Risk factors for chronic depression--a systematic review

Evolution of perinatal depressive symptoms from pregnancy to two years postpartum in a low-risk sample: the MATQUID cohort

BACKGROUND

Few studies have explored the evolution of perinatal depressive symptoms (PNDS) throughout the perinatal period.

AIMS

To evaluate in a low-risk sample, whether different evolutive profiles of PNDS exist from pregnancy to 2-years postpartum, and whether the subgroups differ regarding psychopathological and demographic characteristics.

METHODS

In a prospective, longitudinal study from 8 months pregnancy to 2 years postpartum, repeated measures of PNDS using the CES-D were performed on a sample of 579 women at low-risk for PNDS. First, semiparametric mixture models were used to identify groups of women with distinct trajectories of PNDS. Second, multinomial logistic regressions were used to identify risk factors for each group.

RESULTS

Four distinct trajectories of PNDS evolution were found: (i) 72% of the women never presented with clinically significant depressive symptoms; (ii) 4% presented with depressive symptoms only during the postnatal period; (iii) 21% presented with depressive symptoms throughout the follow-up period, with a higher intensity during pregnancy; (iv) 3% presented with stable highly intense symptoms throughout the follow-up period. Psychosocial risk factors for PNDS were mainly identified in the patients of the third group, with an influence of socio-economical variables and anxiety traits.

LIMITATIONS

The main limitations of the present study are the small size of the sample and the low level of risk for PNDS, so the results cannot be extrapolated to all types of populations.

CONCLUSION

Different subtypes of evolutionary profiles of PNDS are found in a low-risk sample, and are associated with different profiles of risk factors.

Who adopts improved fuels and cookstoves? A systematic review

BACKGROUND

The global focus on improved cookstoves (ICSs) and clean fuels has increased because of their potential for delivering triple dividends: household health, local environmental quality, and regional climate benefits. However, ICS and clean fuel dissemination programs have met with low rates of adoption.

OBJECTIVES

We reviewed empirical studies on ICSs and fuel choice to describe the literature, examine determinants of fuel and stove choice, and identify knowledge gaps.

METHODS

We conducted a systematic review of the literature on the adoption of ICSs or cleaner fuels by households in developing countries. Results are synthesized through a simple vote-counting meta-analysis.

RESULTS

We identified 32 research studies that reported 146 separate regression analyses of ICS adoption (11 analyses) or fuel choice (135 analyses) from Asia (60%), Africa (27%), and Latin America (19%). Most studies apply multivariate regression methods to consider 7-13 determinants of choice. Income, education, and urban location were positively associated with adoption in most but not all studies. However, the influence of fuel availability and prices, household size and composition, and sex is unclear. Potentially important drivers such as credit, supply-chain strengthening, and social marketing have been ignored.

CONCLUSIONS

Adoption studies of ICSs or clean energy are scarce, scattered, and of differential quality, even though global distribution programs are quickly expanding. Future research should examine an expanded set of contextual variables to improve implementation of stove programs that can realize the "win-win-win" of health, local environmental quality, and climate associated with these technologies.

Management of treatment-resistant depression

Given the limitations of evidence for treatment options that are consistently effective for TRD and the possibility that TRD is in fact a form of depression that has a low probability of resolving, how can clinicians help patients with TRD? Perhaps the most important conceptual shift that needs to take place before treatment can be helpful is to accept TRD as a chronic illness, an illness similar to many others, one that can be effectively managed but that is not, at our present level of knowledge, likely to be cured. An undue focus on remission or even a 50% diminution of symptoms sets unrealistic goals for both patients and therapists and may lead to overtreatment and demoralization. The focus should be less on eliminating depressive symptoms and more on making sense of and learning to function better in spite of them. It is important to acknowledge the difficult nature of the depressive illness, to remove blame from the patient and clinician for not achieving remission, to set realistic expectations, and to help promote better psychosocial functioning even in the face of persisting symptoms. The critical element when implementing such an approach is a judicious balance between maintaining hope for improvement without setting unrealistic expectations. It is important to reemphasize that following a disease management model with acceptance of the reality of a chronic illness is not nihilistic and does not mean the abandonment of hope for improvement. The first step in treating a patient with TRD is to perform a comprehensive assessment of the patient’s past and current treatment history to ensure that evidence-based treatment trials have in fact been undertaken, and if not, such treatment trials should be implemented. If the patient continues to have significant residual symptoms, it is important to determine the impact is of these symptoms on the patient’s quality of life and ability to function. It is also important to evaluate the factors that may be contributing to the persistence of depressive symptoms such as comorbid personality disorders, somatic disorders, substance abuse, and work and interpersonal conflicts. The treatment of patients with TRD needs to move beyond attempts to modify symptoms without taking into consideration and attempting to modify the patient’s personality, coping skills, and social system. Further somatic treatment trials can be undertaken, if desired by the patient and therapist, as a small (5%–15%) percentage of patients may respond and further treatment trials, and this may engender hope. The risk with this approach is that patients and therapists may not work at disease management skills if they believe there may be a resolution of the depression if they could just find the right medication or intervention. Therapists may also feel pressured by patients, families, insurance companies, as well as their own sense of helplessness to escalate treatment in a more and more aggressive manner in an attempt to achieve an elusive remission. A disease management program can provide the therapist and patient with sufficient structure, skills, and goals to encourage ongoing treatment without resorting to unproven measures that may create more side effects and problems. It is particularly important to include the patient’s significant others in the reformulation of the patient’s problem and thereby learn how to manage the illness more effectively. Significant others and family members can be invaluable in providing support for dealing with the difficult process of acquiring a new skill set. Indeed, they spend significantly more time with the patient than does any therapist. Family members are likely to provide this kind of support only if they have been part of the assessment and treatment process. Patients with a wide range of chronic medical illnesses can and do learn to function effectively and to achieve a satisfying quality of life in spite of their illness. There is no reason to think that patients with TRD should not be able to achieve a similar level of illness management, functioning, and quality of life.

Physical function as predictor for the persistence of depressive and anxiety disorders

INTRODUCTION

Depressive and anxiety disorders often involve a chronic course. This study examined whether objective physical function is a predictor for the persistence of depressive and anxiety disorders.

METHOD

The study sample consisted of 1206 persons with depressive and anxiety disorders at baseline. Hand grip strength and lung function were used as objective physical function measurements and were determined at baseline. Outcome variable was a 6-month depressive and/or anxiety diagnosis after 2 years of follow-up.

RESULTS

Lower hand grip strength predicted the persistence of depressive and/or anxiety disorders at 2-year follow-up (per SD increase: OR=0.82, CI: 0.69-0.99, p=0.04). Associations were consistent for depressive and anxiety disorder persistence. Poorer lung function was associated with the persistence of depressive disorders (per SD increase: OR=0.83, CI: 0.70-0.98, p=0.03) but not with anxiety disorders.

LIMITATIONS

Follow-up was limited to 2 years.

CONCLUSIONS

Objectively measured poorer physical function predicted the persistence of depressive and/or anxiety disorders.

Is major depressive disorder specifically associated with mesial temporal sclerosis?

PURPOSE

Whether a specific lesion such as mesial temporal sclerosis (MTS) increases the risk for a mood disorder in epilepsy remains subject to debate. Despite evidence of limbic system involvement in the genesis of emotional symptoms, recent studies fail to support an association between depression and MTS. We aimed to clarify this controversial issue by overcoming prior methodologic limitations, hypothesizing that rates of major depressive disorder (MDD) would be higher in patients with MTS.

METHODS

Three hundred eight patients with focal epilepsy (International League Against Epilepsy [ILAE] criteria), were classified into three groups on the basis of neuroimaging findings: MTS, a lesion different from MTS, or absence of lesion. Patients were assessed using the Structured Interview for DSM-IV axis I psychiatric disorders (SCID-I), by a psychiatrist blinded to epilepsy subtype. The Spanish version of the Hospital Anxiety and Depression Scale (HADS) was also administered. A complete logistic regression analysis was performed to investigate the association between MTS and MDD.

KEY FINDINGS

MTS increased the likelihood of a lifetime MDD by nearly 2.5. No other current or "postseizure onset" lifetime Axis I DSM-IV psychiatric disorder was associated with MTS. Female gender, primary education, comorbid anxiety disorders, and antidepressant treatment were also associated with an increased risk of MDD. Marriage was found to be a protective factor for MDD.

SIGNIFICANCE

Our results support a specific association between MTS and lifetime "postseizure onset," MDD. The lack of association with current depression is in line with the hypothesis that the link between MTS and depression is more of a chronic than a state-dependent condition.

Predictors of long-term prognosis of depression

BACKGROUND

Many people with depression experience repeated episodes. Previous research into the predictors of chronic depression has focused primarily on the clinical features of the disease; however, little is known about the broader spectrum of sociodemographic and health factors inherent in its development. Our aim was to identify factors associated with a long-term negative prognosis of depression.

METHODS

We included 585 people aged 16 years and older who participated in the 2000/01 cycle of the National Population Health Survey and who reported experiencing a major depressive episode in 2000/01. The primary outcome was the course of depression until 2006/07. We grouped individuals into trajectories of depression using growth trajectory models. We included demographic, mental and physical health factors as predictors in the multivariable regression model to compare people with different trajectories.

RESULTS

Participants fell into two main depression trajectories: those whose depression resolved and did not recur (44.7%) and those who experienced repeated episodes (55.3%). In the multivariable model, daily smoking (OR 2.68, 95% CI 1.54-4.67), low mastery (i.e., feeling that life circumstances are beyond one's control) (OR 1.10, 95% CI 1.03-1.18) and history of depression (OR 3.5, 95% CI 1.95-6.27) were significant predictors (p < 0.05) of repeated episodes of depression.

INTERPRETATION

People with major depression who were current smokers or had low levels of mastery were at an increased risk of repeated episodes of depression. Future studies are needed to confirm the predictive value of these variables and to evaluate their accuracy for diagnosis and as a guide to treatment.

Serotonin transporter gene polymorphisms and chronic illness of depression

Clinical course of depression is variable. The serotonin transporter gene is one of the most studied genes for depression. We examined the association of serotonin transporter gene polymorphisms with chronicity and recurrent tendency of depression in Korean subjects. This cross-sectional study involved 252 patients with major depression. Patients were genotyped for s/l polymorphisms in 5-HTT promoter region (5-HTTLPR), s/l variation in second intron of the 5-HTT gene (5-HTT VNTR intron2). Chronicity was associated with 5-HTTLPR. Patients with l/l had higher rate of chronicity than the other patients (l/l vs s/l or s/s; odds ratio, 4.45; 95% confidence interval, 1.59-12.46; P=0.005; logistic regression analysis). Recurrent tendency was not associated with 5-HTTLPR. Chronicity and recurrent tendency were not associated with 5-HTT VNTR intron2. These results suggest that chronic depression is associated with 5-HTTLPR.