Dysthymic disorder and double depression: prediction of 10-year course trajectories and outcomes

Effort and Appetitive Responding in Depression: Examining Deficits in Motivational and Consummatory Stages of Reward Processing Using the Effort-Doors Task

Background

Reward sensitivity is a dimensional construct central to understanding the nature of depression. Psychophysiological research on this construct has primarily focused on the reward positivity, an event-related potential (ERP) that indexes consummatory reward sensitivity. This study extended prior research by focusing on ERPs that index the motivational component of reward.

Methods

A novel effort-for-reward task was used to elicit motivational and consummatory ERPs. Groups consisting of 34 participants with depression and 32 participants without depression were compared across a range of reward-related ERPs.

Results

Participants with depression exhibited reduced responsivity to effort completion cues following high effort expenditure, reduced anticipation of rewards after low effort expenditure (i.e., the stimulus preceding negativity), and reduced reward positivity following high effort expenditure. ERPs occurring prior to reward receipt accounted for unique variance in depression status and differentiated between subgroups of depressed individuals.

Conclusions

Findings support the utility of leveraging multiple ERPs that index separate reward processing deficits to better characterize depression and depressive subtypes.

An update on the pharmacotherapeutic strategies for the treatment of dysthymic disorder: a systematic review

INTRODUCTION

Longer treatment times, more comorbidity, more severe impairments in social, psychological, and emotional functioning, increased healthcare use, and more hospitalizations are all factors that are related to dysthymia. Given the significant prevalence of dysthymia (including persistent depressive disorder) worldwide, its comorbidity with several mental disorders, and the detrimental effects of these comorbidities, it is important to conduct a systematic review to compare the effects of pharmacological acute and maintenance treatments for dysthymia with placebo and standard care in the last 10 years, based on the publication of DSM5.

AREAS COVERED

This systematic review was performed according to PRISMA guidelines. Databases, including PubMed and Cochrane Central Register of Controlled Trials, were searched to assess the effects of pharmacological acute and maintenance treatments for dysthymia in comparison with placebo and treatment as usual.

EXPERT OPINION

Our review shows that SSRIs and SNRIs present efficacy for dysthymia treatment, and L-Acetylcarnitine should be investigated further for this condition in elderly patients. The comparison of antidepressant medication versus placebo showed coherent results based on three studies favoring pharmacotherapy as an effective treatment for participants with dysthymia. However, the scarcity of research on continuation and maintenance therapy in people with dysthymia highlights the need for more primary research.

Childhood adversities and mental disorders in first-year college students: results from the World Mental Health International College Student Initiative

BACKGROUND

This study investigates associations of several dimensions of childhood adversities (CAs) with lifetime mental disorders, 12-month disorder persistence, and impairment among incoming college students.

METHODS

Data come from the World Mental Health International College Student Initiative (WMH-ICS). Web-based surveys conducted in nine countries (n = 20 427) assessed lifetime and 12-month mental disorders, 12-month role impairment, and seven types of CAs occurring before the age of 18: parental psychopathology, emotional, physical, and sexual abuse, neglect, bullying victimization, and dating violence. Poisson regressions estimated associations using three dimensions of CA exposure: type, number, and frequency.

RESULTS

Overall, 75.8% of students reported exposure to at least one CA. In multivariate regression models, lifetime onset and 12-month mood, anxiety, and substance use disorders were all associated with either the type, number, or frequency of CAs. In contrast, none of these associations was significant when predicting disorder persistence. Of the three CA dimensions examined, only frequency was associated with severe role impairment among students with 12-month disorders. Population-attributable risk simulations suggest that 18.7-57.5% of 12-month disorders and 16.3% of severe role impairment among those with disorders were associated with these CAs.

CONCLUSION

CAs are associated with an elevated risk of onset and impairment among 12-month cases of diverse mental disorders but are not involved in disorder persistence. Future research on the associations of CAs with psychopathology should include fine-grained assessments of CA exposure and attempt to trace out modifiable intervention targets linked to mechanisms of associations with lifetime psychopathology and burden of 12-month mental disorders.

Familial risk for depressive and anxiety disorders: associations with genetic, clinical, and psychosocial vulnerabilities

BACKGROUND

In research and clinical practice, familial risk for depression and anxiety is often constructed as a simple Yes/No dichotomous family history (FH) indicator. However, this measure may not fully capture the liability to these conditions. This study investigated whether a continuous familial loading score (FLS), incorporating family- and disorder-specific characteristics (e.g. family size, prevalence of depression/anxiety), (i) is associated with a polygenic risk score (PRS) for major depression and with clinical/psychosocial vulnerabilities and (ii) still captures variation in clinical/psychosocial vulnerabilities after information on FH has been taken into account.

METHODS

Data came from 1425 participants with lifetime depression and/or anxiety from the Netherlands Study of Depression and Anxiety. The Family Tree Inventory was used to determine FLS/FH indicators for depression and/or anxiety.

RESULTS

Persons with higher FLS had higher PRS for major depression, more severe depression and anxiety symptoms, higher disease burden, younger age of onset, and more neuroticism, rumination, and childhood trauma. Among these variables, FH was not associated with PRS, severity of symptoms, and neuroticism. After regression out the effect of FH from the FLS, the resulting residualized measure of FLS was still associated with severity of symptoms of depression and anxiety, rumination, and childhood trauma.

CONCLUSIONS

Familial risk for depression and anxiety deserves clinical attention due to its associated genetic vulnerability and more unfavorable disease profile, and seems to be better captured by a continuous score that incorporates family- and disorder-specific characteristics than by a dichotomous FH measure.

The 9-year clinical course of depressive and anxiety disorders: New NESDA findings

BACKGROUND

In longitudinal research, switching between diagnoses should be considered when examining patients with depression and anxiety. We investigated course trajectories of affective disorders over a nine-year period, comparing a categorical approach using diagnoses to a dimensional approach using symptom severity.

METHOD

Patients with a current depressive and/or anxiety disorder at baseline (N = 1701) were selected from the Netherlands Study of Depression and Anxiety (NESDA). Using psychiatric diagnoses, we described 'consistently recovered,' 'intermittently recovered,' 'intermittently recurrent', and 'consistently chronic' at two-, four-, six-, and nine-year follow-up. Additionally, latent class growth analysis (LCGA) using depressive, anxiety, fear, and worry symptom severity scores was used to identify distinct classes.

RESULTS

Considering the categorical approach, 8.5% were chronic, 32.9% were intermittently recurrent, 37.6% were intermittently recovered, and 21.0% remained consistently recovered from any affective disorder at nine-year follow-up. In the dimensional approach, 66.6% were chronic, 25.9% showed partial recovery, and 7.6% had recovered.

LIMITATIONS

30.6% of patients were lost to follow-up. Diagnoses were rated by the interviewer and questionnaires were completed by the participant.

CONCLUSIONS

Using diagnoses alone as discrete categories to describe clinical course fails to fully capture the persistence of affective symptoms that were observed when using a dimensional approach. The enduring, fluctuating presence of subthreshold affective symptoms likely predisposes patients to frequent relapse. The commonness of subthreshold symptoms and their adverse impact on long-term prognoses deserve continuous clinical attention in mental health care as well further research.

Parent- and child-reported anxiety disorders differentiating major depressive disorder and dysthymic disorder in children and adolescents

OBJECTIVE

To date, specific parent- and child-defined anxiety disorders associated with dysthymic disorder (DD; DSM-5 persistent depressive disorder equivalent) with and without major depressive disorder (MDD) have not been investigated in children and adolescents.

METHOD

In a cross-sectional study, we compared point prevalence rates of parent- and child-reported anxiety disorders in DD alone (N = 154), MDD alone (N = 29), comorbid DD and MDD (N = 130) and anxiety disorders alone (N = 126) groups.

RESULTS

DD alone and MDD alone did not differ with respect to comorbid anxiety disorders from parent and child reports, while parent-reported panic disorder (PD) was significantly increased in the DD and MDD group compared to the other three groups as was child-reported post-traumatic stress disorder (PTSD) compared to the MDD alone and anxiety disorders alone groups. In contrast, specific phobia (SpPh) was significantly increased in the anxiety disorders alone group compared to the DD and MDD group.

CONCLUSION

The findings suggest that specific fear-related anxiety disorders, especially parent-reported PD and child-reported PTSD, may aid the early recognition of DD and MDD.

Thirty-year outcome of anxiety and depressive disorders and personality status: comprehensive evaluation of mixed symptoms and the general neurotic syndrome in the follow-up of a randomised controlled trial

BACKGROUND

Cohort studies of the long-term outcome of anxiety, depression and personality status rarely join together.

METHODS

Two hundred and ten patients recruited with anxiety and depression to a randomised controlled trial between 1983 and 1987 (Nottingham Study of Neurotic Disorder) were followed up over 30 years. At trial entry personality status was assessed, together with the general neurotic syndrome, a combined diagnosis of mixed anxiety-depression (cothymia) linked to neurotic personality traits. Personality assessment used a procedure allowing conversion of data to the ICD-11 severity classification of personality disorder. After the original trial, seven further assessments were made. Observer and self-ratings of psychopathology and global outcome were also made. The primary outcome at 30 years was the proportion of those with no Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis.Data were analysed using multilevel repeated measures models that adjusted for age and gender. Missing data were assumed to be missing at random, and the models allowed all subjects to be included in the analysis with missing data automatically handled in the model estimation.

RESULTS

At 30 years, 69% of those with a baseline diagnosis of panic disorder had no DSM diagnosis compared to 37-47% of those with generalised anxiety disorder, dysthymia or mixed symptoms (cothymia) (p = 0.027). Apart from those with no personality dysfunction at entry all patients had worse outcomes after 30 years with regard to total psychopathology, anxiety and depression, social function and global outcome.

CONCLUSIONS

The long-term outcome of disorders formerly called 'neurotic' is poor with the exception of panic disorder. Personality dysfunction accentuates poor recovery.

Test-retest & familial concordance of MDD symptoms

Psychopathology research has increasingly sought to study the etiology and treatment of individual symptoms, rather than categorical diagnoses. However, it is unclear whether commonly used measures have adequate psychometric properties for assessing individual symptoms. This study examined the test-retest reliability and familial concordance (an indicator of validity) of the symptoms of Major Depressive Disorder (MDD), a disorder consisting of nine core symptoms, most of which are aggregated (e.g., symptom 7 of the DSM criteria for MDD is worthlessness or guilt). Lifetime MDD symptoms were measured in 504 young adults (237 sibling pairs) using the Structured Clinical Interview for DSM-5 (SCID). Fifty-one people completed a second SCID within three weeks of their first SCID. Results indicated that aggregated and unaggregated symptoms demonstrated moderate to substantial test-retest reliability and generally significant, but slight to fair familial concordance (with the highest familial concordance being for markedly diminished interest or pleasure and its unaggregated components - decreased interest and decreased pleasure). Given the increasing focus on the differential validity of individual MDD symptoms, the present study suggests that interview-based assessments of depression can assess most individual symptoms with adequate levels of reliability and validity.

Treatment of double depression: A meta-analysis

BACKGROUND

Double depression (DD), the co-existence of DSM-IV major depressive disorder (MDD) and dysthymia, is a poorly known and sparsely studied phenomenon. Nevertheless, it is prevalent in clinical samples of patients with depression. Thus, it is important to understand the efficacy of its treatment.

METHODS

We conducted a meta-analysis of studies in which antidepressant medication was used to treat depression. Systematic searches in bibliographical databases resulted in 11 samples, including 775 patients that met inclusion criteria.

RESULTS

The overall effect size indicating the differences in depressive symptoms before and after pharmacotherapy was 1.81 (95% CI: 1.47, 2.16), suggesting that individuals with depression exhibited a significant reduction in their depressive symptoms following treatment. Importantly, a moderation analysis indicated that a higher proportion of individuals with DD within a sample was associated with lower effect sizes. Publication bias did not pose a major threat to the stability of the findings.

LIMITATIONS

High observed heterogeneity indicated substantial variability in effect sizes and elucidation of the potential moderators of treatment outcome was limited due to a paucity of relevant data.

CONCLUSIONS

Pharmacotherapy seems to be effective in treating DD, but DD may be more difficult to treat than either MDD or dysthymia alone. More research specifically focusing on the treatment of DD with larger sample sizes using randomized control trials is needed to make a firm conclusion.

Maladaptive Personality Traits and 10-Year Course of Psychiatric and Medical Symptoms and Functional Impairment Following Trauma

Background

Personality is a major predictor of many mental and physical disorders, but its contributions to illness course are understudied.

Purpose

The current study aimed to explore whether personality is associated with a course of psychiatric and medical illness over 10 years following trauma.

Methods

World Trade Center (WTC) responders (N = 532) completed the personality inventory for DSM-5, which measures both broad domains and narrow facets. Responders' mental and physical health was assessed in the decade following the WTC disaster during annual monitoring visits at a WTC Health Program clinic. Multilevel modeling was used in an exploratory manner to chart the course of health and functioning, and examine associations of maladaptive personality domains and facets with intercepts (initial illness) and slopes (course) of illness trajectories.

Results

Three maladaptive personality domains-negative affectivity, detachment and psychoticism-were uniquely associated with initial posttraumatic stress disorder (PTSD); detachment and psychoticism were also associated with initial functional impairment. Five facets-emotional lability, anhedonia, callousness, distractibility and perceptual dysregulation-were uniquely associated with initial mental and physical health and functional impairment. Anxiousness and depressivity facets were associated with worse initial levels of psychiatric outcomes only. With regard to illness trajectory, callousness and perceptual dysregulation were associated with the increase in PTSD symptoms. Anxiousness was associated with greater persistence of respiratory symptoms.

Conclusions

Several personality domains and facets were associated with initial levels and long-term course of illness and functional impairment in a traumatized population. Results inform the role of maladaptive personality in the development and maintenance of chronic mental-physical comorbidity. Personality might constitute a transdiagnostic prognostic and treatment target.

The Existential Model of Perfectionism and Depressive Symptoms: Tests of Unique Contributions and Mediating Mechanisms in a Sample of Depressed Individuals

The Existential Model of Perfectionism and Depressive Symptoms (EMPDS) is a promising integrative model. According to the EMPDS, self-oriented perfectionism and socially prescribed perfectionism indirectly influence depressive symptoms through rumination and difficulty accepting the past. Yet, the extent to which self-oriented perfectionism, socially prescribed perfectionism, rumination, and difficulty accepting the past uniquely and collectively influence depressive symptoms is unestablished. Likewise, supporting evidence derives from relatively healthy university students, rendering the generalizability of the EMPDS to more distressed individuals unclear. Our study addressed these important limitations. Data were obtained from 393 depressed individuals. Congruent with the EMPDS, bias-corrected bootstrapped tests of mediation indicated that socially prescribed perfectionism indirectly predicted depressive symptoms through rumination and difficulty accepting the past. In contrast, self-oriented perfectionism indirectly predicted depressive symptoms through rumination, but not difficulty accepting the past. Overall, the current findings highlight similarities and differences between trait perfectionism dimensions in mechanisms that link them with depression.

Persistent depressive disorder has long-term negative impacts on depression, anxiety, and somatic symptoms at 10-year follow-up among patients with major depressive disorder

OBJECTIVE

The study aimed to investigate the impacts of persistent depressive disorder (PDD) and pharmacotherapy on depression, anxiety, and somatic symptoms among patients with major depressive disorder (MDD) over a ten-year period.

METHODS

290 outpatients with MDD were enrolled, including 117 with PDD, at baseline. Subjects were followed-up at six-month, two-year, and 10-year points. MDD and dysthymic disorder were diagnosed using the Structured Clinical Interview for DSM-IV-TR. The Hamilton Depression Rating Scale, the Hospital Anxiety and Depression Scale, and the Depression and Somatic Symptoms Scale were used. Generalized Estimating Equation models were used to investigate the impacts.

RESULTS

MDD patients with PDD had greater severities of depression, anxiety, and somatic symptoms at the three follow-up points as compared with those without; however, these results were of statistical significance only in patients without pharmacotherapy. MDD patients with PDD had a longer duration of pharmacotherapy and a lower remission rate as compared with those without. After controlling for depression and anxiety at baseline, PDD was independently associated with more severe depression, anxiety, and somatic symptoms.

LIMITATION

At the ten-year follow-up, approximately half of the subjects were lost to follow-up; this, in addition to the unequal follow-up intervals, might have caused bias.

CONCLUSIONS

Among the patients, PDD continued to have negative impacts on depression, anxiety, and somatic symptoms over the subsequent ten years. Differences in symptomatology between the patients with and without PDD were statistically insignificant when pharmacotherapy was utilized; however, pharmacotherapy did not fully compensate for the negative impacts of PDD.

Cognitive Behavioral Analysis System of Psychotherapy as group psychotherapy for chronically depressed inpatients: a naturalistic multicenter feasibility trial

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a relatively new approach in the treatment of chronic depression (CD). Adapted as group psychotherapy for inpatients, CBASP is attracting increasing attention. In this naturalistic multicenter trial, we investigated its feasibility after 10 sessions of CBASP group therapy over a treatment time of at least 5 to a maximum of 10 weeks. Treatment outcome was additionally assessed. Across four centers, 116 inpatients with CD (DSM-IV-TR) attended CBASP group psychotherapy. Feasibility was focused on acceptance, and evaluated for patients and therapists after five (t1) and ten sessions (t2) of group psychotherapy. Observer- and self-rating scales (Hamilton Depression Rating Scale-24 items, HDRS₂₄; Beck Depression Inventory-II, BDI-II; World Health Organization Quality of Life assessment, WHOQOL-BREF) were applied before group psychotherapy (t0) and at t2. Dropouts were low (10.3%). Patients' evaluation improved significantly from t1 to t2 with a medium effect size (d = 0.60). Most of the patients stated that the group had enriched their treatment (75.3%), that the size (74.3%) and duration (72.5%) were 'optimal' and 37.3% wished for a higher frequency. Patients gave CBASP group psychotherapy an overall grade of 2 ('good'). Therapists' evaluation was positive throughout, except for size of the group. Outcome scores of HDRS₂₄, BDI-II, and WHOQOL-BREF were significantly reduced from t0 to t2 with medium to large effect sizes (d = 1.48; d = 1.11; d = 0.67). In this naturalistic open-label trial, CBASP, when applied as inpatient group psychotherapy, was well accepted by patients and therapists. The results point towards a clinically meaningful effect of inpatient treatment with CBASP group psychotherapy on depression and quality of life. Other potential factors that could have promoted symptom change were discussed. A future controlled study could investigate the safety and efficacy of CBASP group psychotherapy for inpatients.

Symptomatic and Functional Recovery From Major Depressive Disorder in the Ibadan Study of Ageing

OBJECTIVES

Very little is known about the association between symptomatic and functional recovery from late-life major depressive disorder (MDD) in sub-Saharan Africa. We investigated factors associated with sustained symptomatic remission (SR) from MDD and the 5-year trajectory of post-MDD physical functioning.

DESIGN

5-year prospective study with three follow-up waves in 2007, 2008, and 2009.

SETTING/PARTICIPANTS

Household multistage probability sample of 2,149 Nigerians who were aged 65 years or older.

MEASUREMENTS

Activities of Daily Living (ADL) and MDD were assessed using the Kadz index and Composite International Diagnostic Interview, respectively. We studied those with current MDD (prevalent in 2003-2004 or incident in 2007), and who achieved SR in subsequent waves compared with a chronic/recurrent course (CR).

RESULTS

Baseline demographic characteristics, health, and lifestyle factors were not associated with SR in logistic regression analyses. In mixed-effect linear regression models adjusting for age, sex, and socioeconomic status, ADL worsened in SR (β = 1.0, 95% CI: 0.2, 1.8), but more so in CR (β = 2.3, 95% CI: 1.6, 3.0). Poorer ADL at follow-up was predicted by age (β = 2.9, 95% CI: 1.8, 4.0) and economic status (β = 1.4, 95% CI: 0.3, 2.4).

CONCLUSIONS

There was a deteriorating course of disability despite symptomatic recovery from late-life MDD in this sample. This finding has implications for policy and guidelines for the management of late-life depression and disability.

Treatment course and its predictors in patients with somatoform disorders: A routine outcome monitoring study in secondary psychiatric care

AIM

Somatoform disorders are common and often chronic. It would be helpful to distinguish those patients who are likely to have a positive treatment course from those who are likely to follow a negative course. Such studies of different somatoform disorders are scarce, especially in secondary psychiatric care. This study examined the 6-month treatment course of psychological, physical symptoms, and functioning, and its predictors in a naturalistic sample of secondary psychiatric care outpatients with somatoform disorders.

METHOD

The present study used routine outcome monitoring data of patients with somatoform disorders regarding their 6-month treatment course of psychological and physical symptoms as well as functioning. The following patient groups were included: total group of somatoform disorders (N = 435), and undifferentiated somatoform disorder (N = 242), pain disorder (N = 102), body dysmorphic disorder (N = 51), and hypochondriasis (N = 40). Measures were Mini-International Neuropsychiatric Interview plus, Brief Symptom Inventory, Montgomery-Ǻsberg Depression Rating Scale, Brief Anxiety Scale, Short Form Health Survey 36, and Physical Symptom Checklist (PSC).

RESULTS

The study population generally showed high co-morbidity, especially with anxiety and mood disorders. The PSC total score, body dysmorphic disorder, and hypochondriasis were significant predictors for the treatment course of symptoms (Brief Symptom Inventory), whereas the PSC total score was the only significant predictor for the course of functioning (Short Form Health Survey 36).

CONCLUSION

Secondary psychiatric care outpatients with somatoform disorders showed high co-morbidity with anxiety and mood disorders, and an unfavourable 6-month course of both symptoms and functioning. Clinical implications are discussed, such as additional treatment of co-morbidity in somatoform disorders.

The effects of optimism, religion, and hope on mood and anxiety disorders in women with the FMR1 premutation

BACKGROUND

The FMR1 premutation, caused by a CGG trinucleotide repeat expansion on the FMR1 gene, has been identified as a genetic risk factor for mood and anxiety disorders. Building on recent studies identifying increased risk for mood and affective disorders in this population, we examined effects of potential protective factors (optimism, religion, hope) on depression and anxiety diagnoses in a prospective, longitudinal cohort.

METHODS

Eighty-three women with the FMR1 premutation participated in the Structured Clinical Interview for DSM-IV-TR Disorders at two-time points, 3 years apart. Participants also completed measures of optimism, religion, personal faith, hope, and child and family characteristics. We used logistic regression to examine correlates of major depressive disorder (MDD) and anxiety disorders at the initial assessment, as well as predictors of the diagnostic course over time.

RESULTS

Lower optimism and higher religious participation relevant to fragile X syndrome at the initial assessment were associated with a lifetime history of MDD. Lower optimism also predicted the occurrence and reoccurrence of an anxiety disorder 3 years later.

CONCLUSIONS

In women with the FMR1 premutation, elevated optimism may reduce the occurrence or severity of MDD and anxiety disorders. These findings underscore the importance of supporting mental health across the FMR1 spectrum of involvement.

Polyunsaturated fatty acid composition and childhood adversity: Independent correlates of depressive symptom persistence

Childhood experiences, personality, and polyunsaturated essential fatty acid (PUFA) composition have all been shown to affect the likelihood of depressive symptoms. Few studies have addressed relationships between these factors in their influence on the occurrence or course of depressive symptoms. The following analysis was designed to do so. Subjects, 15-20 years old, had either begun antidepressant treatment within the preceding month (n = 88), or had never taken psychiatric medications (n = 92). Baseline assessments included a structured diagnostic interview, the self-completed Multiphasic Personality Questionnaire, and a determination of plasma PUFA phospholipid composition. Depressive symptom levels were assessed at baseline and again at 4, 8 and 12 months. Omega-3 composition and general childhood trauma scores were unrelated to each other but both correlated, in predicted directions, with negative emotionality. Low omega-3 composition and history of childhood trauma were associated with persistence of depressive symptoms during follow-up, largely through their effects on negative emotionality. Negative emotionality appears to comprise a final common pathway to depressive disorder through which the diverse risk factors of childhood adversity and low omega-3 composition are expressed.

Using patient self-reports to study heterogeneity of treatment effects in major depressive disorder

BACKGROUNDS

Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful.

METHOD

We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments.

RESULTS

Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials.

CONCLUSIONS

Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.

Testing a machine-learning algorithm to predict the persistence and severity of major depressive disorder from baseline self-reports

Heterogeneity of major depressive disorder (MDD) illness course complicates clinical decision-making. Although efforts to use symptom profiles or biomarkers to develop clinically useful prognostic subtypes have had limited success, a recent report showed that machine-learning (ML) models developed from self-reports about incident episode characteristics and comorbidities among respondents with lifetime MDD in the World Health Organization World Mental Health (WMH) Surveys predicted MDD persistence, chronicity and severity with good accuracy. We report results of model validation in an independent prospective national household sample of 1056 respondents with lifetime MDD at baseline. The WMH ML models were applied to these baseline data to generate predicted outcome scores that were compared with observed scores assessed 10-12 years after baseline. ML model prediction accuracy was also compared with that of conventional logistic regression models. Area under the receiver operating characteristic curve based on ML (0.63 for high chronicity and 0.71-0.76 for the other prospective outcomes) was consistently higher than for the logistic models (0.62-0.70) despite the latter models including more predictors. A total of 34.6-38.1% of respondents with subsequent high persistence chronicity and 40.8-55.8% with the severity indicators were in the top 20% of the baseline ML-predicted risk distribution, while only 0.9% of respondents with subsequent hospitalizations and 1.5% with suicide attempts were in the lowest 20% of the ML-predicted risk distribution. These results confirm that clinically useful MDD risk-stratification models can be generated from baseline patient self-reports and that ML methods improve on conventional methods in developing such models.

The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials

BACKGROUND

Chronic depression is a severe and disabling condition. Compared to an episodic course, chronic depression has been shown to be less responsive to psychopharmacological and psychological treatments. The cognitive behavioral analysis system of psychotherapy (CBASP) has been developed as a specific psychotherapy for chronic depression. However, conflicting results concerning its efficacy have been reported in randomized-controlled trials (RCT). Therefore, we aimed at examining the efficacy of CBASP using meta-analytical methods.

METHODS

Randomized-controlled trials assessing the efficacy of CBASP in chronic depression were identified by searching electronic databases (PsycINFO, PubMed, Scopus, Cochrane Central Register of Controlled Trials) and by manual searches (citation search, contacting experts). Searching period was restricted from the first available entry to October 2015. Identified studies were systematically reviewed. The standardized mean difference Hedges' g was calculated from posttreatment and mean change scores. The random-effects model was used to compute combined overall effect sizes. A risk of publication bias was addressed using fail-safe N calculations and trim-and-fill analysis.

RESULTS

Six studies comprising 1.510 patients met our inclusion criteria. The combined overall effect sizes of CBASP versus other treatments or treatment as usual (TAU) pointed to a significant effect of small magnitude (g = 0.34-0.44, P < 0.01). In particular, CBASP revealed moderate-to-high effect sizes when compared to TAU and interpersonal psychotherapy (g = 0.64-0.75, P < 0.05), and showed similar effects when compared to antidepressant medication (ADM) (g = -0.29 to 0.02, ns). The combination of CBASP and ADM yielded benefits over antidepressant monotherapy (g = 0.49-0.59, P < 0.05).

LIMITATIONS

The small number of included studies, a certain degree of heterogeneity among the study designs and comparison conditions, and insufficient data evaluating long-term effects of CBASP restrict generalizability yet.

CONCLUSIONS

We conclude that there is supporting evidence that CBASP is effective in the treatment of chronic depression.

Depressive disorders and comorbidities among the elderly: a population-based study

Objective The present study assessed the prevalence of depressive disorders and associated factors in a sample of elderly persons in the south of Santa Catarina. Methods A cross-sectional study based on population data was performed, evaluating 1021 elderly individuals aged between 60 and 79 years. Home interviews were carried out using the Portuguese version of the Mini International Neuropsychiatric Interview (MINI), in order to collect demographic data, information on hypertension and reports of acute myocardial infarction. The disorders studied were current depressive episode, dysthymia and a comorbidity of a depressive episode and dysthymia, representing double depression. The comparison of mean age and prevalence was made with the t-test and other associations were analyzed using the Chi-squared test. Results The prevalence of depression was 26.2%, while 5.5% of the sample suffered from dysthymia and 2.7% experienced double depression. Risk factors for depression were: nine or more years of schooling [PR = 1.44 (1.17 to 1.77); p <0.05] and being a current smoker [OR = 1.63 (1.30-2.05); p <0.05]. Dysthymia was associated with the male gender [OR = 6.46 (3.29 to 12.64); p <0.05], reports of hypertension [OR = 2.55 (1.53 to 4.24); p <0.05] and being either a current [OR = 1.86 (1.02 to 3.42); p <0.05] or past or former [OR = 2.89 (1.48 to 5.65); p <0.05] smoker. The same risk factors as for dysthymia were found for double depression: male [OR = 4.21 (1.80 to 9.81); p <0.05], reports of hypertension [OR = 8.11 (3.32 to 19.80); p <0.05], and being either a current [OR = 5.72 (1.64 to 19.93); p <0.05] or past [PR = 13.11 (3.75 to 45.86); p <0.05] smoker. Conclusions The present study shows that depressive disorders are a common phenomenon among the elderly. The results not only corroborated with other studies, but found slightly higher levels of depressive disorders among the elderly population.

Prognosis of depressive disorders in the general population- results from the longitudinal Finnish Health 2011 Study

BACKGROUND

Depressive disorders are among the most pressing public health challenges worldwide. Yet, not enough is known about their long-term outcomes. This study examines the course and predictors of different outcomes of depressive disorders in an eleven-year follow-up of a general population sample.

METHODS

In a nationally representative sample of Finns aged 30 and over (BRIF8901), major depressive disorder (MDD) and dysthymia were diagnosed with the Composite International Diagnostic Interview (M-CIDI) in 2000. The participants were followed up in 2011 (n=5733). Outcome measures were diagnostic status, mortality, depressive symptoms and health-related quality of life. Multiple imputation (MI) was used to account for nonresponse.

RESULTS

At follow-up, 33.8% of persons with baseline MDD and 42.6% with baseline dysthymia received a diagnosis of depressive, anxiety or alcohol use disorder. Baseline severity of disorder, measured by the Beck Depression Inventory, predicted both persistence of depressive disorder and increased mortality risk. In addition, being never-married, separated or widowed predicted persistence of depressive disorders, whereas somatic and psychiatric comorbidity, childhood adversities and lower social capital did not. Those who received no psychiatric diagnosis at follow-up still had residual symptoms and lower quality of life.

LIMITATIONS

We only had one follow-up point at eleven years, and did not collect information on the subjects' health during the follow-up period.

CONCLUSIONS

Depressive disorders in the general population are associated with multiple negative outcomes. Severity of index episode is the strongest predictor of negative outcomes. More emphasis should be placed on addressing the long-term consequences of depression.

Identifying depressive symptom trajectory groups among Korean adults and psychosocial factors as group determinants

BACKGROUND

Longitudinal research is needed to examine the depressive symptom trajectories of different groups during adulthood and their antecedents and consequences, because depressive symptoms may be changeable and heterogeneous over time.

AIMS

This study examined the number of trajectory groups describing the depressive symptoms of Korean adults, as well as the shape of the trajectories and the association between trajectory group membership and psychosocial factors identified based on the ecosystem model.

METHOD

This study used Nagin's semi-parametric group-based modeling to analyze Year 1 to Year 7 data from Korea Welfare Panel Survey (N = 13,735), a nationally representative sample of community-dwelling adults.

RESULTS

Three distinct trajectory groups were identified: a low stable depressive symptoms group, a moderate depressive symptoms group and a high depressive symptoms group. Result from multinominal logit analysis showed that all psychosocial factors except family relationships affected the likelihood of membership in the three depressive symptoms groups. Especially, self-esteem was the psychosocial factor with the largest impact on depressive symptom trajectory group membership. When screening for depressive symptoms, individuals with a low socioeconomic status should be a primary concern and intervention should be made available to them.

CONCLUSION

Prevention or intervention with members of the identified trajectory groups would likely require integrative approaches targeting psychosocial factors across multiple contexts.

Impact of childhood exposure to psychological trauma on the risk of psychiatric disorders and somatic discomfort: single vs. multiple types of psychological trauma

We examined whether childhood exposure to multiple types of potentially traumatic events (PTEs) relative to a single type of PTE is associated with a higher prevalence of psychiatric disorders and greater somatic discomfort in Korean adults. The Composite International Diagnostic Interview 2.1 (K-CIDI 2.1) was administered to 6027 subjects aged 18-74 years. Subjects who experienced a traumatic event before the age of 18 years, the childhood trauma exposure group, were compared with controls without childhood exposure to PTEs. In the childhood trauma exposure group, subjects who experienced only a single type of PTE and subjects who experienced two or more types of PTEs were compared further. Childhood exposure to PTEs was linked to a wide range of psychiatric comorbidities, with a higher risk for exposure to multiple types of PTEs than for exposure to a single type of PTE. Obsessive-compulsive disorder, generalized anxiety disorder, and somatoform disorder were significantly associated with exposure to multiple types of PTEs but not with exposure to a single type of PTE. Exposure to multiple types of PTEs was associated with reports of marked fatigue and pain. Future research should examine the psychiatric sequelae associated with various types of childhood PTEs.

Schema therapy for patients with chronic depression: a single case series study

BACKGROUND AND OBJECTIVES

This study tested the effectiveness of schema therapy (ST) for patients with chronic depression.

METHODS

Twelve patients with a diagnosis of chronic depression participated. The treatment protocol consisted of 60 sessions, with the first 55 sessions offered weekly and the last five sessions on a biweekly basis. A single case series A-B-C design, with 6 months follow-up was used. Baseline (A) was a wait period of 8 weeks. Baseline was followed by introduction to ST and bonding to therapist (phase B) with individually tailored length of 12-16 sessions, after which further ST was provided (phase C) up to 60 sessions (included the sessions given as introduction). Patients were assessed with Hamilton Rating Scale for Depression three times during baseline, at the end of phase B, then every 12 weeks until the end of treatment and at 6 months follow-up. Secondary outcome measures were the Hamilton Rating Scale for Anxiety and the Young Schema Questionnaire.

RESULTS

At the end of treatment 7 patients (approximately 60%) remitted or satisfactorily responded. The mean HRSD dropped from 21.07 during baseline to 9.40 at post-treatment and 10.75 at follow-up. The effects were large and the gains of treatment were maintained at 6-month follow-up. Only one patient dropped out for reasons not related to treatment.

LIMITATIONS

The lack of control group, the small sample and the lack of a multiple baseline case series.

CONCLUSIONS

This preliminary study supports the use of ST as an effective treatment for chronic depression.

Predictors of remission from chronic depression: a prospective study in a nationally representative sample

PURPOSE

The aims of this study were to identify predictors of remission from chronic depression in a prospective longitudinal general population survey; second, to determine the relative level functioning and well-being of those in remission.

METHODS

The sample included respondents who met the criteria for major depressive disorder from Wave 1 (2001-2002) and through Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

Panic Disorder, Generalized Anxiety Disorder, Cluster B personality disorders and a history of Physical Abuse were correlated with reduced likelihood of chronic depression remission. The functioning and well-being of the remitted group was below the norm.

CONCLUSIONS

These prognostic factors are similar to those found in clinical samples. Despite remission from chronic depression, a significant proportion have impairments in functioning.

Personality disorders and outcome of inpatient treatment for depression: a 1-year prospective follow-up study

This study examines the relationship of personality disorders (PDs) with the outcome of an inpatient treatment for depression. One hundred sixty-eight inpatients with unipolar depression (41% with PD according to SCID-II) were assessed at admission, discharge, and 1-year follow-up. Patients without as well as with PD showed a significant and comparable intake-to-discharge symptom reduction in all inventories. At posttreatment, patients with PD scored higher in self-report measures of symptom severity (Brief Symptom Inventory, Beck Depression Inventory) than patients without PD, due to their higher symptom levels at intake. However, there was no difference in clinician-rated therapy outcome (Hamilton Rating Scale for Depression [17-item version], Global Assessment of Functioning Scale, Clinical Global Impression Scale) between both patient groups at discharge. At 1-year follow-up, patients without PD maintained their treatment outcome, whereas patients with PD showed a slight increase in symptom severity, compared to discharge. The results suggest that a difference in acute treatment outcome between depressed patients with and without PD may be found using self-ratings but not expert ratings of symptom severity. Furthermore, the importance of subsequent outpatient treatment that takes into account the special needs of depressed patients with comorbid PD is highlighted.

[Dysthymia in the Clinical Context]

Dysthymia is defined as a chronic mood disorder that persists for at least two years in adults, and one year in adolescents and children. According to DSM IV-TR, Dysthymia is classified into two subtypes: early-onset, when it begins before 21 years-old, and late onset Dysthymia, when it starts after this age. Before age 21, symptoms of conduct disorder, attention deficit disorder and hyperactivity with a few vegetative symptoms are usually present. It is important to distinguish it from other types of depression, as earlier as possible. This would allow providing these patients with the appropriate treatment to attenuate the impact of symptoms, such as poor awareness of self-mood, negative thinking, low self-esteem, and low energy for social and family activities, which progressively deteriorate their life quality. The etiology of Dysthymia is complex and multifactorial, given the various biological, psychological and social factors involved. Several hypotheses attempt to explain the etiology of Dysthymia, highlighting the genetic hypothesis, which also includes environmental factors, and an aminergic hypothesis suggesting a deficiency in serotonin, norepinephrine and dopamine in the central nervous system. From our point of view, dysthymia cannot be conceived as a simple mild depressive disorder. It is a distinct entity, characterized by a chronic depressive disorder which could persist throughout life, with important repercussions on the life quality of both patients and families.

Parameters of education and the course of depression: an analysis in the Turkish sociocultural context

BACKGROUND

Major depression (MD) is often marked by an unfavourable course. Education repeatedly was found to be associated with better mental health variables, but longitudinal data are scarce. This evaluation seeks to identify the predictive role of specific aspects of education on the course of depression in a socioculturally defined setting.

METHODS

A sample of 69 unipolar MD outpatients in university and primary health care in Antalya, Turkey were observed naturalistically for a mean 11-month period. The baseline examination included several psychosocial variables, among them the highest attained schooling degree (DEG), possible further but unfulfilled educational aspirations (UEA), and the participants' parental educational level (PEL). The depressive symptomatology was assessed with the HAM-D-17 at baseline and at four-monthly follow-ups. A binary variable differentiated 'non-remissive' from 'remissive' courses, the latter displaying at least temporal partial remissions.

RESULTS

Forty-two per cent of the sample displayed a non-remissive one-year course of MD. Half of the participants reported UEA. This was more prevalent among women, and qualitative information added causal gender-specific perceptions. In logistic regression, DEG proved prognostic impact, but was exceeded by the combination of UEA and PEL as the strongest predictor model (Cox & Snell R(2) = 0.217). This remained when controlled for place of examination, gender and initial severity of depression. As risk factors for low education, a pattern of female gender and large family size (itself predicted by rural descent) emerged.

CONCLUSIONS

Low education proved to be a risk factor for an unfavourable course of MD. Not only actual experienced schooling, but also unfulfilled academic aspirations and a low parental educational level appear to be of crucial impact.

A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care

BACKGROUND

Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care.

METHODS

789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months.

RESULTS

Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables.

LIMITATIONS

Adult only cohort, self-report measures.

CONCLUSIONS

Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.

The Neural Effects of Psychotropic Medications in Children and Adolescents

Little is known about the neurobiological effects of psychotropic medications used in the treatment of children and adolescents diagnosed with a psychiatric disorder. This review provides a synopsis of the literature demonstrating the neural effects associated with exposure to psychotropic medication in youth using multimodal neuroimaging. The article concludes by illustrating how, taken together, these studies suggest that pharmacological interventions during childhood do indeed affect brain structure and function in a detectable manner, and the effects appear to be ameliorative.

Multiple trajectories of depressive symptoms in middle and late life: racial/ethnic variations

This research aims to identify distinct courses of depressive symptoms among middle-aged and older Americans and to ascertain how these courses vary by race/ethnicity. Data came from the 1995-2006 Health and Retirement Study which involved a national sample of 17,196 Americans over 50 years of age with up to six repeated observations. Depressive symptoms were measured by an abbreviated version of the Center for Epidemiologic Studies Depression scale. Semiparametric group based mixture models (Proc Traj) were used for data analysis. Six major trajectories were identified: (a) minimal depressive symptoms (15.9%), (b) low depressive symptoms (36.3%), (c) moderate and stable depressive symptoms (29.2%), (d) high but decreasing depressive symptoms (6.6%), (e) moderate but increasing depressive symptoms (8.3%), and (f) persistently high depressive symptoms (3.6%). Adjustment of time-varying covariates (e.g., income and health conditions) resulted in a similar set of distinct trajectories. Relative to White Americans, Black and Hispanic Americans were significantly more likely to be in trajectories of more elevated depressive symptoms. In addition, they were more likely to experience increasing and decreasing depressive symptoms. Racial and ethnic variations in trajectory groups were partially mediated by SES, marital status, and health conditions, particularly when both interpersonal and intrapersonal differences in these variables were taken into account.

Diverse Patterns in the Development of Depressive Symptoms Among Emerging Adults

This article examines depressive symptoms over a 4-year period in a racially diverse community sample of 1,143 18- to 22-year-old emerging adults using latent growth and mixture modeling and data collected at three time points. Participants were high school seniors randomly chosen from nine public schools in a metropolitan region in the Northeastern United States. Mixture analyses yielded four distinct groups: one large group with low, stable rates of depression, a smaller group who began with higher levels of depression that then declined steeply, a group who began with moderate levels that steeply increased, and a small group with high stable rates of depressive symptoms. We examined risks for depressive symptoms including poverty status, African American race, Hispanic ethnicity, gender, and trauma history, controlling for socioeconomic status (SES) as represented by maternal education. Some risks predicted membership in more than one symptom group, lending support to the idea that emerging adulthood is a period of diverse outcomes, in which previous circumstances may predict to multiple pathways, and established risk factors do not always lead to poor outcomes.

The effect of pre- vs. post-reward attainment on EEG asymmetry in melancholic depression

Clinical investigators have long theorized about the role of reward processing and positive affect in depression. One theory posits that compared to nonmelancholic depressives, melancholic depressives experience less consummatory (i.e., post-reward), but comparably low anticipatory (prior to reward), positive affect. We tested whether frontal EEG asymmetry, a putative marker of the anticipatory reward system, is present only before an individual receives a reward or also after receiving a reward (i.e., during consummatory reward processing). We also examined whether melancholic depression, a condition characterized by a deficit in consummatory reward processing, is associated with abnormal EEG asymmetries in alpha band power. Effects in other frequency bands (delta, theta, or beta) were also explored. EEG was recorded in 34 controls, 48 nonmelancholic depressives, and 17 melancholic depressives during a slot machine task designed to elicit anticipatory and consummatory reward processing. Results indicated that, for alpha, the frontal EEG asymmetry of greater relative left activity was specific to anticipatory reward processing. During the consummatory phase, individuals with melancholic depression exhibited different posterior EEG asymmetries than individuals with nonmelancholic depression (and controls at a trend level). This second finding was largely due to melancholics exhibiting relatively lower right posterior activity and nonmelancholics exhibiting relatively lower left activity. These results suggest that a posterior asymmetry may be a marker for melancholic depression and aberrant consummatory reward processing.

Impairment in psychosocial functioning associated with dysthymic disorder in the NESARC study

BACKGROUND

Chronic depression is associated with impaired functioning. The National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) is a representative sample (N=43,093) of the United States non-institutionalized population aged 18years and older. We hypothesized that individuals with chronic low-grade depression, dysthymic disorder, would have more impaired functioning than individuals with acute major depression or the general population.

METHOD

Diagnoses were generated by the NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The dysthymic disorder (DD) sample (N=328) consisted of DD diagnosis without current MDD. The dysthymic group was not chosen on the basis of alcohol use or abuse. Individuals with MDD with duration ≦24months, without lifetime DD constituted the acute depression (AD) sample (N=712). All other respondents were classified as general population (GP) (N=42,052). Past year functioning was assessed by Supplemental Social Security Income (SSI), employment, and Medicaid statuses. Past month functioning was assessed by Short-form 12-Item Health Survey (SF-12), with scores for social functioning, role emotional functioning, and mental health, using odds ratios.

RESULTS

Over the past year, compared to AD, persons with DD were less likely to work full-time (36.2% vs. 44%; OR=0.70, CI=.54,.92) and more often received SSI (13.9% vs. 4.5%; OR=3.4, CI=2.0,5.9) and Medicaid (20.2% vs. 13%; OR=1.7 , CI=1.1,2.6). Dysthymics reported accomplishing less over the past month due to emotional problems, and that emotional or physical problems interfered with social activities. Relative to GP, respondents with DD were more likely to receive SSI (13.9% vs. 2.9%; OR=4.6, CI 3.4,6.2) and Medicaid (20.2% vs. 5.9%; OR=2.9, CI 2.0,4.1). Compared to GP, dysthymics reported accomplishing less due to emotional problems, and that emotional or physical problems interfered with social activities and work functioning.

CONCLUSIONS

DD-associated psychosocial impairment in the community setting comprises a significant public health burden.

The epidemiology of chronic major depressive disorder and dysthymic disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To examine the prevalence of chronic major depressive disorder (CMDD) and dysthymic disorder, their sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization.

METHOD

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalences were greater for CMDD (1.5% and 3.1%, respectively) than for dysthymic disorder (0.5% and 0.9%, respectively). Individuals with CMDD and dysthymic disorder shared most sociodemographic correlates and lifetime risk factors for major depressive disorder. Individuals with CMDD and dysthymic disorder had almost identically high rates of Axis I and Axis II comorbid disorders. However, individuals with CMDD received higher rates of all treatment modalities than individuals with dysthymic disorder.

CONCLUSIONS

Individuals with CMDD and dysthymic disorder share many sociodemographic correlates, comorbidity patterns, risk factors, and course. Individuals with chronic depressive disorders, especially those with dysthymic disorder, continue to face substantial unmet treatment needs.

Ethnic differences in the dynamics of depressive symptoms in middle-aged and older Americans

OBJECTIVE

This study examined differences in the trajectory of depressive symptoms between Hispanic, Black, and White Americans in middle and old age.

METHOD

Data came from a national sample of Americans with up to 6 repeated assessments spanning 11 years. Hierarchical linear models with time-varying covariates were used.

RESULTS

Hispanics started with the worst depressive symptomatology, followed by Black Americans, whereas White Americans had the fewest symptoms. These differences, however, diminished over time. More importantly, net of socioeconomic and health differentials, the depressive symptoms trajectory did not differ between Blacks and Whites, whereas Hispanics still started with worse symptoms and had a greater rate of reduction in symptomatology compared to Whites.

DISCUSSION

Significant ethnic differences exist in both the intercept and rate of change in depressive symptoms in middle-aged and older Americans. These variations are substantially confounded by socioeconomic and health differentials.

Adolescents with depressive symptoms and their challenges with learning in school

We examine school performance among 83 adolescents at risk for major depression. Negative mood interfered with subjective measures of school performance, including ability to do well in school, homework completion, concentrate in class, interact with peers, and going to class. No significant relationships were found for mood and objective measures of school performance (school attendance, English, and Math grades). Students with a college-educated parent had stronger performance in objective measures (school attendance and Math grades), whereas males had lower English grades. In qualitative interviews, adolescents reported that negative thinking led to procrastination, which led to poor school performance, which led to more negative thinking. Adolescents with depressive symptoms that do not meet the threshold for referral report struggles in school. Understanding the specific challenges faced by adolescents with even low levels of depressive symptoms can help school nurses, teachers, and parents identify appropriate interventions to help adolescents succeed in school.

Trajectories of recovery of social and physical functioning in major depression, dysthymic disorder and double depression: a 3-year follow-up

BACKGROUND

Depressive disorders have a large impact on psychosocial functioning. Since lower functioning predicts recurrence of a depressive episode, insight into the post-morbid course of psychosocial functioning of persons with different depressive disorders may facilitate recurrence prevention.

METHODS

Data were derived from NEMESIS, an epidemiologic survey in the adult population in the Netherlands. Respondents, who met the CIDI criteria of major depression (MDD; n=102), dysthymic disorder (Dysth; n=66) or double depression (DD; n=73) at baseline, and recovered during three year follow-up, were included; as was a control group without any diagnosis (NoDiag, n=4140). Functioning was assessed using the Groningen Social Disability Schedule (GSDS) and the SF-36 physical health summary-scale. Linear Mixed Models were conducted to compare 3-year trajectories of functioning across depressive groups and with NoDiag group.

RESULTS

Compared to NoDiag, all depressed groups were significantly impaired on social and physical functioning. Dysth and DD had a lower level of post-morbid physical functioning compared to MDD (after 1 and 3 years respectively: Dysth: B=-13.8, p=.002 and B=-8.11, p=.09; DD: B=-8.9, p=.03 and B=-9.1, p=.05). Determinants for impaired social functioning (neuroticism) and for impaired physical functioning (age, comorbid somatic disorders and neuroticism) were identified.

LIMITATIONS

Attrition was higher among persons with a depression. Inclusion of the drop-outs would most likely have resulted in stronger associations, since we expect lower functioning among the drop-outs.

CONCLUSION

This study indicates the long-term debilitating effects of psychopathology, even after recovery of depressive disorders. Duration of the index symptoms appears to be associated with impaired functioning, since especially those with Dysthymia (either with or without a MDD) showed slower and less recovery of functioning.

Maternal deprivation induces depressive-like behaviours only in female rats

Maternal deprivation (MD) has been developed to study the effects of early adverse experiences on behaviour and neurobiology. It has been proposed to represent a potential animal model of major depression. The purpose of our study was to examine the responses induced by MD in male and female adult Long-Evans rats in tasks designed to explore depressive-like behaviours (forced swimming test (FST), repeated open space swim test (OSST), sucrose solution consumption) and in the novel object recognition and object location tasks. A consistent sexual dimorphism was observed in the responses of male and female rats that underwent MD. In male rats, MD led to increased transitions between behaviours in the FST and increased consumption and preference for sucrose (1%) in comparison with non-deprived rats. In female rats, MD induced a decreased swimming activity on the second day of the OSST and reduced the cognitive performance in an object location task. In both sexes, MD did not alter the swimming activity in the FST and the performance in a novel object recognition task. These divergent responses in male and female rats can be related to the gender differences which exist in depression. However, due to the low amplitude of responses obtained in our study, the MD model in Long-Evans rats does not seem to mimic symptoms of major depression. In contrast, our present results suggest the use of the MD model, especially in females, as a model of the dysthymia, a mild chronic-depressive condition, which has been related to poorer maternal relationship.

Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) III: associations with functional impairment related to DSM-IV disorders

BACKGROUND

Despite evidence that childhood adversities (CAs) are associated with increased risk of mental disorders, little is known about their associations with disorder-related impairment. We report the associations between CAs and functional impairment associated with 12-month DSM-IV disorders in a national sample.

METHOD

We used data from the US National Comorbidity Survey Replication (NCS-R). Respondents completed diagnostic interviews that assessed 12-month DSM-IV disorder prevalence and impairment. Associations of 12 retrospectively reported CAs with impairment among cases (n=2242) were assessed using multiple regression analysis. Impairment measures included a dichotomous measure of classification in the severe range of impairment on the Sheehan Disability Scale (SDS) and a measure of self-reported number of days out of role due to emotional problems in the past 12 months.

RESULTS

CAs were positively and significantly associated with impairment. Predictive effects of CAs on the SDS were particularly pronounced for anxiety disorders and were significant in predicting increased days out of role associated with mood, anxiety and disruptive behavior disorders. Predictive effects persisted throughout the life course and were not accounted for by disorder co-morbidity. CAs associated with maladaptive family functioning (MFF; parental mental illness, substance disorder, criminality, family violence, abuse, neglect) were more consistently associated with impairment than other CAs. The joint effects of co-morbid MFF CAs were significantly subadditive. Simulations suggest that CAs account for 19.6% of severely impairing disorders and 17.4% of days out of role.

CONCLUSIONS

CAs predict greater disorder-related impairment, highlighting the ongoing clinical significance of CAs at every stage of the life course.

A systematic review of long-term studies of drug treated and non-drug treated depression

BACKGROUND

The evidence base for long term antidepressant pharmacotherapy is limited. This review describes long-term outcomes of antidepressant-treated depression during the modern pharmacological era (post-1988).

METHODS

Review of Medline, PsycInfo, EMBASE, and the Cochrane Library using keywords and controlled vocabulary terms for long-term outcome studies (10 years or more) of antidepressant-treated cohorts (with at least 1 follow-up assessment post 1988) and non-drug treated cohorts (no time frame). Manual search of references of included articles.

RESULTS

Searches resulted in 24 publications on 12 naturalistic studies of antidepressant-treated cohorts (n=3901 at final follow-up). Most participants were White females with one inpatient stay. Recurrence of depression ranged from 40% to 85%. About one-quarter of individuals achieved a rating of well or improved, as many as experienced systematically poor outcomes. Frequency, duration, and severity of episodes varied substantially. Functional and social outcomes were infrequently measured. Few studies adequately assessed treatments. Outcomes for 3 non-drug treated samples with 1160 patients were no worse than outcomes achieved in antidepressant-treated cohorts.

LIMITATIONS

Heterogeneity of study designs and outcome definitions, and crude measures of pharmacotherapy precluded a statistical analysis.

CONCLUSIONS

Long-term outcomes in depression appear generally poor. No clear relationship emerged between drug treatment and positive outcomes. A lack of evidence from these long-term naturalistic studies of depression precludes any recommendation for maintenance antidepressant pharmacotherapy. Given its public health significance, more data is needed to address this area.

Does personality disorder decrease the likelihood of remission in early-onset chronic depression?

BACKGROUND

The impact of personality disorders (PD) on the course of depression has been gaining interest among clinical researchers over the past decade. Recent observational studies have found that PD was associated with impaired social functioning and reduced likelihood of depression recovery. Elevated rates of PD have been noted in early-onset and chronic forms subtypes of depression. However, scant data exist regarding the link between PD and outcome for this depression subtype.

METHODS

The National Epidemiological Survey on Alcohol and Related Conditions database was analyzed. This survey included 43 093 respondents, 18 years and older, conducted in 2001 through 2002. Logistic regression was used to identify demographic and clinical predictors of remission in early-onset chronic depression.

RESULTS

The absence of PD, having more years of education, and being married considerably improved the likelihood of remission. Paranoid personality disorder and obsessive-compulsive disorder were the only specific PD found to be associated with a reduced probability of remission.

LIMITATIONS

Depression remission status may have biased the recollection of PD symptoms. Borderline personality disorder, narcissistic personality disorder, and schizotypal personality disorder were not assessed.

CONCLUSIONS

This study suggests that PD are significant predictors of remission in early-onset chronic depression.

Three-year follow-up of syndromal antisocial behavior in adults: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To present nationally representative findings on total antisocial personality disorder (ASPD) symptoms, major violations of others' rights (MVOR), and violent symptoms over a 3-year follow-up in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions among adults diagnosed at Wave 1 with ASPD versus syndromal adult antisocial behavior without conduct disorder before age 15 years (AABS, not a codable DSM-IV disorder).

METHOD

Face-to-face interviews were conducted with 34,653 respondents aged 18 years and older. Antisocial syndromes and comorbid lifetime substance use, mood, and 6 additional personality disorders were diagnosed at Wave 1 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The Wave 2 AUDADIS-IV assessed antisocial symptoms over follow-up, lifetime attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder, and borderline, narcissistic, and schizotypal personality disorders. Wave 1 was conducted in 2001-2002 and Wave 2 in 2004-2005 by the National Institute on Alcohol Abuse and Alcoholism.

RESULTS

In unadjusted analyses, respondents with ASPD reported significantly more total, MVOR, and violent symptoms over follow-up than did respondents with AABS. Adjustment for baseline sociodemographics and psychiatric comorbidity attenuated these associations; after further adjustment for parallel antisocial symptom counts from age 15 years to Wave 1, associations with antisocial syndromes disappeared. Independent Wave 1 predictors of persistent antisociality over follow-up included male sex, not being married or cohabiting, low income, high school or less education, lifetime drug use disorders, additional personality disorders, and ADHD.

CONCLUSIONS

The distinction between ASPD and AABS holds limited value in predicting short-term course of antisocial symptomatology among adults. However, the prediction of persistent antisociality by psychiatric comorbidity argues for comprehensive diagnostic assessments, treatment of all identified disorders, and investigation of whether treatment of comorbidity might hasten remission of antisociality.

Unipolar depressive disorders have a common genotype

BACKGROUND

The purpose of this study was to estimate the contribution of genetic, common- and unique environmental factors in the aetiology of unipolar major depression (MD), and to investigate whether the unipolar depressive disorders; MD, atypical depression/depression NOS, dysthymia and depressive adjustment disorder can be viewed as various expressions of an underlying genetic commonality.

METHODS

A sample consisting of same-sexed mono- and dizygotic twins was drawn from in- and outpatient hospital registers (N=303). DSM-III-R criteria were assessed by personal interviews. One hundred and forty-three of the probands fulfilled the criteria for one or another unipolar depressive disorder. Cross-tabulations were used to compare concordance rates for MD and different combinations of MD and other unipolar depressive disorders. Correlations in liability and estimations of the heritability (h(2)) with biometrical model fitting were performed.

RESULTS

Concordance rates were higher among MZ- than among DZ pairs for both MD and all the different combinations of MD and other unipolar depressive disorders. Cross-concordance between MD and other unipolar disorders was observed. In all instances, except for the situation when MD was considered alone, the correlations in liability among MZ pairs were more than twice the correlations in liability among DZ pairs. The heritability of MD was 0.42, of MD+atypical depression 0.51, of MD+atypical depression+dysthymia 0.45 and of MD+atypical depression+dysthymia+depressive adjustment disorder 0.46.

LIMITATION

Probands were not sampled from the general population. Most often the same person interviewed both twins in a pair.

CONCLUSION

Unipolar MD is moderately heritable without significant shared family environmental effects. Unipolar depressive disorders taken together are moderately heritable without any detectable shared family environmental effects. The tendency is towards higher heritability estimates for the combined groups compared to MD alone. The study suggests that the disorders in the unipolar depressive spectrum may be different manifestations of the same genetic liability.