Life stress and treatment course of recurrent depression: II. Postrecovery associations with attrition, symptom course, and recurrence over 3 years

Aging alone and financial insecurity predict depression: a path analysis of objective and subjective indices

OBJECTIVES

This study draws on conservation of resources theory and transactional stress theory to guide our understanding of how social isolation, financial insecurity, and social support serve as a balance of both risk and protection for late-life depression.

METHODS

Data were from the Leave-Behind Questionnaire in the 2016 (N = 4293) and 2018 (N = 4714) waves of the Health and Retirement Study. We conducted a cross-sectional path analysis via structural equation modeling, including objective and subjective perspectives. The same model was tested in both samples.

RESULTS

Both social isolation and financial insecurity were associated with depression. We found several mediating risks and protective factors of these relationships. Objective financial status affected depression through both perceived financial insecurity and perceived social isolation, whereas objective isolation affected depression through perceived social support. This mediation model was -significant after adjusting for confounders.

CONCLUSION

This study underscores the importance of investigating the balance between risk and protection for depression, in the rising number of older adults aging alone in society. Findings suggest that objective and perceived measures offer unique windows into psychological constructs. Considering both objective and subjective perspectives may provide alternative targets for subsequent interventions to improve mental health in later life.

Acute and chronic stress predict anti-depressant treatment outcome and naturalistic course of major depression: A CAN-BIND report

BACKGROUND

In treatment studies of major depressive disorder (MDD), exposure to major life events predicts less symptom improvement and greater likelihood of relapse. In contrast, the impact of minor life events has received less attention. We hypothesized that the impact of minor events on symptom improvement and risk of relapse would be heightened in the presence of concurrent chronic stress. We also hypothesized that major events would predict less symptom improvement and greater risk of relapse independently of chronic stress.

METHODS

Adult patients experiencing an episode of MDD were enrolled into a 16-week trial with antidepressant treatments (n = 156). Forty-three fully remitted patients agreed to participate in a naturalistic 18-month follow-up, and 30 had full data for analyses. Life events and chronic stressors were assessed using a contextual life stress interview.

RESULTS

Greater exposure to minor events predicted greater improvement in symptoms during acute treatment, but this relation was specific to those who reported greater severity of chronic stress. During follow-up, however, major life events predicted increased risk of relapse, and this effect was not moderated by chronic stress.

LIMITATION

High attrition rates led to a small sample size for the follow-up analyses.

CONCLUSIONS

Exposure to minor events may provide an opportunity to practice problem-solving skills, thereby facilitating symptom improvement. Nevertheless, acute treatment did not protect patients from relapse when they subsequently faced major events during follow-up. Therefore, adjunctive strategies may be needed to enhance outcomes during pharmacotherapy, consolidating benefits from acute treatment and providing skills to prevent relapse.

Comparison of Team and Participant Ratings of Event Dependence: Inferential Style, Cognitive Style, and Stress Generation

Introduction: Previous research has linked negative cognitive styles with stress generation. However, measures of cognitive styles have replied on ratings for hypothetical events, not experienced events. We examined the relationship between stress generation and attributional style for experienced events (i.e., inferential style) at both macro and daily levels.

Methods: We measured stress generation in college students using the traditional objective team ratings (i.e., observer) as well as via participants’ own ratings (i.e., actor), which we argue captures more information and is consistent with calls for participant-centered research.

Results: Cognitive style and inferential style positively correlated, indicating consistency between these two forms of assessment. Actor and observer identified events were significantly correlated for both dependent and independent events, suggesting that participants and teams are consistent in these categorizations. Results from both studies showed that inferential style was associated with actor but not observer identified dependent events.

Discussion: Our findings provide some of the first evidence for the role of inferential style in actor identified stress generation and indicate that it is useful to examine both participant and observer ratings of stressful life events.

[Risk factors and prevention of recurrent dynamics of depression]

The existing literature in the field demonstrates that in the majority of cases depressive disorder has a recurrent course that resulted in negative consequences: an increase in a number of chronic and marked episodes, a higher risk of suicide and stable cognitive deficit. An analysis of predictors promoting the formation of recurrent depressive disorder allows an identification of a constellation of biological, psychological, therapeutic, social factors which should be taken into account in the choice of methods of prevention of the next episode of depression. Currently, the prolonged supporting psychopharmacotherapy, including antidepressant therapy, is a main tactics in the prevention of recurrent dynamics of depressive disorder though its efficacy is understudied.

Evidence for clinical progression of unipolar and bipolar disorders

OBJECTIVE

It is a widely held belief that affective disorders are progressive of nature; however, some recent reviews have questioned this belief. The objective of the present systematic literature review was to present evidence for associations between number of affective episodes and (i) the risk of recurrence of episodes, (ii) probability of recovery from episodes, (iii) severity of episodes, (iv) the threshold for developing episodes, and (v) progression of cognitive deficits in unipolar and bipolar disorders.

METHOD

A systematic review comprising an extensive literature search conducted in Medline, Embase, and PsychInfo up to September 2016 and including cross-references from identified papers and reviews.

RESULTS

Most of the five areas are superficially investigated and hampered by methodological challenges. Nevertheless, studies with the longest follow-up periods, using survival analysis methods, taking account of the individual heterogeneity all support a clinical progressive course of illness. Overall, increasing number of affective episodes seems to be associated with (i) increasing risk of recurrence, (ii) increasing duration of episodes, (iii) increasing symptomatic severity of episodes, (iv) decreasing threshold for developing episodes, and (v) increasing risk of developing dementia.

CONCLUSION

Although the course of illness is heterogeneous, there is evidence for clinical progression of unipolar and bipolar disorders.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

Background: Internet-based cognitive therapy with monitoring via text messages (mobile CT), in addition to treatment as usual (TAU), might offer a cost-effective way to treat recurrent depression. Method: Remitted patients with at least 2 previous episodes of depression were randomized to mobile CT in addition to TAU (n = 126) or TAU only (n = 113). A linear mixed model was used to examine the effect of the treatment condition on a 3-month course of depressive symptoms after remission. Both an intention-to-treat analysis (n = 239) and a completer analysis (n = 193) were used. Depressive symptoms were assessed using the Inventory of Depressive Symptomatology (IDS-SR₃₀) at baseline and 1.5 and 3 months after randomization. Results: Residual depressive symptoms showed a small but statistically significant decrease in the intention-to-treat group over 3 months in the mobile CT group relative to the TAU group (difference: -1.60 points on the IDS-SR₃₀ per month, 95% CI = -2.64 to -0.56, p = 0.003). The effect of the treatment condition on the depressive symptomatology at the 3-month follow-up was small to moderate (Cohen's d = 0.44). All analyses among completers (≥5 modules) showed more pronounced treatment effects. Adjustment for unequally distributed variables did not markedly affect the results. Conclusions: Residual depressive symptoms after remission showed a more favorable course over 3 months in the mobile CT group compared to the TAU group. These results are a first indication that mobile CT in addition to TAU is effective in treating recurrently depressed patients in remission. However, demonstration of its long-term effectiveness and replication remains necessary. © 2015 S. Karger AG, Basel.

The effect of recent bereavement on outcomes in a primary care depression intervention study

OBJECTIVES

Although bereavement and depression are both common in older primary care patients, the effect of bereavement on depression intervention outcomes is unknown. We examined whether standard interventions for depression in primary care were as effective for bereaved as for non-bereaved depressed patients.

DESIGN

Randomized controlled trial.

SETTING

Twenty community-based primary care practices in New York City, greater Philadelphia, and Pittsburgh. Randomization to either intervention or usual care occurred by practice.

PARTICIPANTS

Patients aged 60 years or older who met criteria for major depression or clinically significant minor depression (N = 599). Patients who did not complete the bereavement measure or who were missing 4-month data were excluded (final N = 417).

INTERVENTION

Study-trained depression care managers offered guideline-concordant recommendations to primary care physicians at intervention sites and assisted patients with treatment adherence. Patients who did not wish to take antidepressants could receive interpersonal psychotherapy.

MEASUREMENTS

Bereavement was captured using the Louisville Older Persons Events Schedule. Depression severity was assessed using the 24-item Hamilton Depression Rating Scale (HDRS). Outcomes at 4 months were remission (HDRS ≤7) and response (HDRS reduction ≥50% from baseline).

RESULTS

Logistic regressions indicated that, for non-bereaved participants, response and remission were higher in intervention than usual care. However, recently bereaved older adults were less likely to achieve response or remission at 4 months if treated in the intervention condition.

CONCLUSIONS

Standard depression care management appears to be ineffective among recently bereaved older primary care patients. Greater attention should be paid in primary care to emotional distress in the context of bereavement.

The scars of childhood adversity: minor stress sensitivity and depressive symptoms in remitted recurrently depressed adult patients

Background

Childhood adversity may lead to depressive relapse through its long-lasting influence on stress sensitivity. In line with the stress sensitization hypothesis, minor (daily) stress is associated with depressive relapse. Therefore, we examine the impact of childhood adversity on daily stress and its predictive value on prospectively assessed depressive symptoms in recurrently depressed patients.

Method

Daily stress was assessed in recurrently depressed adult patients, enrolled into two randomized trials while remitted. The reported intensity and frequency of dependent and independent daily stress was assessed at baseline. Independent stress is externally generated, for example an accident happening to a friend, while dependent stress is internally generated, for example getting into a fight with a neighbor. Hierarchical regression analyses were performed with childhood adversity, independent and dependent daily stress as predictor variables of prospectively measured depressive symptoms after three months of follow-up (n = 138).

Results

We found that childhood adversity was not significantly associated with a higher frequency and intensity of daily stress. The intensity of both independent and dependent daily stress was predictive of depressive symptom levels at follow-up (unadjusted models respectively: B = 0.47, t = 2.05, p = 0.041, 95% CI = 0.02–0.92; B = 0.29, t = 2.20, p = 0.028, 95% CI = 0.03–0.55). No associations were found between childhood adversity and depressive symptoms at follow-up.

Conclusion

No evidence was found supporting stress sensitization due to the experience of childhood adversity in this recurrently depressed but remitted patient group. Nevertheless, our research indicates that daily stress might be a target for preventive treatment.

Trial Registration

Trial A: Nederlands Trial Register NTR1907 Trial B: Nederlands Trial Register NTR2503

Negative socioeconomic changes and mental disorders: a longitudinal study

BACKGROUND

There is increasing interest on whether the current global economic uncertainties have an influence on the population's mental health. In this paper, we examined the association of negative socioeconomic changes, job loss and household income reductions with incident mental disorders. The moderating effect of gender was assessed.

METHODS

Data come from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative population-based, longitudinal study. Individuals with a paid job and without a 12-month mental disorder at baseline were selected and reassessed 3 years later (2007-2009/2010-2012). Substantial household income reductions and not being at a paid job anymore were self-reported at follow-up. Multivariate logistic models were utilised to investigate the association between these negative socioeconomic changes and the incidence of mood, anxiety and substance use Diagnostic and Statistical Manual-IV disorders assessed by the Composite International Diagnostic Interview 3.0.

RESULTS

After 3 years, 6% had lost their job, 11% had a substantial household income reduction and 12.2% had developed a mental disorder. Household income reductions increased the risk of any mental disorder (aOR=1.77), particularly the risk of mood (aOR=2.24). Job loss increased the risk of mood disorders (aOR=2.02). Gender modified the relationship: job loss increased the risk of any mental disorder among men (aOR=3.04) and household income reductions did so among women (aOR=2.32).

CONCLUSIONS

Negative socioeconomic changes occurring within a short time period significantly increased the risk of incident mental disorders, particularly of mood disorders. Effective interventions to alleviate the public mental health impact of negative socioeconomic changes on men and women are needed.

Stressful life events severity in patients with first and recurrent depressive episodes

BACKGROUND

Stressful life events are associated with depression and their role in first onset and recurrences is a promising but controversial perspective of research. The objective is to analyze the role of number of previous episodes and life events exposure in a large sample of primary care depressive patients taking into account life events severity.

METHOD

10,257 patients with DSM-IV criteria for a current single or recurrent major depressive episode were recruited by 2,056 general practitioners in a cross-sectional epidemiological study. Patients answered the Montgomery-Asberg Depression Rating Scale, the Patient Health Questionnaire and the Social Readjustment Rating Scale (SRRS). Stressful life events were categorized into three levels of severity (severe, moderate and mild). All relevant confounding variables were analyzed: age, gender, depression severity, somatic symptoms severity and length of episode.

RESULTS

We found a significant positive correlation with number of episodes and depression severity. There was no significant correlation of SRRS scores with age, gender and length of episode. ANOVA exploring life events severity with regard to number of episodes showed statistically differences in SRRS total score, moderate life events and mild life events (F = 15.14, p < 0.001) but not for severe life events.

CONCLUSIONS

Prevention and treatment strategies for recurrent depression need to manage life stressful events during mild and long-term periods and not just in the initial recurrences of the disease.

Using attentional bias modification as a cognitive vaccine against depression

BACKGROUND

Negative attentional biases are thought to increase the risk of recurrence in depression, suggesting that reduction of such biases may be a plausible strategy in the secondary prevention of the illness. However, no previous study has tested whether reducing negative attentional bias causally affects risk factors for depressive recurrence. The current experimental medicine study reports the effects of a computerized attentional bias modification (ABM) procedure on intermediate measures of the risk of depressive recurrence (residual depressive symptoms and the cortisol awakening response) in patients with recurrent depression.

METHODS

Sixty-one patients with at least two previous episodes of depression who were currently in remission were randomized to receive either an active (positive) or placebo computer-based ABM regime. The ABM regime presented either pictures of faces or words. Residual depressive symptoms, measured using the Beck Depression Inventory and the cortisol awakening response were measured immediately before and after completion of the bias modification and then again after 4 weeks' follow-up.

RESULTS

Positive, face-based ABM reduced both measures of recurrence risk (Beck Depression Inventory and cortisol awakening response). This effect occurred during the month following completion of bias modification. Word-based modification did not influence the outcome measures.

CONCLUSIONS

Positive face-based ABM was able to reduce intermediate measures of recurrence risk in previously depressed patients. These results suggest that ABM may provide a "cognitive vaccine" against depression and offer a useful strategy in the secondary prevention of the illness.

The effects of neuroticism, extraversion, and positive and negative life events on a one-year course of depressive symptoms in euthymic previously depressed patients versus healthy controls

We investigated a) the concurrent impact of positive and negative life events on the course of depressive symptoms in persons remitted from depression and healthy controls, b) whether the impact of life events on symptom course is moderated by the history of depression and the personality traits of neuroticism and extraversion, and c) whether life events mediate possible relationships of history of depression and personality traits with symptom course. Using data from the Netherlands Study of Depression and Anxiety, we examined 239 euthymic participants with a previous depressive disorder based on DSM-IV and 450 healthy controls who completed a) baseline assessments of personality dimensions (NEO Five-Factor Inventory) and depression severity (Inventory of Depressive Symptoms [IDS]) and b) 1-year follow-up assessments of depression severity and the occurrence of positive and negative life events during the follow-up period (List of Threatening Events Questionnaire). Remitted persons reported higher IDS scores at 1-year follow-up than did the controls. Extraversion and positive and negative life events independently predicted the course of depressive symptoms. The impact of life events on symptom course was not moderated by history of depression or personality traits. The effect of extraversion on symptom course was partly caused by differential engagement in positive life events.

Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer

OBJECTIVE

The generalizability of palliative care intervention research is often limited by high rates of study attrition. This study examined factors associated with attrition from a randomized controlled trial comparing meaning-centered group psychotherapy (MCGP), an intervention designed to help advanced cancer patients sustain or enhance their sense of meaning to the supportive group psychotherapy (SGP), a standardized support group.

METHODS

Patients with advanced solid tumor cancers (n = 153) were randomized to eight sessions of either the MCGP or SGP. They completed assessments of psychosocial, spiritual, and physical well-being pretreatment, midtreatment, and 2 months post-treatment. Attrition was assessed in terms of the percent of participants who failed to complete these assessments, and demographic, psychiatric, medical, and study-related correlates of attrition were examined for the participants in each of these categories.

RESULTS

The rates of attrition at these time points were 28.1%, 17.7%, and 11.1%, respectively; 43.1% of the participants (66 of 153) completed the entire study. The most common reason for dropout was patients feeling too ill. Attrition rates did not vary significantly between study arms. The participants who dropped out pretreatment reported less financial concerns than post-treatment dropouts, and the participants who dropped out of the study midtreatment had poorer physical health than treatment completers. There were no other significant associations between attrition and any demographic, medical, psychiatric, or study-related variables.

CONCLUSIONS

These findings highlight the challenge of maintaining advanced cancer patients in longitudinal research and suggest the need to consider alternative approaches (e.g., telemedicine) for patients who might benefit from group interventions but are too ill to travel.

The direct and interactive effects of neuroticism and life stress on the severity and longitudinal course of depressive symptoms

The direct and interactive effects of neuroticism and stressful life events (chronic and episodic stressors) on the severity and temporal course of depression symptoms were examined in 826 outpatients with mood and anxiety disorders, assessed on 3 occasions over a 1-year period (intake and 6- and 12-month follow-ups). Neuroticism, chronic stress, and episodic stress were uniquely associated with intake depression symptom severity. A significant interaction effect indicated that the strength of the effect of neuroticism on initial depression severity increased as chronic stress increased. Although neuroticism did not have a significant direct effect on the temporal course of depression symptoms, chronic stress significantly moderated this relationship such that neuroticism had an increasingly deleterious effect on depression symptom improvement as the level of chronic stress over follow-up increased. In addition, chronic stress (but not episodic stress) over follow-up was uniquely predictive of less depression symptom improvement. Consistent with a stress generation framework, however, initial depression symptom severity was positively associated with chronic stress during follow-up. The results are discussed in regard to diathesis-stress conceptual models of emotional disorders and the various roles of stressful life events in the onset, severity, and maintenance of depressive psychopathology.

Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

Within the past 20 years, depression research has given increasing consideration to the possibility of complex and reciprocal relations between stress and depression. Not only does stress increase risk for depression (i.e., a stress exposure model of depression), but depression, or depressogenic vulnerabilities, in turn, also increases susceptibility to stressful events that are at least in part influenced by the individual (i.e., stress generation; Hammen, 1991). The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression. The research thus far appears most consistent in supporting the role of depression in predicting generated stress, although more research is still required. In addition to highlighting these findings, methodological limitations and conceptual gaps in the literature are discussed with the view of informing future research in this area.

Risk for recurrence in depression

Depression is a highly recurrent disorder with significant personal and public health consequences. Prevention of recurrence would be extremely desirable, and thus researchers have begun to identify risk factors that are specific to recurrence, which may be different from risk factors for first onset of depression. Methodological issues in this area of research are briefly reviewed (e.g., the various definitions of "recurrence" and "depression"), followed by a review of studies on specific risk factors, including demographic variables (gender, socio-economic status, and marital status), clinical variables (age at first onset, number of prior episodes, severity of first/index episode, and comorbid psychopathology), family history of psychopathology, and psychosocial and psychological variables (level of psychosocial functioning, cognitions, personality, social support, and stressful life events). In addition, scar theories are evaluated for their potential to explain how these variables and recurrent depression are linked. Our review suggests that recurrent depression reflects an underlying vulnerability that is largely genetic in nature and that may predispose those high in the vulnerability not only to recurrent depressive episodes, but also to the significant psychosocial risk factors that often accompany recurrent depression.

Life stress and the long-term treatment course of recurrent depression: III. Nonsevere life events predict recurrence for medicated patients over 3 years

Research has consistently documented the significance of severe life events for onset of major depression. Theory, however, suggests other forms of stress are relevant for depression's recurrence. Nonsevere life events were tested in relation to depression for 126 patients with recurrent depression in a 3-year randomized maintenance protocol. Life stress was assessed every 12 weeks and rated along dimensions of severity, focus, and independence. A significant interaction between specific types of nonsevere life events and medication was found. For medicated patients, subject-focused independent nonsevere life events predicted recurrence; for unmedicated patients, these events predicted fewer recurrences. Other nonsevere life events did not predict recurrence. The findings underscore the potential importance of specific stressors for triggering recurrences of depression.

Life stress, the "kindling" hypothesis, and the recurrence of depression: considerations from a life stress perspective

Major depression is frequently characterized by recurrent episodes over the life course. First lifetime episodes of depression, however, are typically more strongly associated with major life stress than are successive recurrences. A key theoretical issue involves how the role of major life stress changes from an initial episode over subsequent recurrences. The primary conceptual framework for research on life stress and recurrence of depression is the "kindling" hypothesis (R. M. Post, 1992). Despite the strengths of the kindling hypothesis, a review of the research literature reveals inconsistencies and confusion about life stress and its implications for the recurrence of depression. Adopting a life stress perspective, the authors introduce 3 major themes that resolve the inconsistencies in the current literature. They integrate these themes and extrapolate the ideas with available data to develop a preliminary framework for evaluating competing explanatory models and to guide research on life stress and the recurrence of depression.

Status of minor depression or dysthymia in primary care following a randomized controlled treatment

This report describes the rates of recovery and remission from minor depression or dysthymia in primary care patients three months after completing a randomized controlled treatment trial. The subjects were primary care patients who received > or =4 treatment sessions with Problem-Solving Treatment, paroxetine, or placebo and who completed an independent assessment 3 months after the study (201 with minor depression, 229 with dysthymia). The 17-item Hamilton Rating Scale for Depression (HAMD), semistructured questions about postintervention depression treatments, and baseline medical comorbidity, neuroticism, and social function were the primary measures. For minor depression 76% and for dysthymia 68% of subjects who were in remission at the end of the 11-week treatment trial were recovered (HAMD < or =6) three months after the treatment trial. Of patients who were not in remission at 11 weeks, for minor depression 37% and for dysthymia 31% went on to achieve remission at 25 weeks. The majority of patients chose not to use antidepressants or psychotherapy after the trial. Patients with minor depression that had greater baseline social function and lower neuroticism scores were more likely to be recovered. For patients with minor depression, these findings suggest a need for some matching of continuation and maintenance treatment to patient characteristics rather than uniform, automatic treatment recommendations. Because of the chronic, relapsing nature of dysthymia, practical improvements in encouraging effective continuation and maintenance phases of treatment are indicated.

Life stress and the symptoms of major depression

Life stress has been found to be associated with onset of depression and with greater severity of depressive symptoms. It is unclear, though, if life stress is related to particular classes or specific symptoms in depression. The association between severe life events and depressive symptoms was tested in 59 individuals diagnosed by Research Diagnostic Criteria with endogenous primary nonpsychotic major depression. As predicted, life stress was associated principally with cognitive-affective symptoms, not somatic symptoms. There also was a consistent association across different assessment methods between severe events and suicidal ideation. Finally, associations held specifically for severe events occurring before onset, not for severe events occurring after onset. Symptom variation in major depression is related specifically to severe stressors before onset and includes primarily cognitive-affective types of symptoms. There is an especially pronounced association of prior severe stress with suicidal ideation. The implications of stress-symptom associations are addressed for enlarging understanding of symptom heterogeneity and subtype distinctions in major depression.

Long-term posttreatment functioning among patients with unipolar depression: an integrative model

This study tested an integrative structural equation model of posttreatment functioning among 165 depressed patients followed for an average of 9 years after the end of an episode of treatment. The model examined (a) the link between life change and psychosocial resource change and (b) the role of resource change in mediating the relationship between life change and change in depression. An increase in the preponderance of negative over positive life events was associated with a decline in resources and an increase in depressive symptoms. A decline in resources was associated with an increase in depressive symptoms. The association between changes in events and depressive symptoms was completely mediated through resource change. These findings indicate that life stressors contribute to posttreatment depression through an erosion of personal and social resources.

Predictors of recurrence in affective disorder--analyses accounting for individual heterogeneity

BACKGROUND

Previous studies suggest that gender, age at onset, and marital status act as risk factors for further recurrence initially during the course of affective disorder but not at a later stage. These studies did, however, not take the individual liability to recurrence into account.

METHOD

The effect of predictors of recurrence was estimated with the use of generalised linear mixed models in a case register study including a random sample of all patients admitted with primary affective disorder in Denmark during 1971-1993.

RESULTS

In total, 7047 first admission patients with a diagnosis of affective disorder, depressive or manic/circular type were included in the analyses. The study confirmed that the effect of the type of disorder, age at first admission, and never being married decreased during the course of illness even when the individual liability to recurrence was taken into account. No differences in the effect of gender and in the effect of a recent divorce were found between early and later episodes and the effect of a recent death of a spouse seemed to increase during the course of illness. The risk of recurrence increased with every new episode for all sub-groups of patients.

CONCLUSION

The effect of some, but not all, predictors of recurrence decline during the course of affective illness. The number of previous episodes predicts recurrence in most subgroups of patients.

LIMITATION

The data relate to re-admissions rather than recurrence.

CLINICAL RELEVANCE

The study underscores the importance of the illness process itself.

Risk factors for sustained nonremission of depressive symptoms: a 4-year follow-up

Previous studies have suggested that a considerable number of depressed patients suffer from sustained or repeated episodes of depressive symptoms. We developed a risk factor index based on data obtained at admission to treatment predicting sustained nonremission of depressive symptoms over 4 years for a sample of 370 unipolar depressed inpatients and outpatients. The six risk factors for sustained nonremitted depression are: less education, more severe initial depressive mood and ideation, secondary major depression, prior treatment, comorbid medical conditions, and fewer close relationships. These findings suggest that identification of these risk factors before selecting treatment type and intensity may improve long-term clinical outcomes.

Life circumstances and personal resources as predictors of the ten-year course of depression

A 10-year naturalistic study of 313 patients who entered treatment for unipolar depression and a community comparison group of 284 nondepressed adults was conducted. We compared life stressors, social resources, personal resources, and coping among patients who were remitted (N = 76), partially remitted (N = 146), or nonremitted (N = 91). Compared with the controls and the remitted patients, the partially remitted and nonremitted patients consistently experienced more life stressors and fewer social resources, were less easygoing, and relied more on avoidance coping. A less easygoing disposition, fewer close relationships, and more reliance on avoidance coping were associated with higher odds of experiencing a course of partial remission or nonremission. In addition, more depressive symptoms and medical conditions predicted nonremission.