The factor structure of lifetime depressive spectrum in patients with unipolar depression

From physiological awakening to pathological sleep inertia: Neurophysiological and behavioural characteristics of the sleep-to-wake transition

Sleep inertia refers to the transient physiological state of hypoarousal upon awakening, associated with various degrees of impaired neurobehavioral performance, confusion, a desire to return to sleep and often a negative emotional state. Scalp and intracranial electro-encephalography as well as functional imaging studies have provided evidence that the sleep inertia phenomenon is underpinned by an heterogenous cerebral state mixing local sleep and local wake patterns of activity, at the neuronal and network levels. Sleep inertia is modulated by homeostasis and circadian processes, sleep stage upon awakening, and individual factors; this translates into a huge variability in its intensity even under physiological conditions. In sleep disorders, especially in hypersomnolence disorders such as idiopathic hypersomnia, sleep inertia may be a daily, serious and long-lasting symptom leading to severe impairment. To date, few tools have been developed to assess sleep inertia in clinical practice. They include mainly questionnaires and behavioral tests such as the psychomotor vigilance task. Only one neurophysiological protocol has been evaluated in hypersomnia, the forced awakening test which is based on an event-related potentials paradigm upon awakening. This contrasts with the major functional consequences of sleep inertia and its potentially dangerous consequences in subjects required to perform safety-critical tasks soon after awakening. There is a great need to identify reproducible biomarkers correlated with sleep inertia-associated cognitive and behavioral impairment. These biomarkers will aim at better understanding and measuring sleep inertia in physiological and pathological conditions, as well as objectively evaluating wake-promoting treatments or non-pharmacological countermeasures to reduce this phenomenon.

Smartphone-derived Virtual Keyboard Dynamics Coupled with Accelerometer Data as a Window into Understanding Brain Health: Smartphone Keyboard and Accelerometer as Window into Brain Health

We examine the feasibility of using accelerometer data exclusively collected during typing on a custom smartphone keyboard to study whether typing dynamics are associated with daily variations in mood and cognition. As part of an ongoing digital mental health study involving mood disorders, we collected data from a well-characterized clinical sample (N = 85) and classified accelerometer data per typing session into orientation (upright vs. not) and motion (active vs. not). The mood disorder group showed lower cognitive performance despite mild symptoms (depression/mania). There were also diurnal pattern differences with respect to cognitive performance: individuals with higher cognitive performance typed faster and were less sensitive to time of day. They also exhibited more well-defined diurnal patterns in smartphone keyboard usage: they engaged with the keyboard more during the day and tapered their usage more at night compared to those with lower cognitive performance, suggesting a healthier usage of their phone.

Cognitive Fusion, Ruminative Response Style and Depressive Spectrum Symptoms in a Sample of University Students

Psychological inflexibility is related to depressive symptoms through the ‘ruminative response style’ (RR) and ‘cognitive fusion’ (CF). We aimed at exploring whether university students were more exposed to CF, RR and depressive symptoms because of their intellectual performance than non-university students of the same age. We compared university students (US) (n = 105) vs. non-university students (NUS) (n = 76) through online administration of the ‘Cognitive Fusion Questionnaire’ (CFQ-7), the ‘Depression-Zung Self-Assessment Scale’ (ZSDS) and the ‘Perseverative Thinking Questionnaire’ (PTQ) (study protocol #0077818/2022, approved by the Ethical Committee of the University of Pisa, Italy). University students scored significantly higher than non-university students in the CFQ-7 Total Score (27.5 ± 9.4 vs. 24.4 ± 9.5; p = 0.040), ZSDS Total Score (41.1 ± 7.7 vs. 39.0 ± 7.3; p = 0.031), PTQ Total Score (26.1 ± 13.1 vs. 21.8 ± 13.9; p = 0.029), PTQ ‘Repetitiveness’ (5.3 ± 2.8 vs. 4.5 ± 2.9; p = 0.034), ‘Intrusiveness’ (5.8 ± 3.0 vs. 4.8 ± 3.1; p = 0.046) and ‘Repetitive Negative Thinking capturing mental resources’ (5.0 ± 3.1 vs. 4.0 ± 3.0; p = 0.013) (MANOVA analysis). In a binary logistic regression analysis of US (with ZSDS scores < 44 vs. ≥44 as the dependent variable, and PTQ Total Score and dimensions, CFQ-7 Total Score, age and gender as the covariates), PTQ Total Score predicted the more severe depressive symptomatology (OR = 1.44, 95% CI: 1.017–2.039; p = 0.040). We believe that RR and CF should be specifically targeted through psychoeducational/psychotherapeutic interventions in university students.

Montgomery-Åsberg Depression Rating Scale factors in treatment-resistant depression at onset of treatment: Derivation, replication, and change over time during treatment with esketamine

OBJECTIVE

Derive and confirm factor structure of the Montgomery-Åsberg Depression Rating Scale (MADRS) in patients with treatment-resistant depression (TRD) and evaluate how the factors evident at baseline change over 4 weeks of esketamine treatment.

METHODS

Two similarly-designed, short-term TRANSFORM trials randomized adults to esketamine or matching placebo nasal spray, each with a newly-initiated oral antidepressant, for 4 weeks (TRANSFORM-1: N = 342 patients; TRANSFORM-2: N = 223 patients). The factor structure of MADRS item scores at baseline was determined by exploratory factor analysis in TRANSFORM-2 and corroborated by confirmatory factor analysis in TRANSFORM-1. Change in MADRS factor scores from baseline (day 1) to the end of the 28-day double-blind treatment phase of TRANSFORM-2 was analyzed using a mixed-effects model for repeated measures (MMRM).

RESULTS

Three factors were identified based on analysis of MADRS items: Factor 1 labeled affective and anhedonic symptoms (apparent sadness, reported sadness, lassitude, inability to feel), Factor 2 labeled anxiety and vegetative symptoms (inner tension, reduced sleep, reduced appetite, concentration difficulties), and Factor 3 labeled hopelessness (pessimistic thoughts, suicidal thoughts). The three-factor structure observed in TRANSFORM-2 was verified in TRANSFORM-1. Treatment benefit at 24 h with esketamine versus placebo was observed on all 3 factors and continued throughout the 4-week double-blind treatment period.

CONCLUSIONS

A three-factor structure for MADRS appears to generalize to TRD. All three factors improved over 4 weeks of treatment with esketamine nasal spray.

Exploration of mood spectrum symptoms during a major depressive episode: The impact of contrapolarity-Results from a transdiagnostic cluster analysis on an Italian sample of unipolar and bipolar patients

Background

Subthreshold hypomania during a major depressive episode challenges the bipolar-unipolar dichotomy. In our study we employed a cross-diagnostic cluster analysis - to identify distinct subgroups within a cohort of depressed patients.

Methods

A k-means cluster analysis— based on the domain scores of the Mood Spectrum Self-Report (MOODS-SR) questionnaire—was performed on a data set of 300 adults with either bipolar or unipolar depression. After identifying groups, between-clusters comparisons were conducted on MOODS-SR domains and factors and on a set of sociodemographic, clinical and psychometric variables.

Results

Three clusters were identified: one with intermediate depressive and poor manic symptomatology (Mild), one with severe depressive and poor manic symptomatology (Moderate), and a third one with severe depressive and intermediate manic symptomatology (Mixed). Across the clusters, bipolar patients were significantly less represented in the Mild one, while the DSM-5 “Mixed features” specifier did not differentiate the groups. When compared to the other patients, those of Mixed cluster exhibited a stronger association with most of the illness-severity, quality of life, and outcomes measures considered. After performing pairwise comparisons significant differences between “Mixed” and “Moderate” clusters were restricted to: current and disease-onset age, psychotic ideation, suicidal attempts, hospitalization numbers, impulsivity levels and comorbidity for Cluster B personality disorder.

Conclusions

In the present study, a clustering approach based on a spectrum exploration of mood symptomatology led to the identification of three transdiagnostic groups of patients. Consistent with our hypothesis, the magnitude of subthreshold (hypo)manic symptoms was related to a greater clinical severity, regardless of the main categorical diagnosis.

Adaptation and Pilot Study of a Behavioral Intervention Targeting Morning Activation Deficits in Dementia Caregivers: Scheduling Activity and Monitoring Mornings (SAMM)

OBJECTIVES

Morning activation deficits (MADs) correlate with depression symptom persistence in older dementia caregivers. To clarify the potential of MADs as a target for depression interventions, we aimed to: 1) adapt an existing behavioral activation program, Engage therapy, to target mornings; and 2) evaluate effects on self-reported MADs and depression symptoms.

METHODS

While trialing the 9-week Engage adaption (targeting mornings) in six older dementia caregivers, we incorporated feedback and finalized an adapted program called Scheduling Activity and Monitoring Mornings (SAMM). We delivered the SAMM protocol to 13 dementia caregivers (all female; mean age = 69, standard deviation = 7). We report modifications made/rationale, as well as changes in subjective MADs (relevant items from the Composite Scale of Morningness) and depression symptoms (Patient Health Questionnaire - 9).

RESULTS

Using caregiver and expert input, we adapted the protocol to: include educational materials/content describing the potential relationship between morning inactivity and depression; target activity scheduling within 2 hours of awakening (preferably earlier); and focus only on the main components of morning activity scheduling, planning, and monitoring. This program was associated with decreases in subjective MADs averaging 29% at week 4, 52% at week 6, and 57% by week 9 (all p's <0.005). Initial depression symptoms were significantly reduced, by 62%, at week 9.

CONCLUSIONS

These preliminary findings suggest that subjective MADs can be modified pragmatically, and that doing so may have antidepressant effects. A controlled trial with measures of the putative mechanism is needed to clarify whether, and if so how, targeting MAD with SAMM causally perturbs depression's mechanisms.

Interpersonal Problematic Areas in Liaison Psychiatry: A Feasibility Study

OBJECTIVE

Interpersonal Psychotherapy (IPT) model, with its four problematic areas of grief, deficit, role transition and role dispute, provides a useful frame of reference for a quick case formulation. We aimed at applying the IPT problematic areas assessment in a sample of patients from a liaison psychiatry setting.

METHODS

One-hundred and twenty-nine hospitalized patients of both sexes, aged between 18 and 80 years were interviewed. The 'Interpersonal Problem Areas Rating Scale' (IPARS) was used to detect the interpersonal focuses.

RESULTS

IPARS problematic areas were identified in the 76% of the sample (n=98). Grief and role transition, interpersonal deficits and role disputes were, respectively, the most frequently (43.4 and 42.6%, respectively) and the less frequently described focuses (14 and 11.6%). Moreover, 31 patients (24%) showed no problem areas related to current symptomatology.

CONCLUSIONS

The IPT model has proved to be an easy-to-use tool, able to guide the psychological interview and allowing the collection of information from an interpersonal perspective in a short time, although no specific focuses were detected as related to current psychological distress in around 25% of the sample.

Post-traumatic stress disorder in train crash survivors in Italy: the role of mood spectrum dysregulations and intrusiveness

BACKGROUND

To explore relationships among post-traumatic stress disorder (PTSD), depressive spectrum symptoms, and intrusiveness in subjects who survived the crash of a train derailed carrying liquefied petroleum gas and exploded causing a fire.

METHODS

A sample of 111 subjects was enrolled in Viareggio, Italy. AMOS version 21 (IBM Corp, 2012) was utilized for a structural equation model-path analysis to model the direct and indirect links between the exposure to the traumatic event, the occurrence of depressive symptoms, and intrusiveness. Subjects were administered with the SCID-IV (Structured Clinical Interview for DSM-IV), the Questionnaire for Mood Spectrum (MOODS-SR)-Last Month version, the Trauma and Loss Spectrum Questionnaire (TALS-SR), and the Impact of Event Scale-Revised version (IES-R).

RESULTS

Sixty-six (66/111; 59.4%) subjects met SCID-IV criteria for PTSD. Indices of goodness of fit were as followed: χ2/df = 0.2 P = .6; comparative fit index = 1 and root mean square error of approximation = 0.0001. A significant path coefficient for direct effect of potential traumatic events on depressive symptoms (β = 0.25; P < .04) and from depressive symptoms to intrusiveness (β = 0.34; P < .003) was found. An indirect effect was also observed: standardized value of potential traumatic events on intrusiveness was 0.86. The mediating factor of this indirect effect path was represented by depressive symptoms. Potential traumatic events explained 6.2% of the variance of depressive symptoms; 11.8% of the variance of intrusiveness was accounted for traumatic event and depressive symptoms.

CONCLUSIONS

Path analysis led us to speculate that depression symptoms might have mediated the relationship between the exposure to potential traumatic events and intrusiveness for the onset of PTSD.

Predictability of temperaments and negative experiences on higher-order symptom-based subtypes of depression

BACKGROUND

The identification of subtypes of depression based on higher-order symptoms of emotional, thought, and behavioral dysfunction will broaden understanding of the heterogeneity in depression. Furthermore, exploring the ability of temperaments and negative experiences to predict each subtype is an effective way of facilitating treatment decisions.

METHODS

Participants were 417 patients diagnosed with depressive disorder at the psychiatry department of a major medical hospital in Seoul, Korea. A latent profile analysis was performed based on three higher-order scales of the MMPI-2-RF: Emotional/Internalizing Dysfunction, Thought Dysfunction, and Behavioral/Externalizing Dysfunction. Four temperament dimensions were assessed by the Temperament and Character Inventory-Revised-Short, and negative experiences including recent negative life events, number of lifetime traumatic events, and severity of maltreatment, were used as covariates in a multinomial regression analysis.

RESULTS

Four classes were obtained from the latent profile analysis: a "severe mood class" (39.8%), a "moderate mood class" (37.4%), a "mild mood class" (11.3%), and a "severe mood/thought class" (11.5%). Among temperament dimensions, high harm avoidance and low persistence significantly predicted more severe mood classes. Low reward dependence, number of lifetime traumatic events, and severity of maltreatment in negative experiences were significant predictors of the severe mood/thought class.

LIMITATIONS

This study could not explain the more detailed heterogeneity within depression because of over-inclusiveness of the higher-order scales.

CONCLUSIONS

This study identified three latent classes that differed in emotional severity and one other class with thought problems. The distinct dimensions of temperament and different types of negative experiences predicted the identified subtypes.

Acylcarnitine metabolomic profiles inform clinically-defined major depressive phenotypes

BACKGROUND

Acylcarnitines have important functions in mitochondrial energetics and β-oxidation, and have been implicated to play a significant role in metabolic functions of the brain. This retrospective study examined whether plasma acylcarnitine profiles can help biochemically distinguish the three phenotypic subtypes of major depressive disorder (MDD): core depression (CD+), anxious depression (ANX+), and neurovegetative symptoms of melancholia (NVSM+).

METHODS

Depressed outpatients (n = 240) from the Mayo Clinic Pharmacogenomics Research Network were treated with citalopram or escitalopram for eight weeks. Plasma samples collected at baseline and after eight weeks of treatment with citalopram or escitalopram were profiled for short-, medium- and long-chain acylcarnitine levels using AbsoluteIDQ®p180-Kit and LC-MS. Linear mixed effects models were used to examine whether acylcarnitine levels discriminated the clinical phenotypes at baseline or eight weeks post-treatment, and whether temporal changes in acylcarnitine profiles differed between groups.

RESULTS

Compared to ANX+, CD+ and NVSM+ had significantly lower concentrations of short- and long-chain acylcarnitines at both baseline and week 8. In NVSM+, the medium- and long-chain acylcarnitines were also significantly lower in NVSM+ compared to ANX+. Short-chain acylcarnitine levels increased significantly from baseline to week 8 in CD+ and ANX+, whereas medium- and long-chain acylcarnitines significantly decreased in CD+ and NVSM+.

CONCLUSIONS

In depressed patients treated with SSRIs, β-oxidation and mitochondrial energetics as evaluated by levels and changes in acylcarnitines may provide the biochemical basis of the clinical heterogeneity of MDD, especially when combined with clinical characteristics.

Rumination, posttraumatic stress disorder, and mood symptoms in borderline personality disorder

Background: The interrelationship between mood disorders and borderline personality disorder (BPD) has been long debated in the literature. Increasing attention has also been paid to the relationship between posttraumatic stress disorder (PTSD) and BPD, as well as to the role of rumination in the development and severity of BPD. This study aims to evaluate the association of rumination, PTSD, and mood spectrum among patients with BPD with or without comorbid mood disorders. Methods: Fifty patients with BPD and 69 healthy controls were assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders 5, Mood Spectrum Self-Report (MOODS-SR), and Ruminative Response Scale (RRS). Results: The BPD group was split into subjects with BPD+ mood disorder (MD) or BPD only) . PTSD-criteria fulfillment, MOODS, and RRS scores were significantly higher in both BPD subgroups than in controls, while BPD+MD patients scored significantly higher than the BPD-only group. RRS scores and PTSD-criteria fulfillment were significantly related to the presence of both BPD and BPD+MD, with no effect of MOODS-SR scores. Conclusion: Our findings confirm the presence of a relationship between BPD and the PTSD spectrum, highlighting also a possible role of rumination in BPD psychopathology. Rumination and PTSD symptoms seem to prevail in the effect of mood spectrum in predicting BPD.

Cluster analysis with MOODS-SR illustrates a potential bipolar disorder risk phenotype in young adults with remitted major depressive disorder

OBJECTIVES

Delays in the diagnosis and detection of bipolar disorder can lead to adverse consequences, including improper treatment and increased suicide risk. The Mood Spectrum Self-Report Measure (MOODS-SR) was designed to capture the full spectrum of lifetime mood symptomology with factor scores for depression and mania symptom constellations. The utility of the MOODS-SR as a tool to investigate homogeneous subgroups was examined, with particular focus on a possible bipolar risk subgroup. Moreover, potential patterns of differences in MOODS-SR subtypes were probed using cognitive vulnerabilities, neuropsychological functioning, and ventral striatum connectivity.

METHODS

K-mean cluster analysis based on factor scores of MOODS-SR was used to determine homogeneous subgroupings within a healthy and remitted depressed young adult sample (N = 86). Between-group comparisons (based on cluster subgroupings) were conducted on measures of cognitive vulnerabilities, neuropsychological functioning, and ventral striatum rs-fMRI connectivity.

RESULTS

Three groups of participants were identified: one with minimal symptomology, one with moderate primarily depressive symptomology, and one with more severe manic and depressive symptomology. Differences in impulsivity, neuroticism, conscientiousness, facial perception accuracy, and rs-fMRI connectivity exist between moderate and severe groups.

CONCLUSIONS

Within a sample of people with and without depression histories, a severe subgroup was identified with potentially increased risk of developing bipolar disorder through use of the MOODS-SR. This small subgroup had higher levels of lifetime depression and mania symptoms. Additionally, differences in traits, affective processing, and connectivity exist between those with a more prototypic unipolar subgrouping and those with potential risk for developing bipolar disorder.

Mood spectrum comorbidity in patients with anorexia and bulimia nervosa

PURPOSE

To investigate the presence of mood spectrum signs and symptoms in patients with anorexia nervosa, restricting subtype (AN-R) or bulimia nervosa (BN).

METHOD

55 consecutive female patients meeting DSM-IV criteria for eating disorders (EDs) not satisfying DSM-IV criteria for Axis I mood disorders were evaluated with the Lifetime Mood Spectrum Self-Report (MOODS-SR) and the Mini-International Neuropsychiatric Interview (MINI). The MOODS-SR explored the subthreshold comorbidity for mood spectrum symptoms in patients not reaching the threshold for a mood disorder Axis I diagnosis. MOODS-SR included 161 items. Separate factor analyses of MOODS-SR identified 6 'depressive factors' and 9 'manic-hypomanic factors'.

RESULTS

The mean total score of MOODS-SR was significantly higher in BN than in AN-R patients (97.5 ± 25.4 vs 61.1 ± 38.5, respectively; p = 0.0001). 63.6 % of the sample (n = 35) endorsed the threshold of ≥61 items, with a statistically significant difference between AN-R and BN (39.3 % vs 88.9 %; χ ² = 14.6; df = 1; p = 0.0001). Patients with BN scored significantly higher than AN-R patients on several MOODS-SR factors: (a) MOODS-SR depressive component: 'depressive mood' (11.2 ± 7.4 vs 16.0 ± 5.8; p < 0.05), 'psychomotor retardation' (5.4 ± 5.6 vs 8.9 ± 3.8; p = 0.003), 'psychotic features' (2.0 ± 1.8 vs 4.1 ± 1.6; p = 0.001), 'neurovegetative symptoms' (5.0 ± 2.6 vs 7.7 ± 1.7; p = 0.001); (b) MOODS-SR manic/hypomanic component: 'psychomotor activation' (4.3 ± 3.6 vs 7.4 ± 3.1; p = 0.002), 'mixed instability' (1.0 ± 1.5 vs 2.0 ± 1.6; p < 0.05), 'mixed irritability' (2.5 ± 1.8 vs 3.7 ± 1.6; p < 0.05), 'inflated self-esteem' (1.1 ± 1.4 vs 2.1 ± 1.6; p < 0.05), and 'wastefulness/recklessness' (1.0 ± 1.4 vs 2.0 ± 1.2; p = 0.009).

CONCLUSIONS

MOODS-SR identifies subthreshold mood signs/symptoms among patients with AN-R, and BN and with no Axis I comorbidity for mood disorders, and provides a better definition of clinical phenotypes.

Depressive symptoms and the role of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD): A comparison with bipolar disorder

OBJECTIVES

To investigate the characteristics of depressive symptoms and the influence of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD), in comparison with bipolar disorder (BD) patients and healthy controls (HCs).

METHOD

Sixty patients with ADHD, 50 patients with BD, and 30 HCs were assessed with instruments for measuring depressive symptoms (Beck Depression Inventory-II), and affective temperaments (Temperament Scale of Memphis, Pisa and San Diego, self-administered version; TEMPS-A). In addition, participants were evaluated with scales for measuring ADHD symptoms, impulsiveness, anxiety, executive dysfunction, and quality of life.

RESULTS

ADHD patients showed levels of depressive symptoms similar to BD patients and higher than HCs. Only neurovegetative symptoms of depression differentiated ADHD and BD groups (BD > ADHD). Depressive symptoms in ADHD patients correlated positively with core ADHD, impulsivity, anxiety, and dysexecutive symptoms and negatively with quality of life. Thirty-eight percent of patients with ADHD scored above the cutoff for at least one affective temperament. Cyclothymic was the more common affective temperament (25%). ADHD patients with affective temperamental traits were more depressed and impulsive than patients without those traits and showed a symptomatic profile analogous to BD patients.

LIMITATIONS

The small size of resultant samples when ADHD group was stratified by the presence of affective temperament. In addition, results may not generalize to less severe ADHD patients from the community.

CONCLUSIONS

Concomitant depressive symptoms constitute a common occurrence in adults with ADHD that carries significant psychopathological and functional consequences. The concept of affective temperaments may be an interesting link for explaining depressive symptomatology and emotional impulsivity in a subgroup of patients with ADHD, beyond the classic idea of comorbidity.

Waking up is the hardest thing I do all day: Sleep inertia and sleep drunkenness

The transition from sleep to wake is marked by sleep inertia, a distinct state that is measurably different from wakefulness and manifests as performance impairments and sleepiness. Although the precise substrate of sleep inertia is unknown, electroencephalographic, evoked potential, and neuroimaging studies suggest the persistence of some features of sleep beyond the point of awakening. Forced desynchrony studies have demonstrated that sleep inertia impacts cognition differently than do homeostatic and circadian drives and that sleep inertia is most intense during awakenings from the biological night. Recovery sleep after sleep deprivation also amplifies sleep inertia, although the effects of deep sleep vary based on task and timing. In patients with hypersomnolence disorders, especially but not exclusively idiopathic hypersomnia, a more pronounced period of confusion and sleepiness upon awakening, known as "sleep drunkenness", is common and problematic. Optimal treatment of sleep drunkenness is unknown, although several medications have been used with benefit in small case series. Difficulty with awakening is also commonly endorsed by individuals with mood disorders, disproportionately to the general population. This may represent an important treatment target, but evidence-based treatment guidance is not yet available.

Idiopathic Hypersomnia

Idiopathic hypersomnia (IH) is a chronic neurologic disorder of daytime sleepiness, accompanied by long sleep times, unrefreshing sleep, difficulty in awakening, cognitive dysfunction, and autonomic symptoms. The cause is unknown; a genetic predisposition is suggested. Autonomic, inflammatory, or immune dysfunction has been proposed. Diagnosis involves a clinical history and objective testing. There are no approved treatments for IH, but modafinil is typically considered first-line. A substantial fraction of patients with IH are refractory or intolerant to standard treatments, and different treatment strategies using novel therapeutics are necessary. Even with current treatment options, quality of life and safety may remain impaired.

Effect of desvenlafaxine 50 mg and 100 mg on energy and lassitude in patients with major depressive disorder: A pooled analysis

Nine randomized, double-blind, placebo-controlled studies of major depressive disorder were pooled to evaluate the effects of desvenlafaxine 50- and 100-mg/d on energy and lassitude in adults with major depressive disorder ( n=4279). Changes from baseline to endpoint in 17-item Hamilton Rating Scale for Depression (HAM-D₁₇) Work and Activities, Retardation, and Somatic Symptoms General items, HAM-D₁₇ psychomotor retardation factor, and Montgomery-Åsberg Depression Rating Scale Lassitude item were analyzed with a mixed model for repeated measures analysis of variance. Associations between residual energy measures and functional impairment, based on the Sheehan Disability Scale, were modeled using stepwise multiple linear regression. Improvement from baseline was significantly greater for both desvenlafaxine doses versus placebo on all energy symptom outcomes at week 8 (all p⩽0.005). Both early improvement in HAM-D₁₇ psychomotor retardation at week 2 and residual energy symptoms at week 8 were associated with Sheehan Disability Scale total score at week 8 (all p⩽0.001). Among Sheehan Disability Scale remitters and responders, the HAM-D₁₇ psychomotor retardation score at week 8 was significantly lower with desvenlafaxine (both doses) than placebo. Desvenlafaxine 50 and 100 mg/d significantly improved energy and lassitude symptoms in patients with major depressive disorder. Both early improvement in energy and fewer residual energy symptoms were associated with functional improvement.

Pilot Study of an Exercise Intervention for Depressive Symptoms and Associated Cognitive-Behavioral Factors in Young Adults With Major Depression

This study assesses the feasibility of integrating motivational interviewing (MI) with an exercise intervention. It also explores patterns of depressive symptom changes (cognitive, affective, and somatic subscales) and their relationship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a marker for inflammation) across the exercise intervention. Twelve young adults (20.8 ± 1.7 years) meeting DSM-IV criteria for major depressive disorder received a brief MI intervention followed by a 12-week exercise intervention. Assessments were conducted preintervention, postintervention, throughout the intervention, and at follow-up. Preliminary results show differential effects of exercise, with the largest standardized mean improvements for the affective subscale (-1.71), followed by cognitive (-1.56) and somatic (-1.39) subscales. A significant relationship was observed between increased behavioral activation and lower levels of IL-6. Despite study limitations, the magnitude of changes suggests that natural remission of depressive symptoms is an unlikely explanation for the findings. A randomized controlled trial has commenced to evaluate effectiveness of the intervention.

[Validation of the Montgomery-Åsberg Depression Rating Scale (MADRS) in Colombia]

OBJECTIVE

To adapt and to validate the Montgomery-Åsberg Depression Rating Scale (MADRS) in Colombia.

METHODS

Observational study for scale validation. Validity criteria were used to determine the severity cut-off points of the tool. Taking into account sensitivity and specificity values, those cut points were contrasted with ICD-10 criteria for depression severity. A a factor analysis was performed. The internal consistencY was determined with the same sample of patients used for the validity criteria. Inter-rater reliability was assessed by evaluating the 22 records of the patients that consented to a video interview. Sensitivity to change was established through a second application of the scale in 28 subjects after a lapse of 14 to 28 days.

RESULTS

The study was performed in Bogotá, the tool was applied in 150 patients suffering from major depressive disorder. The cut-off point for moderate depression was 20 (sensitivity, 98%; specificity, 96%), and the cut-off point for severe depression was 34 (sensitivity, 98%; specificity, 92%). The tool appears as a unidimensional scale, which possesses a good internal consistency with (α=.9168). The findings of inter-rater reliability evaluation showed the scale as highly reliable (intraclass correlation coefficient=.9833). The instrument has a good sensitivity to change.

CONCLUSIONS

The Colombian version of the Montgomery-Åsberg Depression Rating Scale has good psychometric properties and can be used in clinical practice and in clinical research in the field of depressive disorder.

Development and Validation of the Sleep Inertia Questionnaire (SIQ) and Assessment of Sleep Inertia in Analogue and Clinical Depression

Sleep inertia is the transitional state from sleep to wake. Research on sleep inertia is important in depression because many people with depression report having difficulty getting out of bed, which contributes to impairment and can impede the implementation of interventions. The first aim was to develop and validate the first self-report measure of sleep inertia, the Sleep Inertia Questionnaire (SIQ). The second aim was to compare reports of sleep inertia across three groups: (1) No-to-Mild-Depression, (2) Analogue-Depression, and (3) Syndromal-Depression. The SIQ demonstrates strong psychometric properties; it has good to excellent internal consistency, strong construct validity, and SIQ severity is associated with less prior sleep duration. Sleep inertia is more severe in the Analogue-Depression and Syndromal-Depression groups compared to the No-to-Mild-Depression group. In conclusion, the SIQ is a reliable measure of sleep inertia and has potential for improving the assessment of sleep inertia in clinical and research settings.

Mood Spectrum Model: Evidence reconsidered in the light of DSM-5

AIM: to investigate studies conducted with the Mood Spectrum Structured Interviews and Self-Report versions (SCI-MOODS and MOODS-SR).

METHODS: We conducted a review of studies published between 1997 and August 2014. The search was performed using Pubmed and PsycINFO databases. Analysis of the papers followed the inclusion and exclusion criteria recommended by the PRISMA Guidelines, namely: (1) articles that presented a combination of at least two terms, “SCI-MOODS” [all fields] or “MOODS-SR” [all fields] or “mood spectrum” [all fields]; (2) manuscript in English; (3) original articles; and (4) prospective or retrospective original studies (analytical or descriptive), experimental or quasi-experimental studies. Exclusion criteria were: (1) other study designs (case reports, case series, and reviews); (2) non-original studies including editorials, book reviews and letters to the editor; and (3) studies not specifically designed and focused on SCI-MOODS or MOODS-SR.

RESULTS: The search retrieved 43 papers, including 5 reviews of literature or methodological papers, and 1 case report. After analyzing their titles and abstracts, according to the eligibility criteria, 6 were excluded and 37 were chosen and included. The SCI-MOODS and the MOODS-SR have been tested in published studies involving 52 different samples across 4 countries (Italy, United States, Spain and Japan). The proposed mood spectrum approach has demonstrated its usefulness mainly in 3 different areas: (1) Patients with the so-called “pure” unipolar depression that might manifest hypomanic atypical and/or sub-threshold aspects systematically detectable with the mood questionnaire; (2) Spectrum features not detected by other instruments are clinically relevant, because they might manifest in waves during the lifespan, sometimes together, sometimes alone, sometimes reaching the severity for a full-blown disorder, sometimes interfering with other mental disorders or complicating the course of somatic diseases; and (3) Higher scores on the MOODS-SR factors assessing “psychomotor disturbances”, “mixed instability” and “suicidality” delineate subtypes of patients characterized by the more severe forms of mood disorders, the higher risk for psychotic symptoms, and the lower quality of life after the remission of the full-blown-episode.

CONCLUSION: The mood spectrum model help researchers and clinicians in the systematic assessment of those areas of psychopathology that are still neglected by the Diagnostic and Statistical Manual of Mental Disorders 5 classification.

Dimensions in major depressive disorder and their relevance for treatment outcome

BACKGROUND

Major depressive disorder (MDD) is a heterogeneous disease. More homogeneous psycho(patho)logical dimensions would facilitate MDD research as well as clinical practice. The first aim of this study was to find potential dimensions within a broad psychopathological assessment in depressed patients. Second, we aimed at examining how these dimensions predicted course in MDD.

METHODS

Ten psychopathological variables were assessed in 75 MDD inpatients. Factor and regression analyses assessed putative relations between psychopathological factors and depression severity and outcome after 8 weeks of treatment.

RESULTS

A 3-factor model (eigenvalue: 54.4%) was found, representing a psychomotor change, anhedonia and negative affect factor. Anhedonia and negative affect predicted depression severity (R(2)=0.37, F=20.86, p<0.0001). Anhedonia predicted non-response (OR 6.00, CI 1.46-24.59) and both negative affect (OR 5.69, CI 1.19-27.20) and anhedonia predicted non-remission (OR 9.28, CI 1.85-46.51).

LIMITATIONS

The sample size of the study was relatively modest, limiting the number of variables included in the analysis.

CONCLUSIONS

Results confirm that psychomotor change, anhedonia and negative affect are key MDD dimensions, two of which are related to treatment outcome.

The Brief Psychiatric Rating Scale (version 4.0) factorial structure and its sensitivity in the treatment of outpatients with unipolar depression

The 24-item Brief Psychiatric Rating Scale (BPRS, version 4.0) enables the rater to measure psychopathology severity. Still, little is known about the BPRS's reliability and validity outside of the psychosis spectrum. The aim of this study was to examine the factorial structure and sensitivity to change of the BPRS in patients with unipolar depression. Two hundred and forty outpatients with unipolar depression were administered the 24-item BPRS. Assessments were conducted at intake and at post-treatment in a Crisis Intervention Centre. An exploratory factor analysis of the 24-item BPRS produced a six-factor solution labelled "Mood disturbance", "Reality distortion", "Activation", "Apathy", "Disorganization", and "Somatization". The reduction of the total BPRS score and dimensional scores, except for "Activation", indicates that the 24-item BPRS is sensitive to change as shown in patients that appeared to have benefited from crisis treatment. The findings suggest that the 24-item BPRS could be a useful instrument to measure symptom severity and change in symptom status in outpatients presenting with unipolar depression.

Psychometric properties of the List of Threatening Experiences--LTE and its association with psychosocial factors and mental disorders according to different scoring methods

BACKGROUND

The List of Threatening Experiences (LTE) questionnaire is frequently used to assess stressful events; however, studies of its psychometric properties are scarce. We examined the LTE's reliability, factorial structure, construct validity and explored the association between LTE scores and psychosocial variables and mental disorders.

METHOD

This study involved interviewing 5442 primary care attendees from Spain. Associations between four different methods of quantifying LTE scores, psychosocial factors, major depression (CIDI), anxiety disorders (PRIME-MD), alcohol misuse and dependence (AUDIT) were measured.

RESULTS

The LTE showed high test-retest reliability (Kappa range=0.61-0.87) and low internal consistency (α=0.44). Tetrachoric factorial analysis yielded four factors (spousal and relational problems; employment and financial problems; personal problems; illness and bereavement in close persons). Logistic multilevel regression found a strong association between greater social support and a lower occurrence of stressful events (OR range=0.36-0.79). The association between religious-spiritual beliefs and the LTE, was weaker. The association between mental disorders and LTE scores was greater for depression (OR range=1.64-2.57) than anxiety (OR range=1.35-1.97), though the highest ORs were obtained with alcohol dependence (OR range=2.86-4.80). The ordinal score (ordinal regression) was more sensitive to detect the strength of association with mental disorders.

LIMITATIONS

We are unable to distinguish the direction of the association between stressful events, psychosocial factors and mental disorders, due to our cross-sectional design of the study.

CONCLUSIONS

The LTE is a valid and reliable measure of stress in mental health, and the strength of association with mental disorders depends on the method of quantifying LTE scores.

Mathematical models as an aid for improving the validity of descriptive psychiatry

Despite available therapies, mental disorders are the predominant chronic diseases of young people. Increasing the validity of descriptive psychiatry is now essential. Mathematical approaches can help characterise clinical phenotypes and aid both causal research and therapeutics in the community and the clinic.

Validity and reliability of the Structured Clinical Interview for Mood Spectrum: Brazilian version (SCIMOODS-VB)

OBJECTIVE

The aim of this study was to translate the Structured Clinical Interview for Mood Spectrum into Brazilian Portuguese, measuring its reliability, validity, and defining scores for bipolar disorders.

METHOD

Questionnaire was translated (into Brazilian Portuguese) and back-translated into English. Sample consisted of 47 subjects with bipolar disorder, 47 with major depressive disorder, 18 with schizophrenia and 22 controls. Inter-rater reliability was tested in 20 subjects with bipolar disorder and MDD. Internal consistency was measured using the Kuder Richardson formula. Forward stepwise discriminant analysis was performed. Scores were compared between groups; manic (M), depressive (D) and total (T) threshold scores were calculated through receiver operating characteristic (ROC) curves.

RESULTS

Kuder Richardson coefficients were between 0.86 and 0.94. Intraclass correlation coefficient was 0.96 (CI 95 % 0.93-0.97). Subjects with bipolar disorder had higher M and T, and similar D scores, when compared to major depressive disorder (ANOVA, p < 0.001). The sub-domains that best discriminated unipolar and bipolar subjects were manic energy and manic mood. M had the best area under the curve (0.909), and values of M equal to or greater than 30 yielded 91.5% sensitivity and 74.5% specificity.

CONCLUSION

Structured Clinical Interview for Mood Spectrum has good reliability and validity. Cut-off of 30 best differentiates subjects with bipolar disorder vs. unipolar depression. A cutoff score of 30 or higher in the mania sub-domain is appropriate to help make a distinction between subjects with bipolar disorder and those with unipolar depression.

Structure and measurement of depression in youths: applying item response theory to clinical data

Our goals in this article were to use item response theory (IRT) to assess the relation of depressive symptoms to the underlying dimension of depression and to demonstrate how IRT-based measurement strategies can yield more reliable data about depression severity than conventional symptom counts. Participants were 3,403 children and adolescents from 12 contributing clinical and nonclinical samples; all participants had received the Kiddie Schedule of Affective Disorders and Schizophrenia for School-Aged Children. Results revealed that some symptoms reflected higher levels of depression and were more discriminating than others. Furthermore, use of IRT-based information about symptom severity and discriminability in the measurement of depression severity was shown to reduce measurement error and increase measurement fidelity.

Incidence and predictors of relapse during continuation treatment of major depression with SSRI, interpersonal psychotherapy, or their combination

BACKGROUND

Despite the availability of many effective treatments, patients with major depression remain at risk for relapse following remission of a depressive episode. The aims of this report are to estimate the relapse rates associated with the acute treatment strategies employed in this study and to investigate demographic and clinical predictors of relapse.

METHODS

The study sample includes 225 patients who entered the 6-month continuation treatment phase after remitting from an acute depressive episode. Treatment during the acute phase was interpersonal psychotherapy, SSRI (escitalopram), or the combination of the two when monotherapy did not lead to response. Relapse was defined by a Hamilton Depression Rating Scale score ≥15, confirmed by the diagnosis of major depression. The probability of relapsing was modeled using logistic regression. Three separate models were fit with subgroups of covariates.

RESULTS

Of the 225 patients, 29 (12.9%) relapsed and 28 (12.4%) discontinued the protocol prematurely. The proportion of patients who relapsed among the group requiring combination treatment to achieve remission was three times as high as among patients who had remitted with monotherapy. In the final logistic regression model, older age, higher baseline HDRS scores, last month (residual) depressive mood spectrum factor score, and requiring combination treatment to achieve remission were each associated with an increased likelihood of relapse.

CONCLUSIONS

Our results suggest that greater initial depression severity, greater difficulty in stabilizing symptoms, and presence of residual mood spectrum symptoms once remission is achieved are predictive of relapse. Risk of relapse is more likely as age increases, partly because aging confers lower resilience.

Does psychomotor retardation define a clinically relevant phenotype of unipolar depression?

BACKGROUND

The recognition and assessment of psychomotor retardation may have implications for better definition of the clinical phenotypes of depression. The aim of this study was to assess the clinical correlates of psychomotor retardation endorsed at any time during the patients' lifetime (LPR).

METHODS

The study sample included 291 patients with non-psychotic major depressive disorder (MDD) participating in the clinical trial, "Depression: The Search for Treatment-Relevant Phenotypes." Psychomotor retardation was measured using a factor derived from the Mood Spectrum Self-Report (MOODS-SR) assessment. Using a pre-defined cut-off score on the lifetime psychomotor retardation (LPR) factor of the MOODS-SR, participants were classified into high and low scorers. Logistic regression analysis was used to evaluate the relationship between LPR and subthreshold bipolarity.

RESULTS

Compared to low scorers, participants with high scores on the LPR factor had greater severity of depression and more bipolarity indicators.

CONCLUSIONS

The MOODS-SR appears to be helpful to identify clinical phenotypes of unipolar depression and to highlight the usefulness of a lifetime approach to the assessment of psychopathology in the characterisation of patients with unipolar depression.

Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy

BACKGROUND

Although many studies suggest that, on average, depression-specific psychotherapy and antidepressant pharmacotherapy are efficacious, we know relatively little about which patients are more likely to respond to one versus the other. We sought to determine whether measures of spectrum psychopathology are useful in deciding which patients with unipolar depression should receive pharmacotherapy versus depression-specific psychotherapy.

METHOD

A total of 318 adult out-patients with major depression were randomly assigned to escitalopram pharmacotherapy or interpersonal psychotherapy (IPT) at academic medical centers at Pittsburgh, Pennsylvania and Pisa, Italy. Our main focus was on predictors and moderators of time to remission on monotherapy at 12 weeks.

RESULTS

Participants with higher scores on the need for medical reassurance factor of the Panic-Agoraphobic Spectrum Self-Report (PAS-SR) had more rapid remission with IPT and those with lower scores on the psychomotor activation factor of the Mood Spectrum Self-Report (MOODS-SR) experienced more rapid remission with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Non-specific predictors of longer time to remission with monotherapy included several panic spectrum and mood spectrum factors and the Social Phobia Spectrum (SHY) total score. Higher baseline scores on the 17- and 25-item Hamilton Depression Rating Scales (HAMD-17 and HAMD-25) and the Work and Social Adjustment Scale (WSAS) also predicted a longer time to remission, whereas being married predicted a shorter time to remission.

CONCLUSIONS

This exploratory study identified several non-specific predictors but few moderators of psychotherapy versus pharmacotherapy outcome. It offers useful indicators of the characteristics of patients that are generally difficult to treat, but only limited guidance as to who benefits from IPT versus SSRI pharmacotherapy.

Factor structure of the Brief Psychiatric Rating Scale in unipolar depression

BACKGROUND

In clinical practice patients with unipolar depression present with a variety of symptom clusters that may combine together in many different ways. However, only few factor analytic studies used general psychopathology scales to investigate the symptom structure of unipolar depression.

METHODS

The study included 163 consecutive inpatients with an ICD-10 diagnosis of depressive disorder (ICD-10 codes F32 to F33). All patients were assessed with the 18-item version of the Brief Psychiatric Rating Scale (BPRS) within 3days from admission. Exploratory factor analysis with Varimax rotation was performed on BPRS items.

RESULTS

Four factors were extracted, explaining 52% of total variance. They were interpreted as Apathy, Dysphoria, Depression and Psychoticism. The distribution of factor scores was approximately normal for Apathy, while it displayed a slight negative skewness for Depression, a slight positive skewness for Dysphoria, and a marked positive skewness for Psychoticism. Patient sex, family history of depression, lifetime history of suicide attempt, and recent serious family conflict were not associated with any factor. Occupational status, age, and age at onset displayed a positive correlation with Apathy. Duration of illness and number of previous admissions were positively correlated with Dysphoria.

LIMITATIONS

Patients were not administered a structured diagnostic interview, and no detailed assessment of personality disorders was performed; also, patients were recruited only at a single site, which reduces the generalizability of the results.

CONCLUSIONS

Our findings suggest that in depressive disorders there are psychopathological dimensions other than depressed mood that are worthy of greater clinical attention and research. Dimensions such as apathy and dysphoria may play an important part in the clinical phenomenology of unipolar depression and deserve systematic and careful assessment in order to provide patients with the best possible treatment and improve clinical outcomes.

Clinical characteristics and treatment outcome of depression in patients with and without a history of emotional and physical abuse

Clinical features and treatment outcome were compared in depressed outpatients with and without a history of emotional and physical abuse (EPA), including childhood maltreatment. Patients were initially randomized to IPT or SSRI and then augmented with the second treatment if they did not remit with monotherapy. Assessments included the SCID-I, the SCID-II for DSM-IV diagnoses, the HRSD, the QIDS and the Mood Spectrum Self-Report (MOODS-SR). Seventy-eight (25%) patients reported a history of EPA; 60 (76.9%) were women. Patients with a history of EPA did not differ from those without on HRSD scores at baseline, but showed an earlier age at onset of depression and a longer duration of illness. The two groups differed on several mood spectrum factors, namely: 'depressivemood' (15.6+/-4.9 vs. 13.5+/-5.4; p<0.004), 'psychomotorretardation' (11.7+/-4.5 vs. 9.6+/-4.7; p<0.001), 'drugandillness-relateddepression' (1.3+/-1.3 vs. 0.6+/-1.0; p<0.0001), and 'neurovegetativesymptoms' (8.3+/-2.6 vs. 6.9+/-2.9; p<0.0001). Patients with EPA had also a significantly longer time to remission (89 vs. 67days, log-rank test, p=0.035). The need for augmentation treatment was significantly more frequent among patients with EPA than in those without. The present study suggests that patients with a history of EPA show a subtype of depression characterized by poor treatment response and more severe neurovegetative and psychomotor symptoms.

Relationship of residual mood and panic-agoraphobic spectrum phenomenology to quality of life and functional impairment in patients with major depression

The aim of this study was to analyze the relationship of residual mood and panic-agoraphobic spectrum phenomenology to functional impairment and quality of life in 226 adult outpatients who had remitted from a major depressive episode. Quality of life and functioning were assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire and the Work and Social Adjustment Scale. Residual symptoms were assessed using the Mood and Panic-Agoraphobic Spectrum Questionnaires. Linear and logistic regression models were used to analyze the relationship of mood and panic-agoraphobic spectrum factors with quality of life and functioning. Poor quality of life was associated with the Mood Spectrum Self-Report Questionnaire factors 'depressive mood' and 'psychotic features' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factors 'separation anxiety' and 'loss sensitivity'. Functional impairment was associated with the Mood Spectrum Self-Report Questionnaire factor 'psychomotor retardation' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factor 'fear of losing control'. These relationships were held after controlling for the severity of depression at the entry in the continuation treatment phase. In conclusion, the spectrum assessment is a useful tool for clinicians to identify areas of residual symptomatology that can be targeted with focused and effective long-term treatment strategies.

Four cases of dysthymic disorder and general malaise successfully treated with traditional herbal (kampo) medicines: kamiuntanto

Traditional herbal (Kampo) medicines have been used since ancient times to treat patients with mental disorders. In the present report, we describe four patients with dysthymia successfully treated with Kampo medicines: Kamiuntanto (KUT). These four patients fulfilled the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dysthymic disorder with easy fatigability and sleeplessness, but did not fulfill the criteria for major depressive disorder. Treatment with KUT relieved depressive status, fatigue and sleeplessness in these patients. As a result, their QOL (quality of life) was considerably improved. KUT may be useful as an additional or alternative treatment for dysthymia, especially in the field of primary health care.

Clinical characteristics and treatment outcome of depression in patients with and without a history of emotional and physical abuse

Clinical features and treatment outcome were compared in depressed outpatients with and without a history of emotional and physical abuse (EPA), including childhood maltreatment. Patients were initially randomized to IPT or SSRI and then augmented with the second treatment if they did not remit with monotherapy. Assessments included the SCID-I, the SCID-II for DSM-IV diagnoses, the HRSD, the QIDS and the Mood Spectrum Self-Report (MOODS-SR). Seventy-eight (25%) patients reported a history of EPA; 60 (76.9%) were women. Patients with a history of EPA did not differ from those without on HRSD scores at baseline, but showed an earlier age at onset of depression and a longer duration of illness. The two groups differed on several mood spectrum factors, namely: 'depressivemood' (15.6+/-4.9 vs. 13.5+/-5.4; p<0.004), 'psychomotorretardation' (11.7+/-4.5 vs. 9.6+/-4.7; p<0.001), 'drugandillness-relateddepression' (1.3+/-1.3 vs. 0.6+/-1.0; p<0.0001), and 'neurovegetativesymptoms' (8.3+/-2.6 vs. 6.9+/-2.9; p<0.0001). Patients with EPA had also a significantly longer time to remission (89 vs. 67days, log-rank test, p=0.035). The need for augmentation treatment was significantly more frequent among patients with EPA than in those without. The present study suggests that patients with a history of EPA show a subtype of depression characterized by poor treatment response and more severe neurovegetative and psychomotor symptoms.