Norbert Schmitz

McGill University, Montréal, Quebec, Canada

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Publications (191)598.63 Total impact

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    ABSTRACT: Specialized Early Intervention services (SEI) for first episode psychosis are shown to be effective for the treatment of positive and negative symptoms, medication adherence, rates of relapse, substance abuse disorders, functional outcome and quality of life at two-year treatment follow up. However, it is also reported that these benefits are not maintained when SEI is not sustained. The objective of this trial is to test the efficacy of a 3-year extension of a SEI service (following 2 years of SEI prior to randomization) for the maintenance and consolidation of therapeutic gains as compared to regular care in the community. Following an initial 2 years of SEI, patients are randomized to receive either 3-years of continued SEI or regular care. SEI provided at three sites within the McGill network of SEI services, using a model of treatment comprised of: modified assertive case management; psycho education for families; multiple family intervention; cognitive behavioural therapy; and substance abuse treatment and monitoring. Blinded research assistants conduct ongoing evaluation of the outcome variables every three months. The primary outcome measure is remission status measured both as the proportion of patients in complete remission and the mean length of remission achieved following randomization during the additional three years of follow up. Based on preliminary data, it is determined that a total of 212 patients are needed to achieve adequate statistical power. Intent to treat with the last observation carried forward will be the primary method of statistical analysis. The "critical period" hypothesis posits that there is a five year window during which the effects of the nascent psychotic illness can be countered and the impact of the disorder on symptomatic and functional outcomes can be offset through active and sustained treatment. Providing SEI throughout this critical period may solidify the benefits of treatment such that gains may be more sustainable over time as compared to intervention delivered for a shorter period. Findings from this study will have implications for service provision in first episode psychosis. ISRCTN11889976.
    BMC Psychiatry 12/2015; 15(1):404. DOI:10.1186/s12888-015-0404-2 · 2.24 Impact Factor
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    ABSTRACT: To examine the association between moderate and severe diabetes distress (DD) and lifestyle behaviors (physical activity, smoking, alcohol consumption) in a community sample of adults with type 2 diabetes mellitus. A total of 1, 971 adults with type 2 diabetes were recruited using mixed methods sampling. Participants were considered eligible if they had a doctor diagnosis of type 2 diabetes (≤10 years), were insulin-naïve, between 40 and 75 years of age and from Quebec, Canada. Participants provided information on DD, lifestyle behaviors, socio-demographic and diabetes related factors. A series of multinomial logistic regressions examined the association between moderate and severe DD and each lifestyle behavior, according to gender. Effect estimates can be interpreted as probability ratios (PR). The prevalence of moderate to severe DD was 23%. In females, physical inactivity was associated with an increased likelihood of moderate distress (PR: 2.2 (1.49-3.24)) and severe distress (PR: 1.80 (1.00-3.24)). In males, only severe distress was associated with physical inactivity (PR: 1.92 (1.00-3.66)). Current smoking was associated with a greater probability of severe distress in both males and females; however this effect was stronger in male smokers (PR: 3.0 (1.54-5.84) than female smokers (PR: 1.32 (0.67-2.60)). No association was found between alcohol consumption and DD in females, however, in males, frequent alcohol consumption was associated with a reduced probability of moderate (PR: 0.56 (0.34-0.91)) and severe distress (PR: 0.47 (0.21-1.06)). The findings in this report suggest important gender differences in the association between DD and lifestyle behaviors. This article is protected by copyright. All rights reserved.
    Journal of Diabetes 04/2015; DOI:10.1111/1753-0407.12298 · 2.35 Impact Factor
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    ABSTRACT: Comorbid depression and cardiometabolic abnormalities might represent an important subgroup of depression. The aim of the present study was to evaluate lifestyle and health-related characteristics of individuals with both depressive symptoms and cardiometabolic abnormalities. Data were from the English Longitudinal Study of Ageing. The sample was comprised of 5365 adults aged 50-80 years. High depressive symptoms were based on the eight-item Center for Epidemiologic Studies - Depression scale. Cardiometabolic abnormalities were defined as having ≥3 cardiometabolic risk factors (hypertension, impaired glycemic control, systemic inflammation, low high-density lipoprotein cholesterol, hypertriglyceridemia, and central obesity). Four groups were created based on Center for Epidemiologic Studies - Depression scores and cardiometabolic abnormalities: those with (i) comorbid depressive symptoms and cardiometabolic abnormalities (DCM); (ii) depressive symptoms only (DnoCM); (iii) cardiometabolic abnormalities only; and (iv) neither depressive symptoms nor cardiometabolic abnormalities. Lifestyle and health-related characteristics of the four groups were compared using chi-square tests. A modified Poisson regression analysis was performed to compare the DCM and the DnoCM groups with respect to lifestyle and health-related characteristics. Those in the DCM group were significantly less physically active (p = 0.003), had poorer self-rated health (p < 0.001), had lower income (p = 0.001), and were more likely to be retired (p < 0.001) than those in the DnoCM group. The pattern of results remained after controlling for other lifestyle and health-related factors. These results provide support for a cardiometabolic subgroup of depression that is associated with physical inactivity, poorer self-rated health, lower income, and retirement. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 04/2015; DOI:10.1002/gps.4290 · 3.09 Impact Factor
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    ABSTRACT: AimDuration of untreated psychosis (DUP) has been associated with negative symptoms in several studies; however, longitudinal findings have been inconsistent. No previous study has accounted for active psychosis after presentation, although this could impact on outcomes in a manner similar to DUP.Methods We measured Scale for the Assessment of Positive Symptoms at frequent intervals during the 12 months after initial presentation to determine the active psychosis duration for 230 individuals with first-episode psychosis. This duration was added to DUP prior to presentation to create a new variable, duration of active psychosis (DAP). Negative symptoms were divided into expressivity and motivation/pleasure domains as measured by Scale for the Assessment of Negative Symptoms (SANS). The relationship of DUP and DAP with negative symptoms at 24-month follow up was determined and confounders controlled for using regression analysis.ResultsWhen DUP and DAP were compared as binary variables with long and short groups, 25.2% of individuals had differing category membership. DAP had a significant uncorrected association with both expressivity domain and motivation/pleasure domains at 24 months; however, relationship with DUP was not significant. DAP remained a significant predictor of 24-month expressivity domain after controlling for potential confounders.Conclusions Active psychosis after presentation is substantial, which is a limitation of DUP studies if active psychosis is considered as the key factor within DUP. DAP is a better predictor of negative symptoms than DUP at 2-year follow up, which suggests this concept requires further research.
    Early Intervention in Psychiatry 02/2015; DOI:10.1111/eip.12217 · 1.74 Impact Factor
  • Journal of Diabetes 01/2015; DOI:10.1111/1753-0407.12274 · 2.35 Impact Factor
  • Journal of Psychosomatic Research 01/2015; DOI:10.1016/j.jpsychores.2015.01.004 · 2.84 Impact Factor
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    ABSTRACT: The inflammatory marker C-reactive protein (CRP) is associated with depression. We examined the directional relations between CRP and symptoms of depression among older adults. The sample consisted of 3397 participants from the English Longitudinal Study of Ageing, a prospective study of community-dwelling older adults. CRP and depressive symptoms were measured at baseline and follow-up. A high CRP level was dichotomized as >3 mg/L. Elevated depressive symptomatology was defined as ≥4 using the 8-item Center for Epidemiologic Studies Depression Scale. Logistic regressions computed the association between high CRP levels at baseline with elevated depressive symptoms at follow-up, and vice versa. After adjusting for baseline depressive symptoms, baseline high CRP levels were associated with subsequent elevated symptoms of depression (OR = 1.49; 95% CI, 1.19-1.88). This relationship was no longer significant after simultaneous adjustments for metabolic and health variables. In the other direction, after adjusting for baseline CRP levels, baseline elevated depressive symptoms was not associated with subsequent high CRP levels (OR = 1.12; 95% CI, 0.88-1.42). High CRP levels at baseline are related to elevated depressive symptomatology at follow-up due to clinical factors. No association was found in the opposite direction. Copyright © 2014 John Wiley & Sons, Ltd. Copyright © 2014 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 12/2014; DOI:10.1002/gps.4250 · 3.09 Impact Factor
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    ABSTRACT: The neighbourhood environment could play a role in the risk of depression in adults and those with a chronic illness. We investigated the effects of a range of neighbourhood characteristics on the 10-year risk of depression in a representative sample of 9026 Canadian adults and subsamples with a chronic condition. Characteristics of neighbourhoods were not significantly related to the risk of depression in the general sample and subsamples with a chronic condition. However, residing near a park was significantly associated with a lower risk of depression for people living in crowded households, and having a local health service nearby was protective for those living in materially deprived neighbourhoods. Living in a neighbourhood that was both socially advantaged and offered cultural services was also associated with lower risk of depression. Additional research is needed for smaller effect size detection. Future intervention research is warranted for health policy recommendations.
    Health & Place 11/2014; 30. DOI:10.1016/j.healthplace.2014.10.009 · 2.44 Impact Factor
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    ABSTRACT: Background Depression is a common co-illness in people with diabetes. Evidence suggests that the neighbourhood environment impacts the risk of depression, but few studies have investigated this effect in those with diabetes. We examined the effect of a range of neighbourhood characteristics on depression in people with Type 2 diabetes.Methods This cohort study used five waves of data from 1298 participants with Type 2 diabetes from the Diabetes Health Study (2008–2013). We assessed depression using the Patient Health Questionnaire. We measured neighbourhood deprivation using census data; density of services using geospatial data; level of greenness using satellite imagery; and perceived neighbourhood characteristics using survey data. The effect of neighbourhood factors on risk of depression was estimated using survival analysis, adjusting for sociodemographic variables. We tested effect modification by age, sex and socio-economic characteristics using interaction terms.ResultsMore physical activity facilities, cultural services and a greater level of greenness in the neighbourhood were associated with a lower risk of depression in our sample, even after adjusting for confounders. Material deprivation was associated with increased risk of depression, particularly in participants who were older or retired.Conclusions Characteristics of neighbourhoods were associated with the risk of depression in people with Type 2 diabetes and there were vulnerable subgroups within this association. Clinicians are encouraged to consider the neighbourhood environment of their patients when assessing the risk of depression. Future intervention research is need for health policy recommendations.This article is protected by copyright. All rights reserved.
    Diabetic Medicine 11/2014; DOI:10.1111/dme.12650 · 3.06 Impact Factor
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    ABSTRACT: Objectives : Raised levels of C-reactive protein (CRP), an inflammatory biomarker, and depressive symptoms are both independently linked to risk of diabetes. The purpose of this study was to assess the joint association of CRP and depressive symptomatology with diabetes incidence in a representative sample of English people ≥ 50 years old. Method : Data were from the English Longitudinal Study of Ageing, a prospective study of community-dwelling older adults. The sample was comprised of 4955 participants without self-reported doctor-diagnosed diabetes at baseline. High CRP level was dichotomized as > 3 mg/L. Elevated depressive symptomatology was defined as ≥ 4 using the 8-item Center for Epidemiologic Studies Depression Scale. Incident diabetes was determined based on newly self-reported doctor-diagnosed diabetes. Cox proportional hazard regressions were used to examine the association between CRP and depressive symptoms with incidence of type 2 diabetes. Results : During approximately 63.2 months of follow-up, 194 participants reported diabetes diagnosis. After adjustment for socio-demographics, lifestyle behaviours, clinical factors, and BMI, the hazard ratio for diabetes was 1.63 (95% CI 0.88-3.01) for people with elevated depressive symptoms only, 1.43 (95% CI 0.99-2.07) for people with high CRP only, and 2.03 (95% CI 1.14-3.61) for people with both high CRP and elevated depressive symptoms. Conclusion : The presence of both high CRP levels and elevated depressive symptoms was associated with risk of diabetes. Further investigation into this relationship could aid in understanding the mechanisms underlying inflammation, depression, and diabetes.
    Journal of Psychosomatic Research 09/2014; 77(3). DOI:10.1016/j.jpsychores.2014.07.012 · 2.84 Impact Factor
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    ABSTRACT: Objective: The problems of obesity and depression in type 2 diabetes mellitus are well documented, yet the role of weight cycling in relation to these 2 chronic conditions has not been examined. The study objective was to determine whether weight cycling predicts the development of depressive symptoms in the course of 1 year. Methods: A cohort study of 1100 adults with type 2 diabetes participating in the Diabetes Health and Well-Being Study (telephone survey using the random-digit-dialling method) had complete data at the 1-year follow up on depressive symptoms (Patient Health Questionnaire 9) and weight cycling frequency (going on a diet and losing >10 kg). Results: At baseline, 56.5% of subjects reported weight cycling on at least 1 occasion in their lifetime; it was found to be associated with baseline body mass index, depression, sex and age (p<0.05). Regression analyses indicated that severe weight cycling (>= 4 times) was not associated with the development of major depressive symptoms; however, it was associated with maintaining major depressive symptoms (p=0.038) but significance disappeared after adjusting for body mass index, physical activity, smoking and sociodemographic characteristics. Development and maintenance of major depressive symptoms were associated with physical inactivity (p<0.05); maintenance of major depressive symptoms was also associated with higher body mass index values (p<0.05). Conclusions: Weight cycling is a widespread phenomenon in diabetes. It was associated with depression, but severe cycling was not an independent predictor of the development and maintenance of major depressive symptoms. Clinicians should consider physical inactivity when evaluating and addressing depression in patients with type 2 diabetes. (C) 2014 Canadian Diabetes Association
    Canadian Journal of Diabetes 07/2014; 38(6). DOI:10.1016/j.jcjd.2014.01.005 · 0.46 Impact Factor
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    ABSTRACT: Interventions aimed at influencing specific pathways to care may reduce the duration of untreated psychosis (DUP). The purpose of this study was to reduce delay in referral to an early intervention service following first contact for help seeking for psychosis in a defined urban catchment area.
    Social Psychiatry and Psychiatric Epidemiology 06/2014; DOI:10.1007/s00127-014-0893-1 · 2.58 Impact Factor
  • Kimberley J. Smith, Norbert Schmitz
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    ABSTRACT: Objective There is a well-documented association between depression and disability in people with diabetes. However less is known about the possible association of co-occurring anxiety on these associations. The objective of this study was to assess the association of elevated anxiety and/or depression symptoms with functional disability and frequent disability days in a community sample with type 2 diabetes. Methods Participants were 1,999 people with diabetes who completed the baseline portion of the Evaluation of Diabetes Treatment study. Functional disability was assessed using the World Health Organisation Disability Assessment Schedule II. Frequent disability days were assessed using a cutoff of ≥ 14 on a question assessing past month functional disability from the Healthy Days Core Module. Depression and Anxiety were assessed with the Patient Health Questionnaire and General Anxiety Questionnaire with cutoffs of ≥ 10 applied to create groups. Additional questions examined diabetes complications, chronic conditions and sociodemographic characteristics. Results Fully-adjusted logistic regression analyses demonstrated an increased likelihood of reporting functional disability for all groups with high anxiety and/or depressive symptoms. Groups with high depressive symptoms with and without high anxiety symptoms were also more likely to report frequent disability days. Conclusions Results indicate that elevated anxiety and depression symptoms are important factors associated with increased functional disability and frequent disability days in people with diabetes.
    Psychosomatics 06/2014; DOI:10.1016/j.psym.2014.05.015 · 1.67 Impact Factor
  • Diabetes Care 06/2014; 37(6):e146-7. DOI:10.2337/dc14-0435 · 8.57 Impact Factor
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    ABSTRACT: Objective: To examine the association between physical inactivity and anxiety symptoms in a community-based sample of men and women with type 2 diabetes mellitus. Methods: Eligibility criteria included residents of Quebec, Canada aged between 40 and 75 years, having a diagnosis of type 2 diabetes (<= 10 years), being insulin-naive and having participated in a previous telephone-based survey of diabetes treatments. Of the 2028 eligible respondents, 1953 (96.3%) provided information on anxiety symptoms and were included in this analysis. Participants were interviewed and provided information on diabetes-related clinical and sociodemographic factors. Results: A total of 27.3% of participants reported being physically inactive. The prevalence of mild to severe anxiety symptoms was 22.9%. Persons with mild anxiety symptoms and moderate to severe anxiety symptoms were 1.4 times and 1.7 times more likely to report being inactive than persons without anxiety symptoms, respectively. Subgroup analyses according to gender revealed that women who had mild anxiety symptoms were 1.5 times more likely to report being inactive compared with women who did not have anxiety symptoms, whereas men who had moderate to severe anxiety symptoms were 2.5 times more likely to be inactive than men who did not have anxiety symptoms. Conclusions: Anxiety symptoms in the mild and moderate to severe range are a relevant clinical comorbidity in persons with type 2 diabetes, and men may represent a particularly vulnerable subgroup. Future research is recommended to further assess the relationship between anxiety symptoms and diabetes-related health behaviours. (C) 2014 Canadian Diabetes Association
    Canadian Journal of Diabetes 05/2014; 38(6). DOI:10.1016/j.jcjd.2013.12.002 · 0.46 Impact Factor
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    ABSTRACT: Background There exists very little evidence to guide clinical management for preventing recurrence of major depression. The objective of this study was to develop and validate a prediction algorithm for recurrence of major depression. Methods Wave 1 and wave 2 longitudinal data from the U.S. National Epidemiological Survey on Alcohol and Related Condition (2001/2002–2003/2004) were used. Participants with a major depressive episode at baseline and who had visited health professionals for depression were included in this analysis (n = 2,711). Mental disorders were assessed based on the DSM-IV criteria. ResultsWith the development data (n = 1,518), a prediction model with 19 unique factors had a C statistics of 0.7504 and excellent calibration (P = .23). The model had a C statistics of 0.7195 in external validation data (n = 1,195) and 0.7365 in combined data. The algorithm calibrated very well in validation data. In the combined data, the 3-year observed and predicted risk of recurrence was 25.40% (95% CI: 23.76%, 27.04%) and 25.34% (95% CI: 24.73%, 25.95%), respectively. The predicted risk in the 1st and 10th decile risk group was 5.68% and 60.21%, respectively. Conclusions The developed prediction model for recurrence of major depression has acceptable discrimination and excellent calibration, and is feasible to be used by physicians. The prognostic model may assist physicians and patients in quantifying the probability of recurrence so that physicians can develop specific treatment plans for those who are at high risk of recurrence, leading to personalized treatment and better use of resources.
    Depression and Anxiety 05/2014; 31(5). DOI:10.1002/da.22215 · 4.29 Impact Factor
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    ABSTRACT: The aim of this study was to assess differences in cardiovascular risk and performance of self-care activities in people who rated their diabetes control as good or poor.A sub-sample of 77 participants who took part in the Evaluation of Diabetes Treatment telephone interview were invited into a clinic to complete a series of laboratory examinations. Self-rated diabetes control was validated using the following laboratory markers: HbA1c, total cholesterol/HDL cholesterol ratio and LDL cholesterol. Differences in blood pressure and BMI were also assessed. Finally, all participants also completed the Summary of Self-Care activities questionnaire.Those people who rated their diabetes control as fair or poor had a significantly higher BMI, HbA1c levels, total cholesterol/HDL-cholesterol ratio and systolic blood pressure. When asked about self-care activities in the past week, those people who reported their diabetes control was fair/poor had spent significantly fewer days following a general diet and exercising.People with poor self-rated diabetes control have unfavourable cardiovascular risk and decreased performance of self-care activities.
    Experimental and Clinical Endocrinology & Diabetes 03/2014; DOI:10.1055/s-0034-1367005 · 1.76 Impact Factor
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    ABSTRACT: To investigate the stability and longitudinal association between depression and smoking status within a community sample with type-2 diabetes, while controlling for socio-demographic and disease related variables. Adults with type-2 diabetes were recruited and agreed to be followed-up via random digit dialing for the Montreal Diabetes Health Study (DHS). At baseline, 1618 individuals were classified as never, former, light (≤10 cigarettes a day) and moderate-heavy (11+ cigarettes a day); Depression was assessed using the Patient Health Questionnaire-9 and individuals were classified as none vs. depression syndrome. Generalized Estimating Equations were used to test the association between depression syndrome and current smoking status, while controlling for other demographic and health related variables. Prevalence rates of smoking and depression showed mild-substantial agreement over time; Depression syndrome was significantly associated with moderate-heavy smoking in the fully adjusted model using cross-sectional (all 4 waves, OR = 1.46, 95% CI 1.08-1.99, p < 0.05) and longitudinal (controlling for depression at baseline; OR = 1.54, 95% CI 1.02-2.31, p < 0.05) data. Smoking and depression prevalence rates appear to be stable over time in our community sample with type-2 diabetes. Moderate-heavy smoking is strongly associated with elevated depression, both in cross-sectional and longitudinal models; persistent moderate-heavy smokers may are at increased risk of both physical and mental health complications. This burden is even greater for those with type-2 diabetes.
    Journal of Diabetes 02/2014; 7(1). DOI:10.1111/1753-0407.12141 · 2.35 Impact Factor
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    ABSTRACT: This realist review seeks to elucidate the modifiable causal pathways through which neighborhoods affect depressive symptoms in adult populations. Studies were identified using Medline, PubMed, PsycInfo, Geobase, and Web of Science databases, and chosen using reproducible selection criteria and systematic critical appraisal. A total of 14 longitudinal studies, published between 2003 and 2011, were included. Eleven of the articles observed a significant relationship between depression and at least one of the following neighborhood-level variables: neighborhood deprivation, disorder, instability, and social ties. Proposed modifiable pathways linking neighborhood characteristics and depression include: (1) the level of neighborhood-based stress that is placed on individuals, (2) the formation and strength of protective and supportive social networks, (3) the level of resiliency to negative affectivity and stress, (4) the perceptions of the esthetic and form of residential space, and (5) the sense of control and agency in place of residence. These pathways represent potential areas for future research and intervention. Further research requires a more systematic use of longitudinal design and a diversity of physical and social environmental measures. Interventions aimed at improving affective resiliency need to be tested.
    Social Psychiatry 01/2014; DOI:10.1007/s00127-013-0810-z · 2.58 Impact Factor
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    ABSTRACT: Prediction algorithms are useful for making clinical decisions and for population health planning. However, such prediction algorithms for first onset of major depression do not exist. The objective of this study was to develop and validate a prediction algorithm for first onset of major depression in the general population. Longitudinal study design with approximate 3-year follow-up. The study was based on data from a nationally representative sample of the US general population. A total of 28 059 individuals who participated in Waves 1 and 2 of the US National Epidemiologic Survey on Alcohol and Related Conditions and who had not had major depression at Wave 1 were included. The prediction algorithm was developed using logistic regression modelling in 21 813 participants from three census regions. The algorithm was validated in participants from the 4th census region (n=6246). Major depression occurred since Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions, assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule-diagnostic and statistical manual for mental disorders IV. A prediction algorithm containing 17 unique risk factors was developed. The algorithm had good discriminative power (C statistics=0.7538, 95% CI 0.7378 to 0.7699) and excellent calibration (F-adjusted test=1.00, p=0.448) with the weighted data. In the validation sample, the algorithm had a C statistic of 0.7259 and excellent calibration (Hosmer-Lemeshow χ(2)=3.41, p=0.906). The developed prediction algorithm has good discrimination and calibration capacity. It can be used by clinicians, mental health policy-makers and service planners and the general public to predict future risk of having major depression. The application of the algorithm may lead to increased personalisation of treatment, better clinical decisions and more optimal mental health service planning.
    Journal of epidemiology and community health 01/2014; DOI:10.1136/jech-2013-202845 · 3.29 Impact Factor

Publication Stats

2k Citations
598.63 Total Impact Points

Institutions

  • 2006–2015
    • McGill University
      • Department of Psychiatry
      Montréal, Quebec, Canada
    • University of Toronto
      • Department of Psychiatry
      Toronto, Ontario, Canada
  • 2014
    • Centre de recherche du diabète de Montréal
      Montréal, Quebec, Canada
  • 2009–2013
    • Douglas Mental Health University Institute
      Montréal, Quebec, Canada
  • 1997–2010
    • Heinrich-Heine-Universität Düsseldorf
      • Clinical Institute of Psychosomatic Medicine and Psychotherapy
      Düsseldorf, North Rhine-Westphalia, Germany
    • Technische Universität Dortmund
      Dortmund, North Rhine-Westphalia, Germany
  • 2001
    • Hannover Medical School
      Hanover, Lower Saxony, Germany
  • 1999
    • Martin Luther University of Halle-Wittenberg
      • Clinic for Psychiatry, Psychotherapy and Psychosomatics
      Halle, Saxony-Anhalt, Germany
  • 1993–1997
    • Ruhr-Universität Bochum
      • Abteilung für Medizinische Psychologie und Medizinische Soziologie
      Bochum, North Rhine-Westphalia, Germany