The Newcastle Chronic Depression Study. Patient characteristics and factors associated with chronicity

High-Definition Transcranial Direct Current Stimulation-Primed Intermittent Theta Burst Stimulation in Treatment-Resistant Depression: A Controlled Study

OBJECTIVES

The aim of this study was to evaluate whether high-definition transcranial direct current stimulation (HDtDCS) priming improves the efficacy of intermittent theta burst stimulation (iTBS) in improving TRD.

METHODOLOGY

A prospective hospital-based, randomized control study where the participants were divided into active or sham HDtDCS-primed iTBS stimulation groups for a total of 10 sessions and were assessed on clinical parameters at baseline, end of week 1, and end of week 2 was done. Primary outcome of the study was the difference in Hamilton Depression Rating Scale (HDRS) scores over 2 weeks of HDtDCS-primed iTBS.

RESULT

A significant effect of time was seen over HDRS scores in both active and sham groups with a large effect size. Significant effect of time was also found over the Clinical Global Impressions-Severity Scale scores of patients with a large effect size. The difference in the improvement in depressive severity as measured using HDRS and Clinical Global Impressions-Severity Scale scores between active and sham groups was also found to be significant with large effect sizes.

CONCLUSION

High-definition tDCS-primed iTBS is superior to normal iTBS in patients with depression who have failed a trial of 2 antidepressants, whereas both mechanisms are of benefit to the patients.

Psychosocial functioning in patients with treatment resistant depression

Background

Depression is a disorder that causes disability, with a profound adverse impact on all areas of psychosocial functioning. This is particularly true for those with treatment resistant depression (TRD). However, to date, no systematic assessments of psychosocial functioning for patients with TRD have been conducted.

Methods

In the present study, we used the Longitudinal Interval Follow-up Evaluation (LIFE) scale to measure psychosocial functioning in 92 patients with TRD. These patients met formal criteria for TRD and were part of a clinical trial examining the efficacy of lithium augmentation of nortriptyline.

Results

Clinicians rated this sample of patients as experiencing mild to moderate impairment in work-related activities, good to fair interpersonal relations, poor level of involvement in recreational activities, and mild impairment of ability to enjoy sexual activity. Patients and clinicians rated global social adjustment as poor.

Conclusions

Patients with formally defined TRD experience significant impairment in psychosocial functioning. In this sample a tendency existed for both clinicians and patients to assign more severely impaired global ratings when compared with ratings for specific functional areas.

Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model - are we there yet?

A number of factors (biogenic amine deficiency, genetic, environmental, immunologic, endocrine factors and neurogenesis) have been identified as mechanisms which provide unitary explanations for the pathophysiology of depression. Rather than a unitary construct, the combination and linkage of these factors have been implicated in the pathogenesis of depression. That is, environmental stressors and heritable genetic factors acting through immunologic and endocrine responses initiate structural and functional changes in many brain regions, resulting in dysfunctional neurogenesis and neurotransmission which then manifest as a constellation of symptoms which present as depression.

Clinical features of patients with dysthymia in a large cohort of Han Chinese women with recurrent major depression

Background

Dysthymia is a form of chronic mild depression that has a complex relationship with major depressive disorder (MDD). Here we investigate the role of environmental risk factors, including stressful life events and parenting style, in patients with both MDD and dysthymia. We ask whether these risk factors act in the same way in MDD with and without dysthymia.

Results

We examined the clinical features in 5,950 Han Chinese women with MDD between 30–60 years of age across China. We confirmed earlier results by replicating prior analyses in 3,950 new MDD cases. There were no significant differences between the two data sets. We identified sixteen stressful life events that significantly increase the risk of dysthymia, given the presence of MDD. Low parental warmth, from either mother or father, increases the risk of dysthymia. Highly threatening but short-lived threats (such as rape) are more specific for MDD than dysthymia. While for MDD more severe life events show the largest odds ratio versus controls, this was not seen for cases of MDD with or without dysthymia.

Conclusions

There are increased rates of stressful life events in MDD with dysthymia, but the impact of life events on susceptibility to dysthymia with MDD differs from that seen for MDD alone. The pattern does not fit a simple dose-response relationship, suggesting that there are moderating factors involved in the relationship between environmental precipitants and the onset of dysthymia. It is possible that severe life events in childhood events index a general susceptibility to chronic depression, rather than acting specifically as risk factors for dysthymia.

Epidemiology of chronic and nonchronic major depressive disorder: results from the national epidemiologic survey on alcohol and related conditions

BACKGROUND

Burden related to major depressive disorder (MDD) derives mostly from long-term occurrence of symptoms. This study aims to examine the prevalence, sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization of chronic major depressive disorder (CMDD) compared to nonchronic major depressive disorder.

METHODS

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalence of CMDD within the population meeting criteria for MDD was 26.5% and 24.0%, respectively. Individuals reporting a chronic course of MDD were socioeconomically and educationally disadvantaged, tended to be older, report loss of spouse or history of divorce, live in rural areas, have public assistance, low self-esteem, worse overall health and more likely to report comorbidities, most importantly dysthymia, generalized anxiety disorder, avoidant, and dependant personality disorder. Individuals with chronic MDD were more likely to report familial but not childhood onset risk factors for MDD. Those suffering CMDD were more likely to seek and receive mental health care than other forms of MDD, even though it took longer to start treatment.

CONCLUSION

Chronic course of MDD is related to still worse socioeconomic conditions, educational achievement, more comorbidities, and family risk factors, although other courses of MDD carried greater risk of unmet treatment.

Chronic Depression: Can Cognitive Therapy Succeed When Other Treatments Fail?

This paper describes the use of cognitive behaviour therapy (CBT) with 24 chronically depressed in-patients. These individuals had previously failed to respond to all other standard antidepressant treatments and had been persistently depressed for at least two years. The clients were divided into two cohorts. The first (n=8) received a standard CBT package of 15 sessions combined with pharmacotherapy. The second cohort received a combined treatment, but the style of delivery of CBT was changed to try to take into account the special needs of the client population. At 12 weeks, 70% of the second cohort of clients showed a greater than 50% change on their pre-treatment objective and subjective depression ratings. The implications of these findings are discussed and further therapy trials in this difficult-to-treat population are encouraged.

Duloxetine in the treatment of major depressive disorder: an assessment of the relationship between outcomes and episode characteristics

Duloxetine, an inhibitor of serotonin and norepinephrine reuptake, has been approved for the treatment of major depressive disorder. In this analysis, data from eight, double-blind, placebo-controlled duloxetine trials were pooled, and the response to duloxetine treatment (40-120 mg/day) was compared between patients experiencing their first episode of depression (n=581) or a subsequent episode (n=1321), and between patients experiencing a depressive episode of short (n=596), medium (n=669), or long (n=649) duration based on tertile divisions. Treatment response was determined on the basis of changes from baseline in the 17-item Hamilton Rating Scale for Depression total score, the Clinical Global Impressions of Severity Scale, and painful physical symptoms (Somatic Symptom Inventory and Visual Analog Scales). Overall, changes on all outcome measures and response and remission rates were significantly greater in duloxetine-treated patients than in placebo-treated patients. Furthermore, the effect of duloxetine was similar across all episode characteristic groups (first/subsequent episode, short/medium/long episode duration). Only for the Somatic Symptom Inventory was the effect of duloxetine significantly different between groups (greater in the subsequent episode group than in the first episode group). Duloxetine was effective in the treatment of first and subsequent episodes of major depressive disorder, and regardless of duration of the current depressive episode.

Factors associated with chronic depressive episodes: a preliminary report from the STAR-D project

OBJECTIVE

To identify baseline sociodemographic and clinical factors associated with a current chronic major depressive episode (MDE).

METHOD

Outpatients with major depressive disorder enrolled in 41 US primary or psychiatric care sites were divided into two groups based on self-report of current episode length (<24 or > or =24 months). Logistic regression models were used to identify factors associated with chronicity of current depressive episode.

RESULTS

About 21.2% of 1380 subjects were in current, chronic MDEs. Older age, less education, lower income, no private insurance, unemployment, greater general medical illness burden, lower physical quality of life, concurrent generalized anxiety disorder, fewer prior episodes, and history of prior suicide attempts were all associated with chronic episodes. Blacks, Hispanics, and patients receiving care in primary as opposed to psychiatric care settings exhibited greater chronicity.

CONCLUSION

Chronic depressive episodes are common and are associated with greater illness burden, comorbidity, socioeconomic disadvantage, and racial/ethnic minority status.

The search for determinants of chronic depression: a review of six factors

While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.

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

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

Sociodemographic predictors of response to antidepressant treatment

OBJECTIVE

Our goal was to assess whether sociodemographic variables such as gender, marital status, level of education, and employment status are related to the changes in social functioning that have been reported after drug treatment in outpatients with major depressive disorder.

METHOD

Eligible subjects were 166 depressed outpatients participating in a study involving open treatment with fluoxetine 20 mg/day for eight weeks. Diagnosis of major depressive disorder was made with the use of the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P), and patients were required to have a seventeen-item Hamilton Rating Scale for Depression (HAM-D-17) score > or = at study entry. All subjects were administered the HAM-d-17 and the Social Adjustment Scale-Self-Report (SAS-SR) before and after treatment with fluoxetine.

RESULTS

We found that SAS-SR scores decreased significantly following treatment with fluoxetine from a mean score at baseline of 2.6 +/- 0.7 to a mean score at endpoint of 2.3 +/- 0.6. After adjusting for the degree of change in HAM-D-17 scores, we found a significant relationship between degree of change in SAS-SR and level of education. No statistically significant relationships were observed between SAS-SR change and age, gender, marital status, and employment status.

CONCLUSION

The degree of improvement in psychosocial functioning observed in depressed outpatients following antidepressant treatment appears to be related to the level of education at study entry, but not to other sociodemographic variables. Further studies need to investigate the nature of this relationship.

Cerebral white matter lesions in bipolar affective disorder: relationship to outcome

BACKGROUND

Twenty per cent of patients with bipolar affective disorder suffer an illness that responds inadequately to treatment and has a poor outcome. Many patients, but not all, with bipolar disorder show white matter abnormalities on T(2)-weighted magnetic resonance imaging (MRI).

AIMS

To explore the hypothesis that white matter abnormalities on MRI are seen more frequently in subjects whose illness has a poor outcome compared with those with a good outcome or controls.

METHOD

Two groups of age- and gender-matched patients with bipolar disorder (14 with a good outcome and 15 with a poor outcome) and 15 controls, aged 20-65 years, were studied. Axial T(2)-weighted MRI scans were examined for the presence and severity of white matter abnormalities.

RESULTS

Significantly more poor outcome group members had deep subcortical punctate, but not periventricular, white matter hyperintensities than the good outcome group (P:=0.035) or controls (P:=0.003) and these abnormalities were of greater severity (P:=0.030 and P:<0.014, respectively).

CONCLUSIONS

Subcortical white matter lesions are associated with poor outcome bipolar disorder.

Gender differences in the short-term course of unipolar depression in a follow-up sample of depressed inpatients

OBJECTIVE

This paper examined sex differences in the short-term course of depression and assessed the impact of possibly outcome-affecting factors, including sex-specific recall artefacts and demographic and clinical characteristics.

METHODS

A cohort of 179 unipolar depressed inpatients was followed up 1 (T1) and 7 months (T2) after discharge.

RESULTS

Residual depression at T1 was comparable in both sexes as was the rate of follow-up nonremissions in patients who had failed to remit from the index episode at T1. In contrast, female gender was a significant predictor of relapse. This sex difference was partly attributable to women who relapsed after T1 and were again in remission at T2. Potential sex-related recall artefacts were tested by contrasting the patients' retrospective assessment of their T1-depression status reported at T2 with their interviewer-rated depression status assessed at T1. Results suggest that the observed sex difference in relapses could neither be explained by memory artefacts nor by differences in demographic and clinical sample compositions.

CONCLUSIONS

It is concluded that due to their higher risk for early relapses, particular efforts with regard to continuation treatment are required for women during the critical period of remission.

Recovery from episodes during the course of affective disorder: a case-register study

OBJECTIVE

The aim of the study was to investigate whether the duration of treated episodes changes during the course of unipolar and bipolar affective disorder.

METHOD

The rate of recovery from successive hospitalized episodes was estimated with survival analyses in a case-register study including all hospital admissions with primary affective disorder in Denmark during the period 1971-1993.

RESULTS

A total of 9174 patients with recurrent episodes were followed from their first admission. The rate of recovery from hospitalized episodes did not change with the number of episodes in unipolar or bipolar disorder. Furthermore, the rate of recovery was constant across episodes, regardless of the combination of age, gender and type of disorder. Initially in the course of the illness, the rate was a little faster for bipolar than for unipolar patients, but later in the course of the illness the rate of recovery was the same for the two disorders.

CONCLUSION

It is concluded that, in modern treatment settings, the duration of affective episodes appears to be stable during the course of unipolar and bipolar disorder.

Family history as a predictor of poor long-term outcome in depression

BACKGROUND

We investigated whether family history had prognostic significance in depression in a study which addressed some of the methodological shortcomings of previous studies.

METHOD

We collected family history data on a consecutive series of 89 patients admitted with RDC major depression, blind to the outcome of the proband. This comprised 116, 283 and 120 first-degree relatives examined with the SADS-L, FH-RDC and case note data, respectively. The outcome of 74 of these probands (83%), previously categorised into four operationally defined groups, was then examined.

RESULTS

A positive family history of severe psychiatric illness (i.e. a relative with a history of either a psychosis, hospitalised depression or suicide) was associated with poor outcome in the proband. This association persisted after controlling for variable family size, age structure and gender. As family history was correlated with neither Kendell's neurotic/psychotic index nor the proband's neuroticism score, an individual with high scores an all three would have a greatly increased chance of having a poor outcome.

CONCLUSIONS

A family history of severe psychiatric illness in a first-degree relative may be useful as one of the vulnerability factors for predicting poor long-term outcome in depression.

Management of resistant depression

The inadequate assessment and management of depression can lead to the erroneous diagnosis of treatment resistance. After briefly considering the definition and diagnosis of resistant depression, the authors describe the principles and methods of antidepressant therapy, emphasizing the systematic use of medication and the importance of therapeutic drug monitoring. The application of these is then discussed in a clinical context, and illustrated with examples.

Definition and epidemiology of treatment-resistant depression

Our results suggest that between 29% and 46% of depressed patients fail to respond fully with antidepressant treatment of adequate dose and duration. In particular, although partial response appears to occur in 12% to 15% of the depressed patients studied, nonresponse is observed in 19% to 34% of this population. The prevalence of treatment-resistant depression derived from studies using ITT analysis is likely to be an overestimate of the actual occurrence of the phenomenon, as these rates also reflect the outcome of patients who were treated inadequately or were intolerant to the treatment. On the other hand, data derived from studies using completer analysis are likely to generate under-estimates of the prevalence of this phenomenon, as patients may have dropped out before completion of the study due to lack of efficacy. One could, therefore, guess that the actual rates of treatment resistance in the clinical population of depressed patients probably lie between these two types of estimates. From an epidemiologic point of view, because the prevalence of depression has been estimated to vary from 2.6% to 5.5% in men and from 6.0% to 11.8% in women, one must conclude that treatment-resistant depression is a very common clinical problem that is likely to affect more than one third of depressed patients. In summary, treatment-resistant depression patients can be defined as those who fail to respond to standard doses (i.e., significantly superior to placebo in double-blind studies) of antidepressants administered continuously for at least 6 weeks. Additional requirements of this operational definition are an accurate diagnosis of depressive disorder, patient compliance with the treatment, the use of valid outcome measures, and therapeutic range of antidepressant blood levels for the tricyclic antidepressants. Finally, symptomatic improvement that is equal or greater than 25% and less than 50% qualifies as partial response, and less than 25% symptomatic improvement is complete nonresponse.

Clinical characteristics of outpatients with chronic major depression

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179). Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.

The relationship between premorbid neuroticism, cognitive dysfunction and persistence of depression: a 1-year follow-up

In a previous report of patients with unipolar major depressive disorder, we found that deficits in autobiographical memory predicted depression levels over a 7-month interval. This follow-up examined predictors of recovery as defined by a period of 8 weeks with no or minimal symptoms of depression and examined the extra predictor variable, neuroticism. In a sample of 21 patients, episode duration was significantly correlated with high levels of premorbid neuroticism, dysfunctional attitudes and overgeneral autobiographical memories produced in response to emotionally negative cue words. When severity of depression was partialled out, high N score was significantly but independently correlated with each of these cognitive variables. The implication of these attitudinal and information processing biases were explored.

Dysthymia: clinical and external validity

This paper reviews current evidence in support of dysthymia as a sub-affective disorder that precedes major affective episodes, often by more than a decade. In cases beginning in childhood or adolescence, dysthymia is associated with high familial rates of mood disorders, and a recurrent pattern of superimposed major depression. At least two trait-like markers, sleep electro-encephalographic and thyroid axis abnormalities-similar to those in major affective disorder-have been reported. These data indicate a common pathophysiological substrate for both dysthymia and major depressive illness. All classes of antidepressants-most recently the serotonin re-uptake and the reversible MAO inhibitors-have been shown to be effective. Dysthymia was fairly recently included in the US(DSM) and WHO(ICD) classifications of mental disorders, because it characterises a prevalent clinical presentation of depression in both psychiatric and general medical settings. Patients given this diagnosis, instead of presenting with acute or full-blown episodes, often complain of low-grade chronic affective malaise for as long as they remember, yet without clinically observable signs of depression. As a result, questions have been raised about its validity, but from fundamentally opposite positions: (i) Is dysthymia better conceptualised as a personality (or neurotic) rather than mood disorder? (ii) Can dysthymia be distinguished from major depressive illness? This paper examines these and related questions along both clinical and external validating strategies, and in particular, the more recent accumulated evidence in support of the utility of the concept of dysthymia.

The role of psychosocial and biological variables in separating chronic and non-chronic major depression and early-late-onset dysthymia

Psychosocial (sociodemographic characteristics, loss and separation and family atmosphere in childhood, recent life events) and biological (family history, DST, TRH-test) variables were investigated in 180 patients with Major Depression (MD) and Dysthymic Disorder (DD). The aim of the study was to reveal certain differences between the chronic and non-chronic course of MD and the early- and late-onset subtypes of dysthymia. When comparing the two course patterns of MD, a higher rate of malignant tumours among first-degree relatives, a greater number of long-lasting stress situations before the index depressive episode, longer duration of the previous episodes, less frequent DST nonsuppression, and a blunted TSH response to TRH were found in patients with a chronic course of MD. Several factors seem to influence the course pattern of MD, or else the chronic form represents a subgroup within MD. The late-onset dysthymics were mainly women with a low level of education, a lower suicidal tendency, normal suppression in DST, and a lack of blunted TSH responses to TRH administration during the period of double depression. The early-onset dysthymics showed a higher number of persons who had never married, who presented a more traumatic and frustrating childhood background, and who had a higher rate of DST non-suppressors and blunted TSH responses after TRH administration during the period of their double depression. Our data suggest that late-onset dysthymia might be a biologically distinct subgroup of chronic depression.

Chronic depression of monopolar, endogenous type: with special reference to the premorbid personality, "Typus melancholicus"

We retrospectively examined 70 depressives, who first visited our outpatient clinic in 1989, agreed to our examination and met the criteria of major depression and melancholic type in DSM-III-R. Forty-nine recovered and 21 had a chronic course of a 2-year duration. Of the items examined in the multivariate analysis, a high total LE score, a long duration prior to entry and a high degree of "Typus melancholicus" greatly contributed to the chronicity in this order of magnitude. Age, severity at entry and sex contributed to it in relatively small degrees and familial loading of depression had almost no effect on the course. The relationship between the degree of "Typus melancholicus" and course of depression was discussed based on data.

General health, health care utilization, and medical comorbidity in dysthymia

OBJECTIVE

This article reviews the literature on the general health, health care utilization, prevalence, medical comorbidity, and treatment of dysthymia in medical settings.

METHOD

The literature was searched by using MEDLINE and by reviewing the bibliographies of recent publications. Studies were selected that included health data on patients with dysthymia or chronic depression according to DSM-III, DSM-III-R, ICD-9, or RDC criteria, or patients who were described as having persistent depressive symptoms.

RESULTS

This review shows that dysthymic patients are at increased risk for poor general health and frequently use medical services. Compared to the general population, dysthymia is more prevalent in primary care and among patients with various medical and neurological conditions, sleep disorders, chronic fatigue, hypothyroidism, and somatoform disorders. Pharmacotherapy is effective, but has not been well studied. Non-tricyclic antidepressants might be especially useful. Psychotherapy studies are virtually non-existent.

CONCLUSIONS

Although dysthymia is considered a minor depressive condition, these findings show that it is a significant public health problem, comparable to major depression. Recent efforts to improve the recognition and treatment of major depression in medical settings, therefore, should be extended to include the entire spectrum of depressive disorders. Future studies should investigate the type and pattern of medical comorbidity and health care utilization, different antidepressant and psychosocial therapies, and the clinical and biological correlates of treatment response in different chronic depressive subtypes in medical settings and compare them to major depressive and subsyndromal depressive conditions.

Can we predict the persistence of depression?

Fifty-five patients with primary major depression were followed up prospectively from time of onset of the index illness episode until recovery. The course of depression in hospital-treated patients was protracted, with a median length of episode of one year. Two factors significantly predicted persistence of symptoms: interval between onset and receipt of treatment, and premorbid neuroticism, which accounted for 55% of the variance in length of episode.

Biological studies of dysthymia

Dysthymic disorder (DD) is a chronic subsyndromal depressive condition that has generated increasing interest since its formal introduction into the psychiatric nomenclature in 1980. Although DD was included among the affective disorders in DSM-III, this classification was controversial. Some clinical and family studies support an association between DD and major depression disorder (MDD), but there has been little additional research firmly establishing the diagnostic validity of DD or clarifying its relation to MDD and to personality disorders. In this article, the literature on the biology of DD is reviewed. Studies of rapid eye movement (REM) latency, electrodermal activity, and the thyroid axis show similarities between DD and MDD, but the findings are mixed. Other investigations, including the Dexamethasone Suppression Test (DST), catecholamines, and several other electroencephalogram (EEG) sleep variables, show more consistent differences between DD and MDD. These findings suggest that DD manifests primarily trait characteristics of depression, thus differentiating it from the state characteristics of MDD. The methodological problems and implications of these studies, and suggestions for future research, are discussed.

Psychotic depression: psychoanalytic psychopathology in relation to treatment and management

Jacobsen's theory of affects and psychotic depression can be of benefit to the management of patients, even when recourse to physical therapies is required. Awareness of such psychodynamic issues would improve staff training, morale, and practice; rotation schemes for junior staff may have serious effects through the abandonment of patients and established therapeutic relationships.

Neuroendocrine dysfunction in psychotic disorders (excluding ACTH)

Neuropeptide and neuroendocrine studies in the two major 'functional' psychotic illnesses have been reviewed. Changes in schizophrenia suggest both central dopamine dysfunction and hypothalamic, and perhaps, limbic pathology. In affective disorders, disruption of rhythmic neuroendocrine control seems to be evident, possibly mediated by either abnormal 5-hydroxytryptamine receptor function, non-specific hypothalamic derangement, or both. It is conceivable that some neuroendocrine changes in depression are trait phenomena which may be markers or mechanisms of vulnerability. The interaction of neuropeptide function and neuroendocrine state in psychotic illness is likely to be the focus of intensive future research.

Factors influencing long-term psychiatric hospitalisation of the elderly in Kuwait

In this study both psychosocial and clinical aspects of elderly patients were investigated in relation to long hospital stay in the only psychiatric hospital in Kuwait. Patients with longer stay did not differ statistically from short stay patients in distributions of sex, age, nationality, marital status, family system, diagnostic categories or factors blocking patients' discharge from hospital. Significant association was found between withdrawal from social interaction, and those admitted for personal suffering and those who had poor relationships with their families. Long stay elderly patients who came from extended families were more likely to be medically unfit for discharge than patients who came from nuclear families. Multivariate explorations of possible associations were performed by hierarchical loglinear analysis which revealed that long stay in hospital was significantly more likely in the widowed who had physical illness and came from extended families with poor relationships. The findings are discussed in relation to cultural and clinical background and compared to similar findings published abroad.

Chronic depression

Defining chronic depression as persistent symptoms for 2 or more years, a prevalence of chronic depression of 12-15% is found in the literature. A four-part classification of chronic depression is proposed: Chronic Primary Major Depression; Chronic Secondary Major Depression; Characterological or Chronic Minor Depression (Dysthymic Disorder); and 'Double Depression'. The literature indicates several factors predicting chronicity in primary major depression: more at risk are female patients, particularly those with premorbid neurotic personality traits, individuals with unipolar disorders, and those with higher familial loading for such disorders. Other factors are the adequacy and appropriateness of the treatment given, and the length of illness episode prior to treatment being received. Larger studies with well-matched controls are needed.