations and perceived health among women of working age.

   Håkansson Carita, Lissner Lauren, Björkelund Cecilia, Sonn Ulla.

   Scandinavian journal of occupational therapy 2009:16(2):110-7.

   [Links: PMID: 19005998 | DOI länk][Source: PubMed®]
8. Prevalence of depressive symptoms and associated factors in elderly primary care patients: a descriptive study.

   Magnil Maria, Gunnarsson Ronny, Björkstedt Karin, Björkelund Cecilia.

   Primary care companion to the Journal of clinical psychiatry 2008:10(6):462-8.

   [Links: PMID: 19287556][Source: PubMed®]
9. Diet, obesity and obesogenic trends in two generations of Swedish women.

   Lissner Lauren, Sjöberg Agneta, Schütze Madlen, Lapidus Leif, Hulthén Lena, Björkelund Cecilia.

   European journal of nutrition 2008:47(8):424-31.

   [Links: PMID: 18931965 | DOI länk][Source: PubMed®]

Tillämpning av resultat - tidsaspekt (projektledarens bedömning)

Resultaten kommer sannolikt att tillämpas inom 1 år från projektslut.

Tillämpning av resultat - genomslag (projektledarens bedömning)

Internationellt (i flera länder)

Tillämpning av resultat - beskrivning

Mental and psychosocial stress is continuously increasing as an important cause of ill health both on population and individual level, resulting in e.g. increased morbidity and mortality as well as decreased performance, chronic fatigue, depressed mood, anxiety, sleep problems, and chronic pain. It’s important to obtain knowledge about the impact of mental stress as etiologic factor concerning national chronic diseases as e.g. CVD, depression, diabetes, and chronic pain. It is also important to obtain knowledge about effective and efficient treatments for the prevention and treatment of the consequences of stress, especially so in the primary care setting, where the majority of the population seek and receive care. If internet mediated cognitive ehavioural therapy with psycologist contact is an effective treatment in primary care, this will

4. Detaljerad projektbeskrivning

Bakgrundsbeskrivning

Major societal changes in psycho-social and socioeconomic factors together with improvements in health care have positively influenced public health during the last forty years, but also contributed to marked changes in the relation between somatic and mental health. Today, the individual is more exposed to long term mental and psychosocial stress than earlier generations (1), resulting in e.g. decreased performance, chronic fatigue, depressed mood, anxiety, sleep problems, and chronic pain. In the Swedish National Public Health Report 2009, the percentage stating sleep problems because of their work had increased from 23 % 1990 to 30 % 2003 in women and 25 to 27% in men (1). Mental stress and mental problems and distress were also major components of the increase in sick-listing, from around 10 to around 30 % of women’s total sickness absence from 1990 to 2003 (2). Furthermore, mental stress and anxiety have been reported to be important risk factors for cardiovascular diseases (CVD), such as stroke and myocardial infarction (3), and for diabetes (4)
The physiological response to stress, resulting in a fight-or-flight reaction, mediated via the autonomic nerve system and increased stress-hormone production, in turn leading to increased pulse and blood pressure, is developed as an immediate defence reaction. Under constant stress, the human body instead reacts with resignation, mediated via hippocampus and dominated by increased activity in the hypothalamic-pituitary-axis (HPA-axis) and increased cortisol production. This in turn ultimately leads to glucose, blood lipid, and blood pressure disturbances, as well as effects on the immune system (Fig 1). This explains the hypothesized relation between socioeconomic status and increased morbidity and mortality via e.g. cardiovascular diseases, depression and diabetes, highlighted by a.o. Michael Marmont and coworkers (5, 6).
From The Population Study of Women in Gothenburg (PPSWG, a prospective study, initiated in 1968 and still ongoing)we can report a clear improvement in risk factor levels compared to earlier generations of middle-aged women, partly associated to contemporary improvements in life-style and diet, but, also, at the same time, large increases in perceived mental stress (7). This seems to be the factor that has changed most in a presumable negative direction since 1968. In 1968, 32% of the participating women stated mental stress, in 2004 75% stated mental stress (Fig 2). Furthermore, abdominal obesity, recorded as waist-hip-ratio, has increased, despite the increased level of physical activity and decreased intake of fat (8). Increased stress-related cortisol production could be the reason for the increased abdominal ratio. Abdominal adiposity is a highly important risk factor in women, shown to be a risk factor of myocardial infarction, stroke, and diabetes (9). For the PPSWG research group network, the Swedish FAS Research Council has financed further studies on the health significances of the increasing perception of stress in modern society in the WISH project- Women Investigating Stress and Health (6.4 SEK 2008-2011).
Also, mean duration of sleep has decreased in 38-year-old women (from 7.3 to 7.1 hours) but not in 50-year-old women (10). In 1968, only 60% of the participating women aged 38 - 50 worked outside the home, compared to 90 % in the same age groups in 2004 (11). In the National Public Health Report 2009, more than 20% of younger women and 13 % of younger men stated stress related physical or mental symptoms, with the greatest ten year increase in women (1).
Stress and cardiovascular disease
Women have lower incidence of cardiovascular disease (CVD) throughout life, but because women live longer than men, ultimately as many women as men die from CVD. Stroke mortality in women as well as men has decreased but incidence has not decreased to the same extent, with one report suggesting an increase for younger women (12). Could the rising experience of perceived mental stress in women, registered as e.g. risk factors as hypertension and hyperlipidemia, and ultimately as stroke and other CVD morbidity, be one factor in the changing pattern? Secondary life style effects of stress as smoking, reduced exercise, unhealthy diet, and alcohol habits also contribute to negative health effects of stress.
Stress and depression
Depression is one of the leading causes of disability and a serious illness, affecting around 10-15% of the population (13). Recently, national epidemiological surveys showed an increase of depressive symptoms in the younger part of the Swedish population (1). The lifetime depression risk for women is almost 45% and for men about 20% (13). Depression is a common problem in patients visiting primary health care, often initially presented as physical symptoms as unspecified pain, chest or abdominal symptoms etc (13). In late life, perception of mental stress impacts on both physical and mental health.
Around 70% of all patients with depression are treated in primary care (14). About 75% of antidepressants are prescribed by general practitioners (GPs). Depression guidelines recommend cognitive behavioural therapy (CBT) in minor and moderate depression and also regular evaluation and monitoring of symptom severity and change for patients with mild to moderate depression (14). However, these guidelines are largely based on consensus or expert opinion. There is a lack of research in primary care providing recommendations for “best practice”. No randomized controlled trials have evaluated depression treatment using computerized/internet-based CBT or the treatment effects of systematic monitoring of symptom change in patients in the primary care context. Knowledge and recommendations of today on management of depression are almost exclusively based on research in psychiatric settings (13).
Stress and pain
Psychosocial factors seem to be associated with unexplained chest pain (UCP) and ought to be taken into consideration when the patient seeks care (15, 16). Patients with UCP have impaired health related quality of life (HRQOL), are more physically inactive, report more sleep problems, more mental strain at work, more stress at home, and more negative life events than a reference control population free from ischemic heart disease. In addition, women, but not men with UCP, have a higher prevalence of cardiovascular risk factors (obesity, smoking, diabetes, and hypertension) than controls.
QUESTION AT ISSUE
Taken together, stress and perception of mental stress is an important health related factor in today’s society with several implications. There is need of enhanced knowledge, both about long term health effects of perceived mental stress in women and men and about possible intervention methods, both methods aiming at reducing perception of stress as well as methods promoting the individual’s own capacity to manage stress and the secondary health effects of stress such as depression, metabolic disturbances, and pain.

Syfte

WORK PLAN
Specifically, the following aspects will be covered:
A. In population studies
1. Longitudinal analyses of perceived mental stress and its association with stroke, CVD, diabetes, depression, abdominal obesity, and health indices (incl. dental health) in a 40-year perspective
2. Incidence and long-term survival in stroke, sensitivity of hypertension effects
3. Cross-sectional analyses of associations between perceived mental stress, quality of life, family/work, personality, oestrogen medication and dental health
B. In trials in the primary care setting
1. Effects of interventions on mild to moderate depression in primary care and on health-related quality of life.
2. Evaluation of effects of continuity of care in older depressed patients in primary care.
3. Evaluation of intervention to alleviate chest pain and improve HRQOL in patients with UCP by cognitive behavioural counselling. Evaluation if early intervention on patients at risk of prolonged chest pain can be managed by collaboration between specialized hospital care and primary care.

Frågeställning / Hypoteser

There is need of enhanced knowledge, both about long term health effects of perceived mental stress in women and men and about possible intervention methods, both methods aiming at reducing perception of stress as well as methods promoting the individual’s own capacity to manage stress and the secondary health effects of stress such as depression, metabolic disturbances, and pain.
Specifically,questions at issue concerning the clinical intervention studies are:
Can treatment of depression, in the primary care setting, be improved by computerized CBT treatment as well as regular patient centered monitoring and evaluation of depression symptoms and change by MADRS-S, in the General Practitioner’s consultation, regarding management, outcome of care, and patient satisfaction, compared to treatment as usual?

Metod: Databearbetning

Principles for data processing and analysis
We will analyze associations between
•perception of mental stress and association to stroke in a 40-year perspective
•perception of mental stress and development of dental health
•perception of mental stress and development of ECG-changes (q-wave, atrial fibrillation, sick sinus syndrome) in 70-year and older men and women
•perception of mental stress in 70-year and older men and women and possible health effects
•association of mental stress and perceived nervousness and moodiness
•perceived mental stress and personality traits (measured by the CMPS and Eysenck scales) in 1968-69 and 2004-05 and analyse differences and resemblances, as well as associations between assumed trends and changes in socio-economic and societal conditions
•perceived mental stress and quality of life, family/work, personality, oestrogen medication and dental health in cross-sectional analyses and cohort comparisons
by using regression models, especially the Cox proportional hazards models using both baseline and updated covariate models.

i+ii : Variables Computer CBT and MADRS-S studies
Outcome variables
The patients are followed up to 1 year after the inclusion by an individual interview (the first visit and after 3, 6 and 12 months). Depressive symptoms are assessed using the Beck Depression Inventory (BDI-II) and MADRS-S (18,19). Other analysis outcome variables are: patient’s quality of life (EuroQoL-5D scale) (21), General health Questionnaire (22) activity/work ability (WAI, Job Strain Model) (23), antidepressants prescription, number of days with sick leave benefits. Initial collection of data also includes socio-demographic and economic variables, alcohol consumption, physical activity, and ethnicity. Analysis of covariance, controlling for baseline value, will be used to estimate the overall treatment effectiveness (difference in score) at final follow ups.
Health economic evaluation
Cost-effectiveness analysis with QALY as measure of effect will be performed. EQ-5D measures five dimensions of quality of life (15). Change from week 0 to week 12, 24 and 52 will be related to generated costs comprising PCC visits, medication, computer and IT, education, and labour loss.
Sample size and power calculations
The main outcome variable is level of depression (measured by BDI-II). If we expect an improvement by 10% in the intervention group and 0% in the control group with (α = 0.05, power = 0.80), each group should include 75 (CBT-trial)/90 (MADRS-S study) participants. Anticipating a 10% dropout rate, the total sample size is rounded to 200 participants.