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Unemployment is known to be associated with poor mental health, but it is not clear how strongly unemployment leads to onset of diagnosed clinical depression (causation), or if depression raises the risks of becoming unemployed (health selection), or indeed if both pathways operate. We therefore investigate the direction of associations between clinical depression and unemployment in a cross-cultural prospective cohort study. 10,059 consecutive general practice attendees (18-75 years) were recruited from six European countries and Chile between 2003 and 2004 and followed up at six, 12 and (in a subset) 24 months. The analysis sample was restricted to 3969 men and women who were employed or unemployed and seeking employment and had data on depression measures. The outcomes were depressive episodes, assessed using the Depression Section of the Composite International Diagnostic Interview (CIDI) and self-reported employment status. Among 3969 men and women with complete data on depression and unemployment, 10% (n = 393) had depression symptoms and a further 6% (n = 221) had major depression at 12 months. 11% (n = 423) of the sample were unemployed by 6 months. Participants who became unemployed between baseline and 6 months compared to those employed at both times had an adjusted relative risk ratio for 12-month depression of 1.58 (95% Confidence Interval 0.76, 3.27). Participants with depression at baseline and 6 months compared to neither time had an odds ratio for 6-month unemployment of 1.58 (95% Confidence Interval 0.97, 2.58). We found evidence that causation and (to a lesser extent) health selection raise the prevalence of depression in the unemployed. Unemployed adults are at particular risk for onset of major clinical depression and should be offered extra services or screened. Given the trend for adults with depression to perhaps be at greater risk of subsequent unemployment, employees with depressive symptoms should also be supported at work as a precautionary principle.

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BACKGROUND: Little is known about the risk of progression to hazardous alcohol use in people currently drinking at safe limits. We aimed to develop a prediction model (predictAL) for the development of hazardous drinking in safe drinkers. METHODS: A prospective cohort study of adult general practice attendees in six European countries and Chile followed up over 6 months. We recruited 10,045 attendees between April 2003 to February 2005. 6193 European and 2462 Chilean attendees recorded AUDIT scores below 8 in men and 5 in women at recruitment and were used in modelling risk. 38 risk factors were measured to construct a risk model for the development of hazardous drinking using stepwise logistic regression. The model was corrected for over fitting and tested in an external population. The main outcome was hazardous drinking defined by an AUDIT score ≥8 in men and ≥5 in women. RESULTS: 69.0% of attendees were recruited, of whom 89.5% participated again after six months. The risk factors in the final predictAL model were sex, age, country, baseline AUDIT score, panic syndrome and lifetime alcohol problem. The predictAL model's average c-index across all six European countries was 0.839 (95% CI 0.805, 0.873). The Hedge's g effect size for the difference in log odds of predicted probability between safe drinkers in Europe who subsequently developed hazardous alcohol use and those who did not was 1.38 (95% CI 1.25, 1.51). External validation of the algorithm in Chilean safe drinkers resulted in a c-index of 0.781 (95% CI 0.717, 0.846) and Hedge's g of 0.68 (95% CI 0.57, 0.78). CONCLUSIONS: The predictAL risk model for development of hazardous consumption in safe drinkers compares favourably with risk algorithms for disorders in other medical settings and can be a useful first step in prevention of alcohol misuse.

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UNLABELLED: This qualitative study of travel-related risk behaviours of Slovene injection drug users was based on interviews with individuals enrolled in drug addiction treatment programmes run by three regional centres for prevention and treatment of drug addiction. The primary objective of the study was to analyse behaviour patterns and practices of injection drug users during travel. METHODS: Travel-related problems of Slovene injection drug users were identified on the basis of data obtained by 25 in-depth interviews. A semi-structured questionnaire with 13 open-ended questions was developed after a preliminary study and review of the literature, and on the basis of experience with the treatment of drug addiction in Slovenia. RESULTS: The sample comprised 25 individuals, 18 men and seven women, aged 25 to 53 years. The interviews were 10 to 30 minutes long. The results obtained were presented as identified risk behaviours. Five categories were generated, providing information on the following topics: procurement of illicit drugs, criminal acts/environment, HIV and hepatitis B and C infections, storage and transport of substitution medication and pre-travel health protection. The first three categories comprise the injection drug users' risk behaviours that are most frequently explored in the literature. The other two categories - storage and transport of medication across the border and pre-travel health protection - reflect national specificities and the effectiveness of substitution treatment programmes. The majority of participants denied having shared needles and other injecting equipment when travelling. Participants who had no doctor's certificate had recourse to various forms of risk behaviour, finding a number of ways to hide the medication at the border. CONCLUSION: This qualitative study provides insight into potential travel-related risk behaviour of injection drug users from two Slovene regions - central and coastal. The potential value of this qualitative study is primarily in the identification of potential risk behaviour of Slovene injection drug users travelling abroad. The study shows that injection drug users' experiences can contribute to better and more efficient treatment of drug addiction in Slovenia.

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CONTEXT: Strategies for prevention of depression are hindered by lack of evidence about the combined predictive effect of known risk factors. OBJECTIVES: To develop a risk algorithm for onset of major depression. DESIGN: Cohort of adult general practice attendees followed up at 6 and 12 months. We measured 39 known risk factors to construct a risk model for onset of major depression using stepwise logistic regression. We corrected the model for overfitting and tested it in an external population. SETTING: General practices in 6 European countries and in Chile. PARTICIPANTS: In Europe and Chile, 10 045 attendees were recruited April 2003 to February 2005. The algorithm was developed in 5216 European attendees who were not depressed at recruitment and had follow-up data on depression status. It was tested in 1732 patients in Chile who were not depressed at recruitment. Main Outcome Measure DSM-IV major depression. RESULTS: Sixty-six percent of people approached participated, of whom 89.5% participated again at 6 months and 85.9%, at 12 months. Nine of the 10 factors in the risk algorithm were age, sex, educational level achieved, results of lifetime screen for depression, family history of psychological difficulties, physical health and mental health subscale scores on the Short Form 12, unsupported difficulties in paid or unpaid work, and experiences of discrimination. Country was the tenth factor. The algorithm's average C index across countries was 0.790 (95% confidence interval [CI], 0.767-0.813). Effect size for difference in predicted log odds of depression between European attendees who became depressed and those who did not was 1.28 (95% CI, 1.17-1.40). Application of the algorithm in Chilean attendees resulted in a C index of 0.710 (95% CI, 0.670-0.749). CONCLUSION: This first risk algorithm for onset of major depression functions as well as similar risk algorithms for cardiovascular events and may be useful in prevention of depression.

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BACKGROUND: There is evidence that the prevalence of common mental disorders varies across Europe. AIMS: To compare prevalence of common mental disorders in general practice attendees in six European countries. METHOD: Unselected attendees to general practices in the UK, Spain, Portugal, Slovenia, Estonia and The Netherlands were assessed for major depression, panic syndrome and other anxiety syndrome. Prevalence of DSM-IV major depression, other anxiety syndrome and panic syndrome was compared between the UK and other countries after taking account of differences in demographic factors and practice consultation rates. RESULTS: Prevalence was estimated in 2,344 men and 4,865 women. The highest prevalence for all disorders occurred in the UK and Spain, and lowest in Slovenia and The Netherlands. Men aged 30-50 and women aged 18-30 had the highest prevalence of major depression; men aged 40-60 had the highest prevalence of anxiety, and men and women aged 40-50 had the highest prevalence of panic syndrome. Demographic factors accounted for the variance between the UK and Spain but otherwise had little impact on the significance of observed country differences. CONCLUSIONS: These results add to the evidence for real differences between European countries in prevalence of psychological disorders and show that the burden of care on general practitioners varies markedly between countries.

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BACKGROUND: Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation. METHODS/DESIGN: This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent. DISCUSSION: Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

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