Internet-based emotion regulation training aimed at reducing violent revictimization and depressive symptoms in victimized depressed patients: Results of a randomized controlled trial

BACKGROUND

Depressed patients who have become victim of violence are prone to revictimization. However, no evidence-based interventions aimed at reducing revictimization in this group exist.

METHODS

This multicenter randomized controlled trial evaluated the effectiveness of an internet-based emotion regulation training (iERT) added to TAU in reducing revictimization, emotion dysregulation, and depressive symptoms in recently victimized, depressed patients compared to TAU alone. Adult outpatients (N = 153) with a depressive disorder who had experienced threat, physical assault, or sexual assault within the previous three years were randomly allocated to TAU+iERT (n = 74) or TAU (n = 79). TAU involved psychotherapy (mainly cognitive behavioral therapy [77.8 %]). iERT comprised six guided online sessions focused on the acquisition of adaptive emotion regulation skills. The primary outcome measure was the number of revictimization incidents at 12 months after baseline, measured with the Safety Monitor. Analyses were performed according to the intention-to-treat principle.

RESULTS

Both groups showed a large decrease in victimization incidents. Mixed-model negative binomial regression analyses showed that TAU+iERT was not effective in reducing revictimization compared to TAU (IRR = 0.97; 95%CI = 0.64,1.46; p = .886). Linear mixed-model analyses demonstrated that TAU+iERT yielded a larger reduction of emotion dysregulation (B = -7.217; p = .046; Cohens d = 0.33), but not depressive symptoms (B = -1.041; p = .607) than TAU.

LIMITATIONS

The study was underpowered to detect small treatment effects. Additionally, uptake of iERT was quite low.

CONCLUSIONS

Although TAU+iERT resulted in a larger decrease of emotion dysregulation than TAU alone, it was not effective in reducing revictimization and depressive symptoms. Patients' revictimization risk substantially decreased during psychotherapy.

A Female-Specific Treatment Group for ADHD-Description of the Programme and Qualitative Analysis of First Experiences

Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants' evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.

Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage

Objective

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition which is underdiagnosed and undertreated in women. For decades, the ADHD field has called for more insight into female-specific therapy. Preliminary findings postulate that changes in sex hormones during the menstrual cycle may influence the effectiveness of psychostimulant medication. Yet, pharmacotherapeutic interventions tailored to women with ADHD remain scarce. Previously, our group showed an increase in mood symptoms in the premenstrual week in women with ADHD. Premenstrual worsening of depressive and ADHD symptoms represent a treatment challenge. In our adult ADHD clinic, we noted several women describing exacerbation of their ADHD and depressive symptoms in the premenstrual week and/or insufficient effect of their established dosage of psychostimulant. We responded to the need expressed by these women by increasing their stimulant dosage in the premenstrual week, while monitoring the response and side effects.

Methods

This community case study of nine consecutive women being treated for ADHD and co-occurring conditions (including depression and premenstrual dysphoric disorder), reports our local experience of increasing the individually prescribed psychostimulant dosage during the premenstrual period. We methodically monitored the effect of this increased dosage on ADHD symptoms, mood and somatic symptoms for the following 6-24 months.

Results

With premenstrual dose elevation, all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy.

Discussion

Our preliminary results demonstrate potential benefits of increasing premenstrual psychostimulant dosage in women with ADHD, experiencing premenstrual worsening of ADHD and mood symptoms. The results concur with previous findings of diminished response to amphetamines in the late luteal phase. Increased dosage may help combat premenstrual worsening of cognitive and emotional symptoms in women with ADHD, with significant clinical implications. Better management of premenstrual ADHD and mood symptoms in vulnerable women can improve treatment outcome and meet an unmet need. However, implementation should be individually explored. Further investigation of luteal phase psychostimulant dose adjustment is required for safe, optimal and individualised treatment for women with ADHD.

Internet-delivered cognitive behavioural therapy for insomnia disorder in depressed patients treated at an outpatient clinic for mood disorders: protocol of a randomised controlled trial

BACKGROUND

Major depression is a highly prevalent disorder causing severe personal distress, and high societal costs. Patients with depression often have comorbid insomnia disorder (ID) leading to even worse personal distress and worse treatment outcomes. Recent results from a non-randomised pilot study with internet-delivered Cognitive Behavioural Therapy (CBTi) for Insomnia (I-Sleep) added to regular depression care were promising regarding feasibility and initial effects on insomnia complaints and depression. However, no randomised controlled trial (RCT) has been performed yet to access the (cost-) effectiveness of I-Sleep for depression. Therefore, this protocol article presents the design of an RCT aimed to assess the (cost-) effectiveness of I-Sleep in addition to usual care for depression compared to usual care alone in depressed patients with a comorbid Insomnia Disorder (ID) treated at outpatient clinics for mood disorders.  METHODS /DESIGN: This is a multi-centre RCT with measurements at baseline and at 3, 6, 9, and 12 months of follow-up. Patients with depression and an ID are randomised to either I-Sleep treatment followed by regular depression care or to regular depression care alone. Our aim is to recruit one hundred and seventy-five patients from multiple outpatient clinics for mood disorders. The primary outcome is the change in depressive symptoms over 12 months of follow-up measured with the Patient Health Questionnaire (PHQ-9). Secondary outcomes are recovery from depression (PHQ-9), insomnia severity (Insomnia Severity Index, ISI), daily functioning (Work and Social Adjustment Scale, WSAS), general quality of life (EuroQol 5-level version, EQ-5D-5L), and societal costs (Adapted versions of the iMTA Productivity Cost Questionnaire, iPCQ and iMTA Medical Cost Questionnaire, iMCQ).

DISCUSSION

We hypothesize that the addition of I-Sleep to usual care will result in a significant improvement in depression treatment outcomes and quality of life as well as a decrease in healthcare and societal costs compared to usual care alone. This study is the first pragmatic RCT evaluating the effectiveness and cost-effectiveness of adding CBTi to usual care for depression.

TRIAL REGISTRATION

Netherlands Trial Register (NL8955). Registered on October 6^th2020. https://trialsearch.who.int/Trial2.aspx?TrialID=NL8955.

[Shared decision-making using outcome information: qualitative research among patients]

BACKGROUND

In the period 2019-2022, eight mental health care organizations have been working on the development and implementation of shared decision-making (SDM) using routine outcome monitoring (ROM) as a source of information.

AIM

To obtain insight in needs and experiences of patients among SDM using ROM, and to investigate which implementation approach this requires.

METHOD

Explorative, qualitative research consisting of semi-structured interviews and focusgroups with patients (n = 101) treated by mental health care organizations across the Netherlands.

RESULTS

Patients reported SDM as important. Generic aspects (listening, trust, complete information and equal input) and customization (connecting to the need for help, and for every decision meta-communication about the roles of patients, relatives and clinicians and the way of giving information) were equally important. Patients valued ROM as source of information during SDM, providing that questionnaires are not too long, are related to the problems and results are discussed.

CONCLUSION

SDM using ROM is as yet not widely implemented in mental health care. This requires continuous stimulation and evaluation. Implementation requires (re)training clinicians and supporting patients by relatives, peer experts and psycho-education. Patients appreciate ROM as an aid in SDM; access to their own ROM is helpful here.

Individual placement and support and employment in personality disorders: a registry based cohort study

BACKGROUND

To explore the relative impact of Individual Placement and Support (IPS) in patients with personality disorders (PDs) as compared to patients with other mental disorders.

METHODS

Data from the Dutch Employee Insurance Agency of participants enrolled in a national IPS trajectory between 2008 and 2018 were linked to corresponding data on employment outcomes, diagnostic and sociodemographic information from Statistics Netherlands. This resulted in a sample of 335 participants with PDs who could be compared with 1073 participants with other mental disorders.

RESULTS

Participants with PD just as often found competitive employment as participants with other mental disorders (37.6% vs. 38.0%, OR_adjusted = 0.97, 95% confidence interval (CI) 0.74 to 1.27). The median time to gaining employment for those gaining employment (37.9%) was 195.5 days (mean number of days 252.5) in the PD group and 178.5 days (mean number of days 234.6) in the other mental disorders group (HR_adjusted = 0.95, 95% CI 0.77 to 1.18). Also, total number of hours paid for competitive employment did not differ significantly between groups (median hours 686.5 vs 781.5, IRR_adjusted = 0.85 95% CI 0.69 to 1.05).

CONCLUSIONS

Based on this study, which includes the largest sample of patients with PDs in any published IPS study, IPS seems to result in an equal percentage of patients with PDs and other mental disorders, gaining and maintaining employment. Although future studies should determine whether PD-specific adaptations to IPS are useful, our findings indicate that IPS could be an effective way to increase employment outcomes in PDs. This is important because the enormous societal costs of PDs are largely driven by loss of economic productivity, and because clinical recovery in PDs is suggested to be enhanced when patients are employed.

[Het spook risicoselectie; ggz onverzekerbaar in huidig stelsel]

BACKGROUND

The Dutch health care system is a hybrid mix of public and market oriented elements. The market orientation harbours strong financial incentives for health insurance companies to select for the most healthy, least costly insurees. This is countered by an elaborate financial compensation for high risk, more costly health care users. Dysfunctioning of the compensatory financial mechanisms would render the mental health sector uninsurable.

AIM

To test the risk-compensatory mechanisms for mental health care in the Netherlands and to discuss consequences of malfunctioning.

METHOD

We used governmental data to study: the distribution of mental health costs, the total mental health expenditures that are redirected to compensate insurance companies, and the accuracy of this compensation. The consequences of putative inaccuracies are discussed.

RESULTS

0.8% of the insured (all Dutch citizens are insured) are responsible for 66% of the mental health care costs. To compensate insurance companies for unequal distribution of costs, 3.9 billion euros were redirected. This compensation is based on inaccurate predictions of future health care costs of individual patients. The consequence is that insurance companies run a loss on every patient that uses mental health care. This loss is directly proportional to the amount of care used and therefore highest in patients with severe mental illness.

CONCLUSION

Due to inaccurate redirection of mental health-care costs, a strong financial incentive is in place to avoid investing in mental health care. Under prevailing regulations, mental health is de facto uninsurable in the Netherlands. This affects especially patients with the most severe and complex mental illness.

Affect fluctuations examined with ecological momentary assessment in patients with current or remitted depression and anxiety disorders

BACKGROUND

There is increasing interest in day-to-day affect fluctuations of patients with depressive and anxiety disorders. Few studies have compared repeated assessments of positive affect (PA) and negative affect (NA) across diagnostic groups, and fluctuation patterns were not uniformly defined. The aim of this study is to compare affect fluctuations in patients with a current episode of depressive or anxiety disorder, in remitted patients and in controls, using affect instability as a core concept but also describing other measures of variability and adjusting for possible confounders.

METHODS

Ecological momentary assessment (EMA) data were obtained from 365 participants of the Netherlands Study of Depression and Anxiety with current (n = 95), remitted (n = 178) or no (n = 92) DSM-IV defined depression/anxiety disorder. For 2 weeks, five times per day, participants filled-out items on PA and NA. Affect instability was calculated as the root mean square of successive differences (RMSSD). Tests on group differences in RMSSD, within-person variance, and autocorrelation were performed, controlling for mean affect levels.

RESULTS

Current depression/anxiety patients had the highest affect instability in both PA and NA, followed by remitters and then controls. Instability differences between groups remained significant when controlling for mean affect levels, but differences between current and remitted were no longer significant.

CONCLUSIONS

Patients with a current disorder have higher instability of NA and PA than remitted patients and controls. Especially with regard to NA, this could be interpreted as patients with a current disorder being more sensitive to internal and external stressors and having suboptimal affect regulation.

[Suicide prevention: challenges and recommendations]

Background DESPITE VARIOUS NATIONAL INITIATIVES AND A STRONG MENTAL HEALTH CARE SYSTEM, THE NUMBER OF SUICIDES IN THE NETHERLANDS AND FLANDERS HAS NOT CHANGED AS HOPED. Aim TO PROVIDE INSIGHT INTO THE CURRENT SUICIDE PREVENTION POLICY IN THE NETHERLANDS AND FLANDERS, AND THE EVIDENCE ON THEIR EFFECTIVENESS. Method DISCUSSION OF UNIVERSAL, SELECTIVE AND INDICATED PREVENTION INITIATIVES, AND OF THE EVIDENCE FOR THE VARIOUS INITIATIVES, BASED ON THE USE OF REVIEWS AND META-ANALYSIS. Results THERE IS A NATIONAL SUICIDE PREVENTION AGENDA IN BOTH THE NETHERLANDS AND FLANDERS. IT IS DIFFICULT TO DEMONSTRATE THE DIRECT EFFECT OF THE VARIOUS INITIATIVES ON NATIONAL SUICIDE RATES, BECAUSE OF THE LOW BASE RATE, AND BECAUSE OF ITS MULTIPLE CAUSES. Conclusion THERE ARE LITTLE EVIDENCE FOR SUICIDE PREVENTION STRATEGIES. THIS DOES NOT MEAN SUICIDE PREVENTION HAS NO USE, BUT MODESTY SEEMS IN PLACE. Key words EVALUATION, POLICY, RCT, SUICIDE PREVENTION TIJDSCHRIFT VOOR PSYCHIATRIE 63(2021)2, 133-137.

Mastery and self-esteem mediate the association between visual acuity and mental health: a population-based longitudinal cohort study

BACKGROUND

With deteriorating eyesight, people often become dependent on others for many aspects of their daily lives. As a result, they feel less 'in control' and experience lower self-esteem. Lower sense of mastery and self-esteem are known to predict depression, but their roles in people with visual impairment have only marginally been investigated. Therefore, this study aimed to determine the influence of mastery and self-esteem on the relationship between visual acuity and mental health.

METHODS

A longitudinal cohort study was performed using data from the Longitudinal Aging Study Amsterdam (LASA), collected between 2001 and 2012. A community-based population of 2599 older adults were included, who were randomly selected from population registers. Outcomes of interest were the Pearlin Mastery Scale, Rosenberg Self-Esteem Scale, Center for Epidemiologic Studies - Depression scale and the Hospital Anxiety Depression Scale - Anxiety subscale. Linear mixed models were used to establish the association between visual acuity and mental health over time.

RESULTS

Mean age was 72 years, 56% was female and 1.2% qualified as having low vision. Visual impairment was associated with a lower sense of mastery (β = - 0.477, p < 0.001), lower self-esteem (β = - 0.166, p = 0.008) and more depression (β = 0.235, p < 0.001). No significant association between visual acuity and anxiety was found. The relationship between visual acuity and depression was mediated by self-esteem (25%) and sense of mastery (79%).

CONCLUSIONS

Vision loss was associated with depression. This association was mediated by self-esteem and sense of mastery. This provides us with new possibilities to identify, support and treat those at risk for developing depression by aiming to increase their self-esteem and sense of mastery.

Employment in Personality Disorders and the Effectiveness of Individual Placement and Support: Outcomes from a Secondary Data Analysis

Purpose Personality disorders (PDs) are associated with severe functional impairment and subsequent high societal costs, increasing the need to improve occupational functioning in PD. Individual placement and support (IPS) is an effective, evidence-based method of supported employment, which so far has been tested in various mixed patient populations with severe mental illness (SMI, including PDs). However, the effectiveness of IPS for PDs per se remains uninvestigated. Methods Data from the SCION trial were used, including 31 SMI patients with PDs and 115 SMI patients with other primary diagnoses (primarily psychotic disorders). First, the interaction effect of diagnosis (PD vs other SMI) and intervention (IPS vs traditional vocational rehabilitation) was studied. Second, in the IPS condition, difference between diagnostic groups in time to first job was studied. Results We did not find evidence of a moderating effect of PD diagnosis on the primary effect of IPS (proportion who started in regular employment) (OR = 0.592, 95% CI 0.80-4.350, p = 0.606) after 30 months. Also, PD diagnosis did not moderate the effect of time until first job in IPS. Conclusions From the present explorative analysis we did not find evidence for a moderating effect of PD diagnosis on the effectiveness of IPS among PD participants. This indicates that IPS could be as effective in gaining employment in participants with PD as it is in participants with other SMI. Future studies, implementing larger numbers, should confirm whether IPS is equally effective in PDs and study whether augmentations or alterations to the standard IPS model might be beneficiary for PD.

[Social isolation, source of income and healthcare consumption for psychiatric patients with and without severe mental illness]

The more severe the psychiatric illness the more patients are dependent on social support and informal care. However, research showed that patients with severe mental illness (smi) have smaller networks than healthy controls.<br/> AIM: To examine the relationship between network size and perceived social support on the one hand and healthcare consumption on the other.<br/> METHOD: A group of 252 patients who got a crisis consultation in Amsterdam, was divided into patients with and without smi on the basis of two years of observation. Mental healthcare consumption was then measured over a period of three years. Bi- and multivariate analyses were used to determine which variables predict levels of mental healthcare consumption.<br/> RESULTS: Both patient groups did not show any change in level of care consumption during the three follow-up years. In both smi patients and other patients, mental healthcare consumption increased with smaller network size (or 0,85; 95% ci 0,75-0,96). Patients with smi showed a more than threefold higher care consumption compared to non-smi patients (or 3.19; 95% ci 1.82-5.61) independent of network size and living situation.<br/> CONCLUSION: smi patients live in conditions that undermine self-reliance: they have a small social network, they often live alone and they usually depend on welfare benefits. They also consume considerably more care than patients with milder disorders and this level of consumption did not decline during the three years of follow-up. A development of new social interventions will be needed to make this patient group more self-reliant and less dependent on care.

[Shared decision making in mental health care; evaluation of the added value for patients and clinicians]

Although the evidence is expanding, in mental health care shared decision making (SDM) is not widely applied. Moreover, little is known about the use of routine outcome monitoring (ROM) and eHealth in SDM.<br/> AIM: PhD research on the added value of SDM using ROM and eHealth for patients and clinicians in mental health care.<br/> METHOD: Three studies: 1. a literature research and a cross-sectional study on decisional conflict; 2. ROM implementation research and a cluster randomised trial on shared decision making using ROM (Breakthrough program); 3. a cluster randomised trial on shared decision making during the intake (regional).<br/> RESULTS: The interventions did not lead to reduced decisional conflict for all patient groups. Decisional conflict gives insight into the patient's perspective on the quality of the decision making process and decisions being made. Only patients with depression, who participated in the national trial, reported less decisional conflict. This trial did not show a higher level of SDM, but did show increased usage of rom in clinical practice. Although the regional trial showed no results on decisional conflict, the application of SDM and treatment outcomes improved.<br/> CONCLUSION: SDM in mental health care needs further improvement. We recommend investigating how to support patients better, taking into account the role that suits them.

The Burden of ADHD in Older Adults: A Qualitative Study

OBJECTIVE

To explore how ADHD may have affected the lives of older adults who meet the diagnostic criteria of ADHD, but are unaware of their diagnosis. Our second aim was to examine whether the reported symptoms change over the life span.

METHOD

A qualitative study was conducted. Seventeen Dutch older people (>65 years) diagnosed in this study with ADHD participated in in-depth interviews. Data were analyzed according to techniques of thematic approach.

RESULTS

Seven themes emerged from the analyses. Four themes correspond to ADHD symptoms: "being active," "being impulsive," "attention problems," and "mental restlessness." In addition, the themes "low self-esteem," "overstepping boundaries," and "feeling misunderstood" emerged. The impact of ADHD symptoms seems to have declined with age.

CONCLUSION

ADHD has a negative impact on late life, and older adults with the disorder may benefit from treatment. Moreover, this study's findings call for early detection and treatment of ADHD in children and adults.

[Providing insight into the construct decisional conflict and its usability to assess shared decision making]

The increased attention for shared decision making (sdm) in mental health care creates a need to evaluate its application. The construct decisional conflict, which refers to the satisfaction of patients regarding both the decision making process and the decisions made, could be of added value.<br/> AIM: Clarifying decisional conflict and reflecting on its feasibility to evaluate sdm in mental health care.<br/> METHOD: A literature study exploring the construct of decisional conflict was conducted, followed by a translation of the results into a visual model.<br/> RESULTS: Decisional conflict is a multi-dimensional construct and consists of factors influencing the decision making process (information, support, values clarity), level of uncertainty concerning the options and the quality of the decision making. Decisional conflict can be illustrated by using a model and assessed with the Decisional Conflict Scale.<br/> CONCLUSION: Decisional conflict is informative and useful in the evaluation of the application of sdm and improvement of the quality of the decision making in mental health care as well. This is of importance since patients who experienced less decisional conflict are more engaged in treatment and show better clinical outcomes.

Light therapy: is it safe for the eyes?

OBJECTIVE

Light therapy has become an increasingly popular treatment for depression and a range of other neuropsychiatric conditions. Yet, concerns have been raised about the ocular safety of light therapy.

METHOD

We conducted the first systematic review into the ocular safety of light therapy. A PubMed search on January 4, 2017, identified 6708 articles, of which 161 were full-text reviewed. In total, 43 articles reporting on ocular complaints and ocular examinations were included in the analyses.

RESULTS

Ocular complaints, including ocular discomfort and vision problems, were reported in about 0% to 45% of the participants of studies involving light therapy. Based on individual studies, no evident relationship between the occurrence of complaints and light therapy dose was found. There was no evidence for ocular damage due to light therapy, with the exception of one case report that documented the development of a maculopathy in a person treated with the photosensitizing antidepressant clomipramine.

CONCLUSION

Results suggest that light therapy is safe for the eyes in physically healthy, unmedicated persons. The ocular safety of light therapy in persons with preexisting ocular abnormalities or increased photosensitivity warrants further study. However, theoretical considerations do not substantiate stringent ocular safety-related contraindications for light therapy.

Demographic and need factors of early, delayed and no mental health care use in major depression: a prospective study

BACKGROUND

Despite the availability of evidence based treatments, many people with major depression receive no or delayed professional treatment, which may put them at risk for adverse outcomes. The aim of this study was to examine which demographic and need factors distinguish early, delayed and no treatment use.

METHODS

Data were obtained from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). People with a diagnosis of major depression in the past 12 months were included (N = 434). Mental health care use was assessed during this same period and at follow up (three years later). Multinomial regression analysis was used to distinguish early, delayed and no mental health care users with respect to demographic and need factors.

RESULTS

The majority of participants accessed treatment early (62%). Early treatment users were characterized by more severe and persistent symptoms and were more likely not to have a partner compared to no treatment users. The majority of those without treatment reached remission in three years (85%). Delayed treatment users were, compared to early users, characterized by relatively mild symptoms and a persistent or new major depressive disorder at follow up.

CONCLUSIONS

Early access to treatment and the finding that need factors determine mental health care use among people with depression show that the filters along the pathway to treatment are not influenced by unfavorable determinants like education or age.

Attention-deficit/hyperactivity disorder symptoms and stress-related biomarkers

OBJECTIVE

The current study examined whether (a) Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms were associated with dysregulation of stress-related mechanisms, and (b) whether ADHD symptoms interact with affective disorders in their association with dysregulated stress-related mechanisms.

METHODS

Data were obtained from 2307 subjects participating in the Netherlands Study of Depression and Anxiety. Stress-related mechanisms were reflected by the following biomarkers: (1) hypothalamic-pituitary-adrenal axis indicators (salivary cortisol awakening curve, evening cortisol, cortisol suppression after a 0.5mg dexamethasone suppression test (DST)); (2) autonomic nervous system measures (heart rate, pre-ejection period, respiratory sinus arrhythmia); (3) inflammatory markers (C-reactive protein, interleukin-6, tumor necrosis factor-alpha); (4) brain-derived neurotrophic factor. ADHD symptoms were measured using Conners' Adult ADHD Rating Scale and used both dichotomous (High ADHD symptoms (yes/no)) and continuous (Inattentive symptoms, Hyperactive/Impulsive symptoms, and the ADHD index).

RESULTS

Regression analyses showed associations between High ADHD symptoms, Inattentive symptoms, the ADHD index and a higher cortisol awakening curve, between Hyperactive/Impulsive symptoms and less cortisol suppression after DST, and between Inattentive symptoms and a longer pre-ejection period. However, the associations with the cortisol awakening curve disappeared after adjustment for depressive and anxiety disorders. No associations were observed between ADHD symptoms and inflammatory markers or BDNF. ADHD symptoms did not interact with affective disorders in dysregulation of stress-related mechanisms.

CONCLUSION

Some associations were observed between ADHD symptoms, the HPA-axis, and the pre-ejection period, but these were mostly driven by depressive and anxiety disorders. This study found no evidence that ADHD symptomatology was associated with dysregulations in inflammatory markers and BDNF. Consequently, ADHD symptoms did not confer an added risk to the disturbances of stress-related mechanisms in an - already at-risk - population with affective disorders.

Genetic effects influencing risk for major depressive disorder in China and Europe

Major depressive disorder (MDD) is a common, complex psychiatric disorder and a leading cause of disability worldwide. Despite twin studies indicating its modest heritability (~30-40%), extensive heterogeneity and a complex genetic architecture have complicated efforts to detect associated genetic risk variants. We combined single-nucleotide polymorphism (SNP) summary statistics from the CONVERGE and PGC studies of MDD, representing 10 502 Chinese (5282 cases and 5220 controls) and 18 663 European (9447 cases and 9215 controls) subjects. We determined the fraction of SNPs displaying consistent directions of effect, assessed the significance of polygenic risk scores and estimated the genetic correlation of MDD across ancestries. Subsequent trans-ancestry meta-analyses combined SNP-level evidence of association. Sign tests and polygenic score profiling weakly support an overlap of SNP effects between East Asian and European populations. We estimated the trans-ancestry genetic correlation of lifetime MDD as 0.33; female-only and recurrent MDD yielded estimates of 0.40 and 0.41, respectively. Common variants downstream of GPHN achieved genome-wide significance by Bayesian trans-ancestry meta-analysis (rs9323497; log10 Bayes Factor=8.08) but failed to replicate in an independent European sample (P=0.911). Gene-set enrichment analyses indicate enrichment of genes involved in neuronal development and axonal trafficking. We successfully demonstrate a partially shared polygenic basis of MDD in East Asian and European populations. Taken together, these findings support a complex etiology for MDD and possible population differences in predisposing genetic factors, with important implications for future genetic studies.