Comparative study of affective disorders in three Asian countries. I. Differences in diagnostic classification

Introducing the concept of modern depression in Japan; an international case vignette survey

AIM

Japanese psychiatrists have increasingly reported patients with depression that does not seem to fit the criteria of the ICD-10 and the DSM-IV, and which has recently been called modern type depression (MTD). We explored whether MTD is frequently seen in Japan and also in other countries, and if so, how patients with MTD are diagnosed and treated.

METHODS

The questionnaires, with two case vignettes (traditional type depression (TTD) and MTD), were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated their opinions about each case's prevalence in their country, etiology, diagnosis, suicide risk, and treatment using Likert scales.

RESULTS

Out of 247 responses (123 from Japan and 124 from other countries), two hundred thirty-nine valid responses were received. MTD was recognized in all participating countries, and especially in urban areas. Generally, the factor of personality was regarded as the most probable cause of MTD. Whereas about 90% of Japanese psychiatrists applied the ICD/DSM criteria to TTD, only about 60% applied the criteria to MTD.

CONCLUSION

Our results indicate that Japan's MTD seems to be occurring in many other countries, and that the present ICD/DSM criteria may not be sufficient to diagnose MTD. Therefore, it could be an important candidate for a new international diagnostic criterion as a subtype of depression. A clear diagnostic framework and consensus on the interventions to treat MTD would be valuable. Further clinical, psychopathological and international epidemiological studies are needed to confirm our preliminary findings of MTD.

Depression and adipose and serum cholesteryl ester polyunsaturated fatty acids in the survivors of the seven countries study population of Crete

BACKGROUND

Studies have shown that depression relates to biomarkers of both short- and long-term polyunsaturated fatty acid (PUFA) intake. However, it is not known which of these two biomarkers has the closest relationship to depression.

OBJECTIVE

To examine the relationship of depression with both adipose tissue and serum cholesteryl ester PUFA and to assess the importance of each of these two biomarkers in relating to depression.

DESIGN

Cross-sectional study of healthy elderly men from the island of Crete.

SETTING

The Preventive Medicine and Nutrition Clinic, University of Crete, Greece.

SUBJECTS

A total of 150 males, aged 80-96 years. The subjects were survivors of the Greek Seven Countries Study group.

METHODS

Fatty acids were determined by gas chromatography in adipose tissue and serum cholesteryl esters. Information about depression was obtained through the use of the short form of the Geriatric Depression Scale (GDS-15).

RESULTS

Regression analysis showed that depression related positively to age and serum cholesteryl ester arachidonic/docosahexaenoic fatty acid ratio. The only significant unadjusted correlation between depression and serum cholesteryl ester and adipose fatty acids was with adipose alpha-linolenic acid (ALA) (r = -0.31, P < 0.01). Depressed males (GDS-15 > 5) had lower adipose ALA and sum n-3 fatty acids than non-depressed ones. There were no significant differences between depressed and non-depressed males in serum cholesteryl ester fatty acids. When adipose tissue ALA was included as one of the independent measures in the regression model, the observed positive relation between GDS-15 depression and cholesteryl ester arachidonic/docosahexaenoic ratio failed to persist. Instead, there was a negative relationship between GDS-15 depression and adipose tissue ALA.

CONCLUSIONS

It appears that the fatty acids of the adipose tissue are better predictors of depression than those of serum cholesteryl esters. This indicates that depression relates more strongly to long-term than to short-term fatty acid intake. The reason for this may be the reported slow rate of deposition of dietary PUFA to the brain.

Depression and adipose polyunsaturated fatty acids in an adolescent group

The purpose of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake and depression. The sample consisted of 90 adolescents from the island of Crete. There were 54 girls and 36 boys, aged 13-18. The mean age was 15.2 years. Subjects were examined by the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D). Unlike other studies, there were no significant relations between adipose tissue n-3 or n-6 polyunsaturated fatty acids and depression. BDI correlated positively with adipose tissue C20:3n-6/C18:3n-6 ratio, while CES-D correlated positively with adipose tissue (C20:3n-6+C22:5n-3)/(C18:3n-6+C20:5n-3) ratio. Depressed subjects (BDI>16, CES-D>16) had significantly elevated adipose tissue C20:3n-6/C18:3n-6 and (C20:3n-6+C22:5n-3)/(C18:3n-6+C20:5n-3) ratios, than non-depressed subjects. The observed positive relation between depression and the particular fatty acid ratios, in the present study, appears to indicate increasing activity of elongases, the enzymes responsible for elongating polyunsaturated fatty acids into their longer-chain derivatives, with increasing depression. This is the first literature report of a possible relation between elongases and depression. The observed relation may stem from a possible over-expression of the HELO1 (ELOVL5) gene, the gene encoding a protein responsible for elongating long-chain polyunsaturated fatty acids, in the adipose tissue of depressed adolescents.

Depression and adipose polyunsaturated fatty acids in the survivors of the Seven Countries Study population of Crete

The purpose of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake and depression. The sample consisted of 150 elderly males from the island of Crete. The subjects were survivors of the Greek Seven Countries Study group. The mean age was 84 years. The number of subjects with complete data on all variables studied was 63. Subjects were examined by the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the short form of the Geriatric Depression Scale (GDS-15). Depression correlated negatively with adipose tissue alpha-linolenic acid (C18:3n-3). Depressed subjects had significantly reduced (-10.5%) adipose tissue C18:3n-3 levels than non-depressed subjects. The observed negative relation between adipose tissue C18:3n-3 and depression, in the present study, appears to indicate increasing long-term dietary C18:3n-3 intakes with decreasing depression. This agrees with findings of other studies indicating an inverse relation between depression and consumption of fish and n-3 polyunsaturated fatty acids. This is the first literature report of a relation between adipose tissue C18:3n-3 and depression. Furthermore, this is the first report of a relation between adipose PUFA and depression in an elderly sample. Depression has been reported to be associated with elevated cytokines, such as, IL-1, IL-2, IL-6, INF-gamma and INF-alpha. Fish oil and omega-3 fatty acids, on the other hand, have been reported to inhibit cytokine production. The observed negative relation between adipose C18:3n-3 and depression, therefore, may stem from the inhibiting effect of C18:3n-3 or its long-chain metabolites on cytokine synthesis.

Transcultural issues in mood and anxiety disorders: a focus on Japan

Accurate comparisons of the prevalence of psychiatric disorders across Eastern and Western cultures are difficult and limited by methodological problems. Nevertheless, using standardized diagnostic and evaluation techniques, recent surveys have suggested that depression and anxiety disorders exist in all countries and cultures examined thus far, although variations in the prevalence rates and symptomatology may exist. This article discusses the influence and impact that culture can have on recognizing and treating mood and anxiety disorders, with a particular focus on Japan. Over the last 20 years, studies have consistently reported an increase in mental illness in Japan, especially symptoms of depression and anxiety. While such symptoms have had an adaptive cultural role in the past, current social and economic changes in Japan have turned any adaptive advantage into a potentially significant disadvantage, with a major impact on the capacity of individuals to function adequately. The situation is compounded by the fact that Japanese patients are reluctant to openly discuss disturbances of mood, since these are considered to be indicative of personal weakness rather than treatable medical conditions. Reluctance to discuss personal mental health hinders timely recognition and appropriate treatment.

Depression and adipose essential polyunsaturated fatty acids

The objective of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake, and depression. The sample consisted of 247 healthy adults (146 males, 101 females) from the island of Crete. The number of subjects with complete data on all variables studied was 139. Subjects were examined at the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the Zung Self-rating Depression Scale. Mildly depressed subjects had significantly reduced (-34.6%) adipose tissue docosahexaenoic acid (DHA) levels than non-depressed subjects. Multiple linear regression analysis indicated that depression related negatively to adipose tissue DHA levels. In line with the findings of other studies, the observed negative relation between adipose tissue DHA and depression, in the present study, appears to indicate increasing long-term dietary DHA intakes with decreasing depression. This is the first literature report of a relation between adipose tissue DHA and depression. Depression has been reported to be associated with increased cytokine production, such as IL-1, IL-2, IL-6, INF-gamma and INF-alpha. On the other hand, fish oil and omega-3 fatty acids have been reported to inhibit cytokine synthesis. The observed negative relation between adipose DHA and depression, therefore, may stem from the inhibiting effect of DHA on cytokine synthesis.

Comparative study of affective disorders in three Asian countries. II. Differences in prevalence rates and symptom presentation

This study used standardized diagnostic criteria and method to investigate both prevalence rates and nature of symptoms of depressive disorders in three Asian centres--Nagasaki, Shanghai and Seoul. Of the patients who visited a psychiatric clinic in each of the 3 centres for the first time, over 20% suffered from depression. Unlike previous reported prevalence rates for Asian countries, these results suggest that rates in Asia may not be much lower than those reported in Western countries. Although prevalence rates of depression were similar in all 3 centres, differences in symptoms were noted.

Cultural influences on depression: a new methodological approach and its results

Transcultural research into psychopathology has often failed to produce a systematic body of findings concerning the relationship between culture and psychopathology. In this paper an attempt is made to overcome this problem by examining the relationship between culture and depression in terms of a theoretical task. Japanese and Australian depressed patients were given measures of depression and decision making. The relationship between specific variables associated with depression and those associated with decision making was investigated. Results showed that those depression variables which influenced decision making for Japanese patients were different to those for Australian patients. These findings are discussed in terms of their implications for psychiatric diagnosis and understanding the relationship between culture and depression.

The macrophage theory of depression

Excessive secretion of macrophage monokines is proposed as the cause of depression. Monokines when given to volunteers can produce the symptoms necessary for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R) diagnosis of major depressive episode. Interleukin-1 (IL-1) can provoke the hormone abnormalities linked with depression. This theory provides an explanation for the significant association of depression with coronary heart disease, rheumatoid arthritis, stroke and other diseases where macrophage activation occurs. The 3:1 female/male incidence of depression ratio is accounted for by estrogen's ability to activate macrophages. The extraordinary low rate of depression in Japan is consistent with the suppressive effect of eicosapentanoic acid on macrophages. Fish oil is proposed as a prophylaxis against depression and omega-6 fat as a promoter. Infection, tissue damage, respiratory allergies and antigens found in food are some of the possible causes of macrophage activation triggering depression.

A study of depression in two cultures: a transcultural study with Japanese and Australian clinically depressed patients

Recently there has emerged a growing interest in transcultural aspects of depressive disorders. Unlike earlier studies, recent research has concentrated on using standardized assessment and evaluation procedures in an effort to reduce "differences" associated with research techniques. The following paper reports a study which, using the WHO developed Standardized Assessment of Depressive Disorders (WHO/SADD) schedule, examines the nature of depressive symptomatology in Australian and Japanese clinically depressed patients. While results supported the presence of a "symptom core" common to both cultures, some unexpected findings in relation to "feelings of guilt" and "severity of depression" were noted.