Recurrent brief depression in general practice. Clinical features, comorbidity with other disorders, and need for treatment

Mental disorders in primary care in Israel: prevalence and risk factors

OBJECTIVE

Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders.

METHOD

Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI).

RESULTS

A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders.

CONCLUSIONS

High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.

Temperament and character in patients with bipolar II disorder and recurrent brief depression

OBJECTIVES

We compared the temperament and character profiles of 21 patients with bipolar II disorder, 40 patients with recurrent brief depression (RBD; at least monthly depressive episodes meeting the diagnostic criteria for major depressive episode except for duration that is less than 2 weeks, typically 2-3 days, without fixed relation to menstrual cycle) of which 21 had no history of hypomania and 19 had experienced hypomanic episodes, and 21 age- and sex-matched controls.

METHODS

Assessments included the Montgomery-Åsberg Depression Rating Scale, Hypomania Checklist, and Temperament and Character Inventory-125. Patients with cluster A and B personality disorders were excluded.

RESULTS

Bipolar II and RBD patients had higher harm avoidance (HA) and lower self-directedness (SD) compared with controls. Excluding panic disorder comorbidity effaced this difference in HA and SD (bipolar II only) and harm avoidance. No other differences were found.

CONCLUSIONS

In this first study comparing personality profiles of patients with bipolar II vs RBD, when controlling for confounders, neither bipolar II nor RBD patients differed significantly from healthy controls. The lower SD scores among RBD patients may reflect sampling bias (a higher rate of Axis 2 cluster C disorders).

Neuropsychological function in unmedicated recurrent brief depression

BACKGROUND

Recurrent brief depression (RBD) is a mood disorder characterized by mild to severe depressive episodes lasting less than 2 weeks and occurring approximately once a month with complete recovery between episodes. The aim of this study was to describe neuropsychological impairments associated with RBD, relating cognitive performance to clinical features and comorbidity.

METHODS

Forty-six ICD-10 defined RBD patients (mean age 33.8) and 24 matched controls were assessed on working memory/attention tasks, executive functions, verbal/visual memory, and psychomotor speed.

RESULTS

Patients were significantly impaired across all domains of cognition except for verbal learning and non-semantic verbal fluency. Neuropsychological performance was not related to depression severity, duration of depressive episodes, interval duration, psychiatric or somatic comorbidity, or attributable to a general reduction in processing speed or effort. Patients reporting previous major depressive episodes were impaired on one measure of psychomotor speed. Previous episodes of hypomania were not related to neuropsychological performance.

LIMITATIONS

The relatively high number of self-referrals, high female-to-male ratio in the patient sample, and the relatively high level of education and intellectual capacity among participants may limit the possibility to generalize our results to the RBD population in general.

CONCLUSIONS

Unmedicated RBD patients demonstrate significant neuropsychological impairment that also may persist into euthymic states. Examining cognitive functions might be equally important in RBD as in major depression with consequences for functional diagnostics and treatment strategies.

The phenomenology of recurrent brief depression with and without hypomanic features

BACKGROUND

The nosologic status of recurrent brief depression (RBD) is debated. We studied the phenomenology of RBD in a clinical sample of outpatients.

METHODS

Forty patients (mean age 33; 73% females) and 21 age- and gender-matched mentally healthy controls were examined (clinical interview, M.I.N.I. neuropsychiatric interview, MADRS, Stanley Foundation Network Entry Questionnaire). Exclusion criteria were bipolar I or II disorders, a history of psychosis, concurrent major depressive episode, organic brain or personality disorders (clusters A and B).

RESULTS

The mean age of onset of RBD was 20 years with a mean of 14 episodes/year with brief (mean 3 days) severe depressive episodes. Nineteen (47%) reported additional short episodes of brief hypomania (>1 day duration; RBD-H) of which nine (23%) never had experienced a major depression. Twenty-one (53%) patients reported RBD only (RBD-O) with or without (n=12) past history of major depression or dysthymia. During the last depressive episode, 76% of the RBD-O and 90% of the RBD-H patients had a melancholic depression. Seventy-one % of the RBD-O and 79% of the RBD-H reported at least two out of three atypical symptoms. Nineteen (48%) of the patients reported anger attacks and panic disorder, the latter being more prevalent in the RBD-H subgroup (68% versus 29%, p=0.012).

LIMITATIONS

Cross-sectional study of self-referrals or patients referred by primary care physicians or psychiatrists.

CONCLUSIONS

The study supports the validity of RBD as a disorder separate from bipolar II, cyclothymia and recurrent major depression. A brief episode of hypomanic symptoms is a severity marker of RBD.

Recurrent brief depression--past and future

Recurrent brief depressive disorder (RBD) is a well-defined and significantly prevalent affective disorder with an increased risk of suicidal behavior and significant clinical impairment in the community and general practice. RBD is characterized by depressive episodes occurring at least once a month and lasting for only a few days. The lifetime co-occurrence of both RBD and major depressive disorder (MDD), called combined depression (CD), increases substantially the risk for suicide attempts, even more than is known for "pure" MDD. Diagnostic criteria for RBD can be found in the ICD-10 and DSM-IV and are helpful in both, research and clinical routine. Furthermore, several methodological issues are covered in this paper, which make clinical diagnostic and drug response evaluation of RBD very different from MDD. However, clinical procedures rather bear a resemblance to those used in the treatment of migraine or epilepsy. Formal differences in the course of RBD and MDD create different needs concerning the design of drug treatment studies. Absence of special methodological requirements and highly selected patient samples has probably been responsible for false negative results in double-blind, placebo-controlled treatment studies. Although several authors reported successful treatment of RBD with different compounds in about 60 patients, it is still not possible to deduce a treatment algorithm for RBD to date. Obviously, future treatment studies without the limitations of previous studies are clearly required for RBD.

Subthreshold depressive and anxiety disorders in the elderly

The aims of the present study were to compare the current and lifetime prevalences for major and subthreshold affective disorders in elderly subjects in the general population, to assess the influence of demographic variables on prevalence rates, and to examine co-morbidity between these disorders. Major and subthreshold disorders were diagnosed in 286 subjects (aged >/= 60 years). Four-point-nine percent of the subjects had a lifetime diagnosis of major depression, 31.8% either minor or recurrent brief depression, 6.6% a major anxiety disorder, and 18.5% a subthreshold anxiety disorder. The risk for current and lifetime subthreshold anxiety was higher in females than in males, the lifetime prevalence for subthreshold anxiety disorders was increased in elderly subjects and subjects with low professional levels. Increased co-morbidity between major and subthreshold depressive and anxiety disorders could not be observed. In the elderly, subthreshold depressive and anxiety disorders are frequent, more so than major affective disorders. The presence of subthreshold anxiety disorders, but not subthreshold depression, is influenced by age, gender, and previous professional level. Further research focusing on detection, evaluation of risk factors and the relevance for the quality of life in the elderly general population is needed.

Subthreshold affective disorders: a useful concept in psychiatric epidemiology?

OBJECTIVE

In recent years an extensive literature has grown up around the concepts of subthreshold, subsyndromal, minor and brief recurrent affective disorder and their applications in population-based research. The aim of this short review is to examine the definitions and current status of these proposed categories with special reference to depression, and to assess their potential contribution to psychiatric epidemiology.

METHOD

A Medline search was carried out for the period 1965-1999, based on the above four terms. Relevant references found in all identified publications were also followed up.

RESULTS

In great measure these constructs have been developed as a response to deficiencies in the DSM classification system and to a lesser extent in the ICD. The groups are all defined by having fewer criterial symptoms, or a shorter duration of symptoms, than the 'official' diagnostic categories. Use of these definitions has resulted in widely varying prevalence estimates.

CONCLUSION

Improved methods are badly needed for classifying all those persons in the wider community who are in need of medical treatment and help for psychological disorder, but do not satisfy operational criteria laid down in the official guidelines. This cannot, however, be achieved simply by lowering operational thresholds in these systems. Further research on clinical and psycho-social characteristics of the common mental disorders is called for, and in many societies a favourable setting is that of primary health care, where a move towards pragmatic, comprehensive classification of community health problems is already under way.

'Subthreshold' mental disorders. A review and synthesis of studies on minor depression and other 'brand names'

BACKGROUND

Subthreshold conditions (i.e. not meeting full diagnostic criteria for mental disorders in DSM-IV or ICD-10) are prevalent and associated with significant costs and disability. Observed more in primary care and community populations than in speciality settings, varying conceptualisations have been applied to define these conditions.

AIMS

To examine definitional issues for subthreshold forms of depression (e.g. minor depression) and to suggest future directions for research and nosology in psychiatry and primary care.

METHOD

A Medline search was conducted. The relevant articles were reviewed with regard to specific categories of information.

RESULTS

Studies applied a myriad of names and definitions for subthreshold depression with varying duration, symptom thresholds and exclusions. Prevalence rates also vary depending upon the definitions, settings and populations researched.

CONCLUSIONS

Future research needs to apply methodological and intellectual rigour and systematically consider a broader clinical and nosological context. In addition, collaboration between psychiatry and primary care on research and clinical issues is needed.

Recurrent brief depression successfully treated with lithium

BACKGROUND

The diagnostic criteria for RBD requires the presence of at least five out of nine depressive symptoms analogous to the symptoms of major depression, yet a duration of less than two weeks, a recurrence of at least 12 times a year, and the evidence of impairment in occupational or other important areas of functioning. The lack of a successful treatment represents one of the main challenges of this disorder. The therapeutic value of lithium in RBD has been suggested by Montgomery, but the specific efficacy of this agent has not been tested yet in the case of patients with recurrent brief depressive disorder.

METHODS

We report on a 38-year-old man who presented a 10-month history of sudden depressive episodes, with monthly recurrences lasting 2-4 days, prior to our first assessment.

RESULTS

The patient was treated with clomipramine, with complete remission of the depressive episode after three days. Nevertheless, in spite of maintaining the treatment, he presented a new episode one month later and two episodes the month after. Since then, lithium therapy was added and during the last 13 months he has remained euthymic, without any recurrence of depressive symptoms. Lithium treatment has been maintained and clomipramine treatment was gradually tapered because of the complaints of impotence, dry mouth, and dizziness.

CONCLUSIONS

The absence of recurrences since lithium treatment was started (during the last 13 months, and especially during the last 10 months, where lithium has been the only treatment), suggests a prophylactic effect of this agent on RBD. Lithium's mechanism of action in preventing depressive recurrences might play a major role in the therapeutic approach of RBD, especially since recurrence (but not the duration of the symptoms) is the main feature that defines the severity of this disorder.

The relationship between major and subthreshold variants of unipolar depression

Recent epidemiological research in the general population and primary care demonstrated that a substantial proportion of disabling depressive syndromes do not meet the diagnostic criteria for major depression. This observation proposes less restrictive diagnostic definitions of depression. However, a gain in sensitivity may induce a substantial loss of specificity. A variety of diagnostic definitions of subthreshold depression has been proposed balancing both aspects. However, the less restrictive diagnostic definitions are, the lower the specificity. This report explores variants of subthreshold depression characterized by current and subsequent disability in a prospectively investigated sample of general practice patients (n = 400), recruited within the framework of the WHO study "Psychological Problems in Primary Care and a survey in the general population. Duration of episodes, recurrence and number of associated symptoms are the main diagnostic variables. Brief depression with multiple episodes per year (including recurrent brief depression as defined by ICD-10) is comparable to major depression by social disability and subsequent course in the sample under study.

The relevance of recurrent brief depression in primary care. A report from the WHO project on Psychological Problems in General Health Care conducted in 14 countries

This report from the WHO project on Psychological Problems in General Health Care examines the relevance in primary care of the concept of recurrent brief depression (RBD) proposed by Jules Angst. RBD refers to brief, severe depressive episodes that recur frequently, i.e. nearly once a month over a 1-year period, according to Angst. Using a structured interview (CIDI), RBD was assessed in patients not meeting the criteria for depressive episodes lasting at least 2 weeks, as defined in the ICD-10 (DE). A substantial proportion of primary care seekers were identified as presenting RBD without other depressive disorders, 3.7% with a formal RBD diagnosis and 2.7% with frequent but not monthly depressive episodes. These two subgroups were found to differ very little in terms of sociodemographic characteristics, severity, disability, and comorbidity with other diagnoses. However, in patients with a formal diagnosis of RBD, a higher rate of history of suicide attempts was found (14.0%), similar to that observed in patients meeting the criteria for DE. Most of the severity and disability indicators show that RBD is a severe condition, associated with substantial impairment, even if they show a higher degree of severity for DE. About one RBD patient out of three is recognized by general practitioners as presenting a psychological disorder, a majority of whom are actually treated. Our results confirm the relevance of the concept of RBD in primary care, and the need to further explore the pertinence of the restrictive recurrence criterion proposed by Angst.

Lack of efficacy of fluoxetine in recurrent brief depression and suicidal attempts

Recurrent brief depression (RBD) fulfills DSM-III-R symptom criteria for major depression but the episodes are of shorter duration than the 2 weeks required by DSM-III-R. The clinical importance of the disorder has been observed in prophylactic studies of suicidal behavior. The possibility that antidepressants with selective action on the reuptake of serotonin might be effective in preventing recurrences of brief depression has been investigated. Fluoxetine in a dose of 120 mg a week, administered biweekly, had no effect on the recurrence rate, which was maintained at approximately the same rate on fluoxetine (1 every 18.7 days) as with placebo (1 every 17.6 days). In a group of patients with two or more prior episodes of suicidal behavior, there were 18 attempted suicides in the 54 patients treated with fluoxetine and the same number in the 53 patients treated with placebo. Fluoxetine neither raised nor lowered the suicide attempt rate as compared with placebo, providing no evidence to support the drug's role in either suicide provocation or prevention. Since fluoxetine is clearly effective with recurrent major depression, it would appear that recurrent brief depression has a different pharmacology.