Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy

Abnormal resting-state EEG phase dynamics distinguishes major depressive disorder and bipolar disorder

Changes in EEG have been reported in both major depressive disorder (MDD) and bipolar disorder (BD). Specifically, power changes in EEG alpha and theta frequency bands during rest and task are known in both disorders. This leaves open whether there are changes in yet another component of the electrophysiological EEG signal, namely phase-related processes that may allow for distinguishing MDD and BD. For that purpose, we investigate EEG-based spontaneous phase in the resting state of MDD, BD and healthy controls. Our main findings show: (i) decreased spontaneous phase variability in frontal theta of both MDD and BD compared to HC; (ii) decreased spontaneous phase variability in central-parietal alpha in MDD compared to both BD and HC; (iii) increased delays or lags of alpha phase cycles in MDD (but not in BD), which (iv) correlate with the decreased phase variability in MDD. Together, we show similar (decreased frontal theta variability) and distinct (decreased central-parietal alpha variability with increased lags or delays) findings in the spontaneous phase dynamics of MDD and BD. This suggests potential relevance of theta and alpha phase dynamics in distinguishing MDD and BD in clinical differential-diagnosis.

Death Anxiety in Caregivers of Chronic Patients

This study aimed to determine the extent to which caregivers of patients with chronic illnesses experience death anxiety, and which variables from caregivers and patients might potentially be related to their death anxiety. It also aimed to compare the levels of death anxiety between patients and caregivers. Web of Science, Scopus, PubMed, Psychology Database, Cochrane, and Google Scholar were searched for original studies available until December 2022 that quantitatively addressed death anxiety in family and informal caregivers of individuals with chronic illnesses. The methodological quality of the included studies was assessed, and a meta-analysis was conducted using Hedges' g as the effect size index and the DerSimonian-Laird method to analyze differences between patients and caregivers in death anxiety. The results of the 11 included studies showed moderate levels of death anxiety in caregivers, and the meta-analysis (k = 7; 614 patients and 586 caregivers) revealed non-significant differences between the death anxiety experienced by patients and caregivers (pooled Hedges' g = -0.03, 95% CI = -0.29 to 0.25, p = 0.802). Some sociodemographic and psychological factors (e.g., gender, depression, and anxiety) might be related to the death anxiety experienced, but additional research is necessary to validate these findings.

The impact of antidepressants on human neurodevelopment: Brain organoids as experimental tools

The use of antidepressants during pregnancy benefits the mother's well-being, but the effects of such substances on neurodevelopment remain poorly understood. Moreover, the consequences of early exposure to antidepressants may not be immediately apparent at birth. In utero exposure to selective serotonin reuptake inhibitors (SSRIs) has been related to developmental abnormalities, including a reduced white matter volume. Several reports have observed an increased incidence of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) after prenatal exposure to SSRIs such as sertraline, the most widely prescribed SSRI. The advent of human-induced pluripotent stem cell (hiPSC) methods and assays now offers appropriate tools to test the consequences of such compounds for neurodevelopment in vitro. In particular, hiPSCs can be used to generate cerebral organoids - self-organized structures that recapitulate the morphology and complex physiology of the developing human brain, overcoming the limitations found in 2D cell culture and experimental animal models for testing drug efficacy and side effects. For example, single-cell RNA sequencing (scRNA-seq) and electrophysiological measurements on organoids can be used to evaluate the impact of antidepressants on the transcriptome and neuronal activity signatures in developing neurons. While the analysis of large-scale transcriptomic data depends on dimensionality reduction methods, electrophysiological recordings rely on temporal data series to discriminate statistical characteristics of neuronal activity, allowing for the rigorous analysis of the effects of antidepressants and other molecules that affect the developing nervous system, especially when applied in combination with relevant human cellular models such as brain organoids.

Can daily actigraphic profiles distinguish between different mood states in inpatients with bipolar disorder? An observational study

Background

Criterion A changes for bipolar disorder (BD) in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition yield new difficulties in diagnosis. Actigraphy has been used to capture the activity features of patients with BD. However, it remains unclear whether long-term actigraphic data could distinguish between different mood states in hospitalized patients with BD.

Methods

In this observational study, 30 hospitalized patients with BD were included. Wrist-worn actigraphs were used to monitor motor activity. The patients were divided into bipolar disorder-depression (BD-D), bipolar disorder-mania (BD-M), and bipolar disorder-mixed state (BD-MS) groups. Motor activity differences were estimated using non-parametric analyses between and within the three groups.

Results

The mean 24 h activity level differed between the groups. In the between-group analysis, the intra-individual fluctuation and minute-to-minute variability in the morning and the mean activity level and minute-to-minute variability in the evening significantly differed between the BD-M and BD-MS groups. In the within-group analysis, the BD-M group showed a disrupted rhythm and reduced activity complexity at night. Both the BD-D and BD-MS groups demonstrated significant differences between several parameters obtained in the morning and evening.

Conclusion

The mean activity levels during the relatively long monitoring period and the intra-day variation within the groups could reflect the differences in motor activity. Sustained activity monitoring may clarify the emotional states and provide information for clinical diagnosis.

Death anxiety and mental health: Requiem for a dreamer

Recently, there has been an increased interest in the role of death anxiety in a broad range of mental health disorders. It has been argued that the fear of death may be a transdiagnostic variable contributing to the development and maintenance of many chronic mental health problems. Further, it has been suggested that death anxiety may be responsible for relapse and the emergence of new disorders in patients that have received successful treatment for earlier conditions in their lives. Given this, the purpose of the present selective review is to: (1) explore contemporary theoretical accounts of the role of death anxiety in a broad range of human behaviours; (2) examine evidence for death anxiety as a key variable in mental health disorders; (3) examine evidence on the treatment of death anxiety in both non-clinical and clinical populations; (4) describe the limitations of the current literature, and; (5) provide a detailed description of the critical future directions for this field.

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Identifying the difference in time perception between major depressive disorder and bipolar depression through a temporal bisection task

BACKGROUND

It is difficult to make a precise diagnosis to distinguish patients with Major Depressive Disorder (MDD) from patients with Bipolar Depressive Disorder (current depressive episode, BD). This study will explore the difference in time perception between MDD and BD using a temporal bisection task.

METHODS

In this temporal bisection task, 30 MDD patients, 30 BD patients, and 30 healthy controls (HC) had to categorize a signal duration, between 400 and 1600 milliseconds (ms), as either short or long. A repeated measurement analysis of variance with 3 (subject type) × 7 (time interval) was performed on the long response ratio with Bonferroni correction for multiple comparisons. Origin software was used to calculate the subjective bisection point (BP), difference limen (DL), and Weber ratio (WR). The Hamilton Depression Rating Scale for depression-17 was used to assess depressive symptoms in the patients.

RESULTS

The data showed that the interaction effect between subject type and duration was significant (F (6,498) = 4.656, p <0.001, η2p = 0.101). At 400 ms, and the long response of the MDD group was greater than HC group (p<0.017, Bonferroni-corrected). At 1200, 1400 and 1600 ms, the long response of BD group is smaller than HC group, (p<0.017, Bonferroni-corrected). The one-way ANOVA revealed significant difference among the HC, MDD and BD groups in the BP values WR values, F(2, 81) = 3.462, p = 0.036 vs. F(2, 81) = 3.311, p = 0.042. Post-hoc tests showed that the value of BP in the MDD group was less than BD group (p = 0.027) and the value of BP in the MDD group was less than HC group (p = 0.027), while there was not significant difference of BP values between BD group and HC group. The WR values in MDD group larger than the HC group (p = 0.022).

LIMITATIONS

Severity of depression not divided and analyzed according to the Hamilton Depression Rating Scale score.

CONCLUSION

The time perception of the MDD and BD groups was different from that of the HC group, they overestimated short time periods. Compared with the BD group, the MDD group had a smaller time bisector, and these patients felt that time passed more slowly. The time sensitivity of MDD group and BD group were less than the HC group. However, there was no statistical difference in time sensitivity between the MDD and BD groups.

Distortions in time perception during collective trauma: Insights from a national longitudinal study during the COVID-19 pandemic

OBJECTIVE

During the protracted collective trauma of the COVID-19 pandemic, lay of distorted perceptions of time (e.g., time slowing, days blurring together, uncertainty about the future) have been widespread. Known as "temporal disintegration" in psychiatric literature, these distortions are associated with negative mental health consequences. However, the prevalence and predictors of temporal disintegration are poorly understood. We examined perceptions of time passing and their associations with lifetime stress and trauma and pandemic-related secondary stress as COVID-19 spread across the United States.

METHOD

A probability-based national sample (N = 5,661) from the NORC AmeriSpeak online panel, which had completed a mental and physical health survey prior to the pandemic, completed two surveys online during March 18-April 18, 2020, and September 26-October 16, 2020. Distorted time perceptions and other pandemic-related experiences were assessed.

RESULTS

Present focus, blurring weekdays and weekdays together, and uncertainty about the future were common experiences reported by over 65% of the sample 6 months into the pandemic. Half of the sample reported time speeding up or slowing down. Predictors of temporal disintegration include prepandemic mental health diagnoses, daily pandemic-related media exposure and secondary stress (e.g., school closures, lockdown), financial stress, and lifetime stress and trauma exposure.

CONCLUSION

During the first 6 months of the COVID-19 pandemic, distortions in time perception were very common and associated with prepandemic mental health, lifetime stress and trauma exposure, and pandemic-related media exposure and stressors. Given that temporal disintegration is a risk factor for mental health challenges, these findings have potential implications for public mental health. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adrift in time: the subjective experience of circadian challenge during COVID-19 amongst people with mood disorders

Social distancing/lockdown policies during the coronavirus (COVID-19) pandemic may alter social rhythms of people through imposition of restrictions on normal daily activities. This may in turn challenge circadian function, particularly in people with mood disorders. Although objective data describing the relationship between circadian disturbances and mood disorders exist, data regarding the subjective experience of circadian challenge is sparse, and its association with mood symptoms is unclear. The present qualitative study was one component of a mixed-methods multi-national project, which took advantage of widespread disruption to daily routines due to Government COVID-related lockdowns during 2020. The Behavior Emotion and Timing during COVID-19 (BEATCOVID) survey study included three open questions generating qualitative data on participants' subjective experience of social disruption due to social distancing/lockdown policies, two of which asked about the barriers and opportunities for stabilizing routines. Responses were coded and analyzed using Thematic Analysis. A total of N = 997 participants responded to at least one of the free-text questions. Four themes were identified: 1) loss of daily timed activities, 2) role of social interaction, 3) altered time perception and 4) disruption to motivation and associated psychological effects. Themes were organized into a provisional heuristic map, generating hypotheses for future research centered on the new concept of 'psychological drift.'

Predictors of diagnostic delay: Assessment of psychiatric disorders in the clinic

BACKGROUND

Diagnostic delay contributes to morbidity in psychiatric disorders.

METHODS

Patients in an ambulatory psychiatry clinic were given patient-reported outcome measures at an initial visit, and a subset (N = 493) were given a structured interview (MINI International Neuropsychiatric Interview, MINI), in addition to the clinical encounter (CLIN). Diagnostic agreement between MINI and CLIN was assessed at an initial and follow-up visit. Diagnostic delay was identified if diagnostic disagreement between MINI and CLIN occurred at the initial visit and changed to an agreement at a follow-up visit. Registry data was compiled by an honest broker.

RESULTS

Significant agreement occurred between MINI and CLIN diagnoses for major depressive disorder (MDD), bipolar disorder (BD), generalized anxiety disorder, and panic disorder. Diagnostic agreement for MDD occurred at initial visit for 63% of patients, and at follow-up for 87% of those with initial diagnostic disagreement; for BD, 75% at initial visit and 28% at follow-up. No demographic, socioeconomic, symptom severity or functioning measures predicted diagnostic agreement for the MDD group at the first visit, however initial psychopathological symptom complexity predicted diagnostic agreement in the diagnostic delay group. Initial diagnostic agreement for BD was predicted by lower symptom burden and better social, physical, and occupational functioning. No factors predicted additional diagnostic agreement at the second visit in the diagnostic delay group.

CONCLUSION

Initial assessment by a structured interview aided physicians in identifying MDD by the second visit in patients with complex psychopathology. Patients with high complexity/severity of symptoms and more difficulty with functioning were less commonly identified with BD even with the assistance of a structured interview. Use of structured assessment tools may improve the detection of psychiatric illness by clinicians at the first visit.

The Dynamic Universal Profiles of Spiritual Awareness: A Latent Profile Analysis

The aim of the current investigation was to identify universal profiles of lived spirituality. A study on a large sample of participants (N = 5512) across three countries, India, China, and the United States, suggested there are at least five cross-cultural phenotypic dimensions of personal spiritual capacity—spiritual reflection and commitment; contemplative practice; perception of interconnectedness; perception of love; and practice of altruism—that are protective against pathology in a community sample and have been replicated in matched clinical and non-clinical samples. Based on the highest frequency combinations of these five capacities in the same sample, we explored potentially dynamic profiles of spiritual engagement. We inductively derived five profiles using Latent Profile Analysis (LPA): non-seeking; socially disconnected; spiritual emergence; virtuous humanist; and spiritually integrated. We also examined, in this cross-sectional data, covariates external to the LPA model which measure disposition towards meaning across two dimensions: seeking and fulfillment, of which the former necessarily precedes the latter. These meaning covariates, in conjunction with cross-profile age differences, suggest the profiles might represent sequential phases along an emergent path of spiritual development. Subsequent regression analyses conducted to predict depression, anxiety, substance-related disorders, and positive psychology based on spiritual engagement profiles revealed the spiritually integrated profile was most protected against psychopathology, while the spiritual emergence profile was at highest risk. While this developmental process may be riddled with struggle, as evidenced by elevated rates of psychopathology and substance use in the intermediate phases, this period is a transient one that necessarily precedes one of mental wellness and resilience—the spiritual development process is ultimately buoyant and protective.

Death anxiety in the time of COVID-19: theoretical explanations and clinical implications

The recent COVID-19 pandemic has triggered a surge in anxiety across the globe. Much of the public's behavioural and emotional response to the virus can be understood through the framework of terror management theory, which proposes that fear of death drives much of human behaviour. In the context of the current pandemic, death anxiety, a recently proposed transdiagnostic construct, appears especially relevant. Fear of death has recently been shown to predict not only anxiety related to COVID-19, but also to play a causal role in various mental health conditions. Given this, it is argued that treatment programmes in mental health may need to broaden their focus to directly target the dread of death. Notably, cognitive behavioural therapy (CBT) has been shown to produce significant reductions in death anxiety. As such, it is possible that complementing current treatments with specific CBT techniques addressing fears of death may ensure enhanced long-term symptom reduction. Further research is essential in order to examine whether treating death anxiety will indeed improve long-term outcomes, and prevent the emergence of future disorders in vulnerable populations.

Key learning aims

(1)To understand terror management theory and its theoretical explanation of death anxiety in the context of COVID-19.(2)To understand the transdiagnostic role of death anxiety in mental health disorders.(3)To understand current treatment approaches for directly targeting death anxiety, and the importance of doing so to improve long-term treatment outcomes.

Predictors of Treatment Resistance Across Different Clinical Subtypes of Depression: Comparison of Unipolar vs. Bipolar Cases

OBJECTIVE

Treatment-resistant depression (TRD) and treatment-resistant bipolar depression (TRBD) poses a significant clinical and societal burden, relying on different operational definitions and treatment approaches. The detection of clinical predictors of resistance is elusive, soliciting clinical subtyping of the depressive episodes, which represents the goal of the present study.

METHODS

A hundred and thirty-one depressed outpatients underwent psychopathological evaluation using major rating tools, including the Hamilton Rating Scale for Depression, which served for subsequent principal component analysis, followed-up by cluster analysis, with the ultimate goal to fetch different clinical subtypes of depression.

RESULTS

The cluster analysis identified two clinically interpretable, yet distinctive, groups among 53 bipolar (resistant cases = 15, or 28.3%) and 78 unipolar (resistant cases = 20, or 25.6%) patients. Among the MDD patients, cluster "1" included the following components: "Psychic symptoms, depressed mood, suicide, guilty, insomnia" and "genitourinary, gastrointestinal, weight loss, insight". Altogether, with broadly defined "mixed features," this latter cluster correctly predicted treatment outcome in 80.8% cases of MDD. The same "broadly-defined" mixed features of depression (namely, the standard Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition-DSM-5-specifier plus increased energy, psychomotor activity, irritability) correctly classified 71.7% of BD cases, either as TRBD or not.

LIMITATIONS

Small sample size and high rate of comorbidity.

CONCLUSIONS

Although relying on different operational criteria and treatment history, TRD and TRBD seem to be consistently predicted by broadly defined mixed features among different clinical subtypes of depression, either unipolar or bipolar cases. If replicated by upcoming studies to encompass also biological and neuropsychological measures, the present study may aid in precision medicine and informed pharmacotherapy.

The effectiveness of 8A model death education on the reduction of death depression: A preliminary study

Aim

Death education using the 8A model can reduce death distress and promote mental health. The aim of the present study was to investigate the effectiveness of the 8A model death education programme for reducing death depression among nurses. The hypothesis was that participating in the 8A model death education programme would reduce death depression.

Design

A pre-test-post-test intervention.

Methods

Ten nurses were selected randomly from the intensive care units and critical care units wards of the Khatom-Al-Anbia General Hospital in Tehran, Iran. They completed the Death Depression Scale before and after intervention. The 8A model was conducted in six workshops weekly, each of 6 hr, for a total of 36 hr.

Results

There was a significant difference between pre-test and post-test on the Death Depression Scale scores.

Discussion

The 8A model appears to be useful for the reduction of death depression and the promotion of mental health in the sample. However, the model should be tested on larger samples and with a control group before concluding that the model is effective in reducing death distress.

Use of ecological momentary assessment to detect variability in mood, sleep and stress in bipolar disorder

Objective

Our aim was to study within-person variability in mood, cognition, energy, and impulsivity measured in an Ecological Momentary Assessment paradigm in bipolar disorder by using modern statistical techniques. Exploratory analyses tested the relationship between bipolar disorder symptoms and hours of sleep, and levels of pain, social and task-based stress. We report an analysis of data from a two-arm, parallel group study (bipolar disorder group N = 10 and healthy control group N = 10, with 70% completion rate of 14-day surveys). Surveys of bipolar disorder symptoms, social stressors and sleep hours were completed on a smartphone at unexpected times in an Ecological Momentary Assessment paradigm twice a day. Multi-level models adjusted for potential subject heterogeneity were adopted to test the difference between the bipolar disorder and health control groups.

Results

Within-person variability of mood, energy, speed of thoughts, impulsivity, pain and perception of skill of tasks was significantly higher in the bipolar disorder group compared to health controls. Elevated bipolar disorder symptom domains in the evening were associated with reduced sleep time that night. Stressors were associated with worsening of bipolar disorder symptoms. Detection of symptoms when an individual is experiencing difficulty allows personalized, focused interventions.

Transdiagnostic psychiatry: a systematic review

The usefulness of current psychiatric classification, which is based on ICD/DSM categorical diagnoses, remains questionable. A promising alternative has been put forward as the "transdiagnostic" approach. This is expected to cut across existing categorical diagnoses and go beyond them, to improve the way we classify and treat mental disorders. This systematic review explores whether self-defining transdiagnostic research meets such high expectations. A multi-step Web of Science literature search was performed according to an a priori protocol, to identify all studies that used the word "transdiagnostic" in their title, up to May 5, 2018. Empirical variables which indexed core characteristics were extracted, complemented by a bibliometric and conceptual analysis. A total of 111 studies were included. Most studies were investigating interventions, followed by cognition and psychological processes, and neuroscientific topics. Their samples ranged from 15 to 91,199 (median 148) participants, with a mean age from 10 to more than 60 (median 33) years. There were several methodological inconsistencies relating to the definition of the gold standard (DSM/ICD diagnoses), of the outcome measures and of the transdiagnostic approach. The quality of the studies was generally low and only a few findings were externally replicated. The majority of studies tested transdiagnostic features cutting across different diagnoses, and only a few tested new classification systems beyond the existing diagnoses. About one fifth of the studies were not transdiagnostic at all, because they investigated symptoms and not disorders, a single disorder, or because there was no diagnostic information. The bibliometric analysis revealed that transdiagnostic research largely restricted its focus to anxiety and depressive disorders. The conceptual analysis showed that transdiagnostic research is grounded more on rediscoveries than on true innovations, and that it is affected by some conceptual biases. To date, transdiagnostic approaches have not delivered a credible paradigm shift that can impact classification and clinical care. Practical "TRANSD"iagnostic recommendations are proposed here to guide future research in this field.

Misevaluating the Future: Affective Disorder and Decision-Making Capacity for Treatment - A Temporal Understanding

BACKGROUND

Within psychiatric practice and policy there is considerable controversy surrounding the nature and assessment of impairments of decision-making capacity (DMC) for treatment in persons diagnosed with affective disorders. We identify the problems of "cognitive bias" and "outcome bias" in assessment of DMC for treatment in affective disorder and aim to help resolve these problems with an analysis of how time is experienced in depression and mania.

SAMPLING AND METHODS

We conducted purposeful sampling and a qualitative phenomenological analysis of interview data on patients with depression and mania, exploring temporal experience and decision-making regarding treatment.

RESULTS

In both severe depression and mania there is a distinctive experience of the future. Two consequences can follow: a loss of evaluative differentiation concerning future outcomes and, relatedly, inductive failure. This temporal inability can compromise an individual's ability to appreciate or "use or weigh" treatment information.

CONCLUSIONS

The decision-making abilities required for self-determination involve an ability to evaluate alternative future outcomes. Our results show that, within severe depression or mania, anticipation of future outcomes is inflexibly fixed at one end of the value spectrum. We therefore propose a temporal model of decision-making abilities, which could be used to improve assessment of DMC in affective disorder.

Bad Healthy State Compress Temporal Extension Both in Past and Future Orientations

We examined how different health states and cancer-related depression influence time perception in temporal extension (TE) regarding the past and the future over individuals' entire lives. We used the magnitude estimation method to investigate TE (past and future) and long duration (20 years), and directly measured patients with cancer and their subjective feelings about their lives. In Experiment 1, we investigated whether there were differences in perceptions of TE between patients with cancer (n = 144) compared to a healthy control group (n = 208). Results indicated that the patients with cancer group evaluated longer TE in healthy states (imagination condition) than in unhealthy states (objectivity condition), and the healthy control group evaluated longer TE in healthy states (objectivity condition) than in unhealthy states (imagination condition). Moreover, the patients with cancer group evaluated longer past-oriented TE than future-oriented TE, whereas the healthy control group evaluated longer future-oriented TE than past-oriented TE. Experiment 2 was conducted to further examine the unexplained findings of Experiment 1. Results indicated that because of the impact of depression on the cancer group, their embodied time system slowed down, and explicit behavior indicated an over-evaluation of time, resulting in group differences. In conclusion, TE could be affected by different health states. Moreover, healthy and unhealthy states may be more associated with future and past orientation, respectively. Lastly, individuals' time perception can be influenced by depression.

Subjective and objective sleep discrepancy in symptomatic bipolar disorder compared to healthy controls

BACKGROUND

Bipolar disorder (BD) is associated with sleep misperception. The objective of this study was to investigate the correlation between subjective and objective measures of sleep in persons with symptomatic bipolar disorder (BDS) compared to healthy controls (HC).

METHODS

We studied 24 BDS and 30 HC subjects similar in age, race and sex. Subjective sleep was measured with Pittsburgh Sleep Quality Index (PSQI) and objective sleep with 7-days of actigraphy. Absolute discrepancy variables were calculated by subtracting objective sleep latency (SL) and total sleep time (TST) on actigraphy from their respective subjective estimates from PSQI. Mood symptoms were measured with Young Mania Rating Scale and Hamilton Depression Rating Scale.

RESULTS

In the BDS group, subjective TST did not significantly correlate with objective TST, while it correlated in the HC group. The BDS group had significantly higher absolute discrepancy between subjective and objective SL and TST compared to the HC group. Multivariable regression analysis showed that severity of depression was associated with greater absolute discrepancy between subjective and objective TST within the BDS group.

LIMITATIONS

Subjects are from a tertiary care center and were on medications for treatment of BD symptoms.

CONCLUSION

There is low correlation between subjective and objective TST in BDS subjects and more severe depressive symptoms are associated with greater absolute discrepancy in TST. Objective rather than subjective measures of sleep, such as actigraphy, may be needed to evaluate sleep in BD subjects. Cognitive-behavioral interventions to address sleep misperception and associated depressed mood may be indicated in BD.

Too Fast or Too Slow? Time and Neuronal Variability in Bipolar Disorder-A Combined Theoretical and Empirical Investigation

Time is an essential feature in bipolar disorder (BP). Manic and depressed BP patients perceive the speed of time as either too fast or too slow. The present article combines theoretical and empirical approaches to integrate phenomenological, psychological, and neuroscientific accounts of abnormal time perception in BP. Phenomenology distinguishes between perception of inner time, ie, self-time, and outer time, ie, world-time, that desynchronize or dissociate from each other in BP: inner time speed is abnormally slow (as in depression) or fast (as in mania) and, by taking on the role as default-mode function, impacts and modulates the perception of outer time speed in an opposite way, ie, as too fast in depression and too slow in mania. Complementing, psychological investigation show opposite results in time perception, ie, time estimation and reproduction, in manic and depressed BP. Neuronally, time speed can be indexed by neuronal variability, ie, SD. Our own empirical data show opposite changes in manic and depressed BP (and major depressive disorder [MDD]) with abnormal SD balance, ie, SD ratio, between somatomotor and sensory networks that can be associated with inner and outer time. Taken together, our combined theoretical-empirical approach demonstrates that desynchronization or dissociation between inner and outer time in BP can be traced to opposite neuronal variability patterns in somatomotor and sensory networks. This opens the door for individualized therapeutic "normalization" of neuronal variability pattern in somatomotor and sensory networks by stimulation with TMS and/or tDCS.

Immediate Mood Scaler: Tracking Symptoms of Depression and Anxiety Using a Novel Mobile Mood Scale

BACKGROUND

Mood disorders are dynamic disorders characterized by multimodal symptoms. Clinical assessment of symptoms is currently limited to relatively sparse, routine clinic visits, requiring retrospective recollection of symptoms present in the weeks preceding the visit. Novel advances in mobile tools now support ecological momentary assessment of mood, conducted frequently using mobile devices, outside the clinical setting. Such mood assessment may help circumvent problems associated with infrequent reporting and better characterize the dynamic presentation of mood symptoms, informing the delivery of novel treatment options.

OBJECTIVES

The aim of our study was to validate the Immediate Mood Scaler (IMS), a newly developed, iPad-deliverable 22-item self-report tool designed to capture current mood states.

METHODS

A total of 110 individuals completed standardized questionnaires (Patient Health Questionnaire, 9-item [PHQ-9]; generalized anxiety disorder, 7-Item [GAD-7]; and rumination scale) and IMS at baseline. Of the total, 56 completed at least one additional session of IMS, and 17 completed one additional administration of PHQ-9 and GAD-7. We conducted exploratory Principal Axis Factor Analysis to assess dimensionality of IMS, and computed zero-order correlations to investigate associations between IMS and standardized scales. Linear Mixed Model (LMM) was used to assess IMS stability across time and to test predictability of PHQ-9 and GAD-7 score by IMS.

RESULTS

Strong correlations were found between standard mood scales and the IMS at baseline (r=.57-.59, P<.001). A factor analysis revealed a 12-item IMS ("IMS-12") with two factors: a "depression" factor and an "anxiety" factor. IMS-12 depression subscale was more strongly correlated with PHQ-9 than with GAD-7 (z=1.88, P=.03), but the reverse pattern was not found for IMS-12 anxiety subscale. IMS-12 showed less stability over time compared with PHQ-9 and GAD-7 (.65 vs .91), potentially reflecting more sensitivity to mood dynamics. In addition, IMS-12 ratings indicated that individuals with mild to moderate depression had greater mood fluctuations compared with individuals with severe depression (.42 vs .79; P=.04). Finally, IMS-12 significantly contributed to the prediction of subsequent PHQ-9 (beta=1.03, P=.02) and GAD-7 scores (beta =.93, P=.01).

CONCLUSIONS

Collectively, these data suggest that the 12-item IMS (IMS-12) is a valid tool to assess momentary mood symptoms related to anxiety and depression. Although IMS-12 shows good correlation with standardized scales, it further captures mood fluctuations better and significantly adds to the prediction of the scales. Results are discussed in the context of providing continuous symptom quantification that may inform novel treatment options and support personalized treatment plans.

Cronbach's α reliability, concurrent validity, and factorial structure of the Death Depression Scale in an Iranian hospital staff sample

OBJECTIVE

Death depression is an important component in the process of death and dying. Death depression is the second element of death. Depression is one of the important features in death distress. The aim of this study was to explore the performance of the Farsi version of the Death Depression Scale with an Iranian convenience sample of nurses (n = 106).

METHODS

Nurses were selected using a convenience sampling method, and completed the Death Depression Scale (DDS), Death Concern Scale (DCS), Collett-Lester Fear of Death Scale (CLFDS), Reasons for Death Fear Scale (RDFS), Templer's Death Anxiety Scale (DAS), and Death Obsession Scale (DOS).

RESULTS

The results of exploratory factor analysis on DDS identified 4 factors (56.16% of variance). Factor 1 labeled "Death sadness", Factor 2 labeled "Death finality/end and Death dread/fear", Factor 3 labeled "Death despair and Death depression", and Factor 4 labeled "Death loneliness". Cronbach's α coefficient was 0.84, Spearman-Brown coefficient 0.85, and Guttman Split-Half coefficient 0.81 The DDS correlated 0.40 with the DCS, 0.39 with the CLFDS, 0.50 with the DAS, 0.35 with the RDFS, and 0.44 with the DOS, indicating good construct and criterion-related validity. Concurrent validity for the DDS with the other scales were significant.

CONCLUSIONS

The DDS has good validity and reliability, and it can use in clinical and research settings.

A factor analytical study report on mania from Nepal

BACKGROUND AND OBJECTIVES

Phenomenological studies on mood disorder are rare in Nepal which prompted us to undertake the current factor analytical study of mania.

MATERIALS AND METHODS

It was a cross-sectional descriptive study for which we did purposive sampling technique according to certain inclusion and exclusion criteria. The study sample consists of fifty patients, who fulfilled the International Classification of Diseases, Tenth Edition (ICD-10) diagnostic criteria for Manic Episode and/or Bipolar Affective Disorder-current episode mania. Tools used were ICD-10 Diagnostic Criteria for Research, Young's Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Principal component factor analysis was applied to the 35 symptoms taken from YMRS and BPRS.

RESULTS

Factor analysis revealed the presence of four main factors, which explained 51.082% of the total variance. These are "pure mania" which isolated 11 manic symptoms, "dysphoric mania" which isolated five depressive symptoms, "hostile mania" which isolated six symptoms, and the fourth factor, we called it "delirious mania," isolated four symptoms.

CONCLUSION

The identified factors and subtypes are a useful conceptualization of atypical features among patients with acute mania. Further validation studies are required to determine whether the identified subtypes are of clinical and theoretical importance.

Swedish Version of Mood Spectrum Self-Report Questionnaire: Psychometric Properties of Lifetime and Last-week Version

BACKGROUND

Mood Spectrum Self Report (MOODS-SR) is an instrument that assesses mood spectrum symptomatology including subthreshold manifestations and temperamental features. There are different versions of the MOODS-SR for different time frames of symptom assessment: lifetime (MOODS-LT), last-month and last-week (MOODS-LW) versions.

OBJECTIVE

To evaluate the psychometric properties of the MOODS-LT the MOODS-LW.

METHODS

The reliability of the MOODS-LT and MOODS-LW was evaluated in terms of internal consistency and partial correlations among domains and subdomains. The known-group validity was tested by comparing out-patients with bipolar disorder (n=27), unipolar depression (n=8) healthy controls (n=68). The convergent and divergent validity of MOODS-LW were evaluated using the Montgomery Åsberg Depression Rating Scale (MADRS), the Young-Ziegler Mania Rating Scale (YMRS) in outpatients as well the General Health Questionnaire (GHQ-12) in healthy controls.

RESULTS

Both MOODS-LT and MOOODS-LW showed high internal consistency with the Kuder-Richardson coefficient ranging from 0.823 to 0.985 as well as consistent correlations for all domains and subdomains. The last-week version correlated significantly with MADRS (r= 0.79) and YMRS (r=0.46) in outpatients and with GHQ-12 (r= 0.50 for depression domain, r= 0.29 for rhythmicity) in healthy controls.

CONCLUSION

The Swedish version of the MOODS-LT showed similar psychometric properties to other translated versions. Regarding MOODS-LW, this first published psychometric evaluation of the scale showed promising psychometric properties including good correlation to established symptom assessment scales. In healthy controls, the depression and rhythmicity domain scores of the last-week version correlated significantly with the occurrence of mild psychological distress.

Humanistic Psychiatry and Psychotherapy: Listening to Patients as Persons in Search of Meaning. The Case of Schizophrenia

Confronted with any kind of critical event, people tend to develop an urgent need for answers that provide a useful interpretation of what they experience as a painfully intruding disaster. This urge results from the often-unbearable suffering and the disruption of everyday life, routines, and relations. Moreover, dreams and aspirations one had for the future, the realization of which they perceived as important in leading a meaningful life, may be lost or have to be reconsidered. Accompanying feelings of disappointment, demoralization, or even desperation are often treated as symptoms of depression. This approach is called into question by the concept of demoralization, which points to the presence of healthy modes of functioning in a state of lucid awareness of one’s condition. In this article, we focus on the case of schizophrenia, as we suppose that having to deal with recurring psychotic episodes constitutes such a pervasive experience, possibly leading to meaning deficiency. We propose then a treatment perspective that integrates care for the processes of mourning and of meaning making. This view, described here in the case of schizophrenic psychosis, is offered as a paradigm that can serve the approach to other serious conditions requiring prolonged care.

Daily mood monitoring of symptoms using smartphones in bipolar disorder: A pilot study assessing the feasibility of ecological momentary assessment

BACKGROUND

Personal device technology has facilitated gathering data in real-time using Ecological momentary assessment (EMA). We hypothesized that using smartphones to measure symptoms in auto-generated surveys twice a day would be feasible in a group with bipolar disorder (BD). A second exploratory objective of this study was to compare potential differences in core symptoms between BD and healthy control (HC) groups.

METHODS

A two-arm, parallel group, observational study was designed to measure completion rates of surveys of symptoms of mood, energy, speed of thought, impulsivity, and social stress in BD (N=10) and HC (N=10) participants. The surveys were auto-generated twice a day for fourteen days, and subjects could also perform self-generated surveys. Completion rates were compared between BD and HC groups. Scores were averaged for each participant over the 14 day period, and group medians were compared.

RESULTS

Median completion rates did not differ between groups: 95% in BD, 88% in HC (p=0.68); the median completion rate of auto-generated surveys in the BD group was 79% and in the HC group was 71% (p=0.22). The BD group had significantly lower median mood score (p=0.043) and energy score (p=0.007) than the HC group. Median scores of speed of thoughts (p=0.739), impulsivity (p=0.123) and social stress (p=0.056) did not significantly differ between BD and HC. The BD group had significantly higher range of variability of group median mood (p=0.043), speed of thoughts (p=0.002) and impulsivity (p=0.005) scores over the course of 14 days than HC, while range of variability of energy (p=0.218) and social stress (p=0.123) scores did not differ. Results were not significantly different between auto-generated and self-generated surveys for BD or HC.

LIMITATIONS

This pilot study was conducted for a short time and with a small sample.

CONCLUSIONS

This study demonstrates feasibility of using EMA with a smartphone to gather data on BD symptoms.

What Is Constructionism in Psychiatry? From Social Causes to Psychiatric Classification

It is common to note that social environment and cultural formation shape mental disorders. The details of this claim are, however, not well understood. The paper takes a look at the claim that culture has an impact on psychiatry from the perspective of metaphysics and the philosophy of science. Its aim is to offer, in a general fashion, partial explications of some significant versions of the thesis that culture and social environment shape mental disorders and to highlight some of the consequences social constructionism about psychiatry has for psychiatric explanation. In particular, it will be argued that the alleged dependence of facts about particular mental disorders and about the second order property of being a mental disorder on social facts amounts to a robust form of constructivism, whereas the view that clinician-patient interaction is influenced by cultural facts is perfectly compatible with an anti-constructivist stance.

The current dialogue between phenomenology and psychiatry: a problematic misunderstanding

A revival of the dialogue between phenomenology and psychiatry currently takes place in the best international journals of psychiatry. In this article, we analyse this revival and the role given to phenomenology in this context. Although this dialogue seems at first sight interesting, we show that it is problematic. It leads indeed to use phenomenology in a special way, transforming it into a discipline dealing with empirical facts, so that what is called "phenomenology" has finally nothing to do with phenomenology. This so-called phenomenology tallies however with what we have always called semiology. We try to explain the reasons why phenomenology is misused in that way. In our view, this transformation of phenomenology into an empirical and objectifying discipline is explained by the role attributed to phenomenology by contemporary authors, which is to solve the problems raised by the Diagnostic and Statistical Manual of Mental Disorders.

Major depressive disorder: a qualitative study on the experiences of Iranian patients

Major depressive disorder (MDD) is one the most common mental disorders; it affects about 5-10% of the world population. This study explores the experiences of people with major depressive disorder in Zanjan, Iran. In order to identify recurring themes and patterns in individuals' experiences of major depressive disorder, semi-structured interviews with 18 patients were recorded and transcribed verbatim. The transcripts were then analyzed based on conventional qualitative content analysis. Five main categories emerged. The first category was called emotional paralysis and included the subcategories feeling severely depressed; feeling anxious; feeling impatient and irritable; and having dyshedonia. The second category was disturbance of thinking and was comprised of the subcategories of preoccupation, instable spiritual beliefs, and guilt. Cognitive decline was the third identified category and was further divided into subcategories of frustration, unawareness of the disorder, negative evaluation, indecisiveness, and loss of focus and loss of memory. Another major category was physical illnesses with the subcategories of physical discomfort, sleep problems, appetite disturbance, facial changes, sexual dysfunction, and medical conditions. The final category was failure in life, which had failure in personal affairs, jeopardized interpersonal relations, and unstable work life as subcategories. These findings provide a base for further research in this area. They also have clinical relevance for health care providers working with patients with MDD. Related cultural issues also are discussed.

Biological rhythms and mood disorders

Integration of several approaches concerning time and temporality can enhance the pathophysiological study of major mood disorders of unknown etiology. We propose that these conditions might be interpreted as disturbances of temporal profile of biological rhythms, as well as alterations of time-consciousness. Useful approaches to study time and temporality include philological suggestions, phenomenological and psychopathological conceptualizatíons, clinical descriptions, and research on circadian and ultradían rhythms, as well as nonlinear dynamics approaches to their analysis.

Time perception, emotions and mood disorders

In this review, we describe recent internal clock models accounting for time perception and look at how they try to explain the time distortions produced by emotion. We then discuss the results of studies of patients suffering from affective disorders (depression) who experience the feeling of time slowing down. A distinction is thus made between time perception and explicit awareness of the passage of time. We conclude that the feeling that time is passing slowly is not systematically associated with a disruption in the basic mechanisms underlying time perception.

Varieties of temporal experience in depression

People with depression often report alterations in their experience of time, a common complaint being that time has slowed down or stopped. In this paper, I argue that depression can involve a range of qualitatively different changes in the structure of temporal experience, some of which I proceed to describe. In addition, I suggest that current diagnostic categories such as "major depression" are insensitive to the differences between these changes. I conclude by briefly considering whether the kinds of temporal experience associated with depression are specific to depression.

The varieties of depressive experience: diagnosing mood disorders

Biopsychosocial eclecticism has led, the authors believe, to a simplistic acceptance of a unitary view of MDD with little scientific solidity. The authors propose a return to careful psychopathology as the basis of all nosology, which has led to identifying four main types of depressive illness, and a method-based, existential approach to understanding depression.

Insight in bipolar disorder: associations with cognitive and emotional processing and illness characteristics

OBJECTIVE

To investigate the multifactorial relationship between illness insight, cognitive and emotional processes, and illness characteristics in bipolar disorder patients.

METHODS

Data from 85 euthymic or mildly to moderately depressed bipolar disorder patients were evaluated. Insight was measured using the Mood Disorder Insight Scale (total score and subscale scores: awareness of illness, symptom attribution, and need for treatment). Cognitive and emotional functioning was measured in four domains (processing speed, memory, executive functioning, and emotional learning) in addition to premorbid IQ. Illness characteristics were assessed using the Mini-International Neuropsychiatric Interview, the Questionnaire for Bipolar Disorder, and the Inventory of Depressive Symptomatology-self rating scale. Regression analyses were performed for the whole sample. Post-hoc, interactions with lifetime psychotic features (LPF) were statistically tested and if significant, analyses were repeated for patients with (n = 36) and without (n = 49) LPF separately.

RESULTS

In the whole group, better insight was associated with lower processing speed, better memory performance, increased emotional learning, higher level of depressive symptoms, and longer duration of illness. Patients with LPF had worse awareness of illness, but better symptom attribution than patients without LPF. No group differences for need for treatment and overall insight were found. Finally, processing speed significantly predicted subscores for symptom attribution in patients with LPF only.

CONCLUSIONS

Cognitive functioning as well as impairments in emotional learning and psychotic features independently contributes to impaired insight in bipolar disorder. Processing speed seems to be a key variable in the prediction of insight in patients with LPF and not in patients without LPF.

Positive aspects of mental illness: a review in bipolar disorder

INTRODUCTION

There is growing interest to understand the role of positive psychological features on the outcomes of medical illnesses. Unfortunately this topic is less studied in relation to mental health, and almost completely neglected in relation to one of the most common severe psychiatric illnesses, bipolar disorder. Certain specific psychological characteristics, that are generally viewed as valuable and beneficial morally or socially, may grow out of the experience of having this affective disorder.

OBJECTIVE

We describe the sources, research and impact of these positive psychological traits in the lives of persons with bipolar disorder based on the few published literature available to date. These include, but are not limited to: spirituality, empathy, creativity, realism, and resilience.

METHODS

After an extensive search in the literature, we found 81 articles that involve descriptions of positive psychological characteristics of bipolar disorder.

RESULTS

We found evidence for enhancement of the five above positive psychological traits in persons with bipolar disorder.

CONCLUSIONS

Bipolar disorder is associated with the positive psychological traits of spirituality, empathy, creativity, realism, and resilience. Clinical and research attention to preserving and enhancing these traits may improve outcomes in bipolar disorder.

Regaining mental capacity for treatment decisions following psychiatric admission: a clinico-ethical study

BACKGROUND

Mental capacity is an emerging ethical legal concept in psychiatric settings but its relation to clinical parameters remains uncertain. We sought to investigate the associations of regaining capacity to make treatment decisions following approximately 1 month of in-patient psychiatric treatment.

METHOD

We followed up 115 consecutive patients admitted to a psychiatric hospital who were judged to lack capacity to make treatment decisions at the point of hospitalization. We were primarily interested in whether the diagnosis of schizophrenia and schizoaffective disorder associated with reduced chances of regaining capacity compared with other diagnoses and whether affective symptoms on admission associated with increased chances of regaining capacity. In addition, we examined how change in insight was associated with regaining capacity in schizophrenia, bipolar affective disorder (BPAD)-mania, and depression.

RESULTS

We found evidence that the category of 'schizophrenia or schizoaffective disorder' associated with not regaining capacity at 1 month compared with BPAD-mania [odds ratio (OR) 3.62, 95% confidence intervals (CI) 1.13-11.6] and depression (OR 5.35, 95% CI 1.47-9.55) and that affective symptoms on admission associated with regaining capacity (OR 1.23, 95% CI 1.02-1.48). In addition, using an interaction model, we found some evidence that gain in insight may not be a good indicator of regaining capacity in patients with depression compared with patients with schizophrenia and BPAD-mania.

CONCLUSIONS

We suggest that clinico-ethical studies using mental capacity provide a way of assessing the validity of nosological and other clinical concepts in psychiatry.

Domains of awareness in schizophrenia

Patients with schizophrenia are often characterized as lacking insight or awareness into their illness and symptoms, yet despite considerable research, we still lack a full understanding of the factors involved in causing poor awareness. Within schizophrenia, there has been shown to be a fractionation across dimensions of awareness into mental illness: of being ill, of symptoms, and of treatment compliance. Recently, attention has turned to evidence of a fractionation between awareness of illness and of cognitive impairments and functioning. The current study investigated the degree of fractionation across a broad range of domains of function in schizophrenia and how each domain may be associated with neuropsychological functioning, clinical, mood, and demographic variables. Thirty-one mostly chronic stable patients with schizophrenia completed a battery of neuropsychological tests and measures of psychopathology, including mood. Cognitive insight and awareness of illness, symptoms, memory, and behavioral functioning were also measured. Insight and awareness were assessed using a combination of semistructured interview, observer-rated, self-rated, and objective measures, and included measures of the discrepancy between carer and self-ratings of impairment. Results revealed that awareness of functioning in each domain was largely independent and that awareness in each domain was predicted by different factors. Insight into symptoms was relatively poor while insight into cognitive deficits was preserved. Relative to neuropsychological variables, cognitive insight, comprising self-certainty and self-reflexivity, was a greater predictor of awareness. In conclusion, awareness is multiply fractionated and multiply determined. Therapeutic interventions could, therefore, produce beneficial changes within specific domains of awareness.

Extra dimensions in all aspects of life-the meaning of life with bipolar disorder

Living with Bipolar Disorder (BD) greatly affects the whole life; still the meaning of it is poorly explored from the perspective of the individuals actually living with it. The aim of this study is thus to explore the existential meaning of life with BD. Ten persons, six women and four men, (aged 30–61), diagnosed with BD were interviewed. A reflective lifeworld perspective based on phenomenological philosophy was used. The findings show that living with BD entails experiencing extra dimensions in all aspects of life, expressed in terms of a magnitude and complexity beyond that which is perceived as pertaining to normal life. The essential meaning of the phenomenon is further described by its constituents: “a specific intensity”, “a struggle to understand”, “an illness that is intertwined with one's whole being”. Living with BD means more for the individual than having episodes of depression and mania and must therefore be understood from a holistic perspective. Adequate care for persons with BD, therefore, includes places for safe and profound reflecting about existential issues, such as identity, trust and self-confidence. The present study recommends the caring services to change their ways to explain and talk about the BD illness.

Psychopathological assessment of schizophrenia: relevance for classification

Considerable effort has been focused on updating the clinical aspects of psychiatric classifications based on recent progress in the field of neurobiology. In this article, recent developments in the primary assessment methods within clinical psychiatry, which are based in phenomenological psychopathology, are reviewed as nosotaxies that are still embedded in clinical description. New directions for research on psychopathology are outlined to elicit better descriptions of subjective experience from patients. Finally, the known limitations of the Kraepelinian dichotomy are summarized, and future problems related to the inclusion of the new dimensional assessment methods in the next psychiatric classifications are described.

Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression

The widely held clinical view of 'antidepressants' as highly effective and specific for the treatment of all types of depressive disorders is exaggerated. This sobering conclusion is supported by recent findings from the NIMH-sponsored STEP-BD and STAR*D projects. Antidepressants have limited short-term efficacy in unipolar depressive disorders and less in acute bipolar depression; their long-term prophylactic effectiveness in recurrent unipolar major depression remains uncertain, and is doubtful in recurrent bipolar depression. These limitations may, in part, reflect the excessively broad concept of major depression as well as unrealistic expectations of universal efficacy of drugs considered 'antidepressants.' Treatment-refractory depression may reflect failure to distinguish depressive conditions, particularly bipolar disorder, that are inherently less responsive to antidepressants. Antidepressants probably should be avoided in bipolar depression, mixed manic-depressive states, and in neurotic depression. Expectations of antidepressants for specific types of patients with symptoms of depression or anxiety require critical re-evaluation. A revival of the concept of neurotic depression would make it possible to identify patients with mild-to-moderate, chronic or episodic dysthymia and anxiety who are unlikely to benefit greatly from antidepressants. Diagnostic criteria for a revival of the concept of neurotic depression are proposed.

Evolutionary analysis of PHLPP1 gene in humans and non-human primates

The chromosome 18q22-23 region has been shown to be implicated in bipolar disorder (BPAD) by several studies. PHLPP1 gene, in the locus (chromosome 18q22-23), is involved in circadian pathways and bears modules like 'PH domain and leucine rich repeat protein phosphatase'. This gene also contains a polyglutamine (CAG or PolyQ) repeat motif at the carboxyl terminal end. A comparative analysis of the PolyQ repeats of the PHLPP1 gene in humans, non-human primates and other species has been attempted in order to investigate the possible significance of repeat length as seen in other triplet-repeat associated diseases. Sequencing of the CAG repeat in humans and in non-human primates revealed that the CAG repeat is not polymorphic in humans; whereas, in other species it shows an area of high variability, both in length and sequence composition. Despite the conservation of circadian clock components in different species, there is remarkable diversity in the protein structure, regulation and biochemical functions of the circadian orthologs. These can be due to specific adaptations in accordance with the physiology of the particular species providing a species-specific biological advantage.

The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective

There is considerable controversy, both within and outside the field of psychiatry, regarding the boundaries of normal sadness and clinical depression. Furthermore, while there are frequent calls for a "pluralistic", comprehensive approach to understanding depression, few writers have tried to integrate insights from the spiritual, philosophical, and neurobiological literature. The author proposes that such a synthesis is possible, and that our understanding of ordinary sorrow and clinical depression is enriched by drawing from these disparate sources. In particular, a phenomenological analysis of sorrow and depression reveals two overlapping but distinct "lifeworlds". These differ in the relational, temporal, dialectical, and intentional realms. Recent brain imaging studies are also beginning to reveal the neurobiological correlates of sorrow and depression. As we come to understand the neurobiology of these states, we may be able to correlate specific alterations in "neurocircuitry" with their phenomenological expressions.