Prevalence and correlates of depression with atypical symptoms in Hong Kong

Characteristics and symptomatology of major depressive disorder with atypical features from symptom to syndromal level

OBJECTIVE

To explore clinical characteristics and symptomatology of major depressive disorder (MDD) with atypical features based on DSM criteria or only reversed vegetative symptoms.

METHOD

A total of 3187 patients who met DSM-IV TR criteria for MDD were enrolled. Demographics and symptomatology covering multiple symptom domains were assessed and compared between three groups of cases: those who met DSM criteria for atypical specifier (the DAD group), those who had at least one reversed vegetative symptoms (hypersomnia or hyperphagia) (the SAD group) without meeting DSM atypical specifier criteria, and those without any reversed vegetative symptoms (the NAD group).

RESULTS

The DAD and SAD group accounted for 4.4 % and 14.4 % of the participants, respectively. The DAD cases were characterized by a highest proportion of hospitalizations, longest duration of current episode and worst quality of life. The DAD and SAD cases were more likely to adopt unhealthy behaviors (smoking and alcohol drinking). Most depressive symptoms related to higher illness severity and treatment resistance were more frequent in the DAD cases, followed by the SAD cases, and least frequent in the NAD cases.

LIMITATIONS

A cross-sectional design and a non-validated questionnaire were used.

CONCLUSIONS

The findings support the role of DSM defined atypical depression as a valid MDD subtype and provide evidence for clinical utility of the simplified approach of defining atypical features based on only reversed vegetative symptoms. This has implications for illness screening, public health, suicide prevention and better treatment planning for depressed individuals with atypical features even below syndromal level.

Depression with atypical neurovegetative symptoms shares genetic predisposition with immuno-metabolic traits and alcohol consumption

BACKGROUND

Depression is a highly prevalent and heterogeneous disorder. This study aims to determine whether depression with atypical features shows different heritability and different degree of overlap with polygenic risk for psychiatric and immuno-metabolic traits than other depression subgroups.

METHODS

Data included 30 069 European ancestry individuals from the UK Biobank who met criteria for lifetime major depression. Participants reporting both weight gain and hypersomnia were classified as ↑WS depression (N = 1854) and the others as non-↑WS depression (N = 28 215). Cases with non-↑WS depression were further classified as ↓WS depression (i.e. weight loss and insomnia; N = 10 142). Polygenic risk scores (PRS) for 22 traits were generated using genome-wide summary statistics (Bonferroni corrected p = 2.1 × 10-4). Single-nucleotide polymorphism (SNP)-based heritability of depression subgroups was estimated.

RESULTS

↑WS depression had a higher polygenic risk for BMI [OR = 1.20 (1.15-1.26), p = 2.37 × 10-14] and C-reactive protein [OR = 1.11 (1.06-1.17), p = 8.86 × 10-06] v. non-↑WS depression and ↓WS depression. Leptin PRS was close to the significance threshold (p = 2.99 × 10-04), but the effect disappeared when considering GWAS summary statistics of leptin adjusted for BMI. PRS for daily alcohol use was inversely associated with ↑WS depression [OR = 0.88 (0.83-0.93), p = 1.04 × 10-05] v. non-↑WS depression. SNP-based heritability was not significantly different between ↑WS depression and ↓WS depression (14.3% and 12.2%, respectively).

CONCLUSIONS

↑WS depression shows evidence of distinct genetic predisposition to immune-metabolic traits and alcohol consumption. These genetic signals suggest that biological targets including immune-cardio-metabolic pathways may be relevant to therapies in individuals with ↑WS depression.

An Overview of the Heterogeneity of Major Depressive Disorder: Current Knowledge and Future Prospective

Major depressive disorder (MDD) is estimated to impose maximum debilitating effects on the society by 2030, with its critical effects on health, functioning, quality of life and concomitant high levels of morbidity and mortality. Yet, the disease is inadequately understood, diagnosed and treated. Moreover, with the recent drastic rise in the pace of life, stress has materialized as one of the most potent environmental factors for depression. In this scenario, it is important to understand the modern pathogenetic hypotheses and mechanisms, and possibly try to shift from the traditional approaches in depression therapy. These include the elaboration of pathophysiological changes in heterogeneous systems such as genetic, epigenetic, serotonergic, noradrenergic, gamma-aminobutyric acid, glutamatergic and endocannabinoid systems, neurotrophic factors, HPA axis, immune system as well as cellular stress mechanisms. These components interact with each other in a complex matrix and further elucidation of their mechanism and cascade pathways are needed. This might aid in the identification of MDD subtypes as well as the development of sophisticated biomarkers. Further, characterization might also aid in developing multitargeted therapies that hold much promise as compared to the conventional monoamine based treatment. New candidate pharmacons, refined psychotherapeutic modalities, advanced neuro-surgical and imaging techniques as well as the implementation of pharmacokinetic, pharmacogenetic prescribing guidelines constitute the emerging expanses of MDD treatment.

Characteristics, comorbidities, and correlates of atypical depression: evidence from the UK Biobank Mental Health Survey

BACKGROUND

Depression is a heterogeneous disorder with multiple aetiological pathways and multiple therapeutic targets. This study aims to determine whether atypical depression (AD) characterized by reversed neurovegetative symptoms is associated with a more pernicious course and a different sociodemographic, lifestyle, and comorbidity profile than nonatypical depression (nonAD).

METHODS

Among 157 366 adults who completed the UK Biobank Mental Health Questionnaire (MHQ), N = 37 434 (24%) met the DSM-5 criteria for probable lifetime major depressive disorder (MDD) based on the Composite International Diagnostic Interview Short Form. Participants reporting both hypersomnia and weight gain were classified as AD cases (N = 2305), and the others as nonAD cases (N = 35 129). Logistic regression analyses were conducted to examine differences between AD and nonAD in depression features, sociodemographic and lifestyle factors, lifetime adversities, psychiatric and physical comorbidities.

RESULTS

Persons with AD experienced an earlier age of depression onset, longer, more severe and recurrent episodes, and higher help-seeking rates than nonAD persons. AD was associated with female gender, unhealthy behaviours (smoking, social isolation, low physical activity), more lifetime deprivation and adversity, higher rates of comorbid psychiatric disorders, obesity, cardiovascular disease (CVD), and metabolic syndrome. Sensitivity analyses comparing AD persons with those having typical neurovegetative symptoms (hyposomnia and weight loss) revealed similar results.

CONCLUSIONS

These findings highlight the clinical and public health significance of AD as a chronic form of depression, associated with high comorbidity and lifetime adversity. Our findings have implications for predicting depression course and comorbidities, guiding research on aetiological mechanisms, planning service use and informing therapeutic approaches.

Glucocorticoid receptor deletion from locus coeruleus norepinephrine neurons promotes depression-like social withdrawal in female but not male mice

Abnormal glucocorticoid levels can cause psychiatric symptoms ranging from depression to euphoria that have been implicated in mood disorders. My overarching hypothesis is that these opposing effects are mediated by glucocorticoid receptors (GR) in different brain regions. My laboratory has shown that GR in the serotonergic dorsal raphé nucleus (DRN) promote depression-like social and behavioral withdrawal in mice. We have also shown that GR in the DRN and noradrenergic locus coeruleus (LC) exhibit divergent regulation by antidepressants that have differential efficacy for depression subtypes with opposing abnormalities in glucocorticoids. The current study tested the hypothesis that LC GR would have effects opposite to those in the DRN by preventing rather than promoting social withdrawal. GR was deleted from LC NE neurons in female and male floxed GR mice by bilateral injections of lentivirus transducing Cre recombinase under control of a multimerized Phox 2a/2b response sequence (PRS) from the dopamine β-hydroxylase promoter (PRS-Cre). Female but not male PRS-Cre mice exhibited lower social interaction compared to controls injected with lentivirus transducing green fluorescent protein (PRS-GFP). Differences in social interaction between PRS-GFP and PRS-Cre females were not associated with differences in exploratory behavior, plasma corticosterone, male-female differences in LC GR expression, or changes in LC mineralocorticoid receptor or tyrosine hydroxylase gene expression. These results indicate that LC NE GR have sex-dependent effects to prevent social withdrawal, supporting the concept that glucocorticoids exert opposing effects on depression symptoms via different brain targets, and potentially revealing novel drug targets to treat depression, particularly in women.

The HPA axis in bipolar disorder: Systematic review and meta-analysis

OBJECTIVES

To provide a quantitative and qualitative synthesis of the available evidence on the role of Hypothalamic-Pituitary-Adrenal (HPA) axis in the pathophysiology of Bipolar Disorder (BD).

METHODS

Meta-analysis and meta-regression of case-control studies examining the levels of cortisol, ACTH, CRH levels. Systematic review of stress reactivity, genetic, molecular and neuroimaging studies related to HPA axis activity in BD.

RESULTS

Forty-one studies were included in the meta-analyses. BD was associated with significantly increased levels of cortisol (basal and post-dexamethasone) and ACTH, but not of CRH. In the meta-regression, case-control differences in cortisol levels were positively associated with the manic phase (p=0.005) and participants' age (p=0.08), and negatively with antipsychotics use (p=0.001). Reviewed studies suggest that BD is associated with abnormalities of stress-related molecular pathways in several brain areas. Variants of HPA axis-related genes seem not associated with a direct risk of developing BD, but with different clinical presentations. Also, studies on unaffected relatives suggest that HPA axis dysregulation is not an endophenotype of BD, but seems related to environmental risk factors, such as childhood trauma. Progressive HPA axis dysfunction is a putative mechanism that might underlie the clinical and cognitive deterioration of patients with BD.

CONCLUSIONS

BD is associated with dysfunction of HPA axis activity, with important pathophysiological implications. Targeting HPA axis dysfunctions might be a novel strategy to improve the outcomes of BD.

Beyond "somatization" and "psychologization": symptom-level variation in depressed Han Chinese and Euro-Canadian outpatients

The finding that people of Chinese heritage tend to emphasize somatic rather than psychological symptoms of depression has frequently been discussed in the culture and mental health literature since the 1970s. Recent studies have confirmed that Chinese samples report more somatic and fewer psychological depression symptoms compared to "Western" samples. The question remains, however, as to whether or not these effects are attributable to variation in all the constituent symptoms or to a subset. If the latter, there is the additional possibility that some symptoms might show a divergent pattern. Such findings would have implications for how cultural variations in symptom presentation are interpreted, and would also inform the cultural study of affective experiences more broadly. The current study addressed these issues in Chinese (n = 175) and Euro-Canadian (n = 107) psychiatric outpatients originally described by Ryder et al. (2008). Differential item functioning (DIF) was used to examine whether specific somatic and psychological symptoms diverged from the overall patterns of cultural variation. Chi-square analyses were used to examine atypical somatic symptoms (e.g., hypersomnia), previously neglected in this literature. No DIF was observed for the typical somatic symptoms, but Euro-Canadians reported greater levels of atypical somatic symptoms, and showed higher rates of atypical depression. DIF was observed for psychological symptoms-the Chinese reported high levels of "suppressed emotions" and "depressed mood," relative to their overall psychological symptom reporting. Chinese outpatients also spontaneously reported "depressed mood" at similar levels as the Euro-Canadians, contrary to prevailing ideas about Chinese unwillingness to discuss depression. Overall, the findings provide a more nuanced picture of how culture shapes symptom presentation and point toward future studies designed to unpack cultural variation in narrower subsets of depressive symptoms.

Seasonal symptoms in bipolar and primary care patients

BACKGROUND

There is evidence of seasonality in bipolar affective disorder (BAD) and the preponderance of atypical symptoms in bipolar depressive episodes is also seen in winter type Seasonal Affective Disorder. Differences in seasonal symptoms between BAD and appropriate comparison populations have been scrutinised only in small studies.

METHODS

Symptoms described on the Seasonal Pattern Assessment Questionnaire (SPAQ) were compared between 183 patients with BAD and 468 patients consulting their general practitioners. Statistical analyses were adjusted for differing age and gender distributions between the two groups.

RESULTS

Compared with the general practice patients, subjects with BAD reported greater seasonal fluctuations in mood (p=0.003). On one measure BAD subjects reported increased seasonal changes in social activity (p<0.001) and greater weight fluctuation over the year (p=0.001). The most striking differences were in sleep patterns; BAD subjects slept significantly more throughout the year, and slept for a mean of 1.8h more in winter than in summer (versus a 1.0h difference in the general practice group, p<0.001). Against 20% of the general practice group, 46% of BAD patients rated seasonal changes in well-being to be at least a moderate problem.

LIMITATIONS

The SPAQ was designed as a screening instrument for Seasonal Affective Disorder, not for studies of this nature. Some of the reported differences, notably in social activity and weight changes, may reflect secondary psychosocial effects of BAD.

CONCLUSIONS

Seasonal changes, most notably winter hypersomnia, should be identified in patients with BAD. These symptoms may respond to treatments such as light therapy that are used in recurrent winter depression.

Beyond the serotonin hypothesis: mitochondria, inflammation and neurodegeneration in major depression and affective spectrum disorders

For many years, a deficiency of monoamines including serotonin has been the prevailing hypothesis on depression, yet research has failed to confirm consistent relations between brain serotonin and depression. High degrees of overlapping comorbidities and common drug efficacies suggest that depression is one of a family of related conditions sometimes referred to as the "affective spectrum disorders", and variably including migraine, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia and generalized anxiety disorder, among many others. Herein, we present data from many different experimental modalities that strongly suggest components of mitochondrial dysfunction and inflammation in the pathogenesis of depression and other affective spectrum disorders. The three concepts of monoamines, energy metabolism and inflammatory pathways are inter-related in many complex manners. For example, the major categories of drugs used to treat depression have been demonstrated to exert effects on mitochondria and inflammation, as well as on monoamines. Furthermore, commonly-used mitochondrial-targeted treatments exert effects on mitochondria and inflammation, and are increasingly being shown to demonstrate efficacy in the affective spectrum disorders. We propose that interactions among monoamines, mitochondrial dysfunction and inflammation can inspire explanatory, rather than mere descriptive, models of these disorders.

The association between physical illness and major depressive episode in general practice

OBJECTIVE

Physical illness and depression are associated. However, it remains unclear whether this association is sufficiently strong to merit systematic screening for depression among primary care patients suffering from physical illness. In the present study, we investigated the strength of the association between physical illness and depression among patients in general practice.

METHOD

Four thousand two hundred and seventy-one consecutive primary care patients completed a diagnostic depression questionnaire. The general practitioner evaluated the patients' physical health, which was then compared to their diagnostic status of depression.

RESULTS

Physical illness was associated with the presence of depression. Two hundred and thirty-six patients (5.5%) fulfilled diagnostic criteria for depression. Fourteen of these suffered from extreme physical illness, 27 from at least severe physical illness and 96 from at least moderate physical illness. The number needed to screen decreased with increasing severity and chronicity of the physical illness.

CONCLUSIONS

Depression is relatively common in primary care patients suffering from physical illness, particularly if the illness is severe and chronic. However, relatively few depressed patients suffer from a comorbid physical illness. Screening for depression among patients with physical illness may therefore only have a modest impact on the under-recognition of depression in general practice.