The Camberwell Collaborative Depression Study. III. Depression and adversity in the relatives of depressed probands

Personality–event interaction models of depression

Several theorists have suggested that excessive concerns about social relatedness or autonomous achievement create vulnerabilities to depression in response to negative interpersonal or achievement events, respectively. In this paper, I describe these models and review empirical studies of them. I then discuss a number of methodological and conceptual issues that arise from these studies and that need to be addressed as this research area matures. Finally, I discuss findings that need to be incorporated by these models, which suggest that the relations among personality, events, and depression are more complex, bi‐directional, and recursive.

Do natural experiments have an important future in the study of mental disorders?

There is an enormous interest in identifying the causes of psychiatric disorders but there are considerable challenges in identifying which risks are genuinely causal. Traditionally risk factors have been inferred from observational designs. However, association with psychiatric outcome does not equate to causation. There are a number of threats that clinicians and researchers face in making causal inferences from traditional observational designs because adversities or exposures are not randomly allocated to individuals. Natural experiments provide an alternative strategy to randomized controlled trials as they take advantage of situations whereby links between exposure and other variables are separated by naturally occurring events or situations. In this review, we describe a growing range of different types of natural experiment and highlight that there is a greater confidence about findings where there is a convergence of findings across different designs. For example, exposure to hostile parenting is consistently found to be associated with conduct problems using different natural experiment designs providing support for this being a causal risk factor. Different genetically informative designs have repeatedly found that exposure to negative life events and being bullied are linked to later depression. However, for exposure to prenatal cigarette smoking, while findings from natural experiment designs are consistent with a causal effect on offspring lower birth weight, they do not support the hypothesis that intra-uterine cigarette smoking has a causal effect on attention-deficit/hyperactivity disorder and conduct problems and emerging findings highlight caution about inferring causal effects on bipolar disorder and schizophrenia.

CACNA1C rs1006737, Threatening Life Events, and Gene-Environment Interaction Predict Major Depressive Disorder

INTRODUCTION

CACNA1C rs1006737 is a novel variant in discovery of replicable associations in major depressive disorder (MDD). However, there have been no specific studies considered effect of environmental pathogens to date examining its clinical significance. In this study we investigated the interaction effect between CACNA1C rs1006737 polymorphism and threatening life events (TLEs) in MDD and carried out a meta-analysis of published findings.

METHODS

A total of 1,177 consecutive participants were genotyped. Information on exposure to TLEs, socio-demographic data, and history of psychological problems among first-degree relatives was collected. MDD was diagnosed according to the Chinese version of the 24-item Hamilton Rating Scale for Depression.

RESULTS

There was a significant interaction effect between CACNA1C rs1006737 polymorphism and TLEs in MDD. A dose-response relationship was found between CACNA1C rs1006737 genotypes and TLEs in MDD. The results of the meta-analysis showed that CACNA1C rs1006737 genotypes interacted with TLEs in MDD.

CONCLUSION

CACNA1C rs1006737 genotype and previous exposure to TLEs interact to influence the risk of developing MDD. We propose that CACNA1C rs1006737 may represent a target for novel pharmacological therapies to prevent or treat MDD.

A direct test of the diathesis-stress model for depression

The diathesis-stress theory for depression states that the effects of stress on the depression risk are dependent on the diathesis or vulnerability, implying multiplicative interactive effects on the liability scale. We used polygenic risk scores for major depressive disorder (MDD) calculated from the results of the most recent analysis from the Psychiatric Genomics Consortium as a direct measure of the vulnerability for depression in a sample of 5221 individuals from 3083 families. In the same we also had measures of stressful life events and social support and a depression symptom score, as well as DSM-IV MDD diagnoses for most individuals. In order to estimate the variance in depression explained by the genetic vulnerability, the stressors and their interactions, we fitted linear mixed models controlling for relatedness for the whole sample as well as stratified by sex. We show a significant interaction of the polygenic risk scores with personal life events (0.12% of variance explained, P-value=0.0076) contributing positively to the risk of depression. Additionally, our results suggest possible differences in the aetiology of depression between women and men. In conclusion, our findings point to an extra risk for individuals with combined vulnerability and high number of reported personal life events beyond what would be expected from the additive contributions of these factors to the liability for depression, supporting the multiplicative diathesis-stress model for this disease.

Major Depression as a Complex Dynamic System

In this paper, we characterize major depression (MD) as a complex dynamic system in which symptoms (e.g., insomnia and fatigue) are directly connected to one another in a network structure. We hypothesize that individuals can be characterized by their own network with unique architecture and resulting dynamics. With respect to architecture, we show that individuals vulnerable to developing MD are those with strong connections between symptoms: e.g., only one night of poor sleep suffices to make a particular person feel tired. Such vulnerable networks, when pushed by forces external to the system such as stress, are more likely to end up in a depressed state; whereas networks with weaker connections tend to remain in or return to a non-depressed state. We show this with a simulation in which we model the probability of a symptom becoming 'active' as a logistic function of the activity of its neighboring symptoms. Additionally, we show that this model potentially explains some well-known empirical phenomena such as spontaneous recovery as well as accommodates existing theories about the various subtypes of MD. To our knowledge, we offer the first intra-individual, symptom-based, process model with the potential to explain the pathogenesis and maintenance of major depression.

A meta-analysis of the risk of major affective disorder in relatives of individuals affected by major depressive disorder or bipolar disorder

BACKGROUND

To conduct a meta-analysis to estimate the incidence of major depressive disorder (MDD) and bipolar disorder (BD) in first-degree relatives (FDRs) of probands affected by MDD or BD. The risk for MDD in FDR of BD probands and vice versa is also investigated.

METHODS

A systematic review of case-control and cohort studies, which were published between 1977 and 2012; reported relative risks (RR) or odd ratios (OR) or equivalent raw data; made an explicit distinction between MDD and BD; used operational diagnostic criteria; and reported systematic proband recruitment and ascertainment of relatives. Studies were obtained by electronic MEDLINE and EMBASE searches and hand-searching. Estimates were derived from pooled data using random effects methods.

RESULTS

Of an initial sample of 241 articles, 22 were eligible for inclusion. For FDRs of one proband with MDD compared to healthy control probands, estimates for MDD were OR=2.14 (95% CI 1.72-2.67), increasing to OR=3.23 (95% CI 2.11-4.94) for two MDD probands. For FDRs of one BD proband compared to healthy control probands, estimates for BD were OR=7.92 (95% CI 2.45-25.61), and OR=6.58 (95% CI 2.64-16.43) for FDRs of two BD probands.

CONCLUSIONS

These findings support previously published data indicating strong familiality for both MDD and BD. Data will be useful in providing individuals with a family history of MDD or BPD with tailored risk estimates.

Life stress and family history for depression: the moderating role of past depressive episodes

Three of the most consistently reported and powerful predictors of depression are a recent major life event, a positive family history for depression, and a personal history of past depressive episodes. Little research, however, has evaluated the inter-relations among these predictors in depressed samples. Such information is descriptively valuable and potentially etiologically informative. In the present article we summarize the existing literature and test four predictions in a sample of 62 clinically depressed individuals: (1) participants who experienced a major life event prior to onset would be less likely than participants who did not experience a major life event to have a positive family history for depression; (2) participants with a recent major life event would have fewer lifetime episodes of depression than would participants without; (3) participants with a positive family history for depression would have more lifetime episodes of depression than would participants with a negative family history for depression; and (4) we would obtain a 3-way interaction in which participants with a positive family history and without a major life event would have the most lifetime episodes, whereas participants with a negative family history and a major life event would have the fewest lifetime episodes. The first three predictions were confirmed, and the fourth prediction partially confirmed. These novel findings begin to elucidate the complex relations among these three prominent risk factors for depression, and point to avenues of research that may help illuminate the origins of depressive episodes.

Serotonin transporter gene as a predictor of stress generation in depression

Research suggests that a polymorphism in the promoter region of the serotonin transporter promoter (5-HTTLPR) interacts with stressful life events to predict depressive onset, with short (s) allele presence associated with greater susceptibility to stressors. However, this research has not considered that depressed individuals often actively generate stressful contexts. Furthermore, little is known about the genetic basis of stress generation. The current study explored the role of 5-HTTLPR genotype in stress generation in a longitudinal sample of 381 adolescents, oversampled for maternal depression, assessed at ages 15 and 20. Genotype did not correlate directly with number or ratings of stressful life events. However, 5-HTTLPR genotype interacted with depression at age 15 to predict dependent stressful events at age 20. Specifically, participants with one or more s alleles showed a stronger association between age 15 depression and age 20 dependent and interpersonal events than long allele homozygotes. Results imply that the 5-HTTLPR genotype predicts reciprocal associations between stress and depression, indicating a more complex relationship between stress, depression, and their genetic underpinnings than previously suggested.

The dappled nature of causes of psychiatric illness: replacing the organic-functional/hardware-software dichotomy with empirically based pluralism

Our tendency to see the world of psychiatric illness in dichotomous and opposing terms has three major sources: the philosophy of Descartes, the state of neuropathology in late nineteenth century Europe (when disorders were divided into those with and without demonstrable pathology and labeled, respectively, organic and functional), and the influential concept of computer functionalism wherein the computer is viewed as a model for the human mind-brain system (brain=hardware, mind=software). These mutually re-enforcing dichotomies, which have had a pernicious influence on our field, make a clear prediction about how 'difference-makers' (aka causal risk factors) for psychiatric disorders should be distributed in nature. In particular, are psychiatric disorders like our laptops, which when they dysfunction, can be cleanly divided into those with software versus hardware problems? I propose 11 categories of difference-makers for psychiatric illness from molecular genetics through culture and review their distribution in schizophrenia, major depression and alcohol dependence. In no case do these distributions resemble that predicted by the organic-functional/hardware-software dichotomy. Instead, the causes of psychiatric illness are dappled, distributed widely across multiple categories. We should abandon Cartesian and computer-functionalism-based dichotomies as scientifically inadequate and an impediment to our ability to integrate the diverse information about psychiatric illness our research has produced. Empirically based pluralism provides a rigorous but dappled view of the etiology of psychiatric illness. Critically, it is based not on how we wish the world to be but how the difference-makers for psychiatric illness are in fact distributed.

Do reasons for major depression act as causes?

We make sense of human behavior using reasons, which produce understanding via a subjective empathy-based first-person perspective and causes, which leads to explanations utilizing objective facts about the world assessed scientifically. We evaluate the common sense hypothesis that for episodes of major depression (MD), reasons act as causes. That is, individuals who have highly understandable depressive episodes will have, on average, fewer objective scientifically validated causes than those who have un-understandable episodes. The understandability of a MD as defined by the Diagnostic and Statistical Manual, 4th Edition (DSM IV) experienced in the past year in 630 personally interviewed twins from a population-based registry was rated, with high reliability, from rich contextual information. We predicted, from these understandability ratings, via linear and logistic regression, 12 validated risk factors for MD reflecting genetic and long-term environmental liability. No significant association was observed between 11 of these indices and the understandability of the depressive episode. The only significant finding-higher cotwin risk for MD associated with greater understandability-was opposite that predicted by the reasons-as-causes hypothesis. Our results do not support the hypothesis that reasons for MD act as causes. These findings, unlikely to result from low power, may be explicable from an empirical and/or philosophical perspective. Our results are, however, consistent with 'the trap of meaning' hypothesis, which suggests that understanding does not equal explanation and that while reasons may be critical to help us empathize with our patients, they are unreliable indices of objective risk factors for illness.

Insensitivity of the analysis of variance to heredity-environment interaction

It makes sense to attribute a definite percentage of variation in some measure of behavior to variation in heredity only if the effects of heredity and environment are truly additive. Additivity is often tested by examining the interaction effect in a two-way analysis of variance (ANOVA) or its equivalent multiple regression model. If this effect is not statistically significant at the α = 0.05 level, it is common practice in certain fields (e.g., human behavior genetics) to conclude that the two factors really are additive and then to use linear models, which assume additivity. Comparing several simple models of nonadditive, interactive relationships between heredity and environment, however, reveals that ANOVA often fails to detect nonadditivity because it has much less power in tests of interaction than in tests of main effects. Likewise, the sample sizes needed to detect real interactions are substantially greater than those needed to detect main effects. Data transformations that reduce interaction effects also change drastically the properties ofthe causal model and may conceal theoretically interesting and practically useful relationships. If the goal ofpartitioning variance among mutually exclusive causes and calculating “heritability” coefficients is abandoned, interactive relationships can be examined more seriously and can enhance our understanding of the ways living things develop.

The nature of nurture: Genetic influence on “environmental” measures

Evidence for genetic influence on environmental measures will emerge in quantitative genetic analyses if genetically influenced characteristics of individuals are assessed by these environmental measures. Recent twin and adoption studies indicate substantial genetic influence when measures of the environment are treated as phenotypes in genetic analyses. Genetic influence has been documented for measures as diverse as videotaped observations of parental behavior toward their children, ratings by parents and children of their family environment, and ratings of peer groups, social support, and life events. Evidence for genetic influence on environmental measures includes some of the most widely used measures of environment – the Home Observation for Measurement of the Environment, the Family Environment Scales, and the Social Readjustment Rating Scale of life events, for example. The goal of this article is to document and discuss these findings and to elicit commentary that might help to shape the course of research on this topic, which has far-reaching implications for the behavioral and brain sciences.

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.

Should the diagnosis of major depression be made independent of or dependent upon the psychosocial context?

BACKGROUND

The diagnosis of certain psychiatric syndromes (e.g. panic attacks, post-traumatic stress disorder) is crucially dependent on the psychosocial context in which they arise. For other syndromes (e.g. schizophrenia), the context is generally irrelevant. Should the diagnosis of major depression (MD) be made dependent upon or independent of the psychosocial context in which it occurs?

METHOD

Twins were selected from a population-based registry who, on personal interview, reported developing a full depressive syndrome either 'out of the blue' or in response to stressful life events (SLEs) rated objectively as having mild, low moderate, high moderate or severe long-term contextual threat (LTCT).

RESULTS

In these depressed subjects, no relationship was found between the level of adversity associated with onset and most indices of liability to depression, including risk of MD in co-twin and parents, level of neuroticism, risk for future depressive episodes, co-morbidity with other internalizing disorders and history of sexual abuse. Compared to the remainder of this epidemiologic cohort, subjects developing depression in response to the severe threat events had substantially elevated levels of all the examined indices of liability to MD.

CONCLUSIONS

Individuals who develop a full depressive syndrome in response to high-threat events do not have an appreciably lower liability to MD than those developing depression after exposure to low adversity and have much higher liability to depression than observed in their population cohort. These results support the hypothesis that, in general, MD can be diagnosed independently of the psychosocial context in which it arises.

From age correction to genome-wide association

OBJECTIVE

Eric Strömgren was one of the pioneers of psychiatric genetics and family studies. There has now been an explosion of interest in this field and research progress, including linkage and association studies, whole genome genotyping, copy number variants and epigenetics is reviewed here.

METHOD

An overview of this area of psychiatric research is presented and discussed based on the relevant literature aiming at giving a recent status of the progress.

RESULTS

Broadly speaking linkage and association are complementary approaches used to locate genes contributing to the genetic aetiology of psychopathology. Linkage can be detected over comparatively large distances, however power is problematic when searching for quantitative trait loci with small effect sizes. In contrast, association studies can detect small effects but only over very small distances. Therefore, while several genome-wide linkage studies in psychiatric disorders have been performed, the majority of association studies have investigated specific functional candidate genes.

CONCLUSION

Due to very recent technological advancements, genome-wide association studies have now become possible and have identified some completely novel susceptibility loci. Other recent advances include the discovery of epigenetic phenomena and copy number variants.

The implications of gene-environment interactions in depression: will cause inform cure?

In a number of human diseases, including depression, interactions between genetic and environmental factors have been identified in the absence of direct genotype-disorder associations. The lack of genes with major direct pathogenic effect suggests that genotype-specific vulnerabilities are balanced by adaptive advantages and implies aetiological heterogeneity. A model of depression is proposed that incorporates the interacting genetic and environmental factors over the life course and provides an explanatory framework for the heterogeneous aetiology of depression. Early environmental influences act on the genome to shape the adaptability to environmental changes in later life. The possibility is explored that genotype- and epigenotype-related traits can be harnessed to develop personalized therapeutic interventions. As diagnosis of depression alone is a weak predictor of response to specific treatments, aetiological subtypes can be used to inform the choice between treatments. As a specific application of this notion, a hypothesis is proposed regarding relative responsiveness of aetiological subtypes of depression to psychological treatment and antidepressant medication. Other testable predictions are likely to emerge from the general framework of interacting genetic, epigenetic and environmental mechanisms in depression.

Life events, anxious depression and personality: a prospective and genetic study

BACKGROUND

The association between life events and anxious depression might be due to causality or to gene-environment correlation. We examined unidirectional and reciprocal causality and a gene-environment correlation model, in which genes that influence the vulnerability for anxious depression also increase the risk of exposure to life events. The effect of genes that influence environmental exposure might be mediated through personality and we therefore also examined the association between life events and personality (neuroticism and extraversion).

METHOD

Information on life events, anxious depression, neuroticism and extraversion was collected in 5782 monozygotic (MZ) and dizygotic (DZ) twins who participated in a longitudinal survey study of the Netherlands Twin Register. To examine causality, data were analysed longitudinally. To examine gene-environment correlation, the co-twin control method was used.

RESULTS

Anxious depression and, to a lesser extent, neuroticism scores increased after exposure to life events. Anxious depression and neuroticism also predicted the experience of life events. Prospectively, extraversion was not associated with life events. Anxious depression, neuroticism and extraversion scores did not differ between the non-exposed subjects of MZ and DZ twin pairs and unrelated subjects discordant for life events.

CONCLUSIONS

Our findings suggest that reciprocal causation explains the relationship between life events and anxious depression and between life events and neuroticism. Extraversion is not related to life events. No evidence was found for gene-environment correlation, i.e. the genes that influence anxious depression, neuroticism or extraversion do not overlap with the genes that increase the risk of exposure to life events.

[The etiopathogenesis of unipolar depression. Neurobiological and psychosocial factors]

Despite its clinical and socio-economic relevance, surprisingly little is known on the etiology of depression. A multitude of neurobiological and psychosocial hypotheses have been postulated but most lack empirical validity or cannot be integrated into comprehensive pathophysiological models. In neurobiological research, most evidence supports a contribution of genetic factors in the causation of depression. However, it seems that only the susceptibility for the disorder is inherited which ultimately causes the onset of depressive symptoms by interacting with psychosocial adversity. More recent research suggests an important role for altered stress responses and disturbed neuroplasticity in the etiopathogenesis of depression. From a psychosocial point of view, the different approaches prioritize different aspects. Psychoanalytical approaches assume a fragile self-worth system developed in early childhood as a decisive vulnerability factor for later depression. Behavioral-cognitive theories focus on dysfunctional cognitions coupled with learned helplessness and behavioural deficits as well as a failing in positive reinforced activities as predisposing factors for affective disorders. Interpersonal theories, however, postulate that the psychosocial and interpersonal context is most important for the development and course of depression. With regard to the etiopathogenesis of the so called difficult-to-treat chronic depression, especially early traumata as well as preoperational patterns of thinking seem to play a decisive role. In conclusion, only bio-psycho-social models which integrate neurobiological and psychosocial vulnerabilities and stressors have the potential to contribute to a better understanding of the etiology of depression.

The interplay of familial depression liability and adverse events in predicting the first onset of depression during a 10-year follow-up

BACKGROUND

The aim of the present article is to explore interaction and correlation effects between familial depression liability and selected adverse (separation and traumatic) events in predicting the first onset of a major depressive episode (MDE) in a 10-year prospective longitudinal community survey.

METHODS

Analyses are based on 1982 subjects (14 to 24 years at baseline) without baseline MDE who participated during the whole study period and for whom diagnostic information about psychopathology in both parents was available. The offspring's familial depression liability was determined by aggregating information on parental depressive symptoms obtained from family history data and direct interviews with parents. Data were assessed with the Munich-Composite International Diagnostic Interview according to its DSM-IV algorithms.

RESULTS

Adverse events predicted a substantially increased incidence of MDE among respondents with familial liability but not in those without familial liability. There was a significant interaction between familial liability and traumatic events with the strongest effect for the number of severe traumatic events (risk difference = 11.3%; 95% confidence interval = 3.55-19.15). Associations with familial liability were most pronounced for separation events.

CONCLUSIONS

Adverse events are particularly pathogenic in individuals with familial liability. The involvement of interactions and correlations between familial liability and adversity might depend on type, severity, and number of events. Both processes are suggested to be concomitant rather than exclusive.

The risk for depression conferred by stressful life events is modified by variation at the serotonin transporter 5HTTLPR genotype: evidence from the Spanish PREDICT-Gene cohort

We report results from the PREDICT-Gene case-control study nested in a prospective cohort designed to identify predictors of the onset of depression among adult primary-care attendees. We tested the potential gene-by-environment interaction between 5HTTLPR genotype at the serotonin transporter gene and previous exposure to threatening life events (TLEs) in depression. A total of 737 consecutively recruited participants were genotyped. Additional information was gathered on exposure to TLEs over a 6-month period, socio-demographic data and family history of psychological problems among first-degree relatives. Diagnoses of depression were ascertained using the Composite International Diagnostic Interview (CIDI) by trained interviewers. Two different depressive outcomes were used (ICD-10 depressive episode and ICD-10 severe depressive episode). Both the s/s genotype and exposure to increasing number of TLEs were significantly associated with depression. Moreover, the 5HTTLPR s/s genotype significantly modified the risk conferred by TLEs for both depressive outcomes. Thus, s/s homozygous participants required minimal exposure to TLE (1 TLE) to acquire a level of risk for depression that was only found among l/s or l/l individuals after significantly higher exposure to TLEs (two or more TLEs). The interaction was more apparent when applied to the diagnosis of ICD-10 severe depressive episode and after adjusting for gender, age and family history of psychological problems. Likelihood ratios tests for the interaction were statistically significant for both depressive outcomes (ICD-10 depressive episode: LR X(2)=4.7, P=0.09 (crude), LR-X(2)=6.4, P=0.04 (adjusted); ICD-10 severe depressive episode: LR X(2)=6.9, P=0.032 (crude), LR-X(2)=8.1, P=0.017 (adjusted)).

Stress generation in depression: reflections on origins, research, and future directions

Depressed individuals report higher rates of stressful life events, especially those that have occurred in part because of the person's characteristics and behaviors affecting interpersonal interactions. Termed stress generation, this phenomenon draws attention to the role of the individual as an active contributor rather than passive player in his or her environment, and is therefore an example of action theory. In this article, the author speculates about the intellectual origins of her stress generation perspective, and notes somewhat similar transactional approaches to the stress-disorder link outside of depression research. The literature on stress generation in depression is reviewed, including studies that attempt to explore its correlates and predictors, covering clinical, contextual, family, genetic, cognitive, interpersonal, and personality variables. Empirical and conceptual gaps in our understanding of processes contributing to stressors in the lives of depressed people remain. The author concludes with suggestions for further research, with the goal of furthering understanding both of mechanisms of depression and of dysfunctional interpersonal processes, as well as development of effective interventions to help break the stress-recurrence cycle of depression.