Preadult onset vs. adult onset of major depressive disorder: a replication study

Integrative intrinsic brain activity and molecular analyses of the interaction between first-episode depression and age

BACKGROUND

Numerous studies have underscored the presence of abnormal intrinsic neural activity (INA) in individuals with depression. However, recognizing that the age stage may influence the pathophysiology of depression, our study sought to delve into the interplay of depression and age on INA and molecular architecture.

METHODS

One hundred and thirty-eight first-episode depression patients and 120 healthy controls (HC) were recruited and underwent resting-state functional magnetic resonance imaging. The participants were stratified into four groups based on age. Utilizing amplitude of low-frequency fluctuation (ALFF) analyses, we employed an ANCOVA to compare INA patterns in four groups. Additionally, we conducted correlation analyses between ALFF and neurotransmitter maps to elucidate molecular underpinnings of INA abnormalities.

RESULTS

In comparison to adolescents with early-onset depression and adult HC, adult-onset depression exhibited increased ALFF in the right paracentral lobule. Conversely, early-onset depression, when contrasted with adolescent HC, displayed reduced ALFF in the right paracentral lobule. The interactive brain regions affected by ALFF alterations were associated with serotonergic, GABAergic, and opioid neurotransmitter systems.

LIMITATIONS

The present study was limited to its cross-sectional design.

CONCLUSIONS

This study illuminates an antagonistic effect of depression and age on brain activity in paracentral lobule and provides molecular underpinnings of the corresponding INA abnormalities related to key neurotransmitter systems. These insights may prove valuable in the development of neuromarkers for clinical intervention and treatment of depression.

Improving usual care outcomes in major depression in youth by targeting memory specificity: A randomized controlled trial of adjunct computerized memory specificity training (c-MeST)

OBJECTIVE

Extending on previous findings that computerized Memory Specificity Training (c-MeST) improves memory specificity and depressive symptoms in Major Depressive Disorder (MDD) in adults, this study aimed to assess the effects of c-MeST in youth with MDD on memory specificity and depression in addition to other treatment.

METHODS

Participants aged 15-25 (N = 359, 76 % female; M age = 19.2, SD = 3.1), receiving predominantly psychological therapy or counseling (85 %) and/or antidepressants (52 %) were randomized to usual care and c-MeST or usual care. Cognitive and clinical outcomes were assessed at baseline and at one, three, and six-month follow-ups.

RESULTS

The usual care and c-MeST group reported higher memory specificity at one-month (d = 0.42, p = .022), but not at three or six months (d's < 0.15, p's > 0.05). The rate of MDE was numerically lower in the c-MeST group at each follow-up time-point, but group was not a statistically significant predictor at one month (64 % usual care and c-MeST vs. 68 % usual care, OR = 0.81, p = .606), three months (67 % usual care and c-MeST vs. 72 % usual care, OR = 0.64, p = .327) or six months (55 % usual care and c-MeST vs. 68 % usual care, OR = 0.56, p = .266). The usual care and c-MeST group did report lower depressive symptoms at one month (d = 0.42, p = .023) and six-months (d = 0.84, p = .001), but not three-months (d = 0.13, p > .05).

CONCLUSIONS

c-MeST may reduce symptoms in youth with MDD when provided alongside other treatments. However, there are significant limitations to this inference, including high attrition in the study and a need for more data on the acceptability of the intervention.

Distinct physiological responses to social-evaluative stress in patients with major depressive disorder reporting a history of peer victimization

Peer victimization is a risk factor for the development of major depressive disorders, but little is known about the mechanisms. This study examined whether peer victimization alters physiological and affective responses to potentially threatening social stimuli. For this purpose, reactions to socially evaluative stimuli of depressive patients and healthy controls with varying histories of peer victimization were compared. In a social conditioning task, we studied heart rate responses to unconditioned socially negative and neutral evaluative video statements, followed by the heart rate reactions to conditioned stimuli, i.e. still images of the faces of the same actors. Diagnosis of depression and peer victimization were both associated with a more pronounced heart rate deceleration in response to unconditioned stimuli, irrespective of valence. The effect of peer victimization was stronger in depressive patients than in healthy controls. However, heart rate responses to the CSs were not related to depression or peer victimization. The results indicate a hypervigilant processing of social stimuli in depressive patients reporting histories of peer victimization. This distinct processing may be associated with inappropriate behavioral and emotional responses to social challenges, putting individuals at risk for depressive symptoms.

Functional dysconnectivity in youth depression: Systematic review, meta-analysis, and network-based integration

Youth depression has been associated with heterogenous patterns of aberrant brain connectivity. To make sense of these divergent findings, we conducted a systematic review encompassing 19 resting-state fMRI seed-to-whole-brain studies (1400 participants, comprising 795 youths with major depression and 605 matched healthy controls). We incorporated separate meta-analyses of connectivity abnormalities across the levels of the most commonly seeded brain networks (default-mode and limbic networks) and, based on recent additions to the literature, an updated meta-analysis of amygdala dysconnectivity in youth depression. Our findings indicated broad and distributed findings at an anatomical level, which could not be captured by conventional meta-analyses in terms of spatial convergence. However, we were able to parse the complexity of region-to-region dysconnectivity by considering constituent regions as components of distributed canonical brain networks. This integration revealed dysconnectivity centred on central executive, default mode, salience, and limbic networks, converging with findings from the adult depression literature and suggesting similar neurobiological underpinnings of youth and adult depression.

Research Into Evidence-Based Psychological Interventions Needs a Stronger Focus on Replicability

Background

It is a precondition for evidence-based practice that research is replicable in a wide variety of clinical settings. Current standards for identifying evidence-based psychological interventions and making recommendations for clinical practice in clinical guidelines include criteria that are relevant for replicability, but a better understanding as well refined definitions of replicability are needed enabling empirical research on this topic. Recent advances on this issue were made in the wider field of psychology and in other disciplines, which offers the opportunity to define and potentially increase replicability also in research on psychological interventions.

Method

This article proposes a research strategy for assessing, understanding, and improving replicability in research on psychological interventions.

Results/Conclusion

First, we establish a replication taxonomy ranging from direct to conceptual replication adapted to the field of research on clinical interventions, propose study characteristics that increase the trustworthiness of results, and define statistical criteria for successful replication with respect to the quantitative outcomes of the original and replication studies. Second, we propose how to establish such standards for future research, i.e., in order to design future replication studies for psychological interventions as well as to apply them when investigating which factors are causing the (non-)replicability of findings in the current literature.

Social threat, fronto-cingulate-limbic morphometry, and symptom course in depressed adolescents: a longitudinal investigation

BACKGROUND

Psychosocial stressors characterized by social threat, such as interpersonal loss and social rejection, are associated with depression in adolescents. Few studies, however, have examined whether social threat affects fronto-cingulate-limbic systems implicated in adolescent depression.

METHODS

We assessed lifetime stressor severity across several domains using the Stress and Adversity Inventory (STRAIN) in 57 depressed adolescents (16.15 ± 1.32 years, 34 females), and examined whether the severity of social threat and non-social threat stressors was associated with gray matter volumes (GMVs) in the anterior cingulate cortex (ACC), amygdala, hippocampus, and nucleus accumbens (NAcc). We also examined how lifetime social threat severity and GMVs in these regions related to depressive symptoms at baseline and over 9 months.

RESULTS

General stressor severity was related to greater depression severity at baseline and over 9 months. Moreover, greater severity of social threat (but not non-social threat) stressors was associated with smaller bilateral amygdala and NAcc GMVs, and smaller bilateral surface areas of caudal and rostral ACC (all pFDR ⩽ 0.048). However, neither social threat nor non-social threat stressor severity was related to hippocampal GMVs (all pFDR ⩾ 0.318). All fronto-cingulate-limbic structures that were associated with the severity of social threat were negatively associated with greater depression severity over 9 months (all pFDR ⩽ 0.014). Post-hoc analyses suggested that gray matter morphometry of bilateral amygdala, NAcc, and rostral and caudal ACC mediated the association between social threat and depression severity in adolescents over 9 months (all pFDR < 0.048).

CONCLUSIONS

Social threat specifically affects fronto-cingulate-limbic pathways that contribute to the maintenance of depression in adolescents.

Young adults with major depression show altered microbiome

There is growing basic and clinical evidence that major depressive disorder (MDD) is associated with gut microbiome alterations, but clinical studies have tended not to adjust for confounding factors. And few studies on the gut microbiome focused on young adults with MDD. Here we performed a pilot study to compare the gut microbiome of young adults with MDD with healthy controls. Shotgun metagenomic sequencing was performed on stool samples obtained from 40 young adults with MDD and 42 healthy controls. After controlling for confounding factors including sex, age, BMI, alcohol or cigarette consumption, bowel movement quality, exercise or defecation frequency, we compared microbiome diversity between groups, identified differentially abundant taxa, and further compared functional differences through gut-brain and gut-metabolic module analysis. There were no significant differences in overall gut microbiome structure and function in young adults with MDD compared with controls. Abundance of Sutterellaceae and species belonging to Clostridium, Eubacterium, and Ruminococcus were significantly different between groups. The cysteine degradation I pathway was increased in MDD. After controlling for most confounding factors, this pilot study provides new evidence on the specific, often subtle gut dysbiosis affecting young adults with depression.

Age of onset for major depressive disorder and its association with symptomatology

BACKGROUND

The age of onset (AOO) is a key factor for heterogeneity in major depressive disorder (MDD). Looking at the effect of AOO on symptomatology may improve clinical outcomes. This study aims to examine whether and how AOO affects symptomatology using a machine learning approach and latent profile analysis (LPA).

METHODS

The study enrolled 915 participants diagnosed with MDD from eight hospitals across China. Depressive symptoms were assessed using the 17-item Hamilton Depression Rating Scale. The relationship between symptom profiles and AOO was explored using Random Forest. The effect of AOO on symptom clusters and subtypes was investigated using multiple linear regression and LPA. A continuous AOO indicator was used to conduct the analyses.

RESULTS

Based on the Random Forest, symptom profiles were closely associated with AOO. The regression model showed that the severity of neurovegetative symptoms was positively associated with AOO (β = 0.18, p < 0.001), and the severity of cognitive-behavioral symptoms was negatively associated with AOO (β = -0.12, p < 0.001). LPA demonstrated that the subgroups characterized by suicide and guilt had earlier onset of depression. The subgroup with the lowest global severity of depression had the latest onset.

LIMITATIONS

AOO was recalled retrospectively. The relative scarcity of participants with childhood and adolescence onset depression.

CONCLUSIONS

AOO has an important impact on symptomatology. The findings may enhance clinical evaluations for MDD and assist clinicians in promoting earlier detection and individualized care in vulnerable individuals.

Neural Activity Associated with Symptoms Change in Depressed Adolescents following Self-Processing Neurofeedback

Adolescent depression is prevalent, debilitating, and associated with chronic lifetime mental health disorders. Understanding the neurobiology of depression is critical to developing novel treatments. We tested a neurofeedback protocol targeting emotional regulation and self-processing circuitry and examined brain activity associated with reduced symptom severity, as measured through self-report questionnaires, four hours after neurofeedback. Depressed (n = 34) and healthy (n = 19) adolescents participated in (i) a brief neurofeedback task that involves simultaneously viewing their own happy face, recalling a positive autobiographical memory, and increasing amygdala-hippocampal activity; (ii) a self- vs. other- face recognition task with happy, neutral, and sad facial expressions before and after the neurofeedback. In depressed youth, reduced depression after neurofeedback was associated with increased self-referential and visual areas' activity during neurofeedback, specifically, increased activity in the cuneus, precuneus and parietal lobe. Reduced depression was also associated with increased activation of emotional regulation and cross-modal areas during a self-recognition task. These areas included the cerebellum, middle temporal gyrus, superior temporal gyrus, and supramarginal gyrus. However, decreased rumination was linked to decreased precuneus, angular and temporal gyri activity during neurofeedback. These results tentatively suggest that neurofeedback may induce short-term neurobiological changes in the self-referential and emotional regulation networks associated with reduced symptom severity among depressed adolescents.

A comparative study of amplitude of low-frequence fluctuation of resting-state fMRI between the younger and older treatment-resistant depression in adults

Background

Treatment-resistant depression (TRD) may have different physiopathological neuromechanism in different age groups. This study used the amplitude of low frequency fluctuations (ALFF) to initially compare abnormalities in local functional brain activity in younger and older patients with TRD.

Materials and methods

A total of 21 older TRD patients, 19 younger TRD, 19 older healthy controls (HCs), and 19 younger HCs underwent resting-state functional MRI scans, and the images were analyzed using the ALFF and further analyzed for correlation between abnormal brain regions and clinical symptoms in TRD patients of different age groups.

Results

Compared with the older TRD, the younger TRD group had increased ALFF in the left middle frontal gyrus and decreased ALFF in the left caudate nucleus. Compared with the matched HC group, ALFF was increased in the right middle temporal gyrus and left pallidum in the older TRD group, whereas no significant differences were found in the younger TRD group. In addition, ALFF values in the left middle frontal gyrus in the younger TRD group and in the right middle temporal gyrus in the older TRD were both positively correlated with the 17-item Hamilton Rating Scale for Depression score.

Conclusion

Different neuropathological mechanisms may exist in TRD patients of different ages, especially in the left middle frontal gyrus and left caudate nucleus. This study is beneficial in providing potential key targets for the clinical management of TRD patients of different ages.

Associations Between Major Depressive Episodes and School- or Community-Based Activity Participation Among Adolescents Using Nationwide Representative Data

BACKGROUND

This study examined the association between participation in school-based and/or community-based activity and major depressive episodes (MDE) in adolescents using nationally representative data.

METHODS

This study utilized cross-sectional data from the National Survey of Drug Use and Health from 2015 to 2019. Nine screening questions determined the presence of past-year MDE in adolescents ages 12-17 (n = 67,033). Participants indicated past-year participation in school-based (eg, team sports, cheerleading, choir, band, student government, or clubs) and/or community-based activities (eg, volunteer activities, sports, clubs, or groups). Sociodemographic variables included sex, race/ethnicity, family income, and age. Descriptive statistics, univariable and multivariable regression analyses were conducted. The multivariable model included interaction terms between age and sex, and age and race/ethnicity.

RESULTS

Overall, 14% of the sample met the criteria for having MDE. The odds of MDE increased with age. Joint effects of age and sex, and age and race/ethnicity significantly influenced the association between MDE and school- or community-based activities. Participation in 1+ community-based activities was protective for MDE across all races/ethnicities.

CONCLUSIONS

Findings help illuminate the direct association of school- and community-based activity participation on MDE risk in adolescents, improving our understanding of MDE across various sociodemographic subgroups in an adolescent population. Schools should aim to facilitate equitable programming and endorse adolescent participation in multiple activities throughout the year. Schools should examine the resources available and consider partnerships that would bolster resources, access, and social capital throughout the community.

Brain morphometry and connectivity differs between adolescent- and adult-onset major depressive disorder

BACKGROUND

Early-onset (EO) major depressive disorder (MDD) patients experience more depressive episodes and an increased risk of relapse. Thus, on a neurobiological level, adult EO patients might display brain structure and function different from adult-onset (AO) patients.

METHODS

A total of 103 patients (66 females) underwent magnetic resonance imaging. Structural measures of gray matter volume (GMV) and functional connectivity networks during resting state were compared between EO (≤19 years) and AO groups. Four residual major depression symptoms, mood, anxiety, insomnia, and somatic symptoms, were correlated with GMV between groups.

RESULTS

We found comparatively increased GMV in the EO group, namely the medial prefrontal and insular cortex, as well as the anterior hippocampus. Functional networks in EO patients showed a comparatively weaker synchronization of the left hippocampus with the adjacent amygdala, and a stronger integration with nodes in the contralateral prefrontal cortex and supramarginal gyrus. Volumetric analysis of depression symptoms associated the caudate nuclei with symptoms of insomnia, and persisting mood symptoms with the right amygdala, while finding no significant clusters for somatic and anxiety symptoms.

CONCLUSIONS

The study highlights the important role of the hippocampus and the prefrontal cortex in EO patients as part of emotion-regulation networks. Results in EO patients demonstrated subcortical volume changes irrespective of sleep and mood symptom recovery, which substantiates adolescence as a pivotal developmental phase for MDD. Longitudinal studies are needed to differentiate neural recovery trajectories while accounting for age of onset.

Impaired dynamic cerebral autoregulation in young adults with mild depression

The incidence of depression is increasing, especially in the young adult population. Impaired cognitive function is one of the characteristics of depression, which may be related to impaired cerebral autoregulation (CA). We investigated the characteristics of CA in young adults with mild depression, as well as its validity for identifying patients with depression. Patients (aged 18-35 years) with Hamilton Depression Rating Scale (HAMD) scores ranging from 8 to 17 and a first episode of mild depression were enrolled in this study. Healthy volunteers were recruited as controls. Noninvasive continuous arterial blood pressure and bilateral middle cerebral artery blood flow velocity were simultaneously recorded from each subject. Transfer function analysis was applied to derive phase difference, gain, coherence and rate of recovery for the assessment of CA. Forty-three patients and 43 healthy controls were enrolled. Phase difference values were significantly compromised in young adults with mild depression and were negatively correlated with HAMD scores. Rate of recovery values estimated from depressed patients was significantly lower. The validity in identifying patients with depression was favorable for the phase difference. The cutoff phase difference value was 29.66. Our findings suggest that dynamic CA was impaired in young patients with mild depression and negatively correlated with HAMD scores. CA represented by phase difference can be used as an objective auxiliary examination of depression, and has clinical diagnostic value for the early identification of patients with depression.

Editorial: For Adolescents With Subthreshold Depression, Is an Ounce of Prevention Worth a Pound of Cure?

Globally, depression is among the leading neuropsychiatric disorders of adolescence. Conventional wisdom indicates that an "ounce of prevention is worth a pound of cure," a perspective bolstered by some studies demonstrating that psychological interventions for subthreshold depression reduce acute symptoms and prevent the onset of major depressive disorder (MDD) over short-term follow-up. However, the meta-analysis by Cuijpers et al.,¹ the first to pool results from all available relevant studies in the field, provides evidence that would seem to challenge this conventional wisdom. The meta-analysis included 12 randomized controlled trials of children and adolescents. This editorial focuses on the 10 studies with adolescents (age range, 13.5-17.4 years), who were recruited from schools (n = 6), medical settings (n = 3), and mass mailings (n = 1). The youths received short-term psychotherapies ranging from 6 to 16 sessions, primarily cognitive-behavioral therapy or interpersonal therapy, or inactive control/care as usual. Results showed significant short-term benefits in reducing acute depression symptoms, even though effect size was small to medium (number needed to treat = 8.4). At 6-18 months of follow-up, however, the likelihood of meeting full criteria for MDD was not significantly different between the intervention and control conditions. We child and adolescent psychiatrists have difficulty yielding our commitment to conventional wisdom and look for evidence that this meta-analysis is not the last word on the value of early interventions for subthreshold depression to prevent MDD in adolescents.

Genetic markers for depressive disorders with earlier age at onset

Age at onset has been considered a potential indicator of underlying genetic risk in depression research. However, the variants associated with earlier age at onset of depressive disorder have not been elucidated. To evaluate the genetic architecture of depression onset, whole-exome sequencing of samples from 1000 patients with depressive disorder was performed. Cox proportional hazard models with false discovery rate-adjusted P-values were used to estimate the hazard ratios; carriers and non-carriers of individual coding variants were compared in terms of age at onset of depression with adjustment for sociodemographic and clinical characteristics. The clinical relevance of the candidate variants was also examined. Whole-exome sequencing revealed four variants in the CCL14, FYB, GPRASP1, and CTNND2 genes associated with an increased risk of depressive disorder with earlier age at onset. Although no individual variant was associated with any clinical characteristic except AAO, together they were associated with younger AAO, younger age at visit for treatment, and recurrent and atypical depression. Our data suggest novel candidate genes for depressive disorder with earlier age at onset. These genes could serve as markers allowing early identification of patients at risk of depression, and thus earlier intervention.

The prevalence of depression in Iranian children: A systematic review and meta-analysis

INTRODUCTION

The present study was conducted to evaluate the prevalence of depression in Iranian children.

METHOD

This meta-analysis was registered in PROSPERO with code (CRD42020216632) and performed based on the MOOSE protocol and PRISMA guidelines. Title and abstract of articles were searched without time limit until April 2020 in international databases PubMed/Medline, Scopus, Embase, Science Direct, Cochrane Library, CINAHL, EBSCO, Web of Science, Google Scholar, and Iranian databases.

RESULTS

In 34 studies with a sample size of 23,779 Iranian children, the prevalence of depression was estimated 42.3 % (95 %CI: 34.9-50.0). Prevalence of depression in girls in 20 studies with a sample size of 11,170 was estimated 42.1 % (95 %CI: 32.7-52.1) and the prevalence of depression in males in 20 studies with a sample size of 4678 was estimated 29.6 % (95 %CI: 21.2-39.7). The odds ratio of female to male depression was 1.33 (95 %CI: 1.07-1.65, P < 0.011). Prevalence of mild, moderate, major and deep depression was 20.3 % (95 %CI: 16.4-24.9), 15.0 % (95 %CI: 11.3-19.7), 14.5 % (95 %CI: 10.8-19.1), and 4.3 % (95 %CI: 1.8-9.8), respectively. In subgroup analysis for prevalence of depression in Iranian children, the variables of geographical area (P = 0.258), quality of studies (P = 0.186), type of questionnaire (P = 0.907), sample size (P = 0.500) and year of studies (P = 0.538) were not significant, but subgroup analysis of province (P < 0.001) and school grade (P < 0.001) were significant.

CONCLUSION

The results of the present meta-analysis showed that depression is common in Iranian children and is much higher than global estimates. These findings emphasize the importance of identifying and providing treatment to children who are most in need.

"She finds you abhorrent" - The impact of emotional context information on the cortical processing of neutral faces in depression

Depression is associated with abnormalities in patterns of information processing, particularly in the context of processing of interpersonal information. The present study was designed to investigate the differences in depressive individuals in cortical processing of facial stimuli when neutral faces were presented in a context that involved information about emotional valence as well as self-reference. In 21 depressive patients and 20 healthy controls, event-related potentials (ERPs) were recorded during the presentation of neutral facial expressions, which were accompanied by affective context information that was either self- or other-related. Across conditions, depressive patients showed larger mean P100 amplitudes than healthy controls. Furthermore, mean late positive potential (LPP) amplitudes of depressive patients were larger in response to faces in self-related than in other-related context. In addition, irrespective of self-reference, mean LPP responses of depressive patients to faces presented after socially threatening sentences were larger compared with faces presented after neutral sentences. Results regarding self-reference supported results of previous studies indicating larger mean amplitudes in self-related conditions. Findings suggest a general heightened initial responsiveness to emotional cues and a sustained emotion processing of socially threatening information in depressive patients.

Dissecting diagnostic heterogeneity in depression by integrating neuroimaging and genetics

Depression is a heterogeneous and etiologically complex psychiatric syndrome, not a unitary disease entity, encompassing a broad spectrum of psychopathology arising from distinct pathophysiological mechanisms. Motivated by a need to advance our understanding of these mechanisms and develop new treatment strategies, there is a renewed interest in investigating the neurobiological basis of heterogeneity in depression and rethinking our approach to diagnosis for research purposes. Large-scale genome-wide association studies have now identified multiple genetic risk variants implicating excitatory neurotransmission and synapse function and underscoring a highly polygenic inheritance pattern that may be another important contributor to heterogeneity in depression. Here, we review various sources of phenotypic heterogeneity and approaches to defining and studying depression subtypes, including symptom-based subtypes and biology-based approaches to decomposing the depression syndrome. We review "dimensional," "categorical," and "hybrid" approaches to parsing phenotypic heterogeneity in depression and defining subtypes using functional neuroimaging. Next, we review recent progress in neuroimaging genetics (correlating neuroimaging patterns of brain function with genetic data) and its potential utility for generating testable hypotheses concerning molecular and circuit-level mechanisms. We discuss how genetic variants and transcriptomic profiles may confer risk for depression by modulating brain structure and function. We conclude by highlighting several promising areas for future research into the neurobiological underpinnings of heterogeneity, including efforts to understand sexually dimorphic mechanisms, the longitudinal dynamics of depressive episodes, and strategies for developing personalized treatments and facilitating clinical decision-making.

Incidence Trends and Risk Prediction Nomogram for Suicidal Attempts in Patients With Major Depressive Disorder

Background: Major depressive disorder (MDD) is often associated with suicidal attempt (SA). Therefore, predicting the risk factors of SA would improve clinical interventions, research, and treatment for MDD patients. This study aimed to create a nomogram model which predicted correlates of SA in patients with MDD within the Chinese population. Method: A cross-sectional survey among 474 patients was analyzed. All subjects met the diagnostic criteria of MDD according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). Multi-factor logistic regression analysis was used to explore demographic information and clinical characteristics associated with SA. A nomogram was further used to predict the risk of SA. Bootstrap re-sampling was used to internally validate the final model. Integrated Discrimination Improvement (IDI) and Akaike Information Criteria (AIC) were used to evaluate the capability of discrimination and calibration, respectively. Decision Curve Analysis (DCA) and the Receiver Operating Characteristic (ROC) curve was also used to evaluate the accuracy of the prediction model. Result: Multivariable logistic regression analysis showed that being married (OR = 0.473, 95% CI: 0.240 and 0.930) and a higher level of education (OR = 0.603, 95% CI: 0.464 and 0.784) decreased the risk of the SA. The higher number of episodes of depression (OR = 1.854, 95% CI: 1.040 and 3.303) increased the risk of SA in the model. The C-index of the nomogram was 0.715, with the internal (bootstrap) validation sets was 0.703. The Hosmer-Lemeshow test yielded a P-value of 0.33, suggesting a good fit of the prediction nomogram in the validation set. Conclusion: Our findings indicate that the demographic information and clinical characteristics of SA can be used in a nomogram to predict the risk of SA in Chinese MDD patients.

Trajectories of depressive symptoms through adolescence as predictors of cortical thickness in the orbitofrontal cortex: An examination of sex differences

Previous research has found associations between orbitofrontal cortex (OFC) structure and symptoms of major depression, though specific aspects of this complex relationship remain unclear. The current study examined sex differences in the influence of individual trajectories of depressive symptoms on cortical thickness (CT) in the OFC during late adolescence. Fifty-four participants enrolled in an ongoing longitudinal study completed assessments of depression symptoms at baseline (M_age = 12.09; SD = 1.06) and at 6-month intervals through adolescence, followed by an MRI assessment (M_age = 17.34; SD = 0.98). Estimates of CT in the OFC were obtained using FreeSurfer. Multilevel modeling (MLM) analyses estimated individuals' symptom trajectories, and identified significant variability in trajectories of depressive symptoms. Trajectory estimates were extracted and included as predictors of CT in multiple regression analyses. Results did not reveal any significant main effect associations between trajectories of depression and CT in the OFC. However, sex moderated the associations between slope of depression and CT in the left OFC; the slope of depressive symptoms demonstrated significant, but opposite, associations with CT in the OFC across sexes, such that greater increases in symptoms across time were associated with reduced CT in males, but increased CT in females.

Harnessing Mental Imagery and Enhancing Memory Specificity: Developing a Brief Early Intervention for Depressive Symptoms in Adolescence

Background

Treatment innovation for depressive symptoms in adolescence is urgently needed. Adult research suggests interventions targeting underlying cognitive mechanisms, such as dysfunctional mental imagery and overgeneral memory, are promising. Here, we describe and evaluate in a case series a brief imagery-based intervention for depressive symptoms that targets these cognitive mechanisms.

Methods

Nine participants completed the four-session intervention, whose principle components were imagery rescripting and memory specificity training. Questionnaires and experimental tasks (assessing symptomatology and cognitive mechanisms) were administered at three time points: pre-intervention, post-intervention and 3-month follow-up.

Results

The intervention was feasible to deliver and acceptable to participants. There was a large reduction in depression symptom scores from pre to post intervention (d = 1.32; 67% showed reliable improvement, RI) and this was maintained at follow-up (d = 1.46; RI = 75%). There were also reductions in anxiety (post: d = 1.15, RI = 44%; follow-up: d = 1.67, RI = 63%), increases in self-esteem (post: d = − 0.70, RI = 44%; follow-up: d = − 1.20, RI = 50%) and noteworthy changes in memory specificity (post: d = − 1.80, RI = 67%; follow-up: d = − 0.94, RI = 63%).

Conclusions

This is the first study to use imagery rescripting and memory specificity training in adolescence. Initial evidence is provided that the intervention is acceptable and may have clinical utility. Future randomised controlled trials are needed to further assess the intervention.

Causes and Consequences of Diagnostic Heterogeneity in Depression: Paths to Discovering Novel Biological Depression Subtypes

Depression is a highly heterogeneous syndrome that bears only modest correlations with its biological substrates, motivating a renewed interest in rethinking our approach to diagnosing depression for research purposes and new efforts to discover subtypes of depression anchored in biology. Here, we review the major causes of diagnostic heterogeneity in depression, with consideration of both clinical symptoms and behaviors (symptomatology and trajectory of depressive episodes) and biology (genetics and sexually dimorphic factors). Next, we discuss the promise of using data-driven strategies to discover novel subtypes of depression based on functional neuroimaging measures, including dimensional, categorical, and hybrid approaches to parsing diagnostic heterogeneity and understanding its biological basis. The merits of using resting-state functional magnetic resonance imaging functional connectivity techniques for subtyping are considered along with a set of technical challenges and potential solutions. We conclude by identifying promising future directions for defining neurobiologically informed depression subtypes and leveraging them in the future for predicting treatment outcomes and informing clinical decision making.

Impact of age at onset on the phenomenology of depression in treatment-seeking adults in the STAR*D trial

BACKGROUND

- Adolescence is characterized by biological, emotional, and behavioral changes. The onset of depression during this vulnerable time may confer specific risks. This study examined whether symptoms of depression were associated with age at onset (AAO), and whether AAO impacted depression symptom networks in adulthood.

METHODS

- Data were from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. 3,184 depressed participants were included in analyses. A series of multiple regressions examined whether pretreatment differences in depression item-level symptom severity varied by AAO. Participants were divided into four groups based on AAO; GLASSO networks of depressive symptoms were estimated in each group and tests of differences between networks were performed.

RESULTS

- Earlier AAO was associated with more severe symptom levels, with the exception of sleep-which increased with AAO, and loss of libido, psychomotor disturbance, and appetite-weight disturbance, which were invariant with AAO. In network analyses, the adolescent AAO symptom network significantly differed from the young adult and middle age AAO networks in structure and strength. In contrast, the child AAO network differed from the middle age AAO network in strength only.

LIMITATIONS

- Age at onset was recalled retrospectively and may be subject to bias. Future prospective studies should be conducted to address this limitation.

CONCLUSIONS

- Adolescence stands out as a time when onset of depression is associated with specific network characteristics. The unique severity of symptoms and network strength and structure caused by onset of depression during adolescence highlights the long-lasting impact of depression on the developing brain.

Does early and late life depression differ in residual symptoms, functioning and quality of life among the first-episode major depressive patients

AIMS & OBJECTIVES

Age differences exist in many aspects in patients with major depressive disorder (MDD). The present study aims to examine the effect of age on treatment outcomes in first-episode MDD.

METHODOLOGY

A total of 982 first-episode major depressive patients, who were above 18 years old and admitted in both psychiatric hospitals and units of general hospitals were recruited for the present study. These patients were newly treated and responded to 8-12 weeks of antidepressant treatment. Depressive symptoms, psychosocial functioning and quality of life were measured using standardized instruments. The study population was divided into three age groups: early adult (18-44 years old), middle adult (45-59 years old), and late adult (60-85 years old).

RESULTS

Earlier age was associated with greater symptom severity, severer depressive symptoms in hypersomnia, concentration/decision making, negative view of the self, suicide ideation and restlessness, more impaired function, poorer satisfaction in social relationship and economic status, when compared to late adults with MDD (all P < 0.05). In the multivariable analyses, among the other variables, early age remained as an independent correlation of residual depressive severity (middle age vs. early age: OR = 0.631, 95%CI[0.462, 0.862]; old age vs. early age: OR = 0.521, 95%CI[0.348, 0.780]) and functional impairment. Comorbidity of physical illness had a negative contribution to all treatment outcomes.

CONCLUSION

In first major depressive episode, early age was strongly associated with depressive severity and functional impairment after responding to antidepressant treatment. Early-life depression may be an indicator of MDD for poor clinical outcomes and high clinical burden.

The Cognitive Neuropsychology of Depression in Adolescents

Purpose of Review

Adolescent depression is a major public health concern associated with severe outcomes. A lack of efficacious interventions has triggered an increase in cognitive neuropsychology research to identify relevant treatment targets for new interventions. This review summarises key neurocognitive findings in adolescent depression and explores the potential of neurocognitive markers as treatment targets in new interventions.

Recent Findings

Studies support difficulties in the voluntary deployment of attention towards and away from emotional stimuli, negative interpretation biases and overgeneralised autobiographical memories in adolescent depression; however, little evidence is given to a general decline in executive function. There is consistent evidence for abnormalities in several distributed neural networks in adolescent depression, including dysfunction in and between the amygdala, medial prefrontal cortex and ventral striatum.

Summary

The relationships between different cognitive biases and abnormalities in specific neural networks remain unclear. Several new experimental interventions targeting these neurocognitive markers await evaluation.

Mental health of adolescents: variations by borderline intellectual functioning and disability

Adolescence is a period of elevated stress for many young people, and it is possible that the challenges of adolescence are different for vulnerable groups. We aimed to document the depressive and anxiety symptoms, emotional-behavioural difficulties and suicidal/self-harming behaviours among adolescents with borderline intellectual functioning (BIF) or a disability, compared to those with neither disability nor BIF. Data were drawn from the nationally representative Longitudinal Study of Australian Children. Participants were 2950 adolescents with complete data for waves 3-6 (years 2008-2014), aged 14-15 years in 2014. Anxiety and depression symptoms and self-harming/suicidal thought/behaviours were self-reported. Emotional-behavioural difficulties items came from the Strengths and Difficulties Questionnaire, and were parent-, and adolescent-reported. Results of logistic regression analyses indicate that the emotional-behavioural difficulties of adolescents with either a disability or BIF, were worse than for those with neither disability nor BIF. While adolescents with a disability reported more anxiety symptoms, no clear associations were observed for self-harming/suicidal thoughts/behaviours or depressive symptoms for those with either BIF or a disability. Adolescents with BIF or a disability are at higher risk of poor mental health than those with neither disability nor BIF, and it is vital that factors contributing to these differences are identified in order to reduce these mental health inequalities.

Reward-circuit biomarkers of risk and resilience in adolescent depression

BACKGROUND

Dysfunctional reward processing is a core feature of major depressive disorder. While there is growing knowledge of reward processing in adolescent depression, researchers have ignored neural mechanisms of resilience to depression. Here, we examine neural correlates of reward processing that characterize resilience and risk in adolescents at risk for depression, facilitating the development of effective intervention approaches that strengthen resilience to psychopathology in at-risk youth.

METHODS

50 adolescent females were followed through age 18: 32 at-risk adolescents who either did (remitted-depressed; n = 15) or did not (resilient; n = 17) experience a depressive episode, and 18 low-risk healthy controls. Participants completed clinical assessments at 18-month intervals and an fMRI reward-processing task in late adolescence. We conducted predictive modeling with a priori reward regions of interest (ROIs).

RESULTS

At-risk resilient and remitted-depressed adolescents exhibited less striatal activation than did controls during anticipation of reward. Resilient adolescents exhibited greater activation than did remitted-depressed adolescents in the middle frontal gyrus during reward anticipation, and less activation in the superior frontal gyrus and cuneus during processing of reward outcome. Using predictive modeling, ventral anterior cingulate cortex and putamen activation during reward processing distinguished resilient from remitted-depressed adolescents with 83% accuracy.

LIMITATIONS

The relatively small sample size of only females and the fact that fMRI data were obtained at one time point in late adolescence are limitations.

CONCLUSIONS

Distinct patterns of neural activation in reward circuitry appear to be markers of risk and resilience that may be targets for prevention and treatment approaches aimed at strengthening adaptive reward processing in at-risk adolescents.

Recurrence of depression in the perinatal period: Clinical features and associated vulnerability markers in an observational cohort

Objective

Antidepressant medication is commonly used for the prevention of depression recurrence in the perinatal period, yet it is unknown what vulnerability markers may play a role in recurrence. The objective of the current study was to provide a descriptive overview of the associated characteristics of women who experienced a perinatal recurrence of depression despite ongoing antidepressant use, and further, to identify clinically measurable vulnerability markers associated with recurrence.

Methods

Eighty-five pregnant women with a history of depression who used antidepressants (e.g. Selective Serotonin Reuptake Inhibitors or Serotonin and Noradrenaline Reuptake Inhibitors) at the start of the study were included. Clinical features, including information on psychiatric history and antidepressant use, were collected throughout the perinatal period (in this study defined as the period between 12 weeks of pregnancy untill three months postpartum). The clinical features of women experiencing recurrence of depression were described in detail. To identify vulnerability markers associated with recurrence of depression, we performed exploratory univariable logistic regression analyses.

Results

Eight women (9.4%) experienced a recurrence of depression; two during pregnancy and six in the first 12 weeks postpartum. All women with recurrence of depression had first onset of depression during childhood or adolescence and had at least 2 psychiatric co-morbidities. Identification of vulnerability markers associated with recurrence of depression yielded associations with depressive symptoms around 16 weeks of pregnancy (OR 1.28, 95%CI 1.08–1.52), number of psychiatric co-morbidities (OR 1.89, 95%CI 1.16–3.09) and duration of antidepressant use (OR 1.01, 95%CI 1.00–1.02).

Conclusion

Implementing adequate risk assessment in pregnant women who use antidepressants can help identify predictors for recurrence of depression in future studies and thus ultimately lead to improved care.

Preliminary examination of gray and white matter structure and longitudinal structural changes in frontal systems associated with future suicide attempts in adolescents and young adults with mood disorders

BACKGROUND

Mood disorders are major risk factors for suicidal behavior. While cross-sectional studies implicate frontal systems, data to aid prediction of suicide-related behavior in mood disorders are limited. Longitudinal research on neuroanatomical mechanisms underlying suicide risk may assist in developing targeted interventions. Therefore, we conducted a preliminary study investigating baseline gray and white matter structure and longitudinal structural changes associated with future suicide attempts.

METHODS

High-resolution structural magnetic resonance imaging, diffusion tensor imaging, and suicide-related behavioral assessment data for 46 adolescents and young adults with mood disorders [baseline age_mean = 18 years; 61% female] were collected at baseline and at follow-up (interval_mean = 3 years). Differences in baseline and longitudinal changes in gray matter volume and white matter fractional anisotropy in frontal systems that distinguished the participants who made future attempts from those who did not were investigated.

RESULTS

Seventeen (37%) of participants attempted suicide within the follow-up period. Future attempters (those attempting suicide between their baseline and follow-up assessment), compared to those who did not, showed lower baseline ventral and rostral prefrontal gray matter volume and dorsomedial frontal, anterior limb of the internal capsule, and dorsal cingulum fractional anisotropy, as well as greater decreases over time in ventral and dorsal frontal fractional anisotropy (p < 0.005, uncorrected).

LIMITATIONS

Sample size was modest.

CONCLUSIONS

Results suggest abnormalities of gray and white matter in frontal systems and differences in developmental changes of frontal white matter may increase risk of suicide-related behavior in youths with mood disorders. Findings provide potential new leads for early intervention and prevention strategies.

A brief early intervention for adolescent depression that targets emotional mental images and memories: protocol for a feasibility randomised controlled trial (IMAGINE trial)

BACKGROUND

Adolescent depression is common and impairing. There is an urgent need to develop early interventions to prevent depression becoming entrenched. However, current psychological interventions are difficult to access and show limited evidence of effectiveness. Schools offer a promising setting to enhance access to interventions, including reducing common barriers such as time away from education. Distressing negative mental images and a deficit in positive future images, alongside overgeneral autobiographical memories, have been implicated in depression across the lifespan, and interventions targeting them in adults have shown promise. Here, we combine techniques targeting these cognitive processes into a novel, brief psychological intervention for adolescent depression. This feasibility randomised controlled trial will test the feasibility and acceptability of delivering this imagery-based cognitive behavioural intervention in schools.

METHODS/DESIGN

Fifty-six adolescents (aged 16-18) with high symptoms of depression will be recruited from schools. Participants will be randomly allocated to the imagery-based cognitive behavioural intervention (ICBI) or the control intervention, non-directive supportive therapy (NDST). Data on feasibility and acceptability will be recorded throughout, including data on recruitment, retention and adherence rates as well as adverse events. In addition, symptom assessment will take place pre-intervention, post-intervention and at 3-month follow-up. Primarily, the trial aims to establish whether it is feasible and acceptable to carry out this project in a school setting. Secondary objectives include collecting data on clinical measures, including depression and anxiety, and measures of the mechanisms proposed to be targeted by the intervention. The acceptability of using technology in assessment and treatment will also be evaluated.

DISCUSSION

Feasibility, acceptability and symptom data for this brief intervention will inform whether an efficacy randomised controlled trial is warranted and aid planning of this trial. If this intervention is shown in a subsequent definitive trial to be safe, clinically effective and cost-effective, it has potential to be rolled out as an intervention and so would significantly extend the range of therapies available for adolescent depression. This psychological intervention draws on cognitive mechanism research suggesting a powerful relationship between emotion and memory and uses imagery as a cognitive target in an attempt to improve interventions for adolescent depression.

TRIAL REGISTRATION

ISRCTN85369879.

Suicidal thoughts and attempts in First Nations communities: links to parental Indian residential school attendance across development

The Indian residential school (IRS) system in Canada ran for over a century until the last school closed in 1996. Conditions in the IRSs resulted in generations of Indigenous children being exposed to chronic childhood adversity. The current investigation used data from the 2008-2010 First Nations Regional Health Survey to explore whether parental IRS attendance was associated with suicidal thoughts and attempts in childhood, adolescence and in adulthood among a representative sample of First Nations peoples living on-reserve across Canada. Analyses of the adult sample in Study 1 (unweighted n=7716; weighted n=186,830) revealed that having a parent who attended IRS was linked with increased risk for suicidal thoughts and attempts in adolescence and adulthood. Although females were negatively affected by having a parent who attended IRS, the link with suicidal ideation in adulthood was greater for males. Analyses of the youth sample in Study 2 (unweighted n=2883; weighted n=30,190) confirmed that parental IRS attendance was associated with an increased risk for suicidal ideation and attempts. In contrast to the adult sample, parental IRS attendance had a significantly greater relation with suicidal ideation among female youth. A significant interaction also emerged between parental IRS attendance and age in the youth sample, with the influence of parental attendance being particularly strong among youth ages 12-14, compared with those 15-17 years. These results underscore the need for culturally relevant early interventions for the large proportions of Indigenous children and youth intergenerationally affected by IRSs and other collective traumas.

Possible predictors of age at illness onset and illness duration in a cohort study comparing younger adults and older major affective patients

BACKGROUND

Major affective conditions are associated with significant disability and psychosocial impairment. Whether specific socio-demographic and clinical characteristics may distinguish subgroups of patients in terms of prognosis and illness trajectories is a matter of debate.

METHODS

The sample of this naturalistic cohort study included 675 currently euthymic patients with major affective disorders of which 428 (63.4%) were diagnosed with unipolar and 247 (36.6%) with bipolar disorders.

RESULTS

Younger adults with a longer duration of untreated illness and residual inter-episodic symptoms were more likely to be single or divorced, students, with an earlier age of first treatment/hospitalization, longer duration of substance abuse and duration of illness than older patients who were, conversely, more likely to be widowed and retired. Multivariate analyses showed a significant positive contribution to age at illness onset by marital status, nonpsychiatric medications, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at first treatment/hospitalization, duration of illness, and current age. According to a further analysis, we also found a significant positive contribution to duration of illness by marital status, educational level, positive history of psychiatric conditions in family, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at illness onset, age at first treatment, and certain cardiovascular disorders.

CONCLUSIONS

There are substantial socio-demographic and clinical differences that may help to distinguish specific subgroups of patients; however, additional studies are requested to replicate these results and further investigate the main factors underlying our findings.

Reduced fronto-amygdalar connectivity in adolescence is associated with increased depression symptoms over time

Depression is common among adolescents, affecting greater than 12% of youth in a given year. Studies have shown aberrant amygdala connectivity in depressed adolescents, compared with controls; however, no studies have examined whether these abnormalities precede and heighten risk for depressive symptom expression. This study used resting state functional connectivity (RSFC) magnetic resonance imaging to examine neurobiological markers of escalating depression symptoms in adolescents (ages 12-16 years; free from psychopathology at baseline). Of a large sample of adolescents, 18 showed ≥ 1 S.D. increase in depression scale t-scores over time ("escalators"; time to escalation ranging from 6 to 54 months in follow up) and were matched and compared to 19 youth showing stable CDI scores over time ("controls"). Whole-brain analyses on baseline RSFC data using an amygdala seed region-of-interest (ROI) showed that controls had greater RSFC, relative to escalators, between the right amygdala and left inferior frontal and supramarginal gyrus and right mid-cingulate cortex. Additionally, relative to escalators, control youth had less RSFC between the left amygdala and cerebellum. Findings suggest a possible neurobiological marker of increasing depressive symptoms during adolescence, characterized in part by reduced fronto-limbic connectivity, suggesting a premorbid deficiency in top-down emotional regulation.

Major Depressive Disorder Among Preadolescent Canadian Children: Rare Disorder or Rarely Detected?

OBJECTIVE

Despite agreement that preadult onset of depression is associated with greater illness severity, and that children can meet the diagnostic criteria for major depressive disorder (MDD), few studies have examined the presentation of MDD among young children. This is the first nationwide study of MDD among preadolescent children in Canada.

METHODS

Pediatrician members (2500) of a Canadian pediatric surveillance network were surveyed monthly over 3 years to report new cases of MDD among 5- to 12-year-olds. Survey response and questionnaire completion rates were 80% and 85%, respectively. Symptom presentation and duration, impairment, medical and psychiatric history, and management were reported.

RESULTS

Twenty-nine new cases of MDD were identified by pediatricians. Of these, 23 (79%) experienced symptoms for >6 months before presentation with global functional impairment. Parental depression or anxiety, commonly maternal, was present in 21 cases (72%). Twenty-two children (76%) reported suicidal ideation; 6 (21%) had attempted suicide. Twenty-three children (79%) were treated with medication. Thirteen children (45%) were treated with 2 or more medications.

CONCLUSIONS

Children with MDD frequently had a parental history of mood disorders, experienced long-standing symptom presence, high symptom burden and functional impairment prior to presentation; and commonly treatment with polypharmacy.

Dissection of major depressive disorder using polygenic risk scores for schizophrenia in two independent cohorts

Major depressive disorder (MDD) is known for its substantial clinical and suspected causal heterogeneity. It is characterized by low mood, psychomotor slowing and increased levels of the personality trait neuroticism; factors also associated with schizophrenia (SCZ). It is possible that some cases of MDD may have a substantial genetic loading for SCZ. The presence of SCZ-like MDD subgroups would be indicated by an interaction between MDD status and polygenic risk of SCZ on cognitive, personality and mood measures. Here, we hypothesized that higher SCZ polygenic risk would define larger MDD case-control differences in cognitive ability, and smaller differences in distress and neuroticism. Polygenic risk scores (PRSs) for SCZ and their association with cognitive variables, neuroticism, mood and psychological distress were estimated in a large population-based cohort (Generation Scotland: Scottish Family Health Study, GS:SFHS). The individuals were divided into those with, and without, depression (n=2587 and n=16 764, respectively) to test for the interactions between MDD status and schizophrenia risk. Replication was sought in UK Biobank (UKB; n=6049 and n=27 476 cases and controls, respectively). In both the cohorts, we found significant interactions between SCZ-PRS and MDD status for measures of psychological distress (βGS=-0.04, PGS=0.014 and βUKB=-0.09, PUKB⩽0.001 for GS:SFHS and UKB, respectively) and neuroticism (βGS=-0.04, PGS=0.002 and βUKB=-0.06, PUKB=0.023). In both the cohorts, there was a reduction of case-control differences on a background of higher genetic risk of SCZ. These findings suggest that depression on a background of high genetic risk for SCZ may show attenuated associations with distress and neuroticism. This may represent a causally distinct form of MDD more closely related to SCZ.

Prevalence of ADHD symptoms across clinical stages of major depressive disorder

BACKGROUND

Depression and ADHD often co-occur in clinical samples. Depression severity may be linked to ADHD symptomatology. We therefore assessed ADHD symptoms across clinical stages of major depressive disorder (MDD).

METHODS

We used 4-year follow-up data of the Netherlands Study of Depression and Anxiety (September 2008 until April 2011), including healthy controls, groups with remitted and current MDD (N=2053; age range 21-69 years; 66.8% females). Probable ADHD was defined as having current ADHD symptoms on the Conners Adult ADHD Rating Scale and a positive score on childhood or early-adolescent ADHD indicators. We examined ADHD symptom rates across (i) those with and without lifetime MDD, (ii) clinical characteristics of MDD including severity, course and outcomes, (iii) clinical stages of MDD.

RESULTS

(i) The prevalence of ADHD symptoms was 0.4% in healthy controls, 5.7% in remitted MDD and 22.1% in current MDD (OR=4.5; 95% CI 3.1-6.5). (ii) ADHD symptom rates and odds were significantly increased among those with more severe depression (29.4%; OR=6.8; 95% CI 2.9-16.1), chronic depression (21.8%; OR=3.8; 95% CI 2.5-5.7), earlier age of onset of depressive symptoms (9.9%; OR=1.5; 95% CI 1.0-2.3), and comorbid anxiety disorders (29.0%; OR=3.4; 95% CI 2.0-5.7). (iii) ADHD symptom rates increased across clinical stages of MDD, up to 22.5% in chronic MDD.

LIMITATIONS

We used self-reports on ADHD symptoms. Also, clinical staging models have not yet been validated for mental disorders.

CONCLUSIONS

ADHD symptoms are very common among MDD patients, especially among those in recurrent and chronic stages of MDD. Considering ADHD may be an important step forward in improving the treatment of depression.

Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease: A Scientific Statement From the American Heart Association

In the 2011 "Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents," several medical conditions among youth were identified that predispose to accelerated atherosclerosis and early cardiovascular disease (CVD), and risk stratification and management strategies for youth with these conditions were elaborated. Major depressive disorder (MDD) and bipolar disorder (BD) among youth satisfy the criteria set for, and therefore merit inclusion among, Expert Panel tier II moderate-risk conditions. The combined prevalence of MDD and BD among adolescents in the United States is ≈10%, at least 10 times greater than the prevalence of the existing moderate-risk conditions combined. The high prevalence of MDD and BD underscores the importance of positioning these diseases alongside other pediatric diseases previously identified as moderate risk for CVD. The overall objective of this statement is to increase awareness and recognition of MDD and BD among youth as moderate-risk conditions for early CVD. To achieve this objective, the primary specific aims of this statement are to (1) summarize evidence that MDD and BD are tier II moderate-risk conditions associated with accelerated atherosclerosis and early CVD and (2) position MDD and BD as tier II moderate-risk conditions that require the application of risk stratification and management strategies in accordance with Expert Panel recommendations. In this scientific statement, there is an integration of the various factors that putatively underlie the association of MDD and BD with CVD, including pathophysiological mechanisms, traditional CVD risk factors, behavioral and environmental factors, and psychiatric medications.

Does age at onset of first major depressive episode indicate the subtype of major depressive disorder?: the clinical research center for depression study

PURPOSE

The purpose of this study was to evaluate the effects of age at onset of the first major depressive episode on the clinical features of individuals with major depressive disorder (MDD) in a large cohort of Korean depressed patients.

MATERIALS AND METHODS

We recruited 419 MDD patients of age over 18 years from the Clinical Research Center for Depression study in South Korea. At the start of the study, the onset age of the first major depressive episode was self-reported by the subjects. The subjects were divided into four age-at-onset subgroups: childhood and adolescent onset (ages <18), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late onset (ages 60+). Using analysis of covariance (ANCOVA) and ordinal logistic regression analysis with adjusting the effect of age, the relationships between clinical features and age at onset of MDD were evaluated.

RESULTS

There was an apparent, but inconsistent correlation between clinical features and age at onset. Earlier onset MDD was significantly associated with higher proportion of female gender [adjusted odds ratio (AOR)=0.570, p=0.022], more previous suicide attempts (AOR=0.635, p=0.038), greater number of previous depressive episodes (F=3.475, p=0.016) and higher scores on the brief psychiatric rating scale (F=3.254, p=0.022), its negative symptom subscale (F=6.082, p<0.0001), and the alcohol use disorder identification test (F=7.061, p<0.0001).

CONCLUSION

Early age at onset may increase the likelihood of distinguishable MDD subtype, and age at onset of the first major depressive episode is a promising clinical indicator for the clinical presentation, course, and outcome of MDD.

Depression Treatment Non-adherence and its Psychosocial Predictors: Differences between Young and Older Adults?

Depression is a common disease among young and older adults. Although it can be treated, non-adherence is very common among individuals of different ages. The aim of the present paper is to review and summarize research findings regarding depression among young and older adults, with a special focus on the phenomenon of treatment non-adherence among young and older adults with depression. The first section of the review focuses on describing the characteristics of depression in young and older adults. The second section focuses on treatment non-adherence of young and older adults, the prevalence of this phenomenon, and its consequences. The third section focuses on several factors (illness beliefs, treatment beliefs, self-stigma, and self-esteem) that were identified as having a significant association with treatment non-adherence of individuals with depression, with special attention focused on age differences. Results of the review of the literature reveal that research in the area of depression treatment non-adherence and its predictors among young and older adults has received, to date, very minor and limited attention. Thus, there is a need to expand the current body of knowledge and promote future interventions geared towards the unique characteristics of depression among young and older adults, in order to increase their treatment adherence.

Does early-onset chronic or recurrent major depression impact outcomes with antidepressant medications? A CO-MED trial report

BACKGROUND

Prior studies have suggested that major depressive disorder (MDD) with pre-adult onset represents a distinct subtype with greater symptom severity and higher rates of suicidal ideation. Whether these patients have poorer response to various types of antidepressant treatment than those with adult-onset MDD is unclear. Method A total of 665 psychiatric and primary care out-patients (aged 18-75 years) with non-psychotic chronic or recurrent MDD participated in a single-blind, randomized trial that compared the efficacy of escitalopram plus placebo, bupropion sustained-release plus escitalopram, or venlafaxine extended-release plus mirtazapine. We compared participants who self-reported MDD onset (before age 18) to those with a later onset (adult onset) with respect to baseline characteristics and treatment/outcome variables at 12 and 28 weeks.

RESULTS

Early-onset chronic/recurrent MDD was associated with a distinct set of sociodemographic (female, younger age) and clinical correlates (longer duration of illness, greater number of prior episodes, greater likelihood of atypical features, higher rates of suicidality and psychiatric co-morbidity, fewer medical problems, poorer quality of life, greater history of child abuse/neglect). However, results from unadjusted and adjusted analyses showed no significant differences in response, remission, tolerability of medications, quality of life, or retention at 12 or 28 weeks.

CONCLUSIONS

Although early-onset chronic/recurrent MDD is associated with a more severe clinical picture, it does not seem to be useful for predicting differential treatment response to antidepressant medication. Clinicians should remain alert to an increased risk of suicidality in this population.

Early and late onset depression in young and middle aged adults: differential symptomatology, characteristics and risk factors?

BACKGROUND

Early onset depression (EOD) and late onset depression (LOD) may be different phenomena. In this study, differences between EOD and LOD in symptomatology, psychiatric characteristics and psychosocial/somatic factors were examined.

METHODS

Baseline data were from 1104 participants with a current major depressive disorder participating in the Netherlands Study of Depression and Anxiety (age range 18-65 years). DSM-IV diagnoses, depressive symptoms and age of onset were assessed with the Composite International Diagnostic Interview. Analyses were performed by using a continuous as well as a dichotomous (cut-off 40 years) age of onset indicator.

RESULTS

Differences between EOD and LOD were observed: longer duration of symptoms (p<.001), a personal history of depressive episodes (p<.001), a serious suicide attempt (p<.001), childhood events (p<.001), a family history of depression (p=.03), and high neuroticism (p<.001) were more often present in EOD than in LOD. Also differences in symptomatology were observed: feelings of sadness (p<.001), diminished concentration (p=.02) and suicidal thoughts (p=.001) were significantly less prevalent at a higher age of onset, whereas decreased appetite/weight loss (p=.01) was more prominent at a higher age of onset.

LIMITATIONS

The age of first depression onset was asked retrospectively and might be biased by selective recall. However, participants can likely recall whether symptoms started earlier or later in life.

CONCLUSIONS

Despite similarities, our observed differential findings in symptoms, psychiatric characteristics, and psychosocial factors between EOD and LOD further support that EOD is associated with more frequent occurrence of some clinical features of depression. These differential findings are important factors to keep in mind for diagnostics, treatment, and prevention.

Prevalence and characteristics of depressive disorders in early adolescents in central Norway

BACKGROUND

Prevalence of depressive disorders among adolescents has varied across studies. The present study aims to assess current and lifetime prevalence and characteristics of adolescent Major Depressive Disorder (MDD), Dysthymia and Depression NOS among adolescents in Central Norway in addition to socio-demographics and use of mental health care.

METHOD

In the Youth and Mental Health Study a representative sample of 2432 junior high school students (mean age 14.9 years, SD = 0.6) from two counties in Central Norway were screened with the Mood and Feelings Questionnaire (MFQ). A subset of 345 of these adolescents (72.5% girls), 220 high scorers (MFQ = > 26), 74 middle scorers (MFQ 7-25), and 50 low scorers (MFQ < 7), 1 unknown score, were drawn and interviewed with the Kiddie SADS-PL (Present-Life Version). In all, 79% had parental interviews as well. All estimates of prevalence rates and population shares were weighted back using a sandwich estimator to yield true population estimates.

RESULTS

Almost one in four subjects (23%) had life-time depression. Prevalences of current Major Depressive Disorder (MDD), Dysthymia and "Double depression" were 2.6%, 1.0% and 0.6%, respectively, and for Depression NOS 6.3%.All depressive disorders were characterized by long duration of episodes with large variations, and for any depressive disorder onset before 12 years of age. In multivariate analyses MDD and Dysthymia were most strongly associated with gender and not living with both biological parents. There was no gender difference for Depression NOS. Although a considerable number of depressed subjects had received mental health care, the reason for contact with services was seldom due to affective symptoms. Less than 20% had been in contact with specialist mental health services.

CONCLUSION

High rates of Depression NOS, early onset of depressive episodes, long duration, and low use of specialized services point to the need for improved diagnostic assessment and treatment for young individuals.

Differences between early and late onset adult depression

BACKGROUND

It is unclear, whether age-of-onset identifies subgroups of depression.

AIM

To assess the clinical presentation of depression with onset in the early adult age (18-30 years) as compared to depression with later onset (31-70 years).

METHOD

A total number of 301 patients with first episode depression were systematically recruited. Characteristics including psychiatric co-morbidity, personality disorders and traits, stressful life events prior to onset, family history, and treatment outcome were assessed by structured interviews and compared by chi-square tests for categorical data, t-tests for continuous parametric data and Mann-Whitney U-test for continuous nonparametric data. Logistic and multiple regression analyses were used to adjust the analyses for potentially confounding variables.

RESULTS

Patients with early onset of depression were characterised by a higher prevalence of co-morbid personality disorders, higher levels of neuroticism, and a lower prevalence of stressful life events preceding onset compared to patients with later age-of-onset. There were no differences in severity of the depressive episode, treatment outcome or family loading of psychiatric illness.

CONCLUSION

Early adult onset of depression is associated with co-morbid personality deviances, whereas late onset is associated with environmental risk factors.

Developmental trajectories during adolescence in males and females: a cross-species understanding of underlying brain changes

Adolescence is a transitional period between childhood and adulthood that encompasses vast changes within brain systems that parallel some, but not all, behavioral changes. Elevations in emotional reactivity and reward processing follow an inverted U shape in terms of onset and remission, with the peak occurring during adolescence. However, cognitive processing follows a more linear course of development. This review will focus on changes within key structures and will highlight the relationships between brain changes and behavior, with evidence spanning from functional magnetic resonance imaging (fMRI) in humans to molecular studies of receptor and signaling factors in animals. Adolescent changes in neuronal substrates will be used to understand how typical and atypical behaviors arise during adolescence. We draw upon clinical and preclinical studies to provide a neural framework for defining adolescence and its role in the transition to adulthood.

Pre-adult versus adult onset major depressive disorder in a naturalistic patient sample: the Leiden Routine Outcome Monitoring Study

BACKGROUND

Pre-adult onset of major depressive disorder (MDD) may predict a more severe phenotype of depression. As data from naturalistic psychiatric specialty care settings are scarce, we examined phenotypic differences between pre-adult and adult onset MDD in a large sample of consecutive out-patients.

METHOD

Altogether, 1552 out-patients, mean age 39.2 ± 11.6 years, were diagnosed with current MDD on the Mini-International Neuropsychiatric Interview Plus diagnostic interview as part of the usual diagnostic procedure. A total of 1105 patients (71.2%) had complete data on all variables of interest. Pre-adult onset of MDD was defined as having experienced the signs and symptoms of a first major depressive episode before the age of 18 years. Patients were stratified according to the age at interview (20-40/40-65 years). Correlates of pre-adult onset were analysed using logistic regression models adjusted for age, age squared and gender.

RESULTS

Univariate analyses showed that pre-adult onset of MDD had a distinct set of demographic (e.g. less frequently living alone) and clinical correlates (more co-morbid DSM-IV - Text Revision diagnoses, more social phobia, more suicidality). In the multivariate model, we found an independent association only for a history of suicide attempts [odds ratio (OR) 3.15, 95% confidence intervals (CI) 1.97-5.05] and current suicidal thoughts (OR 1.81, 95% CI 1.26-2.60) in patients with pre-adult versus adult onset MDD.

CONCLUSIONS

Pre-adult onset of MDD is associated with more suicidality than adult onset MDD. Age of onset of depression is an easy to ascertain characteristic that may help clinicians in weighing suicide risk.

STAR*D: revising conventional wisdom

The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study used a series of sequenced, randomized treatment trials following a first and, if needed, subsequent treatment steps to define the tolerability and effectiveness of various options in both acute and longer term treatment. Adult outpatients (n=4041) with nonpsychotic major depressive disorder, substantial chronic and recurrent depression, and co-morbid psychiatric and general medical conditions were enrolled in 41 representative primary and specialty care settings. About one-third of participants remitted in first step treatment with citalopram, 50% of these within 6 weeks. Poorer outcomes were associated with minority status, socioeconomic disadvantage, more axis I and III co-morbid disorders, lower function and quality of life, and anxious and melancholic features. In step 2 medication switch, there were no significant differences in remission among within-class, out-of-class or dual-action agents: sertraline (27%), bupropion-sustained release (26%) and venlafaxine-extended release (25%). In step 2 medication augmentation of citalopram, there was no significant difference in remission between bupropion-sustained release (39%) and buspirone (33%), although participants using bupropion-sustained release had greater symptom reduction and better tolerability. There were no significant differences in remission in step 2 between cognitive therapy and medication treatment in either the switch (31% vs 27%) or augmentation (31% vs 33%) strategies, although participants in cognitive therapy augmentation had a longer time to remission than those in medication augmentation (55 vs 40 days). In step 3, there were no differences in remission between a switch to mirtazapine (8%) or nortriptyline (12%), or between augmentation with lithium (13%) or T(3) (triiodothyronine, liothyronine) [25%], although more participants discontinued lithium due to adverse effects than discontinued T(3). In the fourth step, there was no difference in remission between tranylcypromine (14%) or venlafaxine-extended release plus mirtazapine (16%), although the combination treatment had fewer adverse effects and had the advantages of not requiring a washout period or diet restrictions. Participants requiring more than two well delivered treatments may be characterized as treatment resistant given the substantially lower remission rates after that point. Treatment resistance was associated with more concurrent axis I or III co-morbid conditions, socioeconomic disadvantage, chronicity and melancholic or anxious features. However, if participants remained in treatment for up to four steps, about 67% reached remission. Times to remission were not substantially longer for later treatment steps. The importance of reaching remission is highlighted by the lower relapse rates in naturalistic follow-up for participants entering in remission compared with those entering with response but not remission (step 1: 34% vs 59%; step 2: 47% vs 68%; step 3: 42% vs 76%; step 4: 50% vs 83%). Clinical decision making based on the itemized measurement of symptoms and adverse effects at each treatment visit was feasible in STAR*D's real world settings and resulted in adequate dosages and durations of treatment that generally exceeded those typically found in practice settings. Although switch and augmentation strategies could not be directly compared due to the equipoise stratified randomized design, the higher remission rates at step 2 with medication augmentation are intriguing and merit further study.

Predictive value of family history on severity of illness: the case for depression, anxiety, alcohol dependence, and drug dependence

CONTEXT

If family history is associated with clinical features that are thought to index seriousness of disorder, this could inform clinicians predicting patients' prognosis and researchers selecting cases for genetic studies. Although tests of associations between family history and clinical features are numerous for depression, such tests are relatively lacking for other disorders.

OBJECTIVE

To test the hypothesis that family history is associated with 4 clinical indexes of disorder (recurrence, impairment, service use, and age at onset) in relation to 4 psychiatric disorders (major depressive episode, anxiety disorder, alcohol dependence, and drug dependence).

DESIGN

Prospective longitudinal cohort study.

SETTING

New Zealand.

PARTICIPANTS

A total of 981 members of the 1972 to 1973 Dunedin Study birth cohort (96% retention).

MAIN OUTCOME MEASURES

For each disorder, family history scores were calculated as the proportion of affected family members from data on 3 generations of the participants' families. Data collected prospectively at the study's repeated assessments (ages 11-32 years) were used to assess recurrence, impairment, and age at onset; data collected by means of a life history calendar at age 32 years were used to assess service use.

RESULTS

Family history was associated with the presence of all 4 disorder types. In addition, family history was associated with a more recurrent course for all 4 disorders (but not significantly for women with depression), worse impairment, and greater service use. Family history was not associated with younger age at onset for any disorder.

CONCLUSIONS

Associations between family history of a disorder and clinical features of that disorder in probands showed consistent direction of effects across depression, anxiety disorder, alcohol dependence, and drug dependence. For these disorder types, family history is useful for determining patients' clinical prognosis and for selecting cases for genetic studies.

Candidate endophenotypes for genetic studies of suicidal behavior

Twin, adoption, and family studies have established the heritability of suicide attempts and suicide. Identifying specific suicide diathesis-related genes has proven more difficult. As with psychiatric disorders in general, methodological difficulties include complexity of the phenotype for suicidal behavior and distinguishing suicide diathesis-related genes from genes associated with mood disorders and other suicide-associated psychiatric illness. Adopting an endophenotype approach involving identification of genes associated with heritable intermediate phenotypes, including biological and/or behavioral markers more proximal to genes, is an approach being used for other psychiatric disorders. Therefore, a workshop convened by the American Foundation for Suicide Prevention, the Department of Psychiatry at Columbia University, and the National Institute of Mental Health sought to identify potential target endophenotypes for genetic studies of suicidal behavior. The most promising endophenotypes were trait aggression/impulsivity, early-onset major depression, neurocognitive function, and cortisol social stress response. Other candidate endophenotypes requiring further investigation include serotonergic neurotransmission, second messenger systems, and borderline personality disorder traits.