Psychosocial and clinical predictors of symptom persistence vs remission in major depressive disorder

Electroconvulsive therapy enhances degree centrality in the orbitofrontal cortex in depressive rumination

Depressive rumination has been implicated in the onset, duration, and treatment response of refractory depression. Electroconvulsive therapy (ECT) is remarkably effective in treatment of refractory depression by modulating the functional coordination between brain hubs. However, the mechanisms by which ECT regulates depressive rumination remain unsolved. We investigated degree centrality (DC) in 32 pre- and post-ECT depression patients as well as 38 matched healthy controls. An identified brain region was defined as the seed to calculate functional connectivity (FC) in whole brains. Rumination was measured by the Ruminative Response Scale (RRS) and its relationships with identified DC and FC alterations were examined. We found a significant negative correlation between DC of the right orbitofrontal cortex (rOFC) before ECT and brooding level before and after treatment. Moreover, rOFC DC increased after ECT. DC of the left superior temporal gyrus (lSTG) was positively correlated with reflective level before intervention, while lSTG DC decreased after ECT. Patients showed elevated FC in the rOFC with default mode network. No significant association was found between decreased RRS scores and changes in DC and FC. Our findings suggest that functional changes in rOFC and lSTG may be associated with the beneficial effects of ECT on depressive rumination.

Childhood Abuse, Social Support, and Long-Term Pharmacological Treatment Outcomes in Patients With Depressive Disorders

OBJECTIVES

This study was performed to investigate the roles of childhood abuse and social support in predicting short- and long-term pharmacological treatment outcomes in outpatients with depressive disorders in a naturalistic 1-year prospective design.

METHODS

Patients were recruited at a university hospital in South Korea between March 2012 and April 2017. Subjects with stepwise pharmacotherapy (switching, augmentation, combination, and mixture of these approaches) included 1246 patients at 12-week points in the acute treatment response and 1,015 patients at 12-months in the long-term treatment response. Remission was defined as Hamilton Depression Rating Scale score ≤ 7. Exposure to three types of childhood abuse (physical, emotional, and sexual) before the age of 16 and perceived social support were assessed at baseline.

RESULTS

Individual associations of childhood abuse were associated with poorer treatment outcomes in the 12-month long-term phase, and no significant individual associations were found for social support level with any period outcome. In combination, any child abuse, emotional abuse, and physical abuse were significantly associated with long-term 12-month remission rate in the presence of higher level of social support after adjustment with significant interaction terms. However, no significant interactions were found with sexual abuse.

CONCLUSION

Synergistic interactive effects of child abuse and social support levels on treatment outcomes in depressive patients were found during long-term pharmacotherapy. Thus, depressed patients with a history of childhood abuse may require specialized clinical approaches, including social support, to enhance the long-term treatment outcomes.

The effect of childhood trauma on the severity of obsessive-compulsive symptoms: A systematic review

BACKGROUND

Childhood trauma is associated with a range of psychiatric disorders, including obsessive-compulsive disorder (OCD). However, our understanding of the different types of childhood trauma and its impact on the different types and severity of obsessive-compulsive symptoms (OCS) is still in its infancy.

AIMS

We conducted a systematic review to synthesise the current knowledge on the possible relationships between childhood trauma and obsessive-compulsive symptoms in clinical and non-clinical populations.

METHODS

We systematically searched four electronic databases for studies reporting on childhood trauma and OCS severity. Subsequently, we qualitatively synthesised results of eligible studies and effect sizes were also calculated.

RESULTS

Twenty-four studies were included in this systematic review. Most studies used OCD samples (k = 16), with a few studies using a sample comprising of a range of psychiatric disorders (k = 6) and some studies using a general community sample (k = 2). Overall, there was support for a significant relationship between childhood trauma and OCS severity (8 out of 16 of the studies using OCD clinical samples, both studies using general population samples, and 5 out of 6 studies used mixed psychiatric samples).

CONCLUSIONS

We found evidence of a significant relationship between exposure to childhood trauma and OCS severity across clinical and non-clinical populations. Our results also suggest that a range rather than a single type of childhood trauma was associated with OCD.

Predictors of poor 6-week outcome in a cohort of major depressive disorder patients treated with antidepressant medication: the role of entrapment

BACKGROUND

Only a small number of consistent processes predict which depressed patients will achieve remission with antidepressant medication. One set of processes is that of social ranking strategies/variables that are related to life events and severe difficulties. Particularly, defeat and entrapment predict poorer response to antidepressants. However, results are inconsistent.

AIM

The current study aimed to evaluate evolutionary strategies, childhood maltreatment, neglect and life events and difficulties (LEDs) as predictors of remission in depressed patients undergoing pharmacological treatment in a psychiatric outpatient sample.

METHODS

A cohort of 139 depressed outpatients undergoing pharmacological treatment was followed prospectively in a naturalistic study for 6 weeks. Two major evaluations were considered at baseline and 6 weeks. We allocated patients to a pharmacological treatment algorithm for depression - the Texas Medication Algorithm Project. Variables evaluated at baseline and tested as predictors of remission included demographic and clinical data, severity of depression, social ranking, evolution informed variables, LEDs and childhood maltreatment.

RESULTS

Of the 139 patients, only 24.5% were remitted at week 6. In univariate analyses, non-remitted patients scored significantly higher in all psychopathology and vulnerability scales except for submissive behaviour and internal entrapment. For the logistic regression, a higher load of LEDs of the entrapment and humiliation dimension in the year before the index episode (OR = 6.62), and higher levels external entrapment in the Entrapment Scale (OR = 1.10) predicted non-remission. These variables accounted for 28.7% of the variance.

CONCLUSIONS

Multivariate analysis revealed that external entrapment was the only predictor of non-remission.

Tomato SlWRKY3 acts as a positive regulator for resistance against the root-knot nematode Meloidogyne javanica by activating lipids and hormone-mediated defense-signaling pathways

Diseases caused by plant-parasitic nematodes in vegetables, among them Meloidogyne spp. root-knot nematodes (RKNs), lead to extensive yield decline. A molecular understanding of the mechanisms underlying plants' innate resistance may enable developing safe alternatives to harmful chemical nematicides in controlling RKNs. A tight relationship has been revealed between the WRKY transcription factors and RKN parasitism on tomato roots. We investigated the function role of tomato SlWRK3 and SlWRKY35 in regulating nematode disease development. Using promoter-GUS reporter gene fusions, we show that both SlWRKY3 and SlWRKY35 are induced within 5 days of infection and through feeding-site development and gall maturation, with a much stronger response of the former vs. the latter to nematode infection. Histological analysis of nematode-feeding sites indicated a high expression of SlWRKY3 in developing and mature feeding cells and associated vasculature cells, whereas SlWRKY35 expression was only observed in mature feeding sites. Both SlWRKY3 and SlWRKY35 promoters were induced by the defense phytohormones salicylic acid and indole-3-butyric acid, with no response to either jasmonic acid or methyl jasmonate. SlWRKY3 overexpression resulted in lower infection of the RKN Meloidogyne javanica, whereas knocking down SlWRKY3 resulted in increased infection. Phytohormone and oxylipin profiles determined by LC-MS/MS showed that the enhanced resistance in the former is coupled with an increased accumulation of defense molecules from the shikimate and oxylipin pathways. Our results pinpoint SlWRKY3 as a positive regulator of induced resistance in response to nematode invasion and infection, mostly during the early stages of nematode infection.

Relations of Shared and Unique Components of Personality and Psychosocial Functioning to Depressive Symptoms

Consistent with theories of depression, several personality (e.g., high neuroticism, low extraversion) and psychosocial (e.g., interpersonal problems, cognitive content) variables predict depressive symptoms substantively. In this extended replication, we clarified whether 13 theoretically relevant personality and psychosocial variables were unique versus overlapping predictors of symptoms among 351 adult outpatients with recurrent major depressive disorder who received acute-phase cognitive therapy (CT). Using factor analysis and regression methods, we partitioned the measures' variance into general components common across the two types of measures (psychosocial and personality), within-type components shared only with other measures of the same type, and scale-specific components. From early to late in CT, and from late in CT through 8 months after response, the general components were the strongest (median r = .23)-and scale-specific components the weakest (median r = .01)-forward predictors of symptoms. We discuss implications for measurement and treatment of depression.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

The role of change in self-criticism across young adulthood in explaining developmental outcomes and psychological wellbeing

OBJECTIVE

Past research has confirmed the role of self-criticism in numerous forms of psychopathology and negative interpersonal outcomes. However, the majority of these studies were cross-sectional and have not addressed the role of possible changes in self-criticism across time for future outcomes. The current study investigated the degree to which changes in self-criticism during young adulthood precede better psychological outcomes beyond the contribution of their baseline levels.

METHOD

A total of 168 Israeli emerging adults were followed for 12 years. Participants completed assessments of self-criticism at age 23, 24, 26.5, and 29, and of developmental tasks and psychological adaptation at age 35. Analyses assessed the extent to which the intercept and linear slope of self-criticism were associated with assessments of coping with age-related tasks and psychological well-being at age 35.

RESULTS

Findings indicated that decreases in self-criticism between the ages of 23 and 29 were associated with better coping with age-related task outcomes and psychological health at age 35.

CONCLUSIONS

These findings are among the first to show that decreases in self-criticism serve as important precursors of coping with age-related tasks and psychological outcomes and point to the positive contributions of changes in personality attributes for future development.

Performance of the biological rhythms interview for assessment in neuropsychiatry: An item response theory and actigraphy analysis

BACKGROUND

Biological rhythm disturbances are widely associated with the pathophysiology of mood disorders. The Biological Rhythms Interview for Assessment in Neuropsychiatry (BRIAN) is a self-report that indexes rhythm disturbance in sleep, activity, social and eating patterns. The aim of this study was to perform an Item Response Theory (IRT) analysis of the BRIAN and investigate its associations with objective sleep and rhythm disturbance measures.

METHODS

103 subjects (31 bipolar, 32 major depression and 40 healthy volunteers) wore an actiwatch for fifteen days, and completed a first morning urine sample and the BRIAN on day 15. IRT analysis assessed individual BRIAN items and their relationship to total score. Individual actiwatch records were processed to produce a sequence of transitions between rest/activity, and a likelihood of transitioning between states was calculated to investigate sleep-wake dynamics. Cosinor analysis produced daily activity rhythms (DARs). Spearman correlations were used to assess the association between sleep/DAR variables and the BRIAN.

RESULTS

IRT analyses showed that 11 of 18 BRIAN items displayed a high level of discrimination between item options across a range of BRIAN total scores. Total BRIAN score correlated with wake after sleep onset, total activity count during sleep, and urinary 6-sulphatoxymelatonin. BRIAN Activity domain correlated with the daytime transition probability from rest to activity.

LIMITATIONS

The sample size may have been underpowered for the graded-response model employed in IRT. The study lacked an objective comparison for BRIAN eating and social domain.

CONCLUSION

The present study reveals the BRIAN displays promising external validity compared to objective parameters of circadian rhythmicity.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

PURPOSE

Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given.

METHODS

We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders.

RESULTS

We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences.

DISCUSSION

The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD.

CONCLUSION

Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

Impact of childhood adversities on the short-term course of illness in psychotic spectrum disorders

Accumulating evidence indicates an impact of childhood adversities on the severity and course of mental disorders, whereas this impact on psychotic disorders remains to be specified. Effects of childhood adversities on comorbidity, on symptom severity of the Positive and Negative Syndrome Scale and global functioning across four months (upon admission, 1 and 4 months after initial assessment), as well as the course of illness (measured by the remission rate, number of re-hospitalizations and dropout rate) were evaluated in 62 inpatients with psychotic spectrum disorders. Adverse experiences (of at least 1 type) were reported by 73% of patients. Patients with higher overall level of childhood adversities (n=33) exhibited more co-morbid disorders, especially alcohol/substance abuse and dependency, and higher dropout rates than patients with a lower levels of adverse experiences (n=29), together with higher levels of positive symptoms and symptoms of excitement and disorganization. Emotional and physical neglect were particularly related to symptom severity. Results suggest that psychological stress in childhood affects the symptom severity and, additionally, a more unfavorable course of disorder in patients diagnosed with psychoses. This impact calls for its consideration in diagnostic assessment and psychiatric care.

Effects of persisting emotional impact from child abuse and norepinephrine transporter genetic variation on antidepressant efficacy in major depression: a pilot study

Objective

Previous studies suggest child abuse and serotonergic polymorphism influence depression susceptibility and anti-depressant efficacy. Polymorphisms of the norepinephrine transporter (NET) may also be involved. Research in the area is possibly clouded by under reporting of abuse in researcher trials.

Methods

Adults (n=51) with major depressive disorder has 8 weeks treatment with escitalopram or venlafaxine. Abuse history was obtained, the ongoing emotional impact of which was measured with the 15-item impact of event scale (IES-15). The 17-item Hamilton Depression Rating Scale (HDRS) was applied serially. Two NET polymorphisms (rs2242446 and rs5569) were assayed, blinded to HDRS ratings and abuse history.

Results

No subjects reporting abuse with high impact in adulthood (IES-15 ≥26, n=12) remitted; whereas 77% reporting low impact (IES-15 <26; n=26) remitted (p<0.001). Subjects reporting high impact abuse (n=12) had a 50-fold (95% confidence interval=4.85–514.6) greater odds of carrying rs2242446-TT genotype, but the small sample size leaves this finding vulnerable to type I error.

Conclusion

The level of persisting impact of child abuse appears relevant to antidepressant efficacy, with susceptibility to such possibly being influence by NET rs2242446 polymorphism. Larger studies may be merited to expand on this pilot level finding given potential for biomarker utility.

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

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

Clinical predictors associated with full remission versus episode of major depressive disorder outpatients: the experience at a teaching hospital in Taiwan

BACKGROUND

When depressed patients are in remission, the clinical characteristics indicate that they are able to participate in social activities more regularly, and their impairment in daily functioning is improved. The present study examines the clinical characteristics associated with one- and two month clinical response in outpatients with Major Depressive Disorder (MDD) in Taiwan.

METHODS

A total of 160 outpatients were initially recruited from the medical centre in Taiwan. Of these participants, 151 MDD patients completed the baseline-assessment interview, 111 were interviewed and assessed again 4 weeks later, and 78 completed the final interview and assessment 8 weeks later. In the present study, asymptomatic was defined as scoring ≤ 7 on the Hamilton Depression Rating Scale (HAM-D); partially symptomatic was defined as scoring 8-14; fully symptomatic was defined as scoring ≥15. Finally, asymptomatic, partially symptomatic, and fully symptomatic were defined in patients with MDD respectively as in full remission, in persistent depressive symptom, and in episode.

RESULTS

Of the remaining 78 patients, a total of 21 (26.9%) were in full remission, 35 (44.9%) were in persistent depressive symptom, and 22 (28.2%) were in episode. Patients in full remission were older (p = 0.03), exhibited greater psychosocial functioning, (p < 0.001), held more-positive beliefs regarding antidepressant medication (p = 0.03), had higher self-efficacy (p = 0.001), and scored lower for neuroticism (p = 0.003), as compared to patients in episode. Younger patients were more prevalent in persistent depression. Repeated-measures ANOVA revealed that differences in four factors (psychosocial functioning, beliefs regarding antidepressant medication, self-efficacy in managing and preventing depression, and neuroticism) were significantly different between full remission and episode. Episode was significantly associated with psychosocial-functioning impairment (OR = 1.12, 95% CI: 1.00-1.26) and poorer self-efficacy (OR = 0.91, 95% CI: 0.82-1.00).

CONCLUSIONS

Our findings identify significant factors of full remission, persistent depressive symptom, and episode. We highlight the importance of enhancing patients' psychosocial functioning and self-efficacy until achieving full remission. Suggestions are provided for clinical health-care management services in Taiwan.

[Stress-related risk factors for depression in girls]

Major depression is a frequent psychiatric disorder among adolescents. Stress-related approaches to adolescent depression postulate acute or chronic stressors as a cause of as well as a consequence of depressive symptomatology. Stress situations persist because the child uses mainly unfavorable stress-coping strategies. The present study investigates stress-related risk factors for the maintenance of depression in 68 young girls in a longitudinal design with two measurement points. Stress load and stress coping were assessed by the Fragebogen zur Erhebung von Stress und Stressbewältigung im Kindes- und Jugendalter (SSKJ). Data on stress-induced salivary cortisol and cortisol-awakening response at first measurement point were also available. A logistic regression model tested the relative contribution of stress-related risk factors. Significant effects were obtained for avoidant coping, a high psychological stress load, and a high stress vulnerability, while physical complaints and cortisol were not relevant. These results confirm theories that postulate stress load and stress coping as causal links for maintenance of depression in youth.

Depression and resilience in women with HIV and early life stress: does trauma play a mediating role? A cross-sectional study

OBJECTIVES

The present study sought to assess the relationship between depressive symptomatology and resilience among women infected with HIV and to investigate whether trauma exposure (childhood trauma, other discrete lifetime traumatic events) or the presence of post-traumatic stress symptomatology mediated this relationship.

DESIGN

Cross-sectional study.

SETTING

Western Cape, South Africa.

PARTICIPANTS

A convenience sample of 95 women infected with HIV in peri-urban communities in the Western Cape, South Africa. All women had exposure to moderate-to-severe childhood trauma as determined by the Childhood Trauma Questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

We examined the relationship between depressive symptomatology and resilience (the Connor-Davidson Resilience Scale) and investigated whether trauma exposure or the presence of post-traumatic stress symptomatology mediated this relationship through the Sobel test for mediation and PLS path analysis.

RESULTS

There was a significant negative correlation between depressive symptomatology and resilience (p=<0.01). PLS path analysis revealed a significant direct effect between depression and resilience. On the Sobel test for mediation, distal (childhood trauma) and proximal traumatic events did not significantly mediate this association (p=> 0.05). However, post-traumatic stress symptomatology significantly mediated the relationship between depression and resilience in trauma-exposed women living with HIV.

CONCLUSIONS

In the present study, higher levels of resilience were associated with lower levels of self-reported depression. Although causal inferences are not possible, this suggests that in this sample, resilience may act as protective factor against the development of clinical depression. The results also indicate that post-traumatic stress symptoms (PTSS), which are highly prevalent in HIV-infected and trauma exposed individuals and often comorbid with depression, may further explain and account for this relationship. Further investigation is required to determine whether early identification and treatment of PTSS in this population may ameliorate the onset and persistence of major depression.

Clinical outcomes of older depressed patients with and without comorbid neuroticism

BACKGROUND

Neuroticism is a psychological construct that includes tendency to exhibit negative affect (NA), having poor stress tolerance and being at risk for depression and anxiety disorders. The consequences of neuroticism in the elderly adults are understudied. We hypothesized that older depressed patients with comorbid neuroticism at baseline would have worse mood and cognitive outcomes compared with older depressed patients without neuroticism.

METHODS

One hundred and ten older depressed adults completed baseline self-reports of depression and the NEO-Personality Inventory as a measure of neuroticism, were administered a battery of cognitive tests annually and were seen by a study psychiatrist who assessed patients using the Montgomery Åsberg Depression Rating Scale (MADRS) and treated patients with antidepressants using an established treatment guideline. Patients were followed as clinically indicated for up to three years. We measured remission (defined as MADRS score ≤ 6) rates at one year as a categorical outcome. In addition, we used Cox proportional hazard models to examine the relationship between neuroticism and change in MADRS and cognitive score over time.

RESULTS

Non-remitters (30%) at one year had higher scores in total neuroticism (TN), vulnerability to stress (VS), and NA. Over three years, time to achieve remission was associated with higher TN, higher VS, and greater NA. In analyses controlling for baseline cognitive score, age, sex, and education, VS was associated with baseline to two-year change in cognition.

CONCLUSIONS

Presence of neuroticism in older depressed patients treated with medication is associated with poor mood outcomes and may indicate increased risk of cognitive decline.

Association of SLC6A4 methylation with early adversity, characteristics and outcomes in depression

Childhood adversities have been associated with onset and worse clinical presentations of depression. Epigenetic changes may reflect childhood adversities, while their effects on clinical characteristics of depression are unknown. This study aimed to investigate whether epigenetic changes were associated with childhood adversities, pretreatment characteristics, and treatment outcomes in depressive patients. In 108 patients with major depressive disorders, the methylation status in the promoter of gene encoding serotonin transporter (SLC6A4) was measured. Childhood adversities, socio-demographic and clinical characteristics including assessment scales for depression (Hamilton Depression Rating Scale, HAMD), anxiety (Hamilton Anxiety Rating Scale, HAMA), functioning (Social and Occupational Functioning Assessment Scale, SOFAS), disability (World Health Organization Disability Assessment Schedule-12, WHODAS-12), and quality of life (World Health Organization Quality of Life-Abbreviated form, WHOQOL-BREF) were evaluated at baseline. After a 12-week treatment with antidepressants, the assessment scales were reevaluated. To avoid type I error by multiple comparisons, Bonferroni corrections were applied. Higher SLC6A4 promoter methylation status was significantly associated with childhood adversities, worse clinical presentation (family history of depression, higher perceived stress, and more severe psychopathology assessed by SOFAS, WHODAS-12, and WHOQOL-BREF), but was not associated with treatment outcomes after considering multiple comparisons. SLC6A4 methylation status could be a proxy marker for childhood adversities and a clinical biomarker for certain presentations of depression.

Psychosocial vulnerabilities to depression after acute coronary syndrome: the pivotal role of rumination in predicting and maintaining depression

Psychosocial vulnerabilities may predispose individuals to develop depression after a significant life stressor, such as an acute coronary syndrome (ACS). The aims are (1) to examine the interrelations among vulnerabilities, and their relation with changes in depressive symptoms 3 months after ACS, (2) to prospectively assess whether rumination interacts with other vulnerabilities as a predictor of later depressive symptoms, and (3) to examine how these relations differ between post-ACS patients who meet diagnostic criteria for depression at baseline versus patients who do not. Within 1 week after hospitalization for ACS, and again after 3 months, 387 patients (41% female, 79.6% white, mean age 61) completed the Beck Depression Inventory (BDI) and measures of vulnerabilities (lack of pleasant events, dysfunctional attitudes, role transitions, poor dyadic adjustment). Exclusion criteria were a BDI score of 5-9, terminal illness, active substance abuse, cognitive impairment, and unavailability for follow-up visits. We used hierarchical regression modeling cross-sectionally and longitudinally. Controlling for baseline (in-hospital) depression and cardiovascular disease severity, vulnerabilities significantly predicted 3 month depression severity. Rumination independently predicted increased depression severity, above other vulnerabilities (β = 0.75, p < 0.001), and also interacted with poor dyadic adjustment (β = 0.32, p < 0.001) to amplify depression severity. Among initially non-depressed patients, the effects of vulnerabilities were amplified by rumination. In contrast, in patients who were already depressed at baseline, there was a direct effect of rumination above vulnerabilities on depression severity. Although all vulnerabilities predict depression 3 months after an ACS event has occurred rumination plays a key role to amplify the impact of vulnerabilities on depression among the initially non-depressed, and maintains depression among those who are already depressed.

Predicting outcome of depression using the depressive symptom profile: the Leiden Routine Outcome Monitoring Study

BACKGROUND

To investigate the predictive value of items for individual depressive symptoms measured with the self-rated Beck Depression Inventory-Revised (BDI-II) self-report scale on outcome in a large naturalistic cohort of depressive outpatients.

METHODS

We used a cohort of 1,489 adult patients aged 18-65 years with major depressive disorder or dysthymic disorder established with the MINI-Plus diagnostic interview. All patients had a routine outcome monitoring baseline measurement in 2004-2009, with a maximum of 2 years follow-up. We used multivariable Cox regression models to predict remission (MADRS < 10; where MADRS stands for Montgomery-Åsberg Depression Rating Scale) and response (≥50% improvement), and adjusted for clinical and demographic characteristics (i.e. marital status, level of education, working status, comorbid anxiety, avoidant and borderline personality traits, and suicidality) that were identified as predictors in earlier studies.

RESULTS

Of the 21 BDI-II items, the items "pessimism" and "loss of energy" independently predicted for both remission and response. For pessimism, the hazard ratio (HR) for remission was 0.81 (95% confidence interval [CI]: 0.73-0.89, P < .001) and for loss of energy, the HR was 0.81 (95% CI: 0.72-0.92, P = .001).

CONCLUSIONS

These findings of robust prediction of poor outcome by baseline items of "pessimism" and "loss of energy" in a naturalistic treatment setting may help clinicians to identify depressive patients in need for additional or alternative therapeutic approaches.

Gene-environment interaction in major depression and antidepressant treatment response

Response to antidepressants is interindividually variable. It has been suggested that this variability is a direct consequence of etiological heterogeneity. Therefore, the same genes, environments, and gene-environment interactions implicated in different etiological pathways to depression may also predict response to treatment. This article reviews the evidence relevant to this hypothesis by first outlining the roles of genes, environments, and gene-environment interplay in the etiology of depression, and then considering the same factors in treatment response. Environmental exposures, such as childhood maltreatment, are potent predictors of both depression and treatment response. Although alone genetic factors have failed to consistently predict either phenotype, several polymorphisms have been shown to moderate the effects of environmental adversity on the development of depression and treatment response. These findings suggest that the dissection of etiological pathways to depression may provide the key to understanding and predicting response to antidepressants.

Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression

BACKGROUND

Although many demographic and clinical characteristics have been suggested to predict treatment outcome of depression, they provide only a weak prediction for clinical response. Based on the predictive values of trauma and biological markers involved in stress response, we investigated the roles of baseline trait anxiety and resilience, which were assumed as vulnerability and resilience factors, respectively, in predicting treatment response in naturalistically treated outpatients with depressive disorders.

METHODS

A total of 178 outpatients with depressive disorders were consecutively recruited and completed measures of trauma experiences, psychological symptoms, and resilience at baseline. Response was defined by Clinical Global Impression (CGI)-Improvement score ≤2 at last visit during a 6month-treatment period. Univariate analyses and multiple logistic regression analysis were performed to determine predictors of treatment response.

RESULTS

Among demographic and clinical variables, treatment response was associated with increased age, longer treatment duration, higher resilience, and lower trait anxiety. In logistic regression analysis, resilience, trait anxiety, and their interaction significantly predicted treatment response after adjusting for age and treatment duration. Interaction between resilience and trait anxiety remained significant in the final model. Examining the interaction between the two, patients with low trait anxiety were only significantly affected by the level of resilience in response rate.

CONCLUSIONS

Low trait anxiety, high resilience, and their interaction might contribute to better treatment response in depressed patients. Our result suggested that individual differences in responding to stress might be important in predicting treatment outcome of depression in addition to other demographic and clinical factors.

Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study

BACKGROUND

There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement.

METHODS

This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records.

RESULTS

721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes.

CONCLUSION

The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Genes, environment, and individual differences in responding to treatment for depression

A principal weakness of evidence-based psychiatry is that it does not account for the individual variability in therapeutic response among individuals with the same diagnosis. The aim of personalized psychiatry is to remediate this shortcoming and to use predictors to select treatment that is most likely to be beneficial for an individual. This article reviews the evidence that genetic variation, environmental exposures, and gene-environment interactions shape mental illness and influence treatment outcomes, with a primary focus on depression. Several genetic polymorphisms have been identified that influence the outcome of specific treatments, but the strength and generalizability of such influences are not sufficient to justify personalized prescribing. Environmental exposures in early life, such as childhood maltreatment, exert long-lasting influences that are moderated by inherited genetic variation and mediated through stable epigenetic mechanisms such as tissue- and gene-specific DNA methylation. Pharmacological and psychological treatments act on and against the background of genetic disposition, with epigenetic annotation resulting from previous experiences. Research in animal models suggests the possibility that epigenetic interventions may modify the impact of environmental stressors on mental health. Gaps in evidence are identified that need to be bridged before knowledge about cause can inform cure in personalized psychiatry.

Gender and remission of mental illness

OBJECTIVES

There is a well-established association between gender and the prevalence of mental illness. The objective of this study was to determine whether gender also influences the timing of remission from illness. The regression analysis undertaken considered remission in terms of all ICD-9 mental disorders (codes 290-314). This analysis compares males and females on average length of treatment for mental illness and examines whether any gender differences in remission are generalized or disorder specific.

METHODS

The statistical analysis was based on longitudinal (1990-2001) administrative data on 5,118 females and 2,470 males. The target population represented all individuals with an ICD-9 diagnosis of mental illness who were treated through the Medical Services Plan in British Columbia. The regression analysis used the generalized estimating equations method to model differences in length of treatment.

RESULTS

There was a non-significant bivariate relation between gender and the timing of remission from mental illness. However, the multivariate findings demonstrated that a significant gender effect on remission emerges after controls were introduced for demographic and socio-economic characteristics. In particular, the timing of remission was somewhat longer for females. This effect was generalized and not restricted to specific illnesses.

CONCLUSIONS

The emergence of a significant effect after considering demographic and socio-economic characteristics suggests that a social disadvantage within the male sample (more single males) was suppressing a small negative effect of female gender on the timing of remission. In other words, a social disadvantage among males concealed an unexplained female disadvantage in remission.

Do stressful life events predict medical treatment outcome in first episode of depression?

BACKGROUND

It is unclear whether medical treatment outcome in first episode depression differ for patients with and without stressful life events prior to onset of depression.

METHODS

Patients discharged with a diagnosis of a single depressive episode from a psychiatric in- or outpatient hospital setting were consecutively sampled from the Danish Psychiatric Central Research Register. Patients participated in an extensive interview including the schedules for clinical assessment in neuropsychiatry (SCAN), the Structured Clinical Interview for DSM-IV axis II personality disorders (SCID-II) and the interview of recent life events (IRLE). Medical treatment history was assessed in detail using standardised procedures (TRAQ). Remission was defined as a score <or= 7 on the Hamilton Depression Rating Scale, 17 items and a score >or= 4 on TRAQ following (1) first trial of antidepressant treatment (2) two adequate trials of antidepressant treatment.

RESULTS

A total of 399 patients participated in the interview and among these 301 patients obtained a SCAN diagnosis of a single depressive episode. A total of 62.8% of the 301 patients experienced at least one moderate to severe stressful life event in a 6 months period prior to symptom onset. The presence of a stressful life event or the number of stressful life events did not predict remission from first or second antidepressant drug trial-nor when adjusted for differences in age, gender or prevalence of co-morbid personality disorders.

CONCLUSIONS

Medical treatment outcome in first episode depression does not depend on the prevalence of moderate to severe stressful life events prior to symptom onset.

Does emotion predict the course of major depressive disorder? A review of prospective studies

PURPOSE

Emotional dysfunction is a hallmark of major depressive disorder (MDD). There has been wide interest in identifying the nature and significance of emotional deficits in MDD. Given the paramount goal of identifying etiological markers of MDD that can sharpen prevention and treatment efforts, researchers have pursued emotion as a functionally significant factor and predictor of clinical course in MDD. This review is the first to summarize the literature examining emotion as a predictor of the clinical course of MDD.

METHOD

We conducted a systematic review of all published studies reporting on the prospective relationship between positive and negative emotionality (PE and NE)--measured at the state or trait level--and the longitudinal course of MDD in diagnosed adults. Physiological, behavioural, and subjective indices of emotion were considered. The primary analyses encompassed 28 research reports that included data from 3,798 participants and tested a total of 60 hypotheses.

RESULTS

Lower levels of PE predicted poorer MDD course with some consistency. Paradoxically, both lower levels of state NE and higher levels of trait NE predicted poorer MDD course. The relationships between emotionality and MDD course generally held even after initial depression symptom severity was taken into account.

CONCLUSION

Emotion shows promise as a predictor of MDD course. Implications of these data for current theories of emotion and MDD, the apparently divergent relation between state and trait NE and course, and future directions to further clarify the functional significance of emotion in the context of MDD are discussed.

The association between parental bonding and obsessive compulsive disorder in offspring at high familial risk

BACKGROUND

The aim of the current study is to estimate the association between parenting factors derived from the Parental Bonding Instrument (PBI) and a lifetime DSM-IV diagnosis of OCD.

METHOD

Data were from approximately 1200 adults from 465 families assessed as part of a large family and genetic study of OCD. The association of three parenting factors, for fathers and mothers, with offspring OCD status were examined; analyses were stratified by parental OCD status and family loading for OCD (multiplex versus sporadic).

RESULTS

Three factors were derived by principal components factor analysis of the PBI (maternal and paternal care, overprotection and control). Maternal overprotection was associated with OCD in offspring with familial OCD (familial cases) but only if neither parent was affected with OCD, which suggests independent but additive environmental and genetic risk (OR = 5.9, 95% CI 1.2, 29.9, p = 0.031). Paternal care was a protective factor in those not at high genetic risk (sporadic cases) (OR = 0.2, 95% CI 0.0, 0.8, p = 0.027). Maternal overprotection was also associated with offspring OCD in sporadic families (OR = 2.9, 95% CI 1.3, 6.6, p = 0.012). The finding that parental overprotection and care were not associated with offspring OCD when at least one parent had OCD addressed directly the hypothesis of maternal or paternal OCD adversely impacting parenting.

CONCLUSIONS

This study provides evidence that aspects of parenting may contribute to the development of OCD among offspring. Prospective studies of children at risk for OCD are needed to explore the direction of causality.

Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone

The main aim of the present novel reanalysis of archival data was to compare the time to remission during 12 weeks of treatment of chronic depression following antidepressant medication (n = 218), psychotherapy (n = 216), and their combination (n = 222). Cox regression survival analyses revealed that the combination of medication and psychotherapy produced full remission from chronic depression more rapidly than either of the single modality treatments, which did not differ from each other. Receiver operating characteristic curve analysis was used to explore predictors (treatment group, demographic, clinical, and psychosocial) of remission. For those receiving the combination treatment, the most likely to succeed were those with low baseline depression (24-item Hamilton Rating Scale for Depression [HRSD; M. Hamilton, 1967] score < 26) and those with high depression scores but low anxiety (HRSD = 26 and Hamilton Anxiety Rating Scale [M. Hamilton, 1959] < 14). Both profiles were associated with at least 40% chance of attaining full remission. The model did not identify predictors for those receiving medication or psychotherapy alone, and it did not distinguish between the 2 monotherapies. The authors conclude that combined antidepressant medications and psychotherapy result in faster full remission of chronic forms of major depressive disorder.

Comparative analysis of physiological adaptation of neonates of abused and nonabused mothers

The investigators examined: (a) the relationships between the mother's abuse status and the newborn's stress responses, and (b) differences in newborn stress responses of abused and nonabused mothers before and after a phenylketonuria (PKU) heel stick. The t-tests show a trend toward statistical significance. Abuse had strong effect sizes on cortisol and oxygen levels at 25 minutes. Findings support further research on the impact that maternal stress resulting from abuse has on neonatal outcomes.

Understanding the link between anxiety symptoms and suicidal ideation and behaviors in outpatients with bipolar disorder

BACKGROUND

Prior studies suggest an association between anxiety comorbidity and suicidal ideation and behaviors in bipolar disorder. However, the nature of this association remains unclear.

METHODS

We examined a range of anxiety symptoms, including panic, phobic avoidance, anxiety sensitivity, worry and fear of negative evaluation, in 98 patients with bipolar disorder. We predicted that each anxiety dimension would be linked to greater suicidal ideation and behavior as measured by Linehan's Suicide Behaviors Questionnaire (SBQ), greater depressive rumination, and poorer emotional processing and expression.

RESULTS

Each anxiety dimension except fear of negative evaluation was associated with greater SBQ score, greater rumination, and lower levels of emotional processing in univariate analyses. Depressive rumination was a significant predictor of higher SBQ scores in a stepwise multivariate model controlling for age, gender, bipolar subtype, and bipolar recovery status; the association between the anxiety symptom dimensions and SBQ score was found to be redundant with depressive rumination. Emotional processing emerged as protective against suicidal ideation and behaviors in men only, while emotional expression was a significant predictor of lower SBQ scores for women and for the full sample; however, emotional expression was not significantly correlated with anxiety symptoms. Confirmatory analyses examining only those in recovery or recovered (n=68) indicated that the link between rumination and suicidality was not explained by depression.

LIMITATIONS

Interpretation is limited by the cross-sectional study design.

CONCLUSIONS

These findings indicate that increased ruminations may mediate the association between anxiety and suicidal ideation/behavior. In men, lower emotional processing may also play a role in this relationship.