Chronic depression

Correlates of chronic depression in the general population: results from the CoLaus|PsyCoLaus study

PURPOSE

Previous population-based studies have partially provided inconsistent results regarding the co-variates of chronic depression, which were likely to be attributable to methodological limitations. The present paper that compared people with chronic major depressive disorder (MDD), non-chronic MDD and no mood disorder in the community focused on specific atypical and melancholic depression symptoms and subtypes of MDD, family history (FH) of mood disorders, measured physical cardio-vascular risk factors (CVRF), personality traits, coping style and adverse life-events.

METHODS

Data stemmed from a population-based cohort including 3618 participants (female 53%, n=1918; mean age 50.9 years, s.d. 8.8 years). Among them 563 had a lifetime history of chronic MDD, 1060 of non-chronic MDD and 1995 of no mood disorder. Diagnostic and FH information were elicited through semi-structured interviews, CVRF were assessed through physical investigations.

RESULTS

The major findings were that chronic MDD was associated with increase in appetite/weight and suicidal ideation/attempts during the most severe episode, higher exposure to life-events in adulthood, higher levels of neuroticism, lower levels of extraversion and lower levels of informal help-seeking behavior but less frequent FH of MDD compared to non-chronic MDD.

CONCLUSION

Chronic MDD is associated with a series of potential modifiable risk factors which are accessible via psychotherapeutic approaches that may improve the course of chronic MDD.

Dysthymic disorder in an inpatient population. A descriptive study

Patients suffering from various subtypes of dysthymia were compared with regard to demographic, clinical and personality characteristics. Patients with secondary dysthymia, as compared to those with primary dysthymia, had an earlier age of onset and a higher frequency of Axis I co-diagnoses (in particular anxiety disorders). Patients with pure dysthymia, as compared to those with double depression, showed an earlier age of onset of Axis I co-diagnoses, a later age of onset of dysthymic disorder and a shorter duration of the disease.

Recognition and subtyping of atypical depression by French Practitioners

A two-part survey of French General practitioners was carried out to determine attitudes and diagnostic criteria for definition of atypical depression, major depressive episodes, and anxiety disorder. Following a preliminary phase in which 90 physicians were interviewed, 500 general practitioners received detailed questionnaires based upon DSM III-R criteria, as well as supplementary questions based upon the Leibowitz and Akiskal criteria. Principal criteria analysis and regression analysis were carried out on the 280 analyzable files received. Results showed that anxiety disorders were primarily defined in terms of somatic criteria, and that there were a number of factors common to anxiety and depression. Minor depression was also defined primarily on the basis of somatic complaints, together with loss of energy and fatigue. Major depression was defined primarily by asthenia, apragmatism and loss of drive, together with less strongly weighted cognitive factors (sadness, Pessimism, inhibition, etc). From a dimensional standpoint, depression is defined as a “vital deficit”, with a failure to cope with social and environmental demands. It is interesting to note that the duration criterion was not considered to be of nosological relevance by the physicians, and was generally ignored in the definition of mental pathologies. The international subtyping of depressive disorders does not form part of the Practice of French practitioners, who prefer to retain the older, psychosocial models.

Standardisation framework for the Maudsley staging method for treatment resistance in depression

BACKGROUND

Treatment-resistant depression (TRD) is a serious and relatively common clinical condition. Lack of consensus on defining and staging TRD remains one of the main barriers to understanding TRD and approaches to intervention. The Maudsley Staging Method (MSM) is the first multidimensional model developed to define and stage treatment-resistance in "unipolar depression". The model is being used increasingly in treatment and epidemiological studies of TRD and has the potential to support consensus. Yet, standardised methods for rating the MSM have not been described adequately. The aim of this report is to present standardised approaches for rating or completing the MSM.

METHOD

Based on the initial development of the MSM and a narrative review of the literature, the developers of the MSM provide explicit guidance on how the three dimensions of the MSM--treatment failure, severity of depressive episode and duration of depressive episode-- may be rated.

RESULT

The core dimension of the MSM, treatment failure, may be assessed using the Maudsley Treatment Inventory (MTI), a new method developed for the purposes of completing the MSM. The MTI consists of a relatively comprehensive list of medications with options for rating doses and provisions treatment for multiple episodes. The second dimension, severity of symptoms, may be assessed using simple instruments such as the Clinical Global Impression, the Psychiatric Status Rating or checklist from a standard diagnostic checklist. The standardisation also provides a simple rating scale for scoring the third dimension, duration of depressive episode.

CONCLUSION

The approaches provided should have clinical and research utility in staging TRD. However, in proposing this model, we are fully cognisant that until the pathophysiology of depression is better understood, staging methods can only be tentative approximations. Future developments should attempt to incorporate other biological/ pathophysiological dimensions for staging.

Depressive Disorders: Treatment with Nonpharmacological Alternatives

The purpose of this article is to provide a review of current social psychology theories explaining depressive disorders and to describe selected nonpharmacological approaches that may be useful in treating disorders related to these causes. It is essential that providers of health care are alert to the signs and symptoms of depression. For many cases of depression, the presentation is not straightforward. Early recognition by both provider and client is important to the successful treatment of depressive disorders. The cognitive-behavioral and interpersonal therapies discussed in this article may be useful to augment other types of alternative and complementary healing modalities or for clients who prefer nonpharmacological treatment.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive disorder-update 2015

These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into five levels of evidence (CE A-F) and five levels of recommendation grades (RG 1-5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electroconvulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults.

Transcranial focused ultrasound as a possible treatment for major depression

Antidepressants are currently used as initial therapies for major depressive disorder (MDD). However, despite the remarkable increase in medications validated as effective in MDD, treatments are still plagued by inadequate responses in part of MDD patients. For MDD with inadequate responses to medications, brain stimulation methods such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have been used as alternative strategies for treatment of depression, although each of these modalities has an indication for MDD treatment resistance and suffers from a limitation or weakness. Thus, development of new strategies based on novel theories of MDD may help to develop faster and more effective treatments for MDD. Recent studies have suggested that decreased brain brain-derived neurotrophic factor (BDNF) may be involved in the pathogenesis of MDD. Moreover, increasing brain BDNF and adult hippocampal neurogenesis have been implicated in some of the therapeutic mechanisms of antidepressants. Transcranial focused ultrasound (tFUS), a novel technique to deliver highly focused acoustic energy to a small brain region, has been used for targeted drug delivery by increasing blood-brain barrier permeability, and it can noninvasively focally modulate human cortical function. Recent animal studies have demonstrated that tFUS stimulation can increase BDNF and neurogenesis in mice. Furthermore, the increase blood-brain barrier (BBB) permeability may increase delivery of serum BDNF to the brain. From the above evidence, tFUS can increase brain BDNF levels and neurogenesis in the hippocampus, suggesting it could be an alternative strategy for the treatment of MDD. Further investigations into the frequency and duration of tFUS stimulation are needed to verify the efficacy of this intervention in depressive disorders.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders

OBJECTIVES

This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions.

METHODS

The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force.

RESULTS

This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults.

CONCLUSIONS

To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.

Prediction of longer-term outcome of treatment-resistant depression in tertiary care

BACKGROUND

Systematic studies on the outcome of treatment-resistant depression are scarce.

AIMS

To describe the longer-term outcome and predictors of outcome in treatment-resistant depression.

METHOD

Out of 150 patients approached, 118 participants with confirmed treatment-resistant depression (unipolar, n = 77; bipolar, n = 27; secondary, n = 14) treated in a specialist in-patient centre were followed-up for between 8 and 84 months (mean = 39, s.d. = 22).

RESULTS

The majority of participants attained full remission (60.2%), most of whom (48.3% of total sample) showed sustained recovery (full remission for at least 6 months). A substantial minority had persistent subsyndromal depression (19.5%) or persistent depressive episode (20.3%). Diagnosis of bipolar treatment-resistant depression and poorer social support were associated with early relapse, whereas strong social support, higher educational status and milder level of treatment resistance measured with the Maudsley Staging Method were associated with achieving quicker remission. Exploratory analysis of treatment found positive associations between treatment with a monoamine oxidase inhibitor (MAOI) in unipolar treatment-resistant depression and attaining remission at discharge and at final follow-up, and duloxetine use predicted attainment of remission at final follow-up.

CONCLUSIONS

Although many patients with treatment-resistant depression experience persistent symptomatology even after intensive, specialist treatment, most can achieve remission. The choice of treatment and presence of good social support may affect remission rates, whereas those with low social support and a bipolar diathesis should be considered at higher risk of early relapse. We suggest that future work to improve the long-term outcome in this disabling form of depression might focus on social interventions to improve support, and the role of neglected pharmacological interventions such as MAOIs.

Long-term course of severe depression: late remission and recurrence may be found in a follow-up after 38-53 years

This study is a follow-up of inpatients diagnosed with severe depression/melancholia between 1956 and 1969. During this period, all inpatients at the Department of Psychiatry, University Hospital, Lund, were rated on a multidimensional diagnostic schedule on discharge. There were 471 patients born from 1920 onward. In the present follow-up, 2006 to 2010, 169 survivors could be traced. They were asked to participate in the study involving a telephone interview, in which a structured life chart was used. Of the patients contacted, 16 were ill or confused and 3 did not remember ever being depressed, leaving 150 who could participate. Seventy-five of these agreed to participate in the study. Long-term course of depression was evaluated by cluster analysis and compared to background variables, such as heredity for depression, perceived parental rearing behaviour, and treatment of index depressive episode. Using a cluster analysis the patients could be separated into six clusters describing the course: i) single or few episodes followed by long-lasting remission; ii) single or few episodes followed by long-lasting remission, although shorter; iii) single or few episodes followed by late recurrence; iv) single or few episodes, but more frequently ill, followed by late recurrence; v) several episodes followed by lasting remission; vi) chronic course of episodes. Remission or recurrence could therefore occur even after more than a decade. In summary, there was a short-term course with or without recurrence or a chronic course with or without late remission. Heredity for depression was significantly related to a chronic course with or without late remission.

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

BACKGROUND

Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression.

METHODS/DESIGN INDEX GROUP

Patients with treatment resistant/treatment refractory depression.

DEFINITION & INCLUSION CRITERIA

Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, ≥14 on the HRSD or ≥21 on the BDI-II, plus complex personality and/or psycho-social difficulties.

EXCLUSION CRITERIA

Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years.

DESIGN

Pragmatic, randomised controlled trial with qualitative and clinical components.

TEST INTERVENTION

18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort.

CONTROL CONDITION

Treatment as usual, managed by the referring practitioner.

RECRUITMENT

GP referrals from primary care.

RCT MAIN OUTCOME

HRSD (with ≤14 as remission).

SECONDARY OUTCOMES

depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records).

FOLLOW-UP

2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change.

DISCUSSION

TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials. We discuss some of the consequent problems and suggest how they may be mitigated.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN40586372.

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.

Low level of parental bonding might be a risk factor among women with prolonged depression: a preliminary investigation

AIMS

The aim of the present study was to determine whether or not the effect of parenting by the father and mother on outcomes for depression may be different between male and female subjects.

METHODS

A total of 115 patients were involved in this investigation: 74 had states of depression that continued for more than 2 years, and 41 had symptoms that remitted within 4 months. The Parental Bonding Instrument (PBI) was used to test for gender differences in the PBI score, the level of education, and the age at which the depression began, using an unpaired t-test.

RESULTS

It is suggested that female patients with low paternal care and low levels of education have a higher likelihood of showing symptoms of prolonged depression in a primary episode. No relationship was found among prolongation of depression, educational level, and parental care in male patients. Furthermore, comparing the PBI quadrants established by Parker showed that female patients who were exposed to paternal care as 'Affectionless Control', had a tendency towards a higher risk of prolonged depression than female patients who received 'Optimal Parenting'.

CONCLUSION

Especially in female patients, the prolongation of depression is likely a result of low levels of paternal care and low education.

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.

Group Cognitive Therapy in Chronic Depression: Results From Two Intervention Studies

This paper describes two interventions used to treat patients suffering with chronic depression. In the first (Study 1), a group of five sufferers from depression of more than one year's duration who had been unresponsive to, or declined drugs were given cognitive therapy for depression in a group format and followed up for a year afterwards. They were compared with a wait-list group with a similar natural history. The treatment group showed greater improvement than the wait list group and maintained most of their gains at follow-up. In the second (Study 2) four patients also suffering from chronic depression who scored highly on the Hollon Severity Index were treated in a cognitive therapy group over a more extended period (28 weeks) using the approach designed to treat personality disorder. Modest gains were made by some patients. The findings are discussed and suggestions for improvement are made.

Long-term depression versus episodic major depression: results from the prospective Zurich study of a community sample

BACKGROUND

Clinical studies have demonstrated a great clinical relevance of long-term depression (LTD). Our study aims to characterise LTD in comparison with episodic (non-chronic) major depressive episodes (MDE) on the basis of data from a community sample.

METHOD

The Zurich Cohort Study is a prospective study of young adults followed from age 20/21 to 40/41 with six interviews. The stratified sample consisted of two thirds high scorers and one third lower scorers on the Symptom Checklist-90 R (SCL-90-R). LTD was assessed from age 27/28 to 40/41 and defined as being symptomatic more days than not over 2 years plus the presence of work impairment. MDE and dysthymia were defined by DSM-III-R criteria.

RESULTS

The cumulative incidence of LTD was 5.7%, and of episodic MDE 20.9%. In both groups we found a similar preponderance of women. LTD subjects reported disturbed memory, feelings of inferiority, hopelessness, fear of everyday tasks, fear of being alone and thoughts of dying significantly more often than subjects with episodic MDE. Subjects with LTD had an earlier age of onset. 82% of them were treated over lifetime for depression compared to 61% with MDE. LTD subjects were less often married, less often in fulltime employment, more often unemployed, and more often receiving social benefits. LTD was comorbid with cardiac and respiratory syndromes, and LTD subjects were more frequently treated for insomnia and pain. They suffered significantly more from social phobia and benzodiazepine abuse; there was also a statistical trend to greater comorbidity with panic attacks, agoraphobia, obsessive-compulsive syndrome, binge eating and neurasthenia. Somatic and psychological well-being were also reduced.

CONCLUSIONS

LTD is common, clinically more serious than episodic MDE and highly comorbid.

LIMITATIONS

The sample is relatively small with an attrition rate of 38.5% over 20 years. The results cannot be generalised to persons over 40 years of age and may be dependent on the definition of LTD.

Clonazepam as a therapeutic adjunct to improve the management of depression: a brief review

Clonazepam, first used for seizure disorders, is now increasingly used to treat affective disorders. We summarize the use of clonazepam to improve the management of depression. Clonazepam is useful for treatment-resistant and/or protracted depression, as well as for acceleration of response to conventional antidepressants. Clonazepam is at this time recommended for use in combination with SSRIs (fluoxetine, fluvoxamine, sertraline) as an antidepressant, and should be used at a dosage of 2.5-6.0 mg/day. If clonazepam is effective, a response should be observed within 2-4 weeks. It is significantly more effective for unipolar than for bipolar depression. Low-dose, long-term treatment with clonazepam exhibits a prophylactic effect against recurrence of depression. Although the mechanism of action of clonazepam has not yet been established, some investigators have been suggested that it involves enhancement of anti-anxiety effects, anticonvulsant effects on subclinical epilepsy, increase in 5-HT/monoamine synthesis or decrease in 5-HT receptor sensitivity mediated through the GABA system, and regulate in GABA activity.

Current evidence for aripiprazole as augmentation therapy in major depressive disorder

Aripiprazole (Abilify) is the first atypical antipsychotic approved as adjunctive therapy for the treatment of major depressive disorder. The pharmacological basis of the action of aripiprazole in major depressive disorder remains unclear, but it may be related to its potent partial agonism of the dopamine D(2)/D(3) receptors, partial agonism of the 5-hydroxytryptamine (5-HT)(1A) receptor and antagonism of the 5-HT(2A) receptor. This article reviews findings on the efficacy and tolerability of aripiprazole from two identical placebo-controlled trials and from smaller open-label and retrospective studies. At doses of 2-15 mg/day aripiprazole was efficacious and well tolerated as adjunctive therapy to antidepressants in patients who had not responded to monotherapy.

Classification of depressive disorders in the DSM-V: proposal for a two-dimension system

The number of categories and specifiers for mood disorders has increased with each successive edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM). Many of these categories and specifiers can be viewed as an effort to map the various permutations of severity and chronicity that characterize the depressive disorders. However, this has resulted in a system that (a) is unnecessarily complex and unwieldy, (b) has created problems with artificial distinctions between categories and artifactual comorbidity, and (c) at the same time obscures what may be more fundamental distinctions. A potentially useful and more parsimonious approach to capturing much of the heterogeneity of depressive disorders is to classify the depressive disorders along 2 dimensions, 1 reflecting severity and the other, chronicity. Considerations in the development of these dimensions are discussed, and a set of examples is presented. Although further research and discussion are needed to determine the optimal form of these dimensions, the next edition of the DSM should consider replacing many of the existing categories and specifiers for depressive disorders with the simpler approach of classifying depressive disorders using the 2 dimensions of severity and chronicity.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Determinants of social functioning in bipolar disorder

BACKGROUND

Evidence indicates that social outcomes in bipolar disorders (BP) are poorer than previously assumed. This study explores determinants of the quality and quantity of social activity.

METHODS

Seventy-seven subjects with BP completed self-report and observer-rated questionnaires assessing demographic and clinical factors, personality and social functioning.

RESULTS

Quality of functioning and spectrum of activity were found to be independent. The best determinants of the quality of functioning, accounting for 33% of the variance, were premorbid neuroticism and the current level of depressive symptoms. Only 30% of subjects were active in all social domains, and the quantity of social activity was largely explained by social circumstances, namely, living with someone else and later age of illness onset.

CONCLUSIONS

The implications of these findings are discussed in this paper. We suggest that future studies need to differentiate between factors associated with the quality of functioning as compared with the quantity of social activity.

Long-term social functioning after depression treated by psychiatrists: a review

OBJECTIVES

Numerous long-term studies of depression in psychiatric settings have shown a poor clinical outcome but little emphasis has been placed on psychosocial or functional outcome in studies to date. This article reviews published data on long-term social functioning after depression and considers why psychosocial recovery appears delayed compared with clinical recovery.

METHODS

Searches were carried out of the databases MEDLINE, PSYCHLIT and EMBASE for articles published from 1980 using keywords relating to social and functional outcomes of unipolar and bipolar depression. Review articles and relevant textbooks were also searched.

RESULTS

The few outcome studies published have described long-term functional impairment in the majority of patients but have been limited by methodological shortcomings. Psychosocial impairment tends to persist even after clinical remission from depression. Residual symptomatology after remission from depression may lead to enduring psychosocial impairment, as may subtle neurocognitive deficits. Axis I and II comorbidities predict a poor psychosocial outcome, but episodes of depression do not appear to lead to personality 'scarring'.

CONCLUSIONS

Future outcome studies need to focus on longitudinal social functioning. Full functional recovery after an episode of depression should be the goal of treatment as enduring residual symptoms lead to long-term psychosocial impairment.

Possible predictors of response to clonazepam augmentation therapy in patients with protracted depression

INTRODUCTION

Clonazepam has been shown to be an effective supplementary treatment for depression. Thus, it would be useful to determine which patient characteristics are associated with response to clonazepam.

AIMS

The purpose of this study was to examine the possible predictors of response to clonazepam in the treatment of depression.

METHOD

A retrospective cohort analysis was carried out in 120 patients with protracted depression who were being treated with clonazepam.

RESULTS

A variety of clinical factors, including age, gender, type of depression, frequency of episodes, family history; and daily dose of clonazepam, were analyzed as possible predictors of response to clonazepam. A Weibull regression analysis showed that the factors that best predicted improvement with clonazepam augmentation were negative family history of psychiatric illness (e(coef) = 0.378), daily clonazepam dose of 2.5-4.0 mg (e(coef) = 0.160), and unipolar depression (e(coef) = 0.147).

CONCLUSIONS

These factors should be considered when clonazepam augmentation therapy is selected for protracted depression.

Intermediate-term outcome of psychiatric inpatients with major depression

BACKGROUND/PURPOSE

A wide range of recovery rates has been reported during the 1st year of follow-up inpatients with depression, and there is a lack of consensus regarding which clinical and psychosocial variables are associated with prognosis. This study investigated the outcome of inpatients with a major depressive episode at 10-22 months (mean +/- SD = 14.0 +/- 3.4 months) of follow-up and the associated psychosocial and clinical variables.

METHODS

The demographic and clinical characteristics of 67 inpatients with a DSM-IV major depressive episode were assessed at admission, discharge and 1 year after the initial assessment. A logistic regression model was used to examine the predictive factors of depressive status at follow-up.

RESULTS

At the 1-year follow-up, 12 patients could not be located, one refused further interview and one had committed suicide 1 month after discharge. Eighty percent of patients had follow-up examinations. Out of 67 patients, 31 (47%) underwent a DSM-IV diagnosis (29 with major depression and two with minor depression) and 22 (33%) recovered. Low socioeconomic status (p = 0.05), long duration of illness before admission (p = 0.03) and number of previous hospitalizations (p = 0.04) were predictive factors for a depressive morbidity at 10-22 months.

CONCLUSION

At follow-up, almost half of the discharged depressive patients were still depressed. Screening for predictive factors of chronic depressive morbidity facilitates better outcome by considering the heterogeneity of psychopathology that can lead to failure in the treatment plan.

Behavioural treatment of trichotillomania: Two-year follow-up results

Post-treatment evaluation studies of behaviour therapy (BT) for trichotillomania (TTM) have shown that BT is successful in reducing symptoms in this impulse-control disorder. The present study was aimed at investigating gain maintenance at long-term follow-up. TTM-related symptoms and other symptom characteristics were evaluated in 28 patients suffering from TTM before and after brief BT and at a 3-month and 2-year follow-up. The manual-based BT consisted of self-control procedures offered in six sessions. Pre-post effect sizes for TTM symptoms at post-treatment evaluation and at the two follow-ups were 2.91, 1.47, and .87. Compared to the post-treatment effects, the 3-month and 2-year follow-up effect sizes had decreased by 49% and 70%, respectively. Better 2-year follow-up results were associated with lower pre-treatment levels of depressive symptoms and with complete abstinence from hair pulling immediately after treatment.

White matter hyperintensities and chronicity of depression

OBJECTIVE

White matter hyperintensities (WMHs) on T(2)-weighted magnetic resonance imaging (MRI) of the brain are associated with advanced age and late-life depression. Most investigations predominantly found these lesions in frontal lobe and basal ganglia supporting the hypothesis of a fronto-striatal dysfunction in depression. A prospective study was undertaken to investigate the association between extent of WMHs and clinical outcome in elderly depressed patients.

METHODS

Thirty-one non-demented depressed subjects underwent a 1.5 T cranial MRI scan. The MRI scans were analysed in consensus by two experienced radiologists. Each MRI scan was assessed for presence and extent of WMHs, which are differentiated in periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs). A total of 21 patients of the original cohort of 31 patients were re-assessed 5 years after baseline assessment. We ascertained the severity of depressive symptoms, the longitudinal course of depression, the cognitive decline and the global assessment of functioning at follow-up visit.

RESULTS

(1) Subjects with greater extent of WMHs had a significant higher Hamilton Depression Rating Scale (HAM-D) score, (2) had more severe longitudinal courses of depression (3) and had a lower Mini-Mental State Examination (MMSE) score.

CONCLUSIONS

WMHs on MRI are associated with poorer outcome in elderly depressed subjects. Further studies are needed to evaluate WHMs as prognostic factor for an appropriate treatment decision-making.

Treatment and response in refractory depression: results from a specialist affective disorders service

BACKGROUND

The best treatment approaches for chronic severe refractory depression remain uncertain. This study aimed to identify short-term outcome and most successful somatic treatments of severe refractory depressives referred to an affective disorders service.

METHODS

Patients with chronic refractory depression referred to a specialist affective disorders service over a 10-year period were studied. Using detailed case records of the index episode, courses of treatment and outcome were examined.

RESULTS

Patients were predominantly middle-aged females with few prior episodes but long index episodes. Patients received higher antidepressant doses and more combinations on the specialist service. Very-high-dose antidepressants (tricyclics, velafaxine or tricyclic--MAOI combinations), usually augmented with lithium and often combined with ECT, were the most effective somatic treatments. Most subjects improved substantially, but few reached premorbid levels.

LIMITATIONS

The study was retrospective. Treatment courses were sequential rather than random.

CONCLUSIONS

Refractory depression is responsive to vigorous somatic therapy, although most patients continue with some symptoms.

Longitudinal syndromal and sub-syndromal symptoms after severe depression: 10-year follow-up study

BACKGROUND

Few follow-up studies of depression have evaluated depressive symptomatology over time at both threshold and sub-threshold levels.

AIMS

To evaluate long-term longitudinal symptomatic course after an episode of severe depression.

METHOD

A total of 61 participants from a previous study cohort underwent a detailed interview covering the longitudinal course of depression and pharmacological treatment over 8-11 years of follow-up.

RESULTS

Of the follow-up months, 52% were spent at an asymptomatic level, 15% at minor symptom level, 20% at residual symptom level and 13% at full depression level. Also, 30% of follow-up months were spent in an episode of depression, and 18% of patients never achieved asymptomatic status during follow-up. The percentage of patients at each symptom level remained relatively stable after the first 2 years, but levels in individuals fluctuated, with a mean of two changes in symptom levels per follow-up year.

CONCLUSIONS

After severe episodes, sub-syndromal levels of depression are common and persistent, with considerable fluctuation suggesting a continuum between sub-syndromal subtypes and full depression.

Unipolar late-onset depression: A comprehensive review

Background

The older population increases all over the world and so also does the number of older psychiatric patients, which manifest certain specific and unique characteristics. The aim of this article is to provide a comprehensive review of the international literature on unipolar depression with onset at old age.

Methods

The authors reviewed several pages and books relevent to the subject but did not search the entire literature because of it's overwhelming size. They chose to review those considered most significant.

Results

The prevalence of major depression is estimated to be 2% in the general population over 65 years of age. The clinical picture of geriatric depression differs in many aspects from depression in younger patients. It is not yet clear whether it also varies across cultures and different socio-economic backgrounds. Biological data suggest that it is associated with an increased severity of subcortical vascular disease and greater impairment of cognitive performance. Many authors consider the existence of a somatic disorder to be related to the presence of depression in late life, even constituting a negative prognostic factor for the outcome of depression. Most studies support the opinion that geriatric depression carries a poorer prognosis than depression in younger patients. The therapeutic intervention includes pharmacotherapy, mainly with antidepressants, which is of established value and psychotherapy which is not equally validated.

Conclusion

A significant number of questions regarding the assessment and treatment of geriatric depression remain unanswered, empirical data are limited, and further research is necessary.

Theories of general personality and mental disorder

BACKGROUND

A major shortcoming of current research into personality is its failure to explore the relationship between theories of general personality and mental disorder.

AIMS

To provide preliminary data to address this deficit.

METHOD

In the first of two studies, we examined the relationship between the Neuroticism, Extraversion and Other - Five-Factor Inventory (NEO-FFI) and DSM personality disorders in a consecutive series of mentally disordered offenders. In the second, we sought to separate the personality dimension neuroticism from symptoms of depressive disorder in a sample of subjects with current depression.

RESULTS

Factors from the NEO-FFI were associated with different personality disorders in a predictable manner (first study). It was possible to identify a component of neuroticism (i.e. 'worry') that could be separated from depressive symptoms (second study).

CONCLUSIONS

Theories of general personality theory can enlighten and refine descriptions of abnormal mental states by informing both their aetiology and their prognosis.

Cognitive therapy of depression: pretreatment patient predictors of outcome

This review examines the role of patient predictors of outcome in cognitive therapy of depression. Studies that meet eligibility criteria are reviewed for demonstrated linkage between various predictors (i.e., pretreatment severity, historical features, demographic predictors, dysfunctional attitudes and other cognitive features, and treatment acceptability) and outcome, and several effects are found. Notably, high pretreatment severity scores are associated with poorer response to cognitive therapy, as are high chronicity, younger age at onset, an increased number of previous episodes, and marital status. High pretreatment levels of dysfunctional attitudes and certain beliefs about the nature of depression were also found to predict differential response to cognitive therapy of depression. Limitations of the research and directions for further investigations of patient predictors of outcome in cognitive therapy of depression are provided.

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.

Chronic, treatment-resistant depression and right fronto-striatal atrophy

BACKGROUND

Treatment-resistant depression (TRD) is relatively common but its neurobiological basis is poorly understood. Fronto-striatal structural brain changes have been reported in patients with depression but their association with treatment resistance and chronicity has not been established.

METHOD

Magnetic resonance images of 20 patients with TRD were compared with images of 20 recovered patients and 20 healthy controls. Images were compared using a voxel-based analysis (VBA) method; the results were validated by conventional volumetric analysis. The clinical associations of magnetic resonance imaging (MRI) changes with illness duration and severity were examined by VBA.

RESULTS

Only the TRD group exhibited right fronto-striatal atrophy, and subtle MRI changes in the left hippocampus on VBA. Atrophy was confirmed on volumetric analysis, the degree correlating with the cumulative number of electroconvulsive therapy (ECT) treatments received, suggesting an acquired deficit.

CONCLUSIONS

This is the first study to demonstrate fronto-striatal atrophy in patients with depression with poor outcome; the atrophy is more marked in those with more severe illness.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with the biological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Rapid cycling bipolar disease: new concepts and treatments

Having been recognized by Kraeplin at the beginning of the 20th century, rapid cycling was first described as a specific entity by Dunner et al. in 1974. The prevalence of rapid cycling ranges from 12% to 20% in patients with bipolar disorder who are not selected for a high rate of cycling.

Antidepressant use in clinical practice: efficacy v. effectiveness

BACKGROUND

Although the efficacy of antidepressants has been demonstrated in randomised, controlled clinical trials, it is how an antidepressant is used in clinical practice that determines its clinical effectiveness, or real-world efficacy.

AIMS

To explore the frequency with which antidepressants are used at adequate dose and duration to obtain remission of symptoms and prevent relapse in clinical practice and discuss potential implications for clinical outcomes.

METHOD

Studies of antidepressant prescribing were reviewed and comparisons made between antidepressant classes and individual compounds within those classes.

RESULTS

Naturalistic studies show that patients who begin therapy on tricyclic antidepressants often receive sub-therapeutic doses for inadequate duration; conversely, patients who begin therapy on selective serotonin reuptake inhibitors more often receive an adequate dose of therapy for a longer duration. CONCLUSIONS; How antidepressants are used in clinical practice can determine the clinical outcomes that are achieved. Antidepressants that are more forgiving of sub-optimal prescribing and use patterns by providers and patients, respectively, may help to improve real-world efficacy.

Depression and stress: a biopsychosocial exploration of evolved functions and mechanisms

Depression is a common and debilitating disorder linked to social adversity and stress. There have been many theories suggesting possible evolved functions of depression but few have explored evolved defensive mechanisms for coping with stressful events and how these maybe compromised in human depression. This paper will review some of the current evolutionary theories of depression and explore how major depression can arise when evolved defences to cope with adversity (e.g., fight, flight, disengage, submit and help-seeking) are aroused but blocked, arrested or ineffective. Psychosocial stressors can be seen as both activating,but also as arresting, evolved stress-coping defences leading to chronic states of stress with physiological effects on mood. This paper is set in the context of an evolution informed biopsychosocial approach.

Personality and outcome in depression: an 18-month prospective follow-up study

BACKGROUND

The relationship between personality and depressive illness is complex. The aim of this study was to assess whether the presence of a personality disorder or high neuroticism (N) scores predicted longer times to discharge or remission onset or higher risks of relapse for a cohort of depressed subjects admitted for the first time.

METHODS

100 consecutive subjects with ICD-10-defined depression were recruited on admission and followed up prospectively over an 18-month period. Personality function was rated using the informant-rated Standard Assessment of Personality in addition to the self-rated Maudsley Personality Inventory. Remission onset and relapse were defined operationally by scores on the Hamilton Rating Scale using recommended criteria.

RESULTS

The presence of a personality disorder predicted longer times to remission onset. Personality trait accentuation did not. Higher end N-scores correlated with longer times to remission onset. Neither personality disorder nor high N-scores predicted relapse or discharge risk. Subjects with a personality disorder were treated as aggressively as those without but those with higher N-scores were not.

LIMITATIONS

It is an in-patient sample. Fifteen subjects dropped out of follow-up and those who did so were more likely to have met criteria for two or more personality disorder categories or four or more traits from one personality disorder category. The analysis assumes that state and scar effects on N-scores were minimised. Treatment decisions were not controlled.

CONCLUSIONS

These findings support the view that the presence of a personality disorder and high N-scores modify the short-term course to remission onset in depression.

Continuation and maintenance therapy in depression

This paper reviews longer term treatment for unipolar depression. Antidepressant continuation for prevention of early relapse has been routine for many years. Recent evidence supports a longer period of 9 months to 1 year after remission. Antidepressants are also effective in maintenance treatment for recurrent depression, and are indicated where there is clear risk of further episodes. Antidepressant withdrawal after continuation and maintenance should always be gradual, over a minimum of 3 months and longer after longer maintenance periods, to avoid withdrawal symptoms or rebound relapse. Trials of interpersonal therapy in the prevention of recurrence show some benefit, but effects are weaker than those of drug and additional benefit in combination is limited. There is better evidence for effects of cognitive therapy in preventing relapse and an emerging indication for its addition to antidepressants, particularly where residual symptoms are present.

The three-year persistence of depressive symptoms in men and women

Little is known about sex differences in the course of depression. The results of the few surveys of the general population are inconsistent. Furthermore, the generalizability of most of these findings is limited. First, only a handful of studies of the general population use a prospective design to estimate the persistence of depression in women and men. Second, in some studies only particular subgroups of the general population are sampled, and finally, depression persistence is often measured using unconventional short time-intervals. Using data from five waves of the Flemish subsample of the Panel Study of Belgian Households (PSBH)--a probability sample of 1168 (52.5%) women and 1055 (47.5%) men--we tried to go beyond these shortcomings. Depression persistence is estimated using a self-report inventory on four occasions separated by intervals of one year (1993, 1994, 1995, 1996). Results show a significant influence of sex, other sociodemographic characteristics, and depression severity at baseline on three-year depression persistence. Women experience more chronicity, a difference that can be partially ascribed to sex differences in employment status, education and marital status. Persistence in linked to marital status in women. In men persistence is associated with level of education and with employment status. Depression severity at baseline, however, largely explains the influence of these social conditions on depression persistence.

Nosologomania: a disorder of psychiatry

For many years, psychiatry has been devoted to nosology. This disease model conceives psychiatric conditions as discrete entities, with a particular pathophysiology and predictable relations between phenomenology, course and outcome. This model witnessed a true revival with the introduction of the DSM III. Its foundations, however, are weak. Many of the disorders, so delineated, are of doubtful validity. This is demonstrated, taking major depression as a paradigm. The nosological way of thought, moreover, carries with it harmful side effects, such as proliferation of new diagnoses, magnification of comorbidity, border problems and neglect of the factor psychogenesis. The question is raised of a possible alternative disease model and the reaction form model is considered to be just that. This model is defined and discussed and the conclusion is reached that it fits clinical practice and biological research better than the nosological disease model. A reconstruction of the diagnostic process in psychiatry is proposed, in such a way that it gains in sophistication and at the same time creates opportunities for comparative studies of the merits of the nosological and the reaction form model for psychiatric practice and research.

Clinical characteristics of familial and non-familial bipolar disorder

OBJECTIVE

To explore the clinical characteristics of familial and non-familial bipolar disorder.

METHOD

Twenty subjects with bipolar disorder, who also had a family history of bipolar disorder in a first degree relative, were matched for current age, age of first onset of bipolar disorder and gender with 20 subjects with bipolar disorder who had no family history of any psychiatric disorders in first or second degree relatives.

RESULTS

Fourteen subjects in each group were female. The mean age at interview was 45.2 years and the mean age at first admission was 26 years. Although familial and non-familial probands had an equivalent number of illness episodes, familial probands were significantly more likely to experience mixed states as compared to non-familial probands. The latter experienced significantly more depressive episodes and had significantly higher neuroticism (N) scores on the Eysenck Personality Inventory (EPI; Eysenck H, Eysenck S. Manual of the Eysenck Personality Inventory. London: University of London Press, 1964.).

CONCLUSIONS

If the results are replicated, they have important implications. For example, such data may aid decisions about the targeting of additional psychosocial interventions in high N score cases. Researchers will wish to investigate whether mixed states show a stronger association with early age of onset or family history of BD.