The role of psychosocial and biological variables in separating chronic and non-chronic major depression and early-late-onset dysthymia

Alcohol Use Disorder and the Persistence/Recurrence of Major Depression: Le trouble de l'usage de l'alcool et la persistance/récurrence de la dépression majeure

OBJECTIVE

This study aims to determine the role of alcohol use disorder and other potential risk factors on persistence/recurrence of major depression in a Canadian population sample.

METHODS

Data were drawn from the National Population Health Survey (1994/1995 to 2010/2011), a prospective epidemiologic survey of individuals 12 years and older, living in 10 Canadian provinces (N = 17,276). Participants were reinterviewed every 2 years for 9 cycles. This study population was a cohort of individuals who at baseline met the diagnosis of a major depressive episode (MDE) in the previous 12 months (n = 908). After the 6-year (cycle 4) and 16-year (cycle 9) follow-up period, 124 of 718 participants and 79 of 461 participants met the criteria for MDE, respectively. Persistence or recurrence of major depression was defined as meeting a diagnosis of MDE after 6 years and 16 years. Modified Poisson regression models were used to assess the role of alcohol dependence and other risk factors on the persistence/recurrence of major depression using Stata 14.

RESULTS

Alcohol use disorder was significantly correlated with a 6-year (odds ratio [OR]: 3.03; 95% confidence interval [CI], 1.68 to 5.48; P < .0001) and 16-year (OR, 3.17; 95% CI, 1.15 to 8.77, P = 0.003) persistence/recurrence of major depression. Other factors associated with the persistence/recurrence of major depression include female sex, childhood traumatic events, chronic pain restricting activities, daily smoking, and low self-esteem.

CONCLUSIONS

Comorbid alcohol use disorder was found to be a strong risk factor for the persistence or recurrence of major depression.

Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications

Persistent depressive disorder is a chronic mood disorder that is common and often more disabling than episodic major depression. In DSM-5, the term subsumes several chronic depressive presentations, including dysthymia with or without superimposed major depressive episodes, chronic major depression, and recurrent major depression without recovery between episodes. Dysthymia can be difficult to detect in psychiatric and primary care settings until it intensifies in the form of a superimposed major depressive episode. Although information is scarce concerning the cause of persistent depressive disorder including dysthymia, the causation is likely to be multifactorial. In this narrative Review, we discuss current knowledge about the nosology and neurobiological basis of dysthymia and persistent depressive disorder, emphasising a dimensional perspective based on course for further research. We also review new developments in psychotherapy and pharmacotherapy for persistent depressive disorder, and propose a tailored, modular approach to accommodate its multifaceted nature.

Differences between chronic and nonchronic depression: Systematic review and implications for treatment

BACKGROUND

There is still uncertainty if and to what extent chronic depression (CD) presents with specific features especially in contrast to the nonchronic course of major depressive disorder (non-CD). This systematic review aims to summarize the existing literature regarding sociodemographic factors, psychopathology, and course of disease in patients with CD in comparison to patients with non-CD.

METHODS

A structured database search (MEDLINE, PsycINFO, Web of Science, CENTRAL) was performed. All studies comparing CD with non-CD patients were included. Twenty-eight studies, including cohort studies, cross-sectional studies, and observational studies, were identified in which both subgroups were diagnosed according to DSM-IV or DSM-5, respectively. Primary outcome were group comparisons focused on sociodemographic factors, childhood adversity, onset of the disorder, comorbidities, severity and course of the depressive symptoms, and specific psychopathology.

RESULTS

Patients with CD had an earlier onset of depressive symptoms, higher rates of psychiatric comorbidities, and a complicated treatment course (e.g., higher rates of suicidality) compared to non-CD. We also found some evidence for specific features in the psychopathology of CD patients (submissive and hostile interpersonal styles) in contrast to non-CD patients. Results were inconsistent with regard to childhood maltreatment. No differences were found regarding the severity of depressive symptoms and most sociodemographic factors.

CONCLUSION

Despite some inconsistencies, the results of this review verified important differences between CD and non-CD. However, future research is needed to characterize especially the specific psychopathology of CD in comparison to non-CD patients to develop more tailored treatment strategies.

Persistence of chronic major depression: a national prospective study

BACKGROUND

Chronic major depressive disorder (CMDD) is highly prevalent and associated with high personal and societal cost. Identifying risk factors for persistence and remission of CMDD may help in developing more effective treatment and prevention interventions.

METHODS

Prospective cohort study of individuals participating in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1; n=43,093) and its 3-year follow-up (Wave 2; n=34,653) who met a diagnosis of CMDD at the Wave 1 assessment.

RESULTS

Among the 504 respondents who met criteria for present CMDD at Wave 1, only 63 (11.52%) of them continued to meet criteria of CMDD. A history of childhood sexual abuse, earlier onset of MDD, presence of comorbidity and a history of treatment-seeking for depression predicted persistence of CMDD three years after the baseline evaluation.

LIMITATIONS

Our sample is limited to adults, our follow-up period was only three-years and the diagnosis of CMDD at baseline was retrospective.

CONCLUSIONS

CMDD shows high rates of remission within three years of baseline assessment, although some specific risk factors predict a persistent course. Given the high personal and societal cost associated with CMDD, there is a need to develop and disseminate effective interventions for CMDD.

Correlates associated with unipolar depressive disorders in a Latino population

BACKGROUND

This study reports the comparison and associations of demographic, clinical and psychosocial correlates with three unipolar depressive disorders: dysthymia (DYS), major depression (MD) and double depression (DD), and examines to which extent these variables predict the disorders.

SAMPLING AND METHOD

Previously collected data from 563 adults from a community in Puerto Rico were analyzed. One hundred and thirty individuals with DYS, 260 with MD and 173 with DD were compared by demographic variables, psychiatric and physical comorbidity, familial psychopathology, psychosocial stressors, functional impairment, self-reliance, problem recognition and formal use of mental health services. Multinomial regression was used to assess the association of the predictor variables with each of the three disorders.

RESULTS

Similarities outweighed the discrepancies between the disorders. The main differences observed were between MD and DD, while DYS shared common characteristics with both MD and DD. After other variables were controlled, anxiety, functional impairment and problem recognition most strongly predicted a DD diagnosis, while age predicted a DYS diagnosis.

CONCLUSION

MD, DYS and DD are not completely different disorders, but they do differ in key aspects that might be relevant for nosology, research and practice. A dimensional system that incorporates specific categories of disorders would better reflect the different manifestations of unipolar depressive disorders.

Prevalence and correlates of chronic depression in the canadian community health survey: mental health and well-being

OBJECTIVE

To determine the prevalence and correlates of chronic depression in comparison with nonchronic depression using a population-representative national database.

METHODS

Our study used data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) to determine the lifetime prevalence and correlates of major depression with chronic symptoms in the population. The CCHS 1.2 is a large, cross-sectional mental health survey conducted by Statistics Canada (n = 36 984, aged 15 years and older).

RESULTS

The observed lifetime prevalence of major depression with chronic symptoms was 2.7%, representing 26.8% of all people with major depressive disorder (MDD). In comparison to nonchronic major depression, chronic depression was associated with more frequent psychiatric and medical comorbidity, greater disability, increased health service use, and higher likelihood of suicidal ideation and attempts.

CONCLUSIONS

Major depression with chronic symptoms is common in the general population, and is associated with more severe health consequences than nonchronic depression. These observations indicate that chronic major depression is a very important subtype of MDD from a public health perspective.

Do major depressive disorder and dysthymic disorder confer differential risk for suicide?

BACKGROUND

Although there has been a tremendous amount of research examining the risk conferred for suicide by depression in general, relatively little research examines the risk conferred by specific forms of depressive illness (e.g., dysthymic disorder, single episode versus recurrent major depressive disorder [MDD]). The purpose of the current study was to examine differences in suicidal ideation, clinician-rated suicide risk, suicide attempts, and family history of suicide in a sample of outpatients diagnosed with various forms of depressive illness.

METHODS

To accomplish this aim, we conducted a cluster analysis using the aforementioned suicide-related variables in a sample of 494 outpatients seen between January 2001 and July 2007 at the Florida State University Psychology Clinic. Patients were diagnosed using DSM-IV criteria.

RESULTS

Two distinct clusters emerged that were indicative of lower and higher risk for suicide. After controlling for the number of comorbid Axis I and Axis II diagnoses, the only depressive illness that significantly predicted cluster membership was recurrent MDD, which tripled an individual's likelihood of being assigned to the higher risk cluster.

LIMITATIONS

The use of a cross-sectional design; the relatively low suicide risk in our sample; the relatively small number of individuals with double depression.

CONCLUSIONS

Our results demonstrate the importance of both chronicity and severity of depression in terms of predicting increased suicide risk. Among the various forms of depressive illness examined, only recurrent MDD appeared to confer greater risk for suicide.

Suicidal intent and the HPA-axis characteristics of suicide attempters with major depressive disorder and adjustment disorders

The main purpose of the study was to investigate Hypothalamic-Pituitary-Adrenal (HPA) axis characteristics in relation to suicidal intent among suicide attempters with Major Depressive Disorder (MDD) and Adjustment Disorders (AD). The relationship between suicidal intent, assessed by means of the Suicidal Intent Scale (SIS), and serum cortisol after a Dexamethasone Suppression Test (DST) was investigated in 78 suicide attempters, divided into diagnostic subgroups. There was a significant negative correlation between suicidal intent and post DST cortisol in patients with MDD. Our findings may be attributed to pathophysiological processes, where a high suicidal intent is revealed during a potential chronic course of MDD, which in turn results in a seemingly normal stress system.

The search for determinants of chronic depression: a review of six factors

While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.

Clinical features of dysthymia and age: a clinical investigation

A few authors have described the clinical picture of dysthymia in groups of elderly patients and pointed out differences from literature reports of dysthymia in younger adults. The present study, an attempt to analyze age effects on clinical characteristics of dysthymia throughout a lifetime, was performed in a sample of 106 patients, all aged > or =18 years, who were diagnosed according to DSM-IV. The patients were evaluated using: (1) a semistructured interview to assess clinical features, family history and previous treatments; (2) the Hamilton Depression Rating Scale; (3) the Interview for Recent Life Events; and (4) the Structured Clinical Interview for DSM-IV Disorders. Statistical analysis with stepwise logistic regression revealed that age was positively related to concomitant medical illnesses and to the total score of recent life events, but negatively related to the presence of avoidant or dependent personality disorders. The data suggested different etiologic pathways in older and younger patients. Dysthymia appeared to be associated in younger adults with abnormalities of personality; in the elderly, with a history of health problems and life losses.

Dysthymia: a review of pharmacological and behavioral factors

Although dysthymia, a chronic, low-grade form of depression, has a morbidity rate as high as that of major depression, and increases the risk for major depressive disorder, limited information is available concerning the etiology of this illness. In the present report we review literature concerning the biological and characterological features of dysthymia, the effectiveness of antidepressant treatments, the influence of stressors in the precipitation and maintenance of the disorder, and both quality of life and psychosocial correlates of the illness. We also provisionally suggest that dysthymia may stem from disturbances of neuroendocrine and neurotransmitter functioning (eg, corticotropin releasing hormone and arginine vasopressin within the hypothalamus, or alternatively monoamine variations within several extrahypothalamic sites), and may also involve cytokine activation. The central disturbances may reflect phenotypic variations of neuroendocrine processes or sensitization of such mechanisms. It is suggested that chronic stressor experiences or stressors encountered early in life lead to the phenotypic neurochemical alterations, which then favor the development of the dysthymic state. Owing to the persistence of the neurochemical disturbances, vulnerability to double depression is increased, and in this instance treatment with antidepressants may attenuate the symptoms of major depression but not those of the basal dysthymic state. Moreover, the residual features of depression following treatment may be indicative of underlying neurochemical disturbances, and may also serve to increase the probability of illness recurrence or relapse.

Interleukin-1 beta production in dysthymia before and after pharmacotherapy

BACKGROUND

Like major depression, dysthymia has been associated with elevated production of interleukin-1 (IL-1 beta) in mitogen-stimulated lymphocytes. In the present investigation, we assessed whether the elevated IL-1 beta production in dysthymic patients would normalize following treatment with sertraline.

METHODS

The production of IL-1 beta was determined in dysthymic patients and in nondepressed control subjects. Patients then received 12 weeks of doses of either sertraline or placebo in a double-blind trial, after which cytokine production was again determined.

RESULTS

Basal IL-1 beta was elevated in dysthymic patients relative to control subjects. Cytokine production was modestly correlated with the severity of symptoms and with the age of illness onset. Relative to placebo treatment, sertraline attenuated the symptoms of depression; however, this was not accompanied by normalization of IL-1 beta production.

CONCLUSIONS

While dysthymia is associated with elevated IL-1 beta production, the failure for the cytokine to normalize following symptom alleviation suggests that either the IL-1 beta may be a trait marker of the illness, or that more sustained treatment is necessary to reduce cytokine production. Given the neuroendocrine and central neurochemical consequences of exogenously administered IL-1 beta, the possibility ought to be explored that increased IL-1 beta production may play a role in the pathophysiology of dysthymia.

Clinical and neuroradiologic features associated with chronicity in late-life depression

The authors conducted a 6-year follow-up of 16 patients with late-life depression to evaluate the relationships between clinical and neuroradiologic variables and disease outcome. Patients had a comprehensive neuropsychiatric evaluation and magnetic resonance imaging (MRI) at baseline and follow-up. Eight of the 16 developed a chronic course of unremitting major depression sufficient to cause significant psychosocial impairment. Six patients with a chronic course and four patients with a non-chronic course of depression had white matter hyperintensities (WMH) on MRI at baseline. Four patients whose WMH increased in size over time developed a chronic unremitting course of depression. No patients with non-chronic depression had large areas of WMH at baseline or exhibited increased WMH size over time. Chronic depression was associated with severity of cerebrovascular risk factors, apathy, and poor quality of life. Treatment and prevention of cerebrovascular disease may improve the outcome of late-life depression.

Delineating psychopathologic clusters within dysthymia: a study of 512 out-patients without major depression

BACKGROUND

The literature indicates that emotional-cognitive symptoms are much more characteristic of dysthymia than the vegetative and psychomotor symptoms of major depression, yet this is insufficiently emphasized in the official criteria listed in the criteria of the American Psychiatric Association. Furthermore, as previous studies have examined these symptoms more in relation to prevalence than to possible symptom aggregation, in the present analyses we address both aspects.

METHODS

In two multicenter collaborative trials, 512 out-patients meeting the symptom criteria of DSM-III-R dysthymia but without major depression were recruited. In this respect they conformed to the conceptual framework of ICD-10 which tends to restrict dysthymia to a subthreshold depression without excursion into severe depressive episodes. The Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (HAM-A) were used to assess depressive and anxiety symptoms.

RESULTS

Symptoms most frequently observed, besides depressed mood (100% by definition), were 'low energy or fatigue' (96%) and 'poor concentration or indecisiveness' (88%), followed by 'low self-esteem' (80%), 'insomnia or hypersomnia' (77%), 'poor appetite or overeating' (69%) and 'feeling of hopelessness' (42%). Interestingly, in the subjects with fewer than five symptoms, the most frequent were low energy or fatigue (93%), poor concentration or indecisiveness (79%) and low self-esteem (77%), the other symptoms being present in no more than half the sample. MADRS factor analysis identified two main factors: the first consisting of apparent and reported sadness, and the second concentration difficulties and lassitude. HAM-A factor analysis identified two factors clearly differentiating somatic and psychic symptoms.

LIMITATIONS

Because suicidal patients were excluded on the ground of human subject concerns, our sample is representative of the milder range of symptomatology within the spectrum of dysthymia. This may in part explain the low prevalence of neurovegetative symptoms.

CONCLUSION

Despite this, the present study involves the largest sample of pure dysthymia ever studied. Our results indicate that dysthymic disorder appears to primarily involve psychologic symptoms. The psychological symptoms themselves seem to cluster into sadness versus mental fatigue; as for anxiety symptoms, they appear divisible into somatic and psychic clusters, with the latter prevailing in dysthymia. Dysthymia proper, dominated by negative affectivity, might be distinguishable from a 'neurasthenic' subform dominated by low energy or 'deficit' symptoms at mental and physical levels.

Nosological validity of dysthymia. Part II: familial, comorbidity, biological and psychological data

If some recent studies seem to reveal a more specific familial relationship for dysthymia in addition to a previously known familial relationship to mood disorders, and if results concerning the relationship between dysthymia and depressive personality as well as the search for possible biological and psychological correlates support the nosological validity of dysthymia, comorbidity studies raise difficult questions. Both comorbidity studies with Axis I and Axis II disorders challenge the validity of dysthymia, but as well they question the categorical model presently in use more than the validity of a definite category.

However, there are now enough data confirming some of the hypotheses implied by the nosological construct of dysthymia inside this model for this category not to be discarded. For instance, dysthymia is definitely not a personality disorder, and appears also distinct from major depression. The problem of the complex nature of the relationship between dysthymia and major depression still remains unsolved.

Psychosocial and physical correlates of chronic depression

This study used a case-control design to address differences in psychosocial, physical and clinical profiles between subjects who presented with a chronic index episode of major depression and those who presented with a non-chronic index episode. Subjects were adult patients participating in the Duke University Mental Health Clinical Research Center (MHCRC) for the Study of Depression in Later Life. Cases (N = 88) who reported duration of depressive symptoms lasting > or = 24 months at enrollment were compared to controls (N = 354) who reported symptoms lasting 1-12 months. The groups were compared with respect to selected demographic and clinical variables, physical function deficits, medical comorbidity, social support constructs and number of recent stressful life events. Social support and physical health were more relevant to chronicity of major depressive illness than were severity of illness or family history. Older age (> 60 years) intensified the deleterious effect of recent negative life events and reduced the deleterious effect of functional impairment on chronic major depression. These findings require special emphasis where treatment for chronic major depression is divorced from considerations of the social environment and functional capacity.

Pituitary-adrenal cortical axis measures as predictors of sustained remission in major depression

To determine the relationship of pretreatment hypothalamic-pituitary-adrenal cortical (HPA) axis measures in major depressives to the occurrence of relapse following discontinuation of successful treatment, we compared pretreatment demographic, clinical, and HPA axis measures in 35 patients with DSM-III-R primary major depression divided into two groups. One group (n = 26) required continuing treatment to hold their symptoms in abeyance, and the other group (n = 9) had been successfully tapered off medication, remained in remission, and had been medication-free for at least 1 month. The major features that differentiated the 26 patients who required continuing medication to abate their symptoms from the 9 patients who were successfully discontinued from treatment were trends toward a longer duration of episode prior to initial study and increased baseline corticotropin (ACTH) 1-39, and significantly higher baseline cortisol and cortisol response to ACTH 1-24, in the former group. These results suggest that measures of HPA axis hyperactivity, along with longer duration of the index depressive episode, may predict the need for continuing medication for patients to remain in remission.

Primary dysthymia: a study of several psychosocial, endocrine and immune correlates

The relationship between primary dysthymia (chronic, low grade depression) and indices of major and minor life stresses, uplifts and coping styles was examined. Additionally, circulating lymphocyte subsets were assessed in dysthymic patients to determine their relationship to stress/coping factors or plasma levels of cortisol, ACTH or norepinephrine. Primary dysthymia was found to be associated with increased minor stressors (daily hassles), reduced uplifts, as well as particular reliance on emotion-focused rather than problem-oriented coping strategies. Interestingly, among dysthymics, the early onset group exhibited a greater degree of hassles and greater emotion-focused coping compared to the late onset subgroup. Although hassles and coping styles were correlated with depressed mood, only coping styles predicted severity of depressed affect. It seems that although dysthymia is characterized by increased hassles and reduced uplifts, these variables do not distinguish between the severity of the depressive affect, whereas the coping styles employed in the face of the increased hassles and reduced uplifts are more closely aligned with depression severity. Dysthymia was associated with elevated levels of circulating natural killer (NK) cells. Since levels of plasma cortisol, ACTH or norepinephrine were not increased in the dysthymic subjects, it is likely that the elevated NK cell number was unrelated to these neuroendorcrine measures. In control subjects circulating NK cells were inversely related to the severity of hassles recently encountered, while in dysthymic patients stress and coping factors were unrelated to NK cell numbers. Thus, it appears that the altered NK cells in dysthymic patients were not related to the increased stress perception and altered coping which characterize these patients.

Predictive validity of subtypes of chronic affective disorders derived by cluster analysis

This study aimed to examine the predictive validity of the cluster-analytically derived 3 subtypes of chronic affective disorders that were proposed on the basis of cross-sectional symptoms and were shown to have some external validity with regard to psychosocial characteristics. Two-year naturalistic follow-up data were available for 38 (97%) of the original 39 patients with chronic affective disorders. The 3 subtypes, which were named psychotic subtype, late-onset female subtype and depressive personality subtype in the previous analyses, did not differ in their depressive severity or social functioning upon entry. In the course of the 2-year follow-up, however, there were significant differences in the Global Assessment of Functioning scores as well as the social adaptation in the economic sphere according to the Social Adjustment Scale-Self Report. All these indices revealed the psychotic subtype to have the worst outcome, followed by the depressive personality subtype, and the late-onset female subtype fared best.

Clinical characteristics of outpatients with chronic major depression

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179). Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.