Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review

BACKGROUND

Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials.

METHOD

Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis.

RESULTS

Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience.

CONCLUSION

Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

Unraveling the comorbidity of depression and anxiety in a large inpatient sample: Network analysis to examine bridge symptoms

BACKGROUND

Comorbidities in mental disorders are often understood by assuming a common cause. The network theory of mental disorders offers an alternative to this assumption by understanding comorbidities as mutually reinforced problems. In this study, we used network analysis to examine bridge symptoms between anxiety and depression in a large sample.

METHOD

Using data from a sample of patients diagnosed with both depression and an anxiety disorder before and after inpatient treatment (N = 5,614, mean age: 42.24, 63.59% female, average treatment duration: 48.12 days), network models of depression and anxiety symptoms are estimated. Topology, the centrality of nodes, stability, and changes in network structure are analyzed. Symptoms that drive comorbidity are determined by bridge node analysis. As an alternative to network communities based on categorical diagnosis, we performed a community analysis and propose empirically derived symptom subsets.

RESULTS

The obtained network models are highly stable. Sad mood and the inability to control worry are the most central. Psychomotor agitation or retardation is the strongest bridge node between anxiety and depression, followed by concentration problems and restlessness. Changes in appetite and suicidality were unique to depression. Community analysis revealed four symptom groups.

CONCLUSION

The estimated network structure of depression and anxiety symptoms proves to be highly accurate. Results indicate that some symptoms are considerably more influential than others and that only a small number of predominantly physical symptoms are strong candidates for explaining comorbidity. Future studies should include physiological measures in network models to provide a more accurate understanding.

Foot health-related quality of life in hemophiliacs: A case-control study

Background: Haemophilia is considered as a chronic genetic disease related with alteration in coagulation mechanism which affects to health related quality of life (HQoL). Purpose: The goal compared marks of HQoL, in haemophiliacs with respect non haemophilic subjects. Methods: A population of 74 subjects, were recruited from association of haemophilic illness separated in haemophilic subjects (n = 37) and no haemophilic (n = 37). For subjects who suffered haemophilia were enlisted from the association of haemophilic illness after a seminar of 45 minutes to them and to their relatives about foot health. Control subjects, were recruited from their relatives who live with the patient. The marks of the Foot Health Status Questionnaire Spanish S_FHSQ sub-scales were recompiled. Results: All S_FHSQ domains as foot pain, foot function, tootwear, general foot health, general health, physical activity and social capacity showed lower scores in the haemophilic than non-haemophilic group (P <0.01) except for vigour (P = 0.173). Regarding the rest sub-scale marks of S_FHSQ, showed no significant difference P <0.01. Conclusion: Subjects with a haemophilia showed significant worse foot QoL in all S_FHSQ domains except vigour domain compared with non-haemophilic subjects.

Serotonin system genes and hoarding with and without other obsessive-compulsive traits in a population-based, pediatric sample: A genetic association study

BACKGROUND

Hoarding, originally only considered a symptom of obsessive-compulsive disorder (OCD), is now categorized as a separate disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We studied candidate serotonergic genes and the distinctness of hoarding in children and adolescents and hypothesized that unique gene variants would be associated with hoarding alone.

METHODS

We examined obsessive-compulsive (OC) traits, including hoarding, in a total of 5,213 pediatric participants in the community. We genotyped candidate serotonin genes (5-HTTLPR polymorphism in SLC6A4 for 2,018 individuals and single nucleotide polymorphisms [SNPs] across genes SLC6A4, HTR2A, and HTR1B for 4,711 individuals). In a previous study conducted by our group in the same sample, we identified a significant association between 5-HTTLPR and hoarding in males. In this study, we examined hoarding more closely by testing the association between serotonin gene variants and hoarding traits with and without other accompanying OC traits.

RESULTS

The [L_G +S] variant in 5-HTTLPR was significantly associated with hoarding alone in males (p-value of 0.009). There were no significant findings for 5-HTTLPR in females. There were no significant findings after correction for multiple comparisons using SNP array data, but top SNP findings suggested that variation downstream of HTR1B may be implicated in hoarding alone in females.

CONCLUSIONS

Our results suggest specific serotonin gene variants are associated with hoarding traits alone, differing between sexes. Top findings are in line with our former study, suggesting that individuals with hoarding alone were driving previous results. Our paper supports hoarding disorder's new designation.

Do I really feel better? Effectiveness of emotion regulation strategies depends on the measure and social anxiety

BACKGROUND

Effective emotion regulation (ER) is important to long-term healthy functioning, but little is known about what constitutes effective ER in the moment or how social anxiety symptoms and different strategies influence short-term effectiveness outcomes.

METHODS

Intensive ecological momentary data from N = 124 college students illustrate how different ways of operationalizing ER effectiveness leads to different conclusions about the short-term effectiveness of different strategies in daily life.

RESULTS

When effectiveness is operationalized as the degree to which participants judged that their ER attempts made them feel better, social anxiety severity was negatively associated with effectiveness, and avoidance-oriented strategies were judged to be less effective than engagement-oriented strategies. In contrast, when effectiveness is operationalized as the degree of change in self-reported affect following ER attempts, social anxiety severity was not related to effectiveness, and avoidance-oriented strategies were more effective than engagement-oriented strategies. Social anxiety and ER strategy type did not interact in either model, regardless of how effectiveness was measured.

CONCLUSIONS

The study highlights discrepancies when examining two common but distinct ways of measuring the same overarching effectiveness construct, and raises intriguing questions about how forms of psychopathology that are intimately tied to emotion dysregulation, like social anxiety, moderate different ways of measuring the effectiveness of ER attempts.

Measurement invariance of the patient health questionnaire-9 (PHQ-9) depression screener in U.S. adults across sex, race/ethnicity, and education level: NHANES 2005-2016

BACKGROUND

Despite its popularity, little is known about the measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) across U.S. sociodemographic groups. Use of a screener shown not to possess measurement invariance could result in under/over-detection of depression, potentially exacerbating sociodemographic disparities in depression. Therefore, we assessed the factor structure and measurement invariance of the PHQ-9 across major U.S. sociodemographic groups.

METHODS

U.S. population representative data came from the 2005-2016 National Health and Nutrition Examination Survey (NHANES) cohorts. We conducted a measurement invariance analysis of 31,366 respondents across sociodemographic factors of sex, race/ethnicity, and education level.

RESULTS

Considering results of single-group confirmatory factor analyses (CFAs), depression theory, and research utility, we justify a two-factor structure for the PHQ-9 consisting of a cognitive/affective factor and a somatic factor (RMSEA = 0.034, TLI = 0.985, CFI = 0.989). On the basis of multiple-group CFAs testing configural, scalar, and strict factorial invariance, we determined that invariance held for sex, race/ethnicity, and education level groups, as all models demonstrated close model fit (RMSEA = 0.025-0.025, TLI = 0.985-0.992, CFI = 0.986-0.991). Finally, for all steps ΔCFI was <-0.004, and ΔRMSEA was <0.01.

CONCLUSIONS

We demonstrate that the PHQ-9 is acceptable to use in major U.S. sociodemographic groups and allows for meaningful comparisons in total, cognitive/affective, and somatic depressive symptoms across these groups, extending its use to the community. This knowledge is timely as medicine moves towards alternative payment models emphasizing high-quality and cost-efficient care, which will likely incentivize behavioral and population health efforts. We also provide a consistent, evidence-based approach for calculating PHQ-9 subscale scores.

Detecting PTSD in a traumatically injured population: The diagnostic utility of the PTSD Checklist for DSM-5

BACKGROUND

The posttraumatic stress disorder (PTSD) Checklist for DSM-5 (PCL-5) is among few validated measures of PTSD severity in line with the DSM-5. Validation efforts among veteran samples have recommended cut scores of 33 and 38 to indicate PTSD; cut scores vary across populations depending on factors such as trauma type. The purpose of this study was to evaluate the diagnostic utility of and identify optimal cut scores for the PCL-5 in relation to the gold standard Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) among traumatically injured individuals 6 months after discharge from a level I trauma center.

METHODS

A total of 251 participants completed the PCL-5 and CAPS-5 6 months after discharge from a level I trauma center following traumatic injury. Receiver operating characteristic curve analyses detailed diagnostic accuracy of the PCL-5 and identified the optimal cut score via Youden's J index. Cut scores were also broken down by intentional versus nonintentional injury.

RESULTS

The PCL-5 produces satisfactory diagnostic accuracy, with adequate sensitivity and specificity, in a traumatically injured population. Estimates indicate the optimal cut score as >30; the optimal cut score for intentional injuries was >34 and >22 for nonintentional injuries.

CONCLUSIONS

This investigation provides support for the PCL-5 in detection of PTSD among injured individuals 6 months after discharge from a level I trauma center. PCL-5 specificity and sensitivity suggest clinicians working with this population can feel confident in using this measure over more onerous structured interviews (e.g., CAPS-5). This study signifies a move toward ensuring those experiencing mental health difficulties after traumatic injury are identified and connected to resources.

Anhedonia and suicidal thoughts and behaviors in psychiatric outpatients: The role of acuity

BACKGROUND

Anhedonia-impairment related to the experience of pleasure-has been identified as a potential risk factor for suicide, with some mixed findings. The current study sought to clarify the role of acuity of anhedonia in the relationship between anhedonia and suicidal thoughts and behaviors by comparing acutely and chronically anhedonic subjects on severity of suicidal ideation (SI) and suicide attempt (SA) history.

METHODS

Psychiatric outpatients (N = 395) were administered the Columbia Suicide Severity Rating Scale, the Beck Scale for Suicidal Ideation and a modified version of the Snaith-Hamilton Pleasure Scale (SHPS); SI measures were readministered at a 1-month follow-up (N = 289, 73%). Participants were classified as acutely anhedonic, chronically anhedonic and nonanhedonic based on their responses to the SHPS at initial assessment.

RESULTS

Controlling for symptoms of anxiety and depression, acute anhedonia was cross-sectionally and prospectively associated with greater severity of SI compared to the nonanhedonic group; no differences in severity of SI were found between the chronically anhedonic and nonanhedonic group at either time point. Anhedonia grouping was not associated with SA history.

CONCLUSION

Changes in capacity to experience pleasure may be more informative of near-term SI than typically low pleasure levels. Future investigation should focus on the relationship between acute anhedonia and imminent suicidal behavior.

Is assessment of depression equivalent for migrants of different cultural backgrounds? Results from the German population-based Gutenberg Health Study (GHS)

BACKGROUND

Bearing in mind the multicultural background of a national population, little is known about the measurement invariance across different cultures or ethnicities of frequently used screeners for depression. For this reason, the main objective of the current study is to assess the measurement invariance of the Patient Health Questionnaire (PHQ-9) across groups with different migration backgrounds.

METHODS

We provided psychometric analyses (descriptive statistics at item and scale level, reliability analysis, exploratory [EFA] and confirmatory factor analyses [CFA]) comparing a native population with first- and second-generation migrants of the German population-based Gutenberg Health Study with N = 13,973 participants completing the PHQ-9. Furthermore, we conducted measurement invariance analyses among different groups of first-generation migrants.

RESULTS

Comparing the native population with first- and second-generation migrants, a higher prevalence for mental distress was found for first generation. Although mean score patterns were similar for all groups, analyses of item loadings among first-generation migrants yielded some variance in patterns pointing out that certain items have a distinct impact on depression for specific groups. With regard to the factorial validity for all groups, EFA and CFA provided evidence for the proposed one latent factor structure of the PHQ-9. Depression assessed by the PHQ-9 turned out to be equivalent from a psychometric perspective across different groups stratified by their migration background.

CONCLUSIONS

Overall, results of thorough scale and item analyses, especially multigroup confirmatory analyses, provided support that depression, assessed by the PHQ-9, can be considered as psychometrically equivalent across all analyzed groups.

Seeing the signs: Using the course of residual depressive symptomatology to predict patterns of relapse and recurrence of major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is characterized by high relapse/recurrence rates. Predicting individual patients' relapse/recurrence risk has proven hard, possibly due to course heterogeneity among patients. This study aimed to (1) identify homogeneous data-driven subgroups with different patterns of relapse/recurrence and (2) identify associated predictors.

METHODS

For a year, we collected weekly depressive symptom ratings in 213 primary care MDD patients. Latent class growth analyses (LCGA), based on symptom-severity during the 24 weeks after no longer fulfilling criteria for the initial major depressive episode (MDE), were used to identify groups with different patterns of relapse/recurrence. Associations of baseline predictors with these groups were investigated, as were the groups' associations with 3- and 11-year follow-up depression outcomes.

RESULTS

LCGA showed that heterogeneity in relapse/recurrence after no longer fulfilling criteria for the initial MDE was best described by four classes: "quick symptom decline" (14.0%), "slow symptom decline" (23.3%), "steady residual symptoms" (38.7%), and "high residual symptoms" (24.1%). The latter two classes showed lower self-esteem at baseline, and more recurrences and higher severity at 3-year follow-up than the first two classes. Moreover, the high residual symptom class scored higher on neuroticism and lower on extraversion and self-esteem at baseline. Interestingly, the steady residual symptoms and high residual symptoms classes still showed higher severity of depressive symptoms after 11 years.

CONCLUSION

Some measures were associated with specific patterns of relapse/recurrence. Moreover, the data-driven relapse/recurrence groups were predictive of long-term outcomes, suggesting that patterns of residual symptoms could be of prognostic value in clinical practice.

Measuring Maladaptive Cognitions in Complicated Grief: Introducing the Typical Beliefs Questionnaire

OBJECTIVES

Maladaptive cognitions related to loss are thought to contribute to development of complicated grief and are crucial to address in treatment, but tools available to assess them are limited. This paper introduces the Typical Beliefs Questionnaire (TBQ), a 25-item self-report instrument to assess cognitions that interfere with adaptation to loss.

DESIGN

Study participants completed an assessment battery during their initial evaluation and again after completing treatment at 20 weeks. Test-retest reliability was assessed on a subsample of the participants who did not show change in complicated grief severity after the first 4 weeks of treatment. To examine latent structure of the TBQ, an exploratory factor analysis (EFA) was performed.

SETTING

Academic medical centers in Boston, New York, Pittsburgh, and San Diego from 2010-2014.

PARTICIPANTS

394 bereaved adults who met criteria for complicated grief.

MEASUREMENTS

The TBQ along with assessments of complicated grief symptoms and related avoidance, depression symptoms, functional impairment, and perceived social support.

RESULTS

The TBQ exhibited good internal consistency (α = 0.82) and test-retest reliability (N = 105; intraclass correlation coefficient = 0.74). EFA indicated a five-factor structure: "Protesting the Death," "Negative Thoughts About the World," "Needing the Person," "Less Grief is Wrong" and "Grieving Too Much." The total score and all factors showed sensitivity to change with treatment.

CONCLUSIONS

This new tool allows a clinician to quickly and reliably ascertain presence of specific maladaptive cognitions related to complicated grief, and subsequently, to use the information to aid a diagnostic assessment, to structure the treatment, and to measure treatment outcomes.

Hypothalamic-pituitary-adrenal axis and depression symptom effects of an arginine vasopressin type 1B receptor antagonist in a one-week randomized Phase 1b trial

BACKGROUND

Arginine vasopressin 1B receptor (V_1B) antagonists may have utility for the treatment of major depressive disorder (MDD).

METHODS

The V_1B antagonist ABT-436 (N = 31) or matching placebo (N = 20) was administered to MDD subjects for 7 days. The main study objectives were to assess the safety and hypothalamic-pituitary-adrenal axis (HPA) effects of ABT-436 in MDD subjects. MDD symptoms were assessed using the 17-item Hamilton Depression Rating Scale (HAM-D-17) and the subject-rated Mood and Anxiety Symptom Questionnaire (MASQ).

RESULTS

The most prevalent safety finding associated with ABT-436 800 mg QD was increased mild-moderate diarrhea (68% v 5%, p < 0.001). Increased nausea (26% v 5%, p < 0.10), decreased systolic blood pressure (3.15-3.44 mmHg, p < 0.10) and increased heart rate (3.42-4.01 bpm, p < 0.05) were also associated with ABT-436 800 mg QD. Basal HPA activity measured by 24-hr urine total glucocorticoids was 25% lower with ABT-436 than placebo (p < 0.001). The reduction was, on average, larger in subjects with higher baseline urine total glucocorticoids. Results on plasma adrenocorticotrophic hormone (ACTH), urine, serum and saliva cortisol, and saliva cortisone also showed basal HPA attenuation with ABT-436. Dynamic HPA activity measured by plasma ACTH and serum cortisol responses to corticotrophin releasing hormone (CRH) were 30-46% lower in ABT-436 subjects (all p < 0.001). Each ABT-436 subject showed response to CRH in or near the baseline range of responses. ABT-436 was associated with more favorable symptom changes on two of five MASQ subscales (estimated effect size 1.47-1.86, p < 0.01) but not on HAM-D-17.

CONCLUSIONS

The results support further clinical study of the antidepressant potential of ABT-436.

Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory

BACKGROUND

We have developed the Suicide Crisis Inventory (SCI) to evaluate the intensity of the Suicidal Crisis Syndrome, an acute state hypothesized to precede suicide attempt. The psychometric properties of the SCI, including predictive validity for suicidal behavior (SB), were assessed.

METHODS

Adult psychiatric patients (n = 201) hospitalized for high suicide risk were assessed. Logistic regression models assessed the SCI's predictive validity for SB in the 4-8 weeks following hospital discharge and its incremental predictive validity over traditional risk factors (n = 137, 64% f/u rate). Internal structure, reliability, convergent and discriminant validity, and state versus trait properties were also assessed.

RESULTS

The SCI had excellent internal consistency (Cronbach's α 0.970). The SCI total score at discharge predicted short-term SB with 64% sensitivity 88% specificity (OR = 13, P = .003) at its optimal cut score. In a test of its incremental predictive validity, SCI total score at discharge improved prediction of SB over traditional risk factors (Chi-squared 5.597, P = .024, model P = .001), with AOR 2.02 (P = .030). The SCI admission versus discharge test-retest reliability and score distributions showed it to be an acute state measure.

CONCLUSION

The SCI was predictive of future SB in high-risk psychiatric inpatients during the crucial weeks following their hospital discharge. Further validation in diverse patient populations is needed.

A simple attention test in the acute phase of a major depressive episode is predictive of later functional remission

BACKGROUND

Functional recovery after a major depressive episode (MDE) requires both clinical remission and preservation of cognitive skills. As attentional deficit may persist after remission, leading to functional impairment, its role as a prognosis marker needs to be considered.

METHODS

Five hundred eight depressed outpatients (DSM-IV) were assessed at baseline for clinical symptoms (QIDS-SR), social functioning (Sheehan Disability Scale, SDS) and attention through the d2 test of attention and the trail making test, simple tests, respectively, requiring to quote or to interconnect relevant items. All patients were treated by agomelatine, and examined 6 to 8 weeks after baseline to assess clinical remission (QIDS-SR ≤ 5) and/or functional remission (SDS ≤ 6).

RESULTS

At follow up, 154 patients (31%) were in clinical and functional remission. Shorter cumulative duration of prior depression, shorter present MDE, and two parameters of the d2 test of attention were predictive of such positive outcome, the number of omission mistakes (F1) being the only one still significantly predictive (P < .05) with a multivariate approach. F1 was unchanged after remission, patients with less than 11 mistakes had a 2.27 times increased chance to reach full remission, and a dose-response relationship was observed, with a regular increase of positive outcome for less mistakes.

CONCLUSIONS

The number of omission mistakes (F1) of the d2 test of attention was a stable marker, being predictive of, and with a dose-effect for, clinical plus functional remission. It may constitute a specific marker of attentional deficit, involved in the resilience process that enables individuals to develop more adequate strategies to cope with everyday functional activities.

Background Stress Inventory: Developing a Measure of Understudied Stress

Background stress is an understudied source of stress that involves both ambient stress and daily hassles upon which new stressors are superimposed. To date, an accurate measure of the background stress construct has not been available. We developed the Background Stress Inventory, a 25-item self-report measure that asks respondents to indicate how distressed they have felt over the past month and the majority of the past year across five domains: financial, occupation, environment, health and social. Seven hundred seventy-two participants completed the paper-and-pencil measure; the sample was randomly split into two separate subsamples for analyses. Exploratory factor analysis suggested five factors corresponding to these domains, and confirmatory factor analysis showed acceptable global fit (X(2)(255) = 456.47, comparative fit index = 0.94, root mean square error of approximation = 0.045). Cronbach's alpha (0.89) indicated good internal reliability. Construct validity analyses showed significant positive relationships with measures of perceived stressfulness (r = 0.62) and daily hassles (0.41), p's < 0.01. Depressive symptoms (0.62) and basal blood pressure (0.21) were both significantly associated with background stress, p's < 0.01. The importance of the proposed measure is reflected in the limited research base on the impact of background stress. Systematic investigation of this measure will provide insight into this understudied form of chronic stress and its potential influence on both psychological and physical endpoints.

APPROXIMATING A DSM-5 DIAGNOSIS OF PTSD USING DSM-IV CRITERIA

BACKGROUND

Diagnostic criteria for DSM-5 posttraumatic stress disorder (PTSD) are in many ways similar to DSM-IV criteria, raising the possibility that it might be possible to closely approximate DSM-5 diagnoses using DSM-IV symptoms. If so, the resulting transformation rules could be used to pool research data based on the two criteria sets.

METHODS

The pre-post deployment study (PPDS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) administered a blended 30-day DSM-IV and DSM-5 PTSD symptom assessment based on the civilian PTSD Checklist for DSM-IV (PCL-C) and the PTSD Checklist for DSM-5 (PCL-5). This assessment was completed by 9,193 soldiers from three US Army Brigade Combat Teams approximately 3 months after returning from Afghanistan. PCL-C items were used to operationalize conservative and broad approximations of DSM-5 PTSD diagnoses. The operating characteristics of these approximations were examined compared to diagnoses based on actual DSM-5 criteria.

RESULTS

The estimated 30-day prevalence of DSM-5 PTSD based on conservative (4.3%) and broad (4.7%) approximations of DSM-5 criteria using DSM-IV symptom assessments were similar to estimates based on actual DSM-5 criteria (4.6%). Both approximations had excellent sensitivity (92.6-95.5%), specificity (99.6-99.9%), total classification accuracy (99.4-99.6%), and area under the receiver operating characteristic curve (0.96-0.98).

CONCLUSIONS

DSM-IV symptoms can be used to approximate DSM-5 diagnoses of PTSD among recently deployed soldiers, making it possible to recode symptom-level data from earlier DSM-IV studies to draw inferences about DSM-5 PTSD. However, replication is needed in broader trauma-exposed samples to evaluate the external validity of this finding.

THE VALIDITY OF THE MOOD DISORDER QUESTIONNAIRE FOR SCREENING BIPOLAR DISORDER: A META-ANALYSIS

We conducted a meta-analysis to review the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) among patients with mood disorders. We used a bivariate random effects model to calculate summary sensitivity and specificity. Twenty-one studies were included. At the standard or modified cutoff value of 7, summary sensitivity was .62 and summary specificity was .85. When we pooled 11 studies including both patients with bipolar disorder (BD) and those with unipolar depression, the summary sensitivity was .76 and summary specificity was .81. However, among the six studies that excluded patients with known BD, the summary sensitivity was significantly reduced to .37 and summary specificity was .88. There were no significant differences on the diagnostic accuracy of the MDQ between studies from Eastern and Western countries after adjusting for various clinical correlates. The overall diagnostic accuracy of the MDQ was relatively good. However, when the MDQ is applied among patients with depression without previous diagnoses of BD, its sensitivity was significantly reduced. This suggests that when the MDQ is applied among this population, its optimal cutoff value should be adjusted to enhance its sensitivity.

Anxious forms of depression

Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of "mixed anxiety depression disorder" (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD-11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.

Experiencing core symptoms of anxiety and unipolar mood disorders in late adolescence predicts disorder onset in early adulthood

BACKGROUND

Identification of youth at risk for anxiety and unipolar mood disorders (UMDs) can improve public health by targeting those who may warrant early or preventive intervention. This study examined whether endorsing core features of anxiety and UMDs predicted onset of later anxiety and UMDs across the next 7-9 years, and whether having subthreshold or subclinical manifestations of these disorders similarly predicted onset.

METHODS

Data from this study come from the Youth Emotion Project (YEP), a two-site investigation of common and specific risk factors for emotional disorders. Endorsement of core features of a disorder and subclinical or subthreshold anxiety and UMD diagnoses were determined using data from the Structured Clinical Interview for DSM-IV (SCID) at the baseline assessment. Participants completed annual SCIDs over the course of the next 7-9 years (depending on cohort).

RESULTS

Endorsement of panic attacks, obsessions and/or compulsions, and depression and/or anhedonia predicted onset of panic disorder, obsessive compulsive disorder, and major depressive disorder, respectively. When including all anxiety disorders in a model, only the presence of panic attacks uniquely predicted anxiety disorder onset. The presence of subclinical or subthreshold panic disorder, obsessive compulsive disorder, and social phobia at baseline predicted the full onset of these disorders over the follow-up period.

CONCLUSIONS

Experiencing some symptoms of anxiety and UMDs in the absence of meeting diagnostic criteria is indicative of risk for later onsets of clinically significant DSM manifestations of these disorders. These individuals should be identified and targeted for prevention programs.

Decreased brainstem and putamen SERT binding potential in depressed suicide attempters using [11C]-zient PET imaging

BACKGROUND

Deficits in serotonergic neurotransmission have been implicated in the pathogenesis of depression and suicidality. The present study utilized a novel positron-emission tomography (PET) ligand to quantitate and compare brain regional serotonin transporter (SERT) binding potential in depressed patients with a past history of suicide attempts to that of healthy comparison subjects.

METHOD

We used [(11) C]-ZIENT PET to label SERT in the serotonergic cell body rich brainstem, and forebrain projection fields. Quantitative PET emission data from 21 adults (10 healthy controls and 11 drug-free patients with major depression) was used for group comparison. SERT binding potential (BPND ) in eight MRI-based brain regions of interest (ROI) were compared in high-resolution PET images.

RESULTS

SERT binding potential was significantly decreased in the midbrain/pons (P = .029) and putamen (P = .04) of depressed patients with a past suicide attempt relative to comparison subjects. Forebrain SERT binding was also reduced in the patient sample, though these region effects did not survive a multiple comparison correction.

CONCLUSION

These results suggest that decreased availability of the brainstem and basal ganglia SERT represents a biomarker of depression and thus confirm and extend the role of dysregulation of brain serotonergic neurotransmission in the pathophysiology of depression and suicide.

Excellent reliability of the Hamilton Depression Rating Scale (HDRS-21) in Indonesia after training

INTRODUCTION

The Hamilton Depression Rating Scale (HDRS) is the most widely used depression rating scale worldwide. Reliability of HDRS has been reported mainly from Western countries. The current study tested the reliability of HDRS ratings among psychiatric residents in Indonesia, before and after HDRS training. The hypotheses were that: (i) prior to the training reliability of HDRS ratings is poor; and (ii) HDRS training can improve reliability of HDRS ratings to excellent levels. Furthermore, we explored cultural validity at item level.

METHODS

Videotaped HDRS interviews were rated by 30 psychiatric residents before and after 1 day of HDRS training. Based on a gold standard rating, percentage correct ratings and deviation from the standard were calculated.

RESULTS

Correct ratings increased from 83% to 99% at item level and from 70% to 100% for the total rating. The average deviation from the gold standard rating improved from 0.07 to 0.02 at item level and from 2.97 to 0.46 for the total rating.

DISCUSSION

HDRS assessment by psychiatric trainees in Indonesia without prior training is unreliable. A short, evidence-based HDRS training improves reliability to near perfect levels. The outlined training program could serve as a template for HDRS trainings. HDRS items that may be less valid for assessment of depression severity in Indonesia are discussed.

Intolerance of uncertainty as a mediator of the relationship between perfectionism and obsessive-compulsive symptom severity

BACKGROUND

Intolerance of uncertainty (IU) and perfectionism have both been shown to predict severity of obsessive-compulsive disorder (OCD) symptoms in populations diagnosed with OCD, as well as analogue samples. According to cognitive models of OCD, symptoms are maintained by dysfunctional beliefs including IU and perfectionism. The purpose of the current study is to extend research on the cognitive theory of OCD by describing how dysfunctional thoughts interact with each other.

METHODS

In an analogue sample for OCD (N = 475), undergraduate students completed measures online pertaining to IU (IU scale), perfectionism (Frost Multidimensional Perfectionism Scale), and OCD symptoms and severity (Florida Obsessive-Compulsive Inventory).

RESULTS

The proposed model of IU fully mediating the relationship between perfectionism and OCD severity was supported using structural equation modeling (SEM) analysis. Bootstrapping testing within AMOS 20 and Sobel tests further corroborated full mediation.

CONCLUSIONS

Results from the current study suggest that IU fully mediates the relationship between perfectionism and severity of OCD symptoms. This finding has an impact for understanding the nature and treatment of OCD with perfectionism as a primary symptom. Findings suggest that in order to address perfectionism, it is necessary to first treat cognitions and obsessions associated with IU and that this practice would lessen distress and interference associated with perfectionistic obsessions.

Irritable mood in adult major depressive disorder: results from the world mental health surveys

BACKGROUND

Although irritability is a core symptom of DSM-IV major depressive disorder (MDD) for youth but not adults, clinical studies find comparable rates of irritability between nonbipolar depressed adults and youth. Including irritability as a core symptom of adult MDD would allow detection of depression-equivalent syndromes with primary irritability hypothesized to be more common among males than females. We carried out a preliminary examination of this issue using cross-national community-based survey data from 21 countries in the World Mental Health (WMH) Surveys (n = 110,729).

METHODS

The assessment of MDD in the WHO Composite International Diagnostic Interview includes one question about persistent irritability. We examined two expansions of the definition of MDD involving this question: (1) cases with dysphoria and/or anhedonia and exactly four of nine Criterion A symptoms plus irritability; and (2) cases with two or more weeks of irritability plus four or more other Criterion A MDD symptoms in the absence of dysphoria or anhedonia.

RESULTS

Adding irritability as a tenth Criterion A symptom increased lifetime prevalence by 0.4% (from 11.2 to 11.6%). Adding episodes of persistent irritability increased prevalence by an additional 0.2%. Proportional prevalence increases were significantly higher, but nonetheless small, among males compared to females. Rates of severe role impairment were significantly lower among respondents with this irritable depression who did not meet conventional DSM-IV criteria than those with DSM-IV MDD.

CONCLUSION

Although limited by the superficial assessment in this single question on irritability, results do not support expanding adult MDD criteria to include irritable mood.