Markers of stress and inflammation as potential mediators of the relationship between exercise and depressive symptoms: findings from the TRAILS study

The hypothalamic-pituitary-adrenal axis, autonomic nervous system, and immune system have been proposed to underlie the antidepressant effect of exercise. Using a population sample of 715 adolescents, we examined whether pathways from exercise to affective and somatic symptoms of depression were mediated by these putative mechanisms. Exercise (hours/week) and depressive symptoms were assessed at age 13.5 (± 0.5) and 16.1 (± 0.6). Cortisol and heart rate responses to a standardized social stress test and C-reactive protein levels were measured at age 16. Exercise was prospectively and inversely related to affective (B = -0.16, 95% CI = -0.30 to -0.03) but not somatic symptoms (B = -0.04, 95% CI = -0.21 to 0.13). Heart rate during social stress partially mediated this relationship (B = -0.03, 95% CI = -0.07 to -0.01). No other mediating effects were found. Hence, the autonomic stress system may play a role in the relationship between exercise and depressive symptoms.

Personality modulates the efficacy of treatment in patients with major depressive disorder

OBJECTIVE

Effects of depression treatment are obscured by heterogeneity among patients. Personality types could be one source of heterogeneity that explains variability in treatment response. Clinically meaningful variations in personality patterns could be captured with data-driven subgroups. The aim of this study was to identify such personality types and to explore their predictive value for treatment efficacy.

METHOD

Participants (N = 146) in the current exploratory study came from a randomized controlled trial in primary care depressed patients, conducted between January 1998 and June 2003, comparing different treatments. All participants were diagnosed with a major depressive disorder (MDD) according to the DSM-IV. Primary (care as usual [CAU] or CAU plus a psychoeducational prevention program [PEP]) and specialized (CAU + PEP + psychiatric consultation or cognitive-behavioral therapy) treatment were compared. Personality was assessed with the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI). Personality classes were identified with latent profile analysis (LPA). During 1 year, weekly depression ratings were obtained by trimonthly assessment with the Composite International Diagnostic Interview. Mixed models were used to analyze the effects of personality on treatment efficacy.

RESULTS

A 2-class LPA solution fit best to the NEO-FFI data: Class 1 (vulnerable, n = 94) was characterized by high neuroticism, low extraversion, and low conscientiousness, and Class 2 (resilient, n = 52) by medium neuroticism and extraversion and higher agreeableness and conscientiousness. Recovery was quicker in the resilient class (class × time: P < .001). Importantly, specialized treatment had added value only in the vulnerable class, in which it was associated with quicker recovery than primary treatment (class × time × treatment: P < .001).

CONCLUSIONS

Personality profile may predict whether specialized clinical efforts have added value, showing potential implications for planning of treatments.

Data-driven course trajectories in primary care patients with major depressive disorder

BACKGROUND

The chronic nature of MDD has been acknowledged as one of the key determinants of the burden associated with depression. Unfortunately, so far described prognostic factors have been inconsistent, possibly due to used course outcomes that are often based on arbitrary criteria/cut-offs. Therefore, the aim of the current study was to use data-driven trajectory groups based on closely spaced weekly severity ratings, as outcomes in prognostic research.

METHODS

The sample consisted of primary care patients with MDD (n = 153), who were followed up for a year with 52 consecutive weekly ratings of the nine DSM-IV MDD criterion symptoms. Growth Mixture Modeling (GMM) was used to reduce the interpersonal growth variation to an optimal set of clinically interpretable trajectory groups. Next, baseline course predictors were investigated and the prognostic (added) value of course-group membership was investigated for clinical outcomes after 1, 2, and 3 years.

RESULTS

GMM resulted in four trajectory groups: "early remission" (40.2%), "late remission" (9.8%), "remission and recurrence" (17.0%), and "chronic" (33.0%). Multivariate predictors of "chronic" group membership were a prior suicide attempt, comorbid dysthymia, and lower levels of somatic depressive symptoms. Group membership predicted differences in depression severity and/or quality of life after 1, 2, and 3 years.

CONCLUSIONS

The used data-driven approach provided a parsimonious and clinically informative way to describe course variation across MDD patients. Using the trajectory groups to investigate prognostic factors of MDD provided insight in potentially useful prognostic factors. Importantly, trajectory-group membership was itself a strong predictor of future mental well-being.

Major depressive disorder subtypes to predict long-term course

BACKGROUND

Variation in the course of major depressive disorder (MDD) is not strongly predicted by existing subtype distinctions. A new subtyping approach is considered here.

METHODS

Two data mining techniques, ensemble recursive partitioning and Lasso generalized linear models (GLMs), followed by k-means cluster analysis are used to search for subtypes based on index episode symptoms predicting subsequent MDD course in the World Mental Health (WMH) surveys. The WMH surveys are community surveys in 16 countries. Lifetime DSM-IV MDD was reported by 8,261 respondents. Retrospectively reported outcomes included measures of persistence (number of years with an episode, number of years with an episode lasting most of the year) and severity (hospitalization for MDD, disability due to MDD).

RESULTS

Recursive partitioning found significant clusters defined by the conjunctions of early onset, suicidality, and anxiety (irritability, panic, nervousness-worry-anxiety) during the index episode. GLMs found additional associations involving a number of individual symptoms. Predicted values of the four outcomes were strongly correlated. Cluster analysis of these predicted values found three clusters having consistently high, intermediate, or low predicted scores across all outcomes. The high-risk cluster (30.0% of respondents) accounted for 52.9-69.7% of high persistence and severity, and it was most strongly predicted by index episode severe dysphoria, suicidality, anxiety, and early onset. A total symptom count, in comparison, was not a significant predictor.

CONCLUSIONS

Despite being based on retrospective reports, results suggest that useful MDD subtyping distinctions can be made using data mining methods. Further studies are needed to test and expand these results with prospective data.

The presence of a depressive episode predicts lower return to work rate after myocardial infarction

CONTEXT

No studies have evaluated whether the presence of a depressive episode is associated with an increased risk of not returning to work following myocardial infarction (MI).

OBJECTIVES

To examine the prospective associations between depressive episode and anxiety disorders with return to work (RTW) after MI at 3 and 12 months based on International Classification of Diseases, 10th Revision.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the North of The Netherlands.

PARTICIPANTS

From a sample of patients hospitalized for MI (n=487), we selected those who had a paid job at the time of the MI (N=200).

MAIN EXPOSURE MEASURES

Presence of a depressive episode and presence of any anxiety disorder during the first 3 months post-MI.

MAIN OUTCOME MEASURES

RTW at 12 months post-MI.

RESULTS

Of the patients with work prior to MI, 75% had returned to work at 12 months. The presence of a depressive episode during the first 3 months (prevalence: 19.4%) was a significant predictor of no RTW at 12 months post-MI, also after controlling for confounders [odds ratio (OR) 3.48; 95% confidence interval (CI): 1.45-8.37]. The presence of an anxiety disorder (prevalence: 11.9%) had a borderline significant association with no RTW as well. This association remained after controlling for confounders (OR 2.90; 95% CI: 1.00-6.38) but diminished when controlling for depression.

CONCLUSIONS

The presence of a depressive episode was associated with an increased risk of no RTW in MI patients. The association between anxiety and risk of no RTW could in part be explained by the presence of depression. Further studies may address the possibility of countering the effect of depression by effective treatment.

Self-attributed seasonality of mood and behavior: a report from the Netherlands study of depression and anxiety

BACKGROUND

Seasonal changes in mood and behavior are considered to be common in the general population and in patients with psychiatric disorders. However, in several studies this seasonality could not be demonstrated. The present study examined self-attributed seasonality of depressive symptoms among patients with a lifetime diagnosis of a depressive disorder (D), an anxiety disorder (A), a comorbid depressive and anxiety disorder (DA), and healthy controls (HC).

METHODS

The CIDI was used to establish diagnoses according to DSM-IV criteria in 2,168 participants of the Netherlands Study of Depression and Anxiety (NESDA). The Seasonal Pattern Assessment Questionnaire (SPAQ) was administered to assess variation in mood and behavior.

RESULTS

Of the 2,168 participants 53.5% reported seasonality of mood. Highest percentages of low mood were seen in the winter months. Although all groups showed this pattern of lowered mood during the winter months, D, A, and DA were significantly (P < .001) more likely to experience seasonality is this respect. This was also shown for seasonal changes in energy, social activities, sleeping, eating, weight and for the Global Seasonality Score. A limitation of this study was the cross-sectional design.

CONCLUSIONS

Seasonal variation in mood and behavior was demonstrated for both participants with a lifetime diagnosis of depression and/or anxiety disorder and for healthy controls, but patients with anxiety and/or depression were more likely to experience this seasonal variation. Clinicians should take into account that the time of the year could influence the feelings of well- and ill-being of their patients.

DSM-5 and ICD-11 definitions of posttraumatic stress disorder: investigating "narrow" and "broad" approaches

BACKGROUND

The development of the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) and ICD-11 has led to reconsideration of diagnostic criteria for posttraumatic stress disorder (PTSD). The World Mental Health (WMH) Surveys allow investigation of the implications of the changing criteria compared to DSM-IV and ICD-10.

METHODS

WMH Surveys in 13 countries asked respondents to enumerate all their lifetime traumatic events (TEs) and randomly selected one TE per respondent for PTSD assessment. DSM-IV and ICD-10 PTSD were assessed for the 23,936 respondents who reported lifetime TEs in these surveys with the fully structured Composite International Diagnostic Interview (CIDI). DSM-5 and proposed ICD-11 criteria were approximated. Associations of the different criteria sets with indicators of clinical severity (distress-impairment, suicidality, comorbid fear-distress disorders, PTSD symptom duration) were examined to investigate the implications of using the different systems.

RESULTS

A total of 5.6% of respondents met criteria for "broadly defined" PTSD (i.e., full criteria in at least one diagnostic system), with prevalence ranging from 3.0% with DSM-5 to 4.4% with ICD-10. Only one-third of broadly defined cases met criteria in all four systems and another one third in only one system (narrowly defined cases). Between-system differences in indicators of clinical severity suggest that ICD-10 criteria are least strict and DSM-IV criteria most strict. The more striking result, though, is that significantly elevated indicators of clinical significance were found even for narrowly defined cases for each of the four diagnostic systems.

CONCLUSIONS

These results argue for a broad definition of PTSD defined by any one of the different systems to capture all clinically significant cases of PTSD in future studies.

Inflammatory and metabolic dysregulation and the 2-year course of depressive disorders in antidepressant users

Scarce evidence suggests that inflammatory and metabolic dysregulation predicts poor response to antidepressants, which could result in worse depression outcome. This study prospectively examined whether inflammatory and metabolic dysregulation predicted the 2-year course of depressive disorders among antidepressant users. Data were from the Netherlands Study of Depression and Anxiety, including 315 persons (18-65 years) with a current depressive disorder (major depressive disorder, dysthymia) at baseline according to the DSM-IV criteria and using antidepressants. Inflammatory (C-reactive protein, interleukin-6 (IL-6), tumor-necrosis factor-α) and metabolic (waist circumference, triglycerides, high-density lipoprotein (HDL) cholesterol, blood pressure, fasting glucose) factors were measured at baseline. Primary outcome for course of depression was indicated by whether or not a DSM-IV depressive disorder diagnosis was still/again present at 2-year follow-up, indicating chronicity of depression. Elevated IL-6, low HDL cholesterol, hypertriglyceridemia, and hyperglycemia were associated with chronicity of depression in antidepressant users. Persons showing ⩾ 4 inflammatory or metabolic dysregulations had a 1.90 increased odds of depression chronicity (95% CI = 1.12-3.23). Among persons who recently (ie, at most 3 months) started antidepressant medication (N = 103), having ⩾ 4 dysregulations was associated with a 6.85 increased odds of depression chronicity (95% CI = 1.95-24.06). In conclusion, inflammatory and metabolic dysregulations were found to predict a more chronic course of depressive disorders among patients using antidepressants. This could suggest that inflammatory and metabolic dysregulation worsens depression course owing to reduced antidepressant treatment response and that alternative intervention treatments may be needed for depressed persons with inflammatory and metabolic dysregulation.

Associations between DSM-IV mental disorders and diabetes mellitus: a role for impulse control disorders and depression

AIMS/HYPOTHESIS

No studies have evaluated whether the frequently observed associations between depression and diabetes could reflect the presence of comorbid psychiatric conditions and their associations with diabetes. We therefore examined the associations between a wide range of pre-existing Diagnostic Statistical Manual, 4th edition (DSM-IV) mental disorders with self-reported diagnosis of diabetes.

METHODS

We performed a series of cross-sectional face-to-face household surveys of community-dwelling adults (n = 52,095) in 19 countries. The World Health Organization Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Diabetes was indicated by self-report of physician's diagnosis together with its timing. We analysed the associations between all mental disorders and diabetes, without and with comorbidity adjustment.

RESULTS

We identified 2,580 cases of adult-onset diabetes mellitus (21 years +). Although all 16 DSM-IV disorders were associated with diabetes diagnosis in bivariate models, only depression (OR 1.3; 95% CI 1.1, 1.5), intermittent explosive disorder (OR 1.6; 95% CI 1.1, 2.1), binge eating disorder (OR 2.6; 95% CI 1.7, 4.0) and bulimia nervosa (OR 2.1; 95% CI 1.3, 3.4) remained after comorbidity adjustment.

CONCLUSIONS/INTERPRETATION

Depression and impulse control disorders (eating disorders in particular) were significantly associated with diabetes diagnosis after comorbidity adjustment. These findings support the focus on depression as having a role in diabetes onset, but suggest that this focus may be extended towards impulse control disorders. Acknowledging the comorbidity of mental disorders is important in determining the associations between mental disorders and subsequent diabetes.

Gender differences in major depressive disorder: results from the Netherlands study of depression and anxiety

BACKGROUND

Although an overall gender difference in prevalence of major depressive disorder (MDD) has been well established, several questions concerning gender differences in the clinical manifestation of depression remain. This study aims to identify gender differences in psychopathology, treatment, and public health consequences in patients with MDD.

METHODS

Baseline data from the Netherlands Study of Depression and Anxiety (NESDA) were used, including 1115 participants (364 men, 751 women, mean age 41 years) with a DSM-IV diagnosis of current MDD. Characteristics studied included symptom profiles, comorbidity, treatment, and public health consequences.

RESULTS

Women reported a younger age of onset of single (27.8 years vs. 31.6 years; p=0.001) and recurrent MDD (24.8 years vs. 27.6 years; p=0.014), a higher comorbidity of panic disorder with agoraphobia (24.9% vs. 17.3%; p=0.006) and life-time overall anxiety disorder (77.6% vs. 71.4%; p=0.029) than men. More men than women suffered from comorbid alcohol dependence or abuse (48.1% vs. 24.5%; p<0.001). An increased prevalence of atypical depression in women (24.6% vs. 17.3%; p=0.009) was found. Women were treated more frequently by an alternative caretaker (20.6% vs. 14.8%; p=0.025), men more often in mental health care organizations (61.0% vs. 53.7%; p=0.025). No gender differences in frequency of medication use or counseling were found.

LIMITATIONS

Cross sectional design.

CONCLUSIONS

Main gender differences in the clinical presentation of MDD concerned a younger age of onset, higher anxiety and lower alcohol use comorbidity and higher prevalence of atypical depression in women. These differences were accompanied by differences in health care use.

Associations between DSM-IV mental disorders and subsequent self-reported diagnosis of cancer

OBJECTIVE

The associations between mental disorders and cancer remain unclear. It is also unknown whether any associations vary according to life stage or gender. This paper examines these research questions using data from the World Mental Health Survey Initiative.

METHODS

The World Health Organization Composite International Diagnostic Interview retrospectively assessed the lifetime prevalence of 16 DSM-IV mental disorders in face-to-face household population surveys in nineteen countries (n = 52,095). Cancer was indicated by self-report of diagnosis. Smoking was assessed in questions about current and past tobacco use. Survival analyses estimated associations between first onset of mental disorders and subsequently reported cancer.

RESULTS

After adjustment for comorbidity, panic disorder, specific phobia and alcohol abuse were associated with a subsequently self-reported diagnosis of cancer. There was an association between number of mental disorders and the likelihood of reporting a cancer diagnosis following the onset of the mental disorder. This suggests that the associations between mental disorders and cancer risk may be generalised, rather than specific to a particular disorder. Depression is more strongly associated with self-reported cancers diagnosed early in life and in women. PTSD is also associated with cancers diagnosed early in life.

CONCLUSION

This study reports the magnitude of the associations between mental disorders and a self-reported diagnosis of cancer and provides information about the relevance of comorbidity, gender and the impact at different stages of life. The findings point to a link between the two conditions and lend support to arguments for early identification and treatment of mental disorders.

Family burden related to mental and physical disorders in the world: results from the WHO World Mental Health (WMH) surveys

OBJECTIVE

To assess prevalence and correlates of family caregiver burdens associated with mental and physical conditions worldwide.

METHODS

Cross-sectional community surveys asked 43,732 adults residing in 19 countries of the WHO World Mental Health (WMH) Surveys about chronic physical and mental health conditions of first-degree relatives and associated objective (time, financial) and subjective (distress, embarrassment) burdens. Magnitudes and associations of burden are examined by kinship status and family health problem; population-level estimates are provided.

RESULTS

Among the 18.9-40.3% of respondents in high, upper-middle, and low/lower-middle income countries with first-degree relatives having serious health problems, 39.0-39.6% reported burden. Among those, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, 23.3-27.1% reported psychological distress, and 6.0-17.2% embarrassment. Mean caregiving hours/week was 12.9-16.5 (83.7-147.9 hours/week/100 people aged 18+). Mean financial burden was 15.1% of median family income in high, 32.2% in upper-middle, and 44.1% in low/lower-middle income countries. A higher burden was reported by women than men, and for care of parents, spouses, and children than siblings.

CONCLUSIONS

The uncompensated labor of family caregivers is associated with substantial objective and subjective burden worldwide. Given the growing public health importance of the family caregiving system, it is vital to develop effective interventions that support family caregivers.

Comorbidity of common mental disorders with cancer and their treatment gap: findings from the World Mental Health Surveys

OBJECTIVE

This study aimed to study the comorbidity of common mental disorders (CMDs) and cancer, and the mental health treatment gap among community residents with active cancer, cancer survivors and cancer-free respondents in 13 high-income and 11 low-middle-income countries.

METHODS

Data were derived from the World Mental Health Surveys (N = 66,387; n = 357 active cancer, n = 1373 cancer survivors, n = 64,657 cancer-free respondents). The World Health Organization/Composite International Diagnostic Interview was used in all surveys to estimate CMDs prevalence rates. Respondents were also asked about mental health service utilization in the preceding 12 months. Cancer status was ascertained by self-report of physician's diagnosis.

RESULTS

Twelve-month prevalence rates of CMDs were higher among active cancer (18.4%, SE = 2.1) than cancer-free respondents (13.3%, SE = 0.2) adjusted for sociodemographic confounders and other lifetime chronic conditions (adjusted odds ratio (AOR) = 1.44, 95% CI 1.05-1.97). CMD rates among cancer survivors (14.6%, SE = 0.9) compared with cancer-free respondents did not differ significantly (AOR = 0.95, 95% CI 0.82-1.11). Similar patterns characterized high-income and low-middle-income countries. Of respondents with active cancer who had CMD in the preceding 12 months, 59% sought services for mental health problems (SE = 5.3). The pattern of service utilization among people with CMDs by cancer status (highest among persons with active cancer, lower among survivors and lowest among cancer-free respondents) was similar in high-income (64.0%, SE = 6.0; 41.2%, SE = 3.0; 35.6%, SE = 0.6) and low-middle-income countries (46.4%, SE = 11.0; 22.5%, SE = 9.1; 17.4%, SE = 0.7).

CONCLUSIONS

Community respondents with active cancer have higher CMD rates and high treatment gap. Comprehensive cancer care should consider both factors.

E-mental health self-management for psychotic disorders: state of the art and future perspectives

OBJECTIVE

The aim of this review was to investigate to what extent information technology may support self-management among service users with psychotic disorders. The investigation aimed to answer the following questions: What types of e-mental health self-management interventions have been developed and evaluated? What is the current evidence on clinical outcome and cost-effectiveness of the identified interventions? To what extent are e-mental health self-management interventions oriented toward the service user?

METHODS

A systematic review of references through July 2012 derived from MEDLINE, PsycINFO, AMED, CINAHL, and the Library, Information Science and Technology database was performed. Studies of e-mental health self-management interventions for persons with psychotic disorders were selected independently by three reviewers.

RESULTS

Twenty-eight studies met the inclusion criteria. E-mental health self-management interventions included psychoeducation, medication management, communication and shared decision making, management of daily functioning, lifestyle management, peer support, and real-time self-monitoring by daily measurements (experience sampling monitoring). Summary effect sizes were large for medication management (.92) and small for psychoeducation (.37) and communication and shared decision making (.21). For all other studies, individual effect sizes were calculated. The only economic analysis conducted reported more short-term costs for the e-mental health intervention.

CONCLUSIONS

People with psychotic disorders were able and willing to use e-mental health services. Results suggest that e-mental health services are at least as effective as usual care or nontechnological approaches. Larger effects were found for medication management e-mental health services. No studies reported a negative effect. Results must be interpreted cautiously, because they are based on a small number of studies.

Associations between mental disorders and subsequent onset of hypertension

BACKGROUND

Previous work has suggested significant associations between various psychological symptoms (e.g., depression, anxiety, anger, alcohol abuse) and hypertension. However, the presence and extent of associations between common mental disorders and subsequent adult onset of hypertension remain unclear. Further, there are few data available on how such associations vary by gender or over life course.

METHODS

Data from the World Mental Health Surveys (comprising 19 countries and 52,095 adults) were used. Survival analyses estimated associations between first onset of common mental disorders and subsequent onset of hypertension, with and without psychiatric comorbidity adjustment. Variations in the strength of associations by gender and by life course stage of onset of both the mental disorder and hypertension were investigated.

RESULTS

After psychiatric comorbidity adjustment, depression, panic disorder, social phobia, specific phobia, binge eating disorder, bulimia nervosa, alcohol abuse and drug abuse were significantly associated with subsequent diagnosis of hypertension (with odds ratios ranging from 1.1 to 1.6). Number of lifetime mental disorders was associated with subsequent hypertension in a dose-response fashion. For social phobia and alcohol abuse, associations with hypertension were stronger for males than females. For panic disorder, the association with hypertension was particularly apparent in earlier-onset hypertension.

CONCLUSIONS

Depression, anxiety, impulsive eating disorders and substance use disorders were significantly associated with the subsequent diagnosis of hypertension. These data underscore the importance of early detection of mental disorders, and of physical health monitoring in people with these conditions.

Psychiatric comorbidity and causal disease models

In psychiatry, comorbidity is the rule rather than the exception. Up to 45% of all patients are classified as having more than one psychiatric disorder. These high rates of comorbidity have led to a debate concerning the interpretation of this phenomenon. Some authors emphasize the problematic character of the high rates of comorbidity because they indicate absent zones of rarities. Others consider comorbid conditions to be a validator for a particular reclassification of diseases. In this paper we will show that those at first sight contrasting interpretations of comorbidity are based on similar assumptions about disease models. The underlying ideas are that firstly high rates of comorbidity are the result of the absence of causally defined diseases in psychiatry, and second that causal disease models are preferable to non-causal disease models. We will argue that there are good reasons to seek after causal understanding of psychiatric disorders, but that causal disease models will not rule out high rates of comorbidity--neither in psychiatry, nor in medicine in general. By bringing to the fore these underlying assumptions, we hope to clear the ground for a different understanding of comorbidity, and of models for psychiatric diseases.

Symptom dimensions of anxiety following myocardial infarction: associations with depressive symptoms and prognosis

OBJECTIVE

Differential associations of symptom dimensions with prognosis in myocardial infarction (MI) patients have been shown for depression, but no studies have focused on anxiety dimensions. The aim of this study was to assess the association between somatic and psychological symptoms of anxiety following acute MI with adverse prognosis and to assess the overlap between anxiety and depression dimensions.

METHOD

Patients (n = 418) were assessed on demographic and clinical variables. The Hamilton Anxiety and Depression Rating Scales were used to measure anxiety and depression 2 months post-MI. Mean follow-up period was 3.8 years and the endpoint consisted of all-cause mortality and recurrent MI.

RESULTS

After adjustment for demographic and clinical variables, somatic anxiety was significantly associated with recurrent MI and mortality (HR: 1.32; 95% CI [1.03, 1.69]; p = .03), and a trend was shown for an association between psychological anxiety and outcome (HR: 1.29; 95% CI [0.99, 1.67]; p = .06). The total anxiety score of the HARS was the strongest predictor of recurrent MI and mortality (HR: 1.38; 95% CI [1.07, 1.78]; p = .02). The HARS and the HDRS were highly correlated (r = .86; p < .01). Dimensions consisting of psychological distress (HR: 1.29; 95% CI [1.02, 1.63]; p = .03) and cardiopulmonary/autonomic symptoms (HR: 1.36; 95% CI [1.06, 1.75]; p = .02) also predicted outcome in adjusted analyses.

CONCLUSIONS

Anxiety was associated with adverse prognosis in MI patients with significant associations for somatic anxiety and total anxiety. When combining anxiety and depression items, psychological distress and cardiopulmonary/autonomic symptoms predicted recurrent MI and mortality. Future research might better focus on dimensions of anxiety and depression simultaneously in MI patients.

A web-based tool to support shared decision making for people with a psychotic disorder: randomized controlled trial and process evaluation

Background

Mental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes.

Objective

This study reports the outcome of a randomized controlled trial and process evaluation of a Web-based intervention to facilitate shared decision making for people with psychotic disorders.

Methods

The study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation.

Results

In all, 73 patients completed the follow-up measurement and were included in the final analysis (response rate 29.2%). More than one-third (48/124, 38.7%) of the patients who were provided access to the Web-based decision aid used it, and most used its full functionality. No differences were found between the intervention and control conditions on perceived involvement in medical decision making (COMRADE satisfaction with communication: F_1,68=0.422, P=.52; COMRADE confidence in decision: F_1,67=0.086, P=.77). In addition, results of the process evaluation suggest that the intervention did not optimally fit in with routine practice of the participating teams.

Conclusions

The development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.

Trial Registration

Dutch Trial Register (NTR) trial number: 10340; http://www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=10340 (Archived by WebCite at http://www.webcitation.org/6Jj5umAeS).

Cognitive vulnerability differentially predicts symptom dimensions of depression

BACKGROUND

We examined the association of cognitive vulnerability to depression with changes in homogeneous measures of depressive symptoms.

METHODS

Baseline and 1-year follow-up data were obtained from 2981 participants of the Netherlands study of depression and anxiety. Multivariate regression analyses were carried out on cognitive reactivity, locus of control and implicit and explicit self-depressive associations in combination with negative life events. The purpose of this analysis was to predict changes on the mood/cognition and anxiety/arousal subscales of the inventory of depressive symptomatology - self report.

RESULTS

Cognitive reactivity, locus of control and explicit self-depressive associations were independently associated with changes in depressive symptoms after adjustment for covariates and baseline severity (all p<0.01). Negative life-events interacted with cognitive vulnerability to depression to predict depressive symptoms. Locus of control (b1=0.16, SE=0.02, η(2)=0.01; b2=0.10, SE=0.02, η(2)=0.004, F=8.69, p<0.01) and explicit self-depressive associations (b1=0.10, SE=0.03, η(2)=0.02; b2=0.02, SE=0.04, F=7.50, p<0.01) were more strongly associated with the cognitive (b1) than the somatic (b2) symptom dimension of depression.

LIMITATIONS

The study sample is over-inclusive of depressed patients. Therefore it might be problematic generalizing the findings to the general population.

CONCLUSION

Cognitive etiological factors may play a role in a "cognitive" subtype of depression. The findings strengthen the notion that homogeneous measures of depressive symptoms enable a greater degree of discrimination between subtypes than a multidimensional conception of depression.

Diagnostic heterogeneity in psychiatry: towards an empirical solution

The launch of the 5th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has sparked a debate about the current approach to psychiatric classification. The most basic and enduring problem of the DSM is that its classifications are heterogeneous clinical descriptions rather than valid diagnoses, which hampers scientific progress. Therefore, more homogeneous evidence-based diagnostic entities should be developed. To this end, data-driven techniques, such as latent class- and factor analyses, have already been widely applied. However, these techniques are insufficient to account for all relevant levels of heterogeneity, among real-life individuals. There is heterogeneity across persons (p:for example, subgroups), across symptoms (s:for example, symptom dimensions) and over time (t:for example, course-trajectories) and these cannot be regarded separately. Psychiatry should upgrade to techniques that can analyze multi-mode (p-by-s-by-t) data and can incorporate all of these levels at the same time to identify optimal homogeneous subgroups (for example, groups with similar profiles/connectivity of symptomatology and similar course). For these purposes, Multimode Principal Component Analysis and (Mixture)-Graphical Modeling may be promising techniques.

Differential association of somatic and cognitive symptoms of depression and anxiety with inflammation: findings from the Netherlands Study of Depression and Anxiety (NESDA)

OBJECTIVE

Depression and anxiety have been suggested to be associated with systemic inflammation upregulation. However, results are not always consistent, which may be due to symptom heterogeneity of depression and anxiety. There are some indications that associations with inflammation are mainly driven by somatic symptoms of depression and anxiety. We therefore set out to evaluate the differential association of somatic and cognitive symptoms of depression and anxiety with inflammation, while adjusting for demographic, health related, and lifestyle related variables.

METHODS

We evaluated baseline data from 2861 participants from the Netherlands Study of Depression and Anxiety (NESDA). The Inventory of Depressive Symptomatology and the Beck Anxiety Inventory were used to assess depressive symptoms and anxiety symptoms. For both scales somatic and cognitive symptoms scales were calculated. Baseline blood samples were collected to determine high sensitivity C-Reactive Protein (CRP), interleukin (IL)-6, and Tumor Necrosis Factor (TNF)-α. We used linear regression to analyze the associations adjusting for demographics and health indicators and markers for an unhealthy lifestyle.

RESULTS

After adjustment for sociodemographic and health indicators, depressive symptoms were associated with higher levels of CRP, IL-6 and TNF-α. This association was mainly driven by somatic symptoms. For anxiety, somatic symptoms were associated with higher levels of CRP, IL-6 and TNF-α, whereas cognitive anxiety symptoms were associated with CRP (men only). Markers of an unhealthy lifestyle explained the significant associations.

CONCLUSIONS

Especially somatic symptoms of depression and anxiety are associated with inflammation. However, this association was mostly mediated through unhealthy lifestyles among depressed and anxious individuals.

Associations between DSM-IV mental disorders and subsequent heart disease onset: beyond depression

BACKGROUND

Prior studies on the depression-heart disease association have not usually used diagnostic measures of depression, or taken other mental disorders into consideration. As a result, it is not clear whether the association between depression and heart disease onset reflects a specific association, or the comorbidity between depression and other mental disorders. Additionally, the relative magnitude of associations of a range of mental disorders with heart disease onset is unknown.

METHODS

Face-to-face household surveys were conducted in 19 countries (n=52,095; person years=2,141,194). The Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Heart disease was indicated by self-report of physician's diagnosis, or self-report of heart attack, together with their timing (year). Survival analyses estimated associations between first onset of mental disorders and subsequent heart disease onset.

RESULTS

After comorbidity adjustment, depression, panic disorder, specific phobia, post-traumatic stress disorder and alcohol use disorders were associated with heart disease onset (ORs 1.3-1.6). Increasing number of mental disorders was associated with heart disease in a dose-response fashion. Mood disorders and alcohol abuse were more strongly associated with earlier onset than later onset heart disease. Associations did not vary by gender.

CONCLUSIONS

Depression, anxiety and alcohol use disorders were significantly associated with heart disease onset; depression was the weakest predictor. If confirmed in future prospective studies, the breadth of psychopathology's links with heart disease onset has substantial clinical and public health implications.