Fifteen years on: evolving ideas in researching sex differences in depression

BACKGROUND

A cohort study of a socially homogeneous group of teachers was commenced in 1978 to pursue possible risk factors contributing to the recognized female preponderance of depression.

METHODS

Multiple measures of depressive experience included: (i) lifetime rates, duration and number of depressive episodes using two caseness definitions, DSM-III-R major depression and 'all depression' (which included a category of minor depression); (ii) self-report measures of state and trait depression, neuroticism, and self-esteem. DSM-III-R anxiety disorder rates are also reported and co-morbidity with major depression examined.

RESULTS

At the 15-year review in 1993, the sample had a mean age of 39 years, there was a trend for a female preponderance in lifetime rates of major depression and 'all depression' (and which was more pronounced with the inclusion of data for anxiety disorders), with statistically significant differences in rates of social and simple phobias and combined anxiety disorders. Mean neuroticism scores were consistently higher for women.

CONCLUSIONS

The strong association between anxiety and depressive disorders suggests that greater reporting of anxiety and higher neuroticism scores in women may be a key determinant that contributes to any female preponderance in depression rates.

How distinct is 'distinct quality' of mood?

BACKGROUND

The DSM-IV criteria for melancholia include the clinical feature 'distinct quality', defined as a mood state differing from that experienced in bereavement. Both propositions-its specificity to melancholia and its definition- remain problematical.

METHODS

We examine both propositions by analysing an adjective checklist completed by melancholic and non-melancholic depressed subjects, as well as by a bereaved sample. The checklist was refined by a principal components analysis to four scales-one assessing a general 'mood' severity or dysphoric dimension, and the other three assessing dimensions of 'fatigue', 'numbness' and 'guilt'.

RESULTS

If the concept of "distinct quality' has validity, we would require specificity of the refined qualitative constructs to melancholic depression. The 'numbness' component met that requirement, but only to a degree. While bereaved subjects did differ from those with melancholic depression on a number of our refined qualitative mood domains, such differences appeared more related to lower levels of depression in the bereaved sample.

CONCLUSIONS

We argue for deleting the 'distinct quality' criterion from diagnostic checklists of melancholia until its definition has been improved, its utility demonstrated and its specificity to any depressive subtype established as having clinical significance.

Morbid jealousy as a variant of obsessive-compulsive disorder

OBJECTIVE

To present a representative case vignette and review several previous reports, and to then suggest that a percentage of those with morbid jealousy may have a variant of obsessive-compulsive disorder (OCD).

CLINICAL PICTURE

A patient presented volunteering a diagnosis of depression and anxiety following recent work and marital stresses, before describing recent jealousy and harassment of his wife over an earlier relationship. Obsessional thinking patterns and compulsive behaviours are described, and it is proposed that the picture supports a diagnosis of obsessive-compulsive disorder.

TREATMENT AND OUTCOME

The patient was treated as if he had an obsessive-compulsive disorder, and reported dissipation of his concerns after cognitive-behavioural intervention.

CONCLUSIONS

The proposition is an important one as a diagnosis of morbid jealousy often invites therapeutic pessimism, and as managements effective for OCD (both drug and behavioural) may well be helpful.

Distinguishing psychotic depression from melancholia

We contrast 25 patients with "psychotic depression" (PD) against two age- and sex-matched groups of melancholic depressed patients. In terms of clinical features, specificity of PD was suggested for several features, including delusions, morbid cognitions (involving guilt and a sense of deserving punishment), hallucinations and constipation. In addition, the PDs had significantly higher levels of behaviourally rated psychomotor disturbance. A comprehensive list of risk factors to depression (e.g., socio-demographic, family history, parental influences, medical disorders, anxiety, stressors and personality style) were examined, without clear differentiation between the comparison groups apart from the suggestion that being a "worrier" and having tenuous stability under stress was over-represented in the PDs. Findings favour the view that psychotic depression is a sub-type of melancholic depression (accounting for the similar expression of the majority of clinical and possible aetiological variables across our contrasted "types'). Findings also suggest possible benefits from future phenomenological studies of psychotic depression relying more on observer-based rather than self-report or symptom data sets. Aetiological studies would benefit from focussing on those features identified as distinguishing the condition from melancholic depression.

Early onset depression: the relevance of anxiety

The aim of this study was to determine risk factors that may differentiate early onset from late onset depression. A non-clinical cohort that had been assessed from 1978 to 1993 at 5 yearly intervals and that had a high prevalence rate of lifetime depression took part in the study. We established an appropriate age cut-off to distinguish early onset (i.e. before 26 years) of major and of minor depression, and examined the relevance of a number of possible determinants of early onset depression assessed over the life of the study. Despite several dimensional measures of depression, self-esteem and personality being considered, they generally failed (when assessed early in the study) to discriminate subsequent early onset depression, with the exception of low masculinity scores being a weak predictor of major and/or minor depression. Early onset depression was strongly predicted, however, by a lifetime episode of a major anxiety disorder, with generalised anxiety being a somewhat stronger and more consistent predictor than panic disorder, agoraphobia and minor anxiety disorders (ie social phobia, simple phobia). The possibility that anxiety may act as a key predispositional factor to early onset depression and to a greater number of depressive episodes is important in that clinical assessment and treatment of any existing anxiety disorder may be a more efficient and useful strategy than focussing primarily on the depressive disorder.

Plumbing the depths: some problems in quantifying depression severity

We first report further studies of the psychometric properties of the AUSSI), a brief (11-item) self-report depression measure assessing mood state severity and disability in a sample of 270 subjects. Total scores (combining mood state and disability) correlated well with another self-report measure of depression severity, the Beck, but minimally with both Hamilton and DSM-III-R Global Assessment of Function (GAF) scores. For a sub-sample where we had complete data sets (including a corroborative witness [CW] form of the AUSSI), we established moderate levels of agreement between self-report and CW AUSSI scores, important in supporting validity of its disability sub-scale. Against expectation, neither mood nor disability AUSSI scale scores differed across clinically meaningful depressive sub-types, while differentiation was demonstrated for the Hamilton and GAF measures. Differentiation for the Hamilton measure was clearly driven by several type-specific component clinical features, but also presumably contributed to by the clinician-rater format. Our study raises questions about the varying reference bases and semantics used by patients, corroborative witnesses and clinicians in rating depression severity, and which may generate similar or contrasting severity estimates across varying depressive sub-types.

Descriptors of depression: the importance of agreed definitions

OBJECTIVE

We suggest that some descriptors and criteria of depressive features lack clarity or are overinclusive, with definitional limitations and vagaries in rating options, leading to variable ratings of similar items across differing measures as well as cloudy interpretation of positive ratings.

METHOD

We illustrate these limitations by reference to two items: 'guilt' and 'distinct quality of mood'.

RESULTS

We note problems emerging from confounded and imprecise definitions.

CONCLUSIONS

We emphasise the need for definitions of depressive descriptors possessing greater specificity.

Defining the personality disorders: description of an Australian database

OBJECTIVE

We seek to improve the definition and classification of the personality disorders (PDs) and derive a large database for addressing this objective.

METHOD

The paper describes the rationale for the development of a large set of descriptors of the PDs (including all DSM-IV and ICD-10 descriptors, but enriched by an additional 109 items), the design of parallel self-report (SR) and corroborative witness (CW) measures, sample recruitment (of 863 patients with a priori evidence of personality disorder or disturbance) and preliminary descriptive data.

RESULTS

Analyses (particularly those comparing ratings on molar PD descriptions with putative PD dimensions) argue for acceptable reliability of the data set, while both the size of the sample and the representation of all PD dimensions of interest argue for the adequacy of the database.

CONCLUSIONS

We consider in some detail current limitations to the definition and classification of the PDs, and foreshadow the analytic techniques that will be used to address the key objectives of allowing the PDs to be modelled more clearly and, ideally, measured with greater precision and validity.

Depressive psychomotor disturbance, cortisol, and dexamethasone

We examine the dexamethasone suppression test as a biological correlate of melancholia as defined by the CORE system, a scale for rating objective signs of psychomotor disturbance. Postdexamethasone cortisol concentrations and rates of nonsuppression were higher in CORE, Newcastle, and DSM-III-R defined melancholic groups. These differences, however, were no longer significant after partialling out the combined effects of age, dexamethasone, and basal cortisol concentrations. There was a significant correlation between the CORE (but not the Newcastle) scale and 8:00 AM postdexamethasone cortisol levels, which persisted after partialling out those same three covariates. Dexamethasone concentrations themselves were lower in CORE- and Newcastle-defined melancholics, though these were no longer significant after covarying for cortisol concentrations. Dexamethasone levels were also significantly inversely correlated with CORE and Newcastle scales. A significant correlation between CORE (but not Newcastle) scores and dexamethasone levels at 4:00 PM persisted after partialling out the effects of age and cortisol. These findings indicate an intriguing relationship between the CORE system as a dimensional construct for rating psychomotor disturbance, and both postdexamethasone cortisol and dexamethasone concentrations.

Occupational medicine and training for general practice

The inclusion of occupational health topics in vocational training for general practice is limited-principally by course overload, and by a lack of local contact between occupational physicians and general practitioners (GPs). There is a need for the Royal College of General Practitioners and the Faculty of Occupational Medicine to review communication and training opportunities between the specialties.

ABC of work related disorders. Working with an occupational health department

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An exploration of the quality of peer review group activities within Australasia

OBJECTIVE

To describe a two-phase study of the structure of Australasian psychiatrist peer review groups. METHOD (Phase one): Initially, information was sought from chairs/coordinators of psychiatrist peer review groups regarding the nature and organisation of their group. RESULTS (Phase one): One hundred and three questionnaires were returned describing a number of models of peer review. Three principal models were identified: a teaching hospital model, a private practice model, and a private institution model. METHOD (Phase two): The second-phase questionnaire sought information on the quality of the review, using six proposed standards developed by the Quality Assurance Committee of the Royal Australian and New Zealand College of Psychiatrists. RESULTS (Phase two): Many groups indicated that four of the proposed standards (those relating to documentation, having clear goals, reviewing actual clinical cases, and rigorous protection of confidentiality) were either already being followed or would be relatively easy to implement. The remaining two proposed standards (including structure, process and outcome dimensions of health care in the case discussion, and the use of explicit criteria) presented more difficulty.

CONCLUSION

The application of such standards to peer review group meetings should assist groups to provide a forum for presentation and evaluation of clinical work where participants know they will be challenged in an environment which is both supportive and educational.

Prediction of ECT response: validation of a refined sign-based (CORE) system for defining melancholia

BACKGROUND

The clinical validity of melancholia has been argued on the basis of its capacity to predict response to electroconvulsive therapy (ECT). We have argued that a sign-based (CORE) rating system of psychomotor disturbance can identify patients with melancholia. Therefore, the clinical validity of the CORE system was tested here in terms of its capacity to predict response to ECT.

METHOD

The response of 81 patients with primary affective disorders to an individualised course of ECT was investigated. CORE scores and other clinical predictors were evaluated in terms of their capacity to predict effect size changes in symptoms and disability.

RESULTS

CORE scores predicted ECT response, as did the presence of psychotic features. The combination of marked psychomotor change (high CORE scores) and psychotic features predicted the best response to ECT.

CONCLUSION

This study supports the clinical validity of the CORE system for diagnosing melancholia.

The development of a patient satisfaction measure for psychiatric outpatients

OBJECTIVE

To describe the first stage of development of a patient satisfaction form designed for psychiatric outpatients.

METHOD

An initial 62-item questionnaire was completed by 172 patients, who were asked to assess the importance of a number of practice and practitioner features in contributing to their satisfaction.

RESULTS

Mean scores prioritized the psychiatrist respecting the rights of the patient; appointment and billing arrangements were of intermediate importance, while amenity issues were rated as unimportant. When rankings across the several practices were examined, very high levels of agreement were demonstrated, supporting the likely validity of the overall rankings. Four underlying domains were identified by factor analysis, the principal one being defined by respect for confidentiality, by support and adequate communication. The three remaining factors were contributed to more by practice (e.g. billing arrangements, amenities) than by practitioner features.

CONCLUSION

We consider how a refined and modified version of the measure might be developed for use by both individual practitioners and group practices, as well as being used as a formal QA component activity.

If the referral fits: bridging the gap between patient and referrer requirements in a tertiary referral unit

OBJECTIVE

We examined the reasons for which doctors refer and patients request referral to our tertiary Mood Disorders Unit (MDU), focussing on congruence and 'fit', and the potential for more efficient use of referral resources.

METHOD

A postal survey of patients (n = 265 or 83% responders) and referrers (n = 156 or 94% responders) sought views regarding referral and service components. Ratings from 156 matched referrer-patient dyads were compared.

RESULTS

Overall, referrers and patients were satisfied with the MDU. There was disparity between what referrers sought and what patients thought were the reasons for referral, and different perceptions of the value of interventions and the amount of improvement. Congruent matched referrer-patient judgements of patient outcome were more likely to correspond with objective clinician ratings than discordant ratings. Satisfaction with MDU contact or intervention was not necessarily linked to improvement; better management of chronic depression was also valued. Referrer and patient responses to open-ended questions highlighted beneficial ingredients of referral.

CONCLUSIONS

There was considerable lack of fit between referrers' and patients' experience of the referral. Better communication between referrer and patients can clarify the purpose of referral and possibly lead to increased compliance with medical regimens.

To whom do you refer? A referrer satisfaction study

OBJECTIVE

To report the development of a referrer satisfaction measure.

METHOD

Urban and rural general practitioners, physicians, neurologists, as well as obstetricians and gynaecologists rated 36 items in terms of their judged importance to the respondent's satisfaction with a psychiatric service. Responses of the whole sample and component practitioner sub-groups were ranked.

RESULTS

We established a high level of agreement across the several subgroups suggesting that we had identified general rather than idiosyncratic variables contributing to referrer satisfaction. Referrers prioritised as most important the immediacy of initial appointment, the psychiatrist reporting at the beginning and end of any treatment course, and ready verbal communication between the referrer and the psychiatrist. Items accorded low priority were the psychiatrist's billing arrangements, the psychiatrist being 'perfect' (in either having a high 'cure' rate or making a definitive diagnosis initially), or the psychiatrist taking complete responsibility for difficult patients. A principal components analysis identified four factors underpinning the item set, and we again established that scores on these factors were not influenced by the particular referrer sub-group.

CONCLUSIONS

Such findings suggest that only minor modifications would need to be made to the item set in developing a referrer satisfaction measure for quality assurance activities.

General practitioners and occupational health services

BACKGROUND

Occupational physicians and general practitioners often appear to differ in their attitudes to the provision of health screening, health promotion and vaccination in the workplace.

AIM

This study aimed to explore the attitudes of occupational physicians and general practitioners to particular aspects of workplace health services.

METHOD

Anonymous piloted postal questionnaires were sent to 400 UK general practitioners and 300 occupational physicians.

RESULTS

Questionnaires were returned by 260 general practitioners (65%) and 223 occupational physicians (74%). There are differences between the specialties in attitude to specific health screening and vaccination at work, and to the role of occupational health services in helping the disabled, but greater agreement on the usefulness of workplace health promotion.

CONCLUSION

General practitioners may misunderstand the role, responsibilities and priorities of occupational health services. Further educational work needs to be done to overcome communication difficulties between the specialties.

Comparative validity of two measures of psychomotor function in patients with severe depression

Psychomotor function is a key construct in depressed patients and two measures have been developed for systematic rating. Parker and colleagues utilise an observer-rated scale (CORE) while the scale (DRRS) developed by Widlöcher assesses motor and ideational aspects. Association between the scales and their relative capacity to predict ECT response were investigated in a sample of 81 depressed patients. Both predicted ECT response. While the CORE scale rates a wider variety of phenomena (including non-interactiveness and agitation) and does not rely on the subject's capacity to report aspects of their cognitive function, the study supports the predictive and comparitive validity of both scales.

Pharmacokinetics of oral mycophenolate mofetil in volunteer subjects with varying degrees of hepatic oxidative impairment

Eighteen patients with compensated alcoholic cirrhosis participated in a single-dose pharmacokinetic study of oral mycophenolate mofetil (MMF). Participants were divided into groups of 6 patients each with mild, moderate, or severe hepatic oxidative impairment as defined by the aminopyrine breath test (APBT). Clinically, hepatic disease was of mild or moderate severity. Six healthy volunteers were included as control subjects. Plasma and urine samples were collected over 96 hours and assayed for the active metabolite mycophenolic aced (MPA) and the glucuronide conjugate, MPAG. Plasma protein binding of MPA also was determined in 6 unrelated patients with cirrhosis. Cirrhosis did not grossly affect plasma pharmacokinetics or plasma binding of MPA. Maximum plasma concentrations (C(max)) and area under the curve (AUC) of MPA and MPAG consistently decreased, increased, and then decreased as oxidative impairment declined from normal to severe. Patients with cirrhosis had comparable or greater recovery of administered drug substance in urine than controls, showing that cirrhosis did not affect the extent of MMF absorption. Urine clearance of MPAG was two times higher in the group with severe impairment than in the other groups. Creatinine clearance was similar in all groups. These results suggest progressive impairment of hepatic glucuronidation of MPA and induction of renal glucuronidation in patients with severe hepatic oxidative impairment.