Mood-congruent and mood-incongruent psychotic symptoms in major depression: the role of severity and personality

Characterizing the distinct imaging phenotypes, clinical behavior, and genetic vulnerability of brain maturational subtypes in mood disorders

BACKGROUND

Mood disorders are characterized by great heterogeneity in clinical manifestation. Uncovering such heterogeneity using neuroimaging-based individual biomarkers, clinical behaviors, and genetic risks, might contribute to elucidating the etiology of these diseases and support precision medicine.

METHODS

We recruited 174 drug-naïve and drug-free patients with major depressive disorder and bipolar disorder, as well as 404 healthy controls. T1 MRI imaging data, clinical symptoms, and neurocognitive assessments, and genetics were obtained and analyzed. We applied regional gray matter volumes (GMV) and quantile normative modeling to create maturation curves, and then calculated individual deviations to identify subtypes within the patients using hierarchical clustering. We compared the between-subtype differences in GMV deviations, clinical behaviors, cell-specific transcriptomic associations, and polygenic risk scores. We also validated the GMV deviations based subtyping analysis in a replication cohort.

RESULTS

Two subtypes emerged: subtype 1, characterized by increased GMV deviations in the frontal cortex, cognitive impairment, a higher genetic risk for Alzheimer's disease, and transcriptionally associated with Alzheimer's disease pathways, oligodendrocytes, and endothelial cells; and subtype 2, displaying globally decreased GMV deviations, more severe depressive symptoms, increased genetic vulnerability to major depressive disorder and transcriptionally related to microglia and inhibitory neurons. The distinct patterns of GMV deviations in the frontal, cingulate, and primary motor cortices between subtypes were shown to be replicable.

CONCLUSIONS

Our current results provide vital links between MRI-derived phenotypes, spatial transcriptome, genetic vulnerability, and clinical manifestation, and uncover the heterogeneity of mood disorders in biological and behavioral terms.

Comparison on the clinical features in patients with or without treatment-resistant depression: A National Survey on Symptomatology of Depression report

Patients with treatment-resistant depression (TRD) have fewer treatment options and worse prognoses than those without TRD. Although the etiology or pathophysiology of TRD remains unclear, certain clinical variables have been found to be related to its severity and prognosis. Therefore, 1151 patients with recurrent depression were recruited from the National Survey on Symptomatology of Depression (NSSD) and their depressive symptoms were assessed by using the doctor-rating assessment questionnaire. Then, the differences between patients with or without TRD were compared by parametric or nonparametric tests and the risk factors for TRD were explored by logistic regression. The results showed there were differences in clinical variables between patients with and without TRD. Additionally, we found depression with more somatic symptoms had a higher risk for TRD. Further analysis by stepwise logistic regression showed that age, gender, religious belief, drinking habit, the total course of depression, the number of hospitalizations, characteristics of seasonal episode remission, depressed mood, hypersexuality, emotionally incoherent psychotic symptoms, psychomotor agitation, respiratory system symptoms and history of suicide attempts were strongly associated with TRD. So, it is crucial for clinicians to identify these clinical features and adjust treatments timely.

Prevalence and related factors of anxiety in first episode and drug naïve Chinese Han outpatients with psychotic major depression

BACKGROUND

Anxiety frequently occurs with major depressive disorder (MDD) but to a different extent in the various subtypes. Psychotic major depression (PMD) is a severe subtype of MDD that is under-identified and under-studied. We investigated the prevalence and related risk factors of anxiety in PMD patients.

METHODS

A total of 1718 first episode and drug naïve MDD patients were recruited. Measures included the Hamilton Depression Scale (HAMD), Clinical Global Impression-Severity scale (CGI-S), Hamilton Anxiety Scale (HAMA), and positive symptom scale of the Positive and Negative Syndrome Scale (PANSS), thyroid hormone levels, and metabolic parameters.

RESULTS

171 of the entire MDD study sample met the criteria for the PMD subtype. The prevalence of severe anxiety was much higher in PMD patients (22.8 %) than in non-PMD patients (0.4 %) (χ² = 294.69, P < 0.001, OR = 75.88, 95 % CI = 31.55-182.52). Compared to PMD patients without severe anxiety, PMD patients with severe anxiety had higher HAMD score, CGI-S score, positive symptom subscale score, suicide attempts, blood pressure, thyroid-stimulating hormone (TSH), anti-thyroglobulin (TgAb), and thyroid peroxidases antibody (TPOAb) levels. Furthermore, logistic regression analysis indicated that HAMD score and TSH levels were associated with severe anxiety in PMD patients.

LIMITATIONS

Our cross-sectional study cannot explain the causal relationship between anxiety severity and risk factors in PMD patients.

CONCLUSIONS

Our results suggest that PMD patients are more likely to experience severe anxiety than non-PMD patients. The severity of depression and TSH levels are independent risk factors for anxiety in PMD patients.

The moderation of maternal parenting on the association of trauma, dissociation, and psychosis in depressive inpatients

BACKGROUND

The effect of dissociation and parenting style on the relationship between psychological trauma and psychotic symptoms has not previously been investigated.

OBJECTIVE

The aim of this study was to develop a moderated mediation model to assess whether the association between psychological trauma and psychotic symptoms is mediated by dissociation and moderated by parental maltreatment.

METHODS

Inpatients with major depressive disorder (MDD) and bipolar depression (BP) were recruited. Self-reported and clinical rating scales were used to measure the level of dissociation, psychotic symptoms, history of psychological trauma and parental maltreatment. The PROCESS macro in SPSS was used to estimate path coefficients and adequacy of the moderated mediation model. High betrayal trauma (HBT), low betrayal trauma (LBT), paternal maltreatment, and maternal maltreatment were alternatively entered into the conceptual model to test the adequacy.

RESULTS

A total of 91 patients (59 with MDD and 32 with BP) were recruited, with a mean age of 40.59 ± 7.5 years. After testing with different variables, the moderated mediation model showed that the association between LBT and psychotic symptoms was mediated by dissociation and moderated by maternal maltreatment. A higher level of maternal maltreatment enhanced the effect of LBT on dissociation.

CONCLUSIONS

Healthcare workers should be aware of the risk of developing psychotic symptoms among depressive patients with a history of LBT and maternal maltreatment.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

Prevalence and clinical correlates of psychotic depression in first-episode and drug-naïve outpatients with major depressive disorder in a Chinese Han population

BACKGROUND

Few systemic studies of psychotic depression (PD) have been conducted in first-episode and drug-naïve (FEDN) patients. This study was to examine the prevalence of PD and its clinical correlates in a large sample of FEDN outpatients with major depressive disorder (MDD) in a Chinese Han population, which to our best knowledge has not been studied.

METHODS

In this cross-sectional study, a total of 1718 FEDN MDD outpatients were recruited. All patients were rated on the positive symptom subscale of the Positive and Negative Syndrome Scale (PANSS) for psychotic symptoms, the 17-item Hamilton Depression Rating Scale (HAMD-17) for depression and Hamilton Anxiety Rating Scale (HAMA) for anxiety.

RESULTS

The prevalence of PD was 10.0% (171/1718) in MDD patients. Compared to the non-PD patients, PD patients had significantly older age, lower educational levels, higher anxiety symptom score and were more likely to attempt suicide. Further logistic regression analysis indicated that PD was associated with older age, suicide attempt and comorbid anxiety (all p < 0.05). Multiple regression analyses showed that both HAMD and HAMA total scores were significantly associated with PANSS positive symptom subscale score.

LIMITATIONS

Our cross-sectional study design does not show a direct causal relationship between psychiatric symptoms and related factors in patients with MDD.

CONCLUSIONS

Our results suggest a high prevalence of PD in MDD patients in the acute early stage in a Chinese Han population, which is associated with demographic variables and clinical symptoms.

Delusional disorder: The role of personality and emotions on delusional ideation

The relationship between personality and Delusional Disorder in still debated. The present study aimed to evaluate the role of personality features and emotional dispositions on the proneness to delusional beliefs, through the lens of a dimensional approach. 91 outpatients were administered the Structured Interview for DSM-IV Personality Disorders, the Pathological Narcissism Inventory, the Positive and Negative Affect Schedule and the Peters et al. Delusions Inventory. Delusion proneness was positively related to the "Hiding the Self" domain of narcissistic vulnerability and to paranoid traits and negatively related to "Positive Affect". Paranoid traits and "Hiding the Self" significantly interacted in influencing delusion ideation. These data suggest that proneness to delusion depends, at least in part, on a complex interplay between specific emotional and paranoid dispositions within personality.

Targeting and transforming major depression

OBJECTIVE

To detail limitations to the construct of 'major depression', argue for repositioning it as a proxy for 'clinical depression' and then operationalize it and its principal constituent depressive subtypes, while preserving the DSM criteria-based format.

METHOD

We summarize limitations to major depression being viewed as a diagnostic entity. Data from 391 clinically depressed patients were analysed to identify high-prevalence non-specific depressive symptoms to define 'clinical depression' as well as the features showing specificity to a melancholic depressive subtype.

RESULTS

We identified a set of high-prevalence and generalized symptoms for defining clinical depression and with many being current criteria for major depression. We also developed a refined set of melancholic features and with their underlying distributions generating two classes that correlated strongly with clinical diagnoses of a melancholic or non-melancholic depression, thus validating its capacity to so differentiate. We append criteria sets for diagnosing clinical depression and its principal diagnostic subtypes (psychotic, melancholic and non-melancholic).

CONCLUSION

This heuristic study reframes and modifies major depression's criteria set to define a domain of clinical depression with additional criteria and then allowing the delineation of three diagnostic subtypes. If this paradigm shift is accepted and further refined, greater precision in diagnosis, treatment and research would be anticipated.

Factors associated with onset timing, symptoms, and severity of depression identified in the postpartum period

BACKGROUND

Unipolar and bipolar depression identified in the postpartum period have a heterogeneous etiology. The objectives of this study are to examine the risk factors that distinguish the timing of onset for unipolar and bipolar depression and the associations between depression onset by diagnosis, and general and atypical depressive symptoms.

METHODS

Symptoms of depression were assessed at 4- to 6-weeks postpartum by the Structured Interview Guide for the Hamilton Depression Rating Scale-Atypical Depression Symptoms in an obstetrical sample of 727 women. Data were analyzed using ANOVA, Chi-square, and linear regression.

RESULTS

Mothers with postpartum onset of depression were more likely to be older, Caucasian, educated, married/cohabitating, have one or no previous child, and have private insurance in contrast to mothers with pre-pregnancy and prenatal onset of depression. Mothers with bipolar depression were more likely to have a pre-pregnancy onset. Three general and two atypical depressive symptoms distinguished pre-pregnancy, during pregnancy, and postpartum depression onset, and the presence of agitation distinguished between unipolar and bipolar depression.

LIMITATIONS

The sample was urban, which may not be generalizable to other populations. The study was cross-sectional, which excludes potential late onset of depression (after 4-6 weeks) in the first postpartum year.

CONCLUSIONS

A collective set of factors predicted the onset of depression identified in the postpartum for mothers distinguished by episodes of unipolar versus bipolar depression, which can inform clinical interventions. Future research on the onset of major depressive episodes could inform prophylactic and early psychiatric interventions.

The three factors of the psychoticism scale of SCL-90-R

Former studies have repeatedly found the psychoticism (PSY) scale of Symptom Checklist-90-Revised to be a heterogeneous construct. The aim of this study was to confirm and further explore the nature of this heterogeneity within a large sample of patients with mainly personality disorders. Within a total sample of 3 794 patients, one-half was randomly selected for explorative factor analysis in order to assess the internal structure of the PSY scale and the other half to cross-validate the findings by a confirmatory factor analysis. The total sample was then used to assess associations between the components from the factor analyses and several clinical measures and diagnoses. A one-factor solution of the PSY scale yielded poor fit to the data, but a proposed structure of three latent constructs was confirmed by good model fit. The three subsets of the PSY scale, labelled metacognitive dysfunction, self-accusation and detachment, shared variance with different personality disorders and different aspects of psychopathology, e.g. previous psychotic episodes. The heterogeneous PSY scale of SCL-90-R can be divided into three meaningful clinical concepts, reflecting different aspects of psychosis-near experiences. The factors warrant confirmation in other populations. Copyright © 2014 John Wiley & Sons, Ltd.

Assessing treatment response to prophylactic lithium use in patients with bipolar disorder

ABSTRACT Objetive To identify potential clinical and epidemiological predictors of long-term response to lithium treatment. Methods A total of 40 adult outpatients followed in an university hospital, with confirmed diagnosis of bipolar disorder and with history of lithium use for at least a six months period, had their response to this medication assessed through the use of a standardized instrument. The ALDA scale is based on retrospective clinical data, in our study assessed through a thoroughly reviewed of the medical charts, and is used to evaluate the clinical improvement with the treatment (Criterion A), corrected by the acknowledgement of possible confounding factors, such as duration of the treatment, compliance and concomitant use of additional medications (Criterion B), in order to estimate the response that can be specifically attributable to lithium. Results Our study found an inverse relation between the number of mood episodes with psychotic symptoms and lithium treatment outcome. Conclusion The results reinforce the hypothesis that lithium seems to be less efficacious in patients with bipolar disorder who present psychotic symptoms.