The Modified Hamilton Rating Scale for Depression: reliability and validity

Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial

Treatment goals and preferences of depressed patients are important, but they are rarely empirically studied. Although clinicians are likely to discuss goals with individual patients, research that clarifies overall patterns in the treatment goals of depressed patients could be useful in informing new interventions for depression. Such research could also potentially help address problems such as poor adherence and psychotherapy drop-out. In this preliminary qualitative investigation, we examined treatment goals established by depressed outpatients in the context of a trial of behaviorally oriented psychotherapy. The treatment goals that were most commonly articulated included improving social and family relationships, increasing physical health behaviors, finding a job, and organizing one's home. These results underscore the fact that, in addition to improvement in the symptoms of depression, functional improvements are viewed as key treatment goals by depressed individuals.

Pancreatic cancer and depression: myth and truth

BACKGROUND

Various studies reported remarkable high incidence rates of depression in cancer patients compared with the general population. Pancreatic cancer is still one of the malignancies with the worst prognosis and therefore it seems quite logical that it is one of the malignancies with the highest incidence rates of major depression.However, what about the scientific background of this relationship? Is depression in patients suffering from pancreatic cancer just due to the confrontation with a life threatening disease and its somatic symptoms or is depression in this particular group of patients a feature of pancreatic cancer per se?

DISCUSSION

Several studies provide evidence of depression to precede the diagnosis of pancreatic cancer and some studies even blame it for its detrimental influence on survival. The immense impact of emotional distress on quality of life of cancer patients enhances the need for its early diagnosis and adequate treatment. Knowledge about underlying pathophysiological mechanisms is required to provide the optimal therapy.

SUMMARY

A review of the literature on this issue should reveal which are the facts and what is myth.

Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures

OBJECTIVE

There have been few treatment trials for psychogenic nonepileptic seizures (PNES). Some psychotherapies have been shown to improve PNES and comorbid symptom outcomes. We evaluated a pharmacologic intervention to test the hypothesis that sertraline would reduce PNES.

METHODS

We conducted a pilot, double-blind, randomized, placebo-controlled trial in an academic medical hospital with epilepsy center outpatients. Subjects aged 18 to 65 years diagnosed with video-EEG-confirmed PNES were treated with flexible-dose sertraline or placebo over 12 weeks. Seizure calendars and symptom scales were charted prospectively. Secondary outcome measures included psychiatric symptom scales and psychosocial variables.

RESULTS

Thirty-eight subjects enrolled, and 26 (68%) completed the trial. Thirty-three subjects with nonzero nonepileptic seizure rates at baseline were included in intent-to-treat analysis of the primary outcome. Subjects assigned to the sertraline arm experienced a 45% reduction in seizure rates from baseline to final visit (p = 0.03) vs an 8% increase in placebo (p = 0.78). Secondary outcome scales revealed no significant between-group differences in change scores from baseline to final visit, after adjustment for differences at baseline.

CONCLUSIONS

PNES were reduced in patients treated with a serotonin selective reuptake inhibitor, whereas those treated with placebo slightly increased. This study provides feasibility data for a larger-scale study.

LEVEL OF EVIDENCE

This study provides Class II evidence that flexible-dose sertraline up to a maximum dose of 200 mg is associated with a nonsignificant reduction in PNES rate compared with a placebo control arm (risk ratio 0.51, 95% confidence interval 0.25-1.05, p = 0.29), adjusting for differences at baseline.

Physician introduction to opioids for pain among patients with opioid dependence and depressive symptoms

This study determined the frequency of reporting being introduced to opioids by a physician among opioid-dependent patients. Cross-sectional analyses were performed using baseline data from a cohort of opioid addicts seeking treatment with buprenorphine. The primary outcome was a response to the question: "Who introduced you to opiates?" Covariates included sociodemographics, depression, pain, and current and prior substance use. Of 140 participants, 29% reported that they had been introduced to opioids by a physician. Of those who were introduced to opioids by a physician, all indicated that they had initially used opioids for pain, versus only 11% of those who did not report being introduced to opioids by a physician (p < .01). There was no difference in current pain (78% vs. 85%, p = .29); however, participants who were introduced to opioids by a physician were more likely to have chronic pain (63% vs. 43%, p = .04). A substantial proportion of individuals with opioid dependence seeking treatment may have been introduced to opioids by a physician.

Disability in late-life major depression: patterns of self-reported task abilities, task habits, and observed task performance

This article describes patterns of concordance/discordance between self-reported abilities ("can do") and habits ("does do") and observed task performance of daily living tasks in three groups of older adults: late life depression with mild cognitive impairment (n=53), late life depression without mild cognitive impairment (n=64), and non-depressed, cognitively normal controls (n=31). Self-reported data were gathered by interview in participants' homes, followed by observation of task performance. Significant differences in the patterns of response were found between controls and respondents with both late life depression and mild cognitive impairment for the cognitive instrumental activities, and between the two depressed groups and controls for the physical instrumental activities. For both sets of activities, controls exhibited the greatest overestimation of task performance. No differences were found among the groups for the less complex functional mobility and personal care tasks. However, for the more complex instrumental activities, concordance was close to, or less than, chance. The findings led us to conclude that when performance testing is not feasible, self-reports of functional status that focus on habits may be more accurate than those that focus on abilities.

Antidepressant treatment does not improve buprenorphine retention among opioid-dependent persons

Our goal was to determine whether treatment of depressive symptoms with escitalopram during buprenorphine treatment for opioid dependence would improve treatment retention compared to placebo in a 12-week, randomized, double-blind trial. Treatment dropout was defined as missing seven consecutive buprenorphine dosing days. Participants were 76% male, 80% non-Hispanic Caucasian, and 64% heroin users. At baseline, the mean Beck Depression Inventory II (BDI-II) score was 28.4 (+/-9.7). Sixty-one percent of participants completed the 12-week buprenorphine protocol. Dropout rates were 33.3% and 44.0% among those randomized to escitalopram or placebo, respectively (p = .19). Relative to baseline, mean BDI-II scores were significantly lower at all follow-up assessments, but the Treatment x Time interaction effect was not statistically significant (p = .18). Participants randomized to escitalopram also did not have a significantly lower likelihood of testing positive for either opiates or other drugs during follow-up. Depressive symptoms often resolved with buprenorphine treatment, and the immediate initiation of escitalopram does not improve treatment retention, depression outcomes, or illicit drug use. Clinicians should determine the need for antidepressant treatment later in buprenorphine care.

Pushing and coasting in dynamic goal pursuit: coasting is attenuated in bipolar disorder

In an experience-sampling study, we tested the influence of goal progress on subsequent effort toward that goal among persons with bipolar disorder (BD) and among control subjects without BD. We hypothesized, overall, that unexpectedly low progress toward a goal would lead to an increase in subsequent effort toward that goal, and unexpectedly high progress would lead to a decrease in effort (permitting effort to be shifted to another goal). Drawing on literature relating BD to elevated goal-approach sensitivity, we hypothesized that persons with BD would be less responsive to unexpectedly high progress than would control subjects. Participants answered questions three times a day, for 21 days, about three goals. The results of the study confirmed our overall hypothesis. In addition, although the reactions of persons with BD did not differ from the reactions of control subjects after lower-than-expected goal progress, persons with BD decreased effort toward goals significantly less than did control subjects after better-than-expected goal progress.

Prognostic value of cognitive functioning for global functional recovery in first-episode schizophrenia

BACKGROUND

It has become widely accepted that cognitive deficits in schizophrenia are related to functional outcome. However, it remains to be seen whether these associations are relevant for predicting which cases will have a global functional recovery. In this study, we attempt to determine whether global functional recovery (integrating social and occupational outcomes) after first-episode schizophrenia (FES) can be predicted by cognitive variables.

METHOD

A total of 131 FES patients with functional deficits (n=97) and functional recovery (n=34) as determined at 1-year follow-up were examined. Neuropsychological, sociodemographic, pre-morbid and clinical data at baseline were analysed using independent groups comparisons and a logistic regression method.

RESULTS

Sustained attention and negative symptoms emerged as significant predictors of good global functional outcome. Although the model revealed a high accuracy (91%) in the classification of patients with functional deficits, it was unacceptably low (26%) in the classification of patients with global functional recovery.

CONCLUSIONS

The limitations found in the prediction of a favourable global functional outcome may well be an indication for a need to address the role of other factors not commonly included in longitudinal studies of long-term outcomes in schizophrenia.

The impact of panic-agoraphobic comorbidity on suicidality in hospitalized patients with major depression

BACKGROUND

Previous research in outpatient samples suggests that panic and agoraphobic comorbidity is related to suicidality in outpatients with major depression. The purpose of the study was to further investigate this relationship specifically in a hospitalized sample.

METHOD

This study examined the severity of current suicidal ideation and behaviors in a psychiatric hospital sample diagnosed with major depressive disorder alone (MDD; n=28) versus MDD plus panic-agoraphobic spectrum disorders (MDD+PAS; n=69).

RESULTS

Members of the MDD+PAS group were significantly more likely to have had a suicide attempt history, higher current depression severity, and higher current suicidal severity compared with individuals in the MDD alone group. The relationship between the current suicidality and comorbid PAS remained significant after controlling for the overall depression severity and other clinical factors.

CONCLUSIONS

These findings suggest that panic-agoraphobic comorbidity is associated with a greater risk for suicidality in hospitalized patients, which cannot be adequately explained by the level of current depression alone. The clinical and research implications for these findings are discussed.

Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: short-term outcome

AIMS

Alcohol use disorders and depression co-occur frequently and are associated with poorer outcomes than when either condition occurs alone. The present study (Depression and Alcohol Integrated and Single-focused Interventions; DAISI) aimed to compare the effectiveness of brief intervention, single-focused and integrated psychological interventions for treatment of coexisting depression and alcohol use problems.

METHODS

Participants (n = 284) with current depressive symptoms and hazardous alcohol use were assessed and randomly allocated to one of four individually delivered interventions: (i) a brief intervention only (single 90-minute session) with an integrated focus on depression and alcohol, or followed by a further nine 1-hour sessions with (ii) an alcohol focus; (iii) a depression focus; or (iv) an integrated focus. Follow-up assessments occurred 18 weeks after baseline.

RESULTS

Compared with the brief intervention, 10 sessions were associated with greater reductions in average drinks per week, average drinking days per week and maximum consumption on 1 day. No difference in duration of treatment was found for depression outcomes. Compared with single-focused interventions, integrated treatment was associated with a greater reduction in drinking days and level of depression. For men, the alcohol-focused rather than depression-focused intervention was associated with a greater reduction in average drinks per day and drinks per week and an increased level of general functioning. Women showed greater improvements on each of these variables when they received depression-focused rather than alcohol-focused treatment.

CONCLUSIONS

Integrated treatment may be superior to single-focused treatment for coexisting depression and alcohol problems, at least in the short term. Gender differences between single-focused depression and alcohol treatments warrant further study.

Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder

OBJECTIVE

The aim of the current study was to evaluate family functioning, social support, and functional impairment as predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder. This study builds upon the extant literature by evaluating these putative psychosocial risk factors simultaneously to determine whether they account for unique variance in clinical outcomes.

METHOD

Patients (N = 92) were recruited from hospital settings during an acute mood episode to participate in pharmacologic or combined family and pharmacologic interventions. The Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, Family Assessment Device, Interpersonal Support Evaluation List, and UCLA Social Attainment Survey were administered at acute phase treatment completion and again at 1-year follow-up. Controlling for mood symptom severity at acute phase treatment completion, multiple regression analyses were used to examine longitudinal associations between the psychosocial variables and subsequent depressive and manic symptoms.

RESULTS

None of the aforementioned psychosocial variables predicted manic symptomatology, and social support alone emerged as a unique predictor of depression at the 1-year follow-up. Effects of social support were moderated by recovery status, such that the strength of association between social support and subsequent depression was stronger for those who had not fully recovered during the acute phase of treatment than for those who had.

CONCLUSIONS

Low levels of social support at acute phase treatment completion, especially in concert with residual symptomatology, may place individuals with bipolar I disorder at risk for subsequent depressive symptoms. These data suggest that maintenance therapies focused on improving level of social support might be especially important to consider in the management of bipolar depression, and add to a growing literature focused on unique vs shared effects of psychosocial risk factors for poor illness course in bipolar disorder.

Affective reactivity in response to criticism in remitted bipolar disorder: a laboratory analog of Expressed Emotion

Potential mechanisms to explain the relationship between Expressed Emotion (EE) and poor outcome within bipolar disorder are poorly understood. One possibility is that people with bipolar disorder have difficulty regulating their affect in response to criticism. The present study examined whether participants with bipolar disorder were more affectively dysregulated than control participants when presented with a criticism by a confederate. There was a trend for people with bipolar disorder to react more negatively to the criticism, but there was also evidence that they recovered as quickly as controls. Exploratory analyses found that female gender, the perception of the criticism as more negative, being disabled, and having fewer positive relationships predicted greater reactivity to criticism among people with bipolar disorder.

The role of depression, shame-proneness, and guilt-proneness in predicting criticism of relatives towards people with bipolar disorder

Expressed emotion (EE) has been associated with poor patient outcomes in many different psychiatric disorders. Given its robust association with relapse, EE has become a major target of family psychoeducational interventions. Most psychoeducational interventions to date have failed to change EE levels among families of those with bipolar disorder. Better intervention strategies, then, may depend on an increased understanding of the predictors of EE. Although EE has traditionally included many facets, criticism appears to be the most robust predictor of outcome within bipolar disorder. The present study tested three primary predictors of criticism among family members of people with bipolar disorder: shame-proneness, guilt-proneness, and depression. Depressive symptoms were significantly associated with EE. Discussion focuses on limitations and implications of the study and suggestions for future research.

Family functioning and depression in low-income Latino couples

Although extensive research has found a strong relationship between poor family functioning and depression, previous research has not examined this relationship among low-income Latinos. In this study, we examined how family functioning may be associated with depression in a sample of low-income Latino couples. In addition, we examined how acculturative stress moderates the relationship between family functioning and depression. Our results indicate that the relationship between family functioning and depression is stronger in women and that acculturative stress moderates this relationship in women. Probing this interaction indicates that women who reported high acculturative stress coupled with poor family functioning experienced more depression. Clinical implications are discussed.

Cognitive/Behavioural Therapy and Pharmacotherapy with Chronic, Drug-Refractory Depressed Inpatients: A Note of Optimism

Several previous studies have reported that cognitive/behavioural treatments have been relatively ineffective for chronic, drug-resistant depressed patients. In the present report, six chronic, drug-resistant depressed patients were treated with an integrated program consisting of cognitive/behavioural treatment, pharmacotherapy, and short term hospitalization. The obtained improvement rates were substantially better than previous studies. Potential explanations for these findings are discussed.

Preventing mania: a preliminary examination of the GOALS Program

There is strong evidence of a relationship between goal dysregulation and mania. Building on these findings, we examined the feasibility of developing a mania prevention treatment program designed to improve goal regulation skills for those with bipolar disorder. Here, we describe the process of developing a manual, delivering the intervention to a series of cases, and then conducting a small open uncontrolled trial. All participants met diagnostic criteria for bipolar I disorder based on the Structured Clinical Interview for DSM-IV and were not currently experiencing episodes of depression or mania. Ten participants (8 female, mean age = 46.7 years) were enrolled in the GOALS program and completed an average of 13.2 weekly sessions. Participants were administered the Bech-Rafaelson Mania Scale (BRMS) and the Modified Hamilton Rating Scale for Depression at baseline and termination. Some participants completed self-report scales including the Altman Self-Rating Mania Scale, the Beck Depression Inventory, and the Willingly Approached Set of Statistically Unrealistic Pursuits at baseline and termination. In addition, participants were administered a consumer satisfaction questionnaire at termination. At termination, all 10 participants found the program highly relevant and helpful. Most importantly, even though levels of mania were low initially, mean levels of manic symptoms on the BRMS decreased significantly from baseline to termination, and all 10 participants were within a healthy range (BRMS <7) at termination. Although the lack of control group or follow-up data limits this study, preliminary evidence suggests that it is feasible to identify treatment targets by drawing from the basic research literature in bipolar disorder. Findings await replication and more careful testing within a randomized controlled trial.

Does the dexamethasone suppression test reliably discriminate between psychotic and nonpsychotic major depression?: an exploratory analysis of potential confounds

Previous research has shown that psychotic major depression (PMD) is often associated with higher rates of nonsuppression on the dexamethasone suppression test (DST) compared with nonpsychotic major depression (NMD), suggesting the potential importance of cortisol hypersecretion in the psychotic subtype of the disorder. However, these patient groups also are known to differ from one another on a variety of other clinical variables, and there are numerous factors independent of diagnostic status known to affect the DST. Thus, we investigated possible confounds that could help account for the apparent DST abnormalities in PMD sometimes reported in past research. Hospitalized patients with PMD (n = 11) and NMD (n = 58) were compared on the DST and other clinical variables. As expected, PMD patients showed significantly higher rates of DST nonsuppression (55% vs. 24%; p = 0.04). However, PMD patients also had significantly higher levels of anxiety severity (p = 0.01). The higher rates of nonsuppression in the PMD group were attenuated when these patients were compared with a subsample of NMD patients matched on anxiety severity (55% vs. 55%). Implications for future research on biological markers of PMD are discussed.

The impact of experiential avoidance on the reduction of depression in treatment for borderline personality disorder

BACKGROUND

Reducing symptoms of depression is an important target in the treatment of borderline personality disorder (BPD). Although current treatments for BPD are effective in reducing depression, the average post-treatment level of depression remains high.

AIM

To test whether experiential avoidance (EA) impedes the reduction of depression during treatment for BPD.

METHOD

EA and depression were assessed in 81 clients at baseline and 4-month intervals during 1 year of therapy. Simple correlations, hierarchical linear modeling, and latent difference score models were used to investigate the association between self-reports of EA and both self-reports and observer-based ratings of depression.

RESULTS

EA was positively associated with greater severity of depression at all points of assessment, and changes in EA were positively associated with changes in depression. Moreover, EA significantly predicted less subsequent reduction in depression whereas no such effect was found for depression on subsequent EA.

CONCLUSION

The findings are consistent with the hypothesis that EA impedes the reduction of depression in the treatment of BPD and should thus be considered an important treatment target.

A prospective pilot study of levetiracetam for body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted.

OBJECTIVE

This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD.

METHODS

Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures.

RESULTS

In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated.

CONCLUSION

Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.

Substance use disorders in an obsessive compulsive disorder clinical sample

The prevalence and clinical correlates of substance use disorders (SUDs) were examined in a clinical sample of Obsessive Compulsive Disorder (OCD). As part of their intake interview into an observational study of the course of OCD, 323 participants completed a battery of standardized measures. Twenty-seven percent of the sample met lifetime criteria for a SUD. 70% of participants with comorbid SUDs reported that OCD preceded SUD onset by at least one year. Younger age at OCD onset and presence of Borderline Personality Disorder (BPD) were each associated with increased risk of alcohol use disorders but only BPD was associated with increased risk of drug use disorders. SUDs affect more than one-quarter of individuals who seek treatment for OCD. Individuals with a juvenile-onset of OCD or comorbid BPD may be especially vulnerable to SUDs. Further research is needed to identify risk factors for SUDs and to better understand their impact on OCD course.

Cognitive behavioral therapy for psychogenic nonepileptic seizures

Treatment trials for psychogenic nonepileptic seizures (PNES) are few, despite the high prevalence and disabling nature of the disorder. We evaluated the effect of cognitive behavioral therapy (CBT) on reduction of PNES. Secondary measures included psychiatric symptom scales and psychosocial variables. We conducted a prospective clinical trial assessing the frequency of PNES in outpatients treated using a CBT for PNES manual. Subjects diagnosed with video/EEG-confirmed PNES were treated with CBT for PNES conducted in 12 weekly sessions. Seizure calendars were charted prospectively. Twenty-one subjects enrolled, and 17 (81%) completed the CBT intervention. Eleven of the 17 completers reported no seizures by their final CBT session. Mean scores on scales of depression, anxiety, somatic symptoms, quality of life, and psychosocial functioning showed improvement from baseline to final session. CBT for PNES reduced the number of PNES and improved psychiatric symptoms, psychosocial functioning, and quality of life.

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

BACKGROUND

A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts.

METHODS

Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes.

RESULTS

Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset.

CONCLUSIONS

The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population.

Suicidality in a placebo-controlled fluoxetine study of body dysmorphic disorder

Serotonin reuptake inhibitors are considered the first-line medication for body dysmorphic disorder (BDD). The relationship between serotonin reuptake inhibitor treatment and suicidality in BDD has been only minimally studied, despite high suicidality rates in BDD. Sixty-seven adults with the Diagnostic and Statistical Manual of Mental Disorders edition IV BDD participated in a 12-week randomized double-blind placebo-controlled study of fluoxetine. Suicidality was assessed with the Hamilton Rating Scale for Depression suicidal ideation item. Analyses examined group differences in worsening and emergence of suicidality, using standard definitions. Among the entire sample, when comparing study baseline with end of week 2 and study endpoint, no patient on fluoxetine had suicidality worsening; a higher proportion of placebo-treated patients had suicidality worsening after 2 weeks of treatment (P=0.014) and at study endpoint (P=0.010). Among patients aged 18-24 years, one patient on placebo had suicidality worsening at the end of week 2, and none in either treatment group had suicidality worsening at study endpoint. With regard to emergence of suicidality at any point during the study, the treatment groups did not significantly differ. Neither suicide attempts nor completed suicides occurred. In summary, fluoxetine and placebo did not significantly differ with regard to emergence of suicidality. Among the entire sample, fluoxetine appeared to exert a protective effect against suicidality worsening.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Decision-making and risk aversion among depressive adults

Depression is associated with behavioral avoidance of potentially rewarding environmental contexts. The present study examined the performance of depressive individuals and controls on a neuropsychological measure of decision-making that favors risk avoidance. Depressive (n=41) and control (n=44) participants were administered the Iowa Gambling Task, which measures the ability of participants to maximize earnings by choosing low-risk, low-reward responses over high-risk, high-reward responses. Results provided partial support for the hypothesis that depressive participants would learn to avoid risky responses faster than control participants. Depressive participants demonstrated better performance than controls, scoring higher than controls overall and showing a trend toward earning more money overall. However, the lack of an interaction between depressive status and time does not support the specific hypothesis of more rapid learning. Findings suggested enhanced feedback-based decision-making and risk aversion among depressive individuals.

Preventing recurrence of bipolar I mood episodes and hospitalizations: family psychotherapy plus pharmacotherapy versus pharmacotherapy alone

OBJECTIVES

This study compared the efficacy of three treatment conditions in preventing recurrence of bipolar I mood episodes and hospitalization for such episodes: individual family therapy plus pharmacotherapy, multifamily group therapy plus pharmacotherapy, and pharmacotherapy alone.

METHODS

Patients with bipolar I disorder were enrolled if they met criteria for an active mood episode and were living with or in regular contact with relatives or significant others. Subjects were randomly assigned to individual family therapy plus pharmacotherapy, multifamily group therapy plus pharmacotherapy, or pharmacotherapy alone, which were provided on an outpatient basis. Individual family therapy involved one therapist meeting with a single patient and the patient's family members, with the content of each session and number of sessions determined by the therapist and family. Multifamily group psychotherapy involved two therapists meeting together for six sessions with multiple patients and their respective family members, with the content of each session preset. All subjects were prescribed a mood stabilizer, and other medications were used as needed. Subjects were assessed monthly for up to 28 months. Following recovery from the index mood episode, subjects were assessed for recurrence of a mood episode and for hospitalization for such episodes.

RESULTS

Of a total of 92 subjects that were enrolled in the study, 53 (58%) recovered from their intake mood episode. The analyses in this report focus upon these 53 subjects, 42 (79%) of whom entered the study during an episode of mania. Of the 53 subjects who recovered from their intake mood episode, the proportion of subjects within each treatment group who suffered a recurrence by month 28 did not differ significantly between the three treatment conditions. However, only 5% of the subjects receiving adjunctive multifamily group therapy required hospitalization, compared to 31% of the subjects receiving adjunctive individual family therapy and 38% of those receiving pharmacotherapy alone, a significant difference. Time to recurrence and time to hospitalization did not differ significantly between the three treatment groups.

CONCLUSION

For patients with bipolar I disorder, adjunctive multifamily group therapy may confer significant advantages in preventing hospitalization for a mood episode.

Occupational functioning and impairment in adults with body dysmorphic disorder

OBJECTIVE

Body dysmorphic disorder (BDD) is relatively common and appears to be associated with marked impairment in psychosocial functioning. Previous reports, however, did not investigate occupational functioning in detail, assess impairment specifically in occupational functioning using standardized measures in a nontreatment seeking sample, or examine correlates of occupational impairment.

METHODS

Occupational functioning and other clinical variables were assessed in 141 adults with BDD. Measures included the Range of Impaired Functioning Tool and other reliable and valid self-report and interviewer-administered measures.

RESULTS

Fewer than half of subjects were working full-time, and 22.7% were receiving disability pay. Thirty-nine percent of the sample reported not working in the past month because of psychopathology. Of those subjects who worked in the past month, 79.7% reported impairment in work functioning because of psychopathology. Adults with BDD who were not working because of psychopathology were comparable to subjects who were working in most demographic variables, delusionality of BDD beliefs, and duration of BDD. However, compared to subjects who worked in the past month, those not currently working because of psychopathology had more severe BDD and more chronic BDD. They also were more likely to be male, had less education, and had more severe depressive symptoms, a higher rate of certain comorbid disorders, poorer current social functioning and quality of life, a higher rate of lifetime suicidality, and were more likely to have been psychiatrically hospitalized.

CONCLUSIONS

A high proportion of individuals with BDD were unable to work because of psychopathology; most who worked reported impairment in occupational functioning. Certain clinical variables, including more severe and chronic BDD, were associated with not working.

The emergence of suicidal ideation during the post-hospital treatment of depressed patients

There is a paucity of research on the emergence of suicidal ideation in recently hospitalized patients undergoing treatment for depression. As part of a larger clinical trial, patients (N = 103) with major depression without suicidal ideation at hospital discharge were followed for up to 6 months while receiving study-related outpatient treatments. Fifty-five percent reported the emergence of suicidal ideation during the outpatient period, with the vast majority (79%) exhibiting this problem within the first 2 months post-discharge. Seventy percent of those reporting severe suicidality prior to hospitalization exhibited a reemergence of suicidal ideation post-discharge. However, 29% without significant suicidality at the index hospitalization later developed suicidal ideation during the outpatient treatment period. A faster time to the emergence of suicidal ideation was predicted by both higher prehospitalization levels of suicidal ideation as well as greater depression severity at hospital discharge. Overall, rates of emergent suicidal ideation found in the current sample of recently hospitalized patients were higher than those reported in previous outpatient samples.

Juvenile-onset OCD: clinical features in children, adolescents and adults

OBJECTIVE

To examine clinical correlates of juvenile-onset OCD across the lifespan.

METHOD

Data collected at the intake interview from 257 consecutive participants with juvenile-onset OCD (20 children, 44 adolescents and 193 adults) in a naturalistic study of the clinical course of OCD were examined. Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures and self-report questionnaires.

RESULTS

Children and adolescents (i.e. juveniles) shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared with adults, juveniles were more likely to be male, recall an earlier age at OCD onset and have different lifetime comorbidity patterns.

CONCLUSION

Juvenile-onset OCD symptom expression is remarkably similar across the lifespan. However, findings also suggest clinically meaningful differences between juveniles and adults. Future work using a prospective design will improve our understanding of course patterns of juvenile-onset OCD.

Prefrontal mechanisms for executive control over emotional distraction are altered in major depression

A dysfunction in the interaction between executive function and mood regulation has been proposed as the pathophysiology of depression. However, few studies have investigated the alteration in brain systems related to executive control over emotional distraction in depression. To address this issue, 19 patients with major depressive disorder (MDD) and 20 healthy controls were scanned using functional magnetic resonance imaging. Participants performed an emotional oddball task in which infrequently presented circle targets required detection while sad and neutral pictures were irrelevant novel distractors. Hemodynamic responses were compared for targets, sad distractors, and for targets that followed sad or neutral distractors (Target-after-Sad and Target-after-Neutral). Patients with MDD revealed attenuated activation overall to targets in executive brain regions. Behaviorally, MDD patients were slower in response to Target-after-Sad than Target-after-Neutra stimuli. Patients also revealed a reversed activation pattern from controls in response to this contrast in the left anterior cingulate, insula, right inferior frontal gyrus (IFG), and bilateral middle frontal gyrus. Those patients who engaged the right IFG more during Target-after-Neutral stimuli responded faster to targets, confirming a role of this region in coping with emotional distraction. The results provide direct evidence of an alteration in the neural systems that interplay cognition with mood in MDD.

Impact of remitted substance use disorders on the future course of bipolar I disorder: findings from a clinical trial

Given the high lifetime prevalence rates of bipolar disorder and comorbid substance use disorders (SUDs), the aim of the study was to examine the effect of a remitted SUD on the future course of bipolar I disorder in patients taking part in a clinical trial. Patients with bipolar I disorder were enrolled in a larger study examining the effects of pharmacotherapy plus family interventions. These patients were recruited during an acute mood episode and their mood symptoms and substance abuse were assessed longitudinally for up to 28 months. Patients with a remitted SUD showed a poorer acute treatment response, a longer time to remission of their acute mood episode, and a greater percentage of time with subthreshold but clinically significant depression and manic symptoms over follow-up compared to those without this comorbidity pattern. Subsequent substance abuse during follow-up could not fully account for the poorer course of illness. As remitted SUDs appear to negatively predict treatment outcome, current findings have implications for both clinical trials of bipolar patients as well as clinical practice.

Development of the treatment attitudes questionnaire in bipolar disorder

Despite the success of pharmacotherapy in the management of bipolar disorder, as many as one-half of those in treatment discontinue their medication over time. Currently, no self-report measure is available that predicts treatment engagement in bipolar disorder. The goal of the current study was to develop a measure of awareness of symptoms and attitudes toward treatment among those with bipolar disorder. Sixty-six participants diagnosed with bipolar I disorder on the SCID completed the Treatment Attitudes Questionnaire (TAQ) and were then followed for up to 2 years to assess symptom levels. Medication data were available for 37 participants. Analyses of the TAQ were conducted to examine reliability, predictors of subscales, and how well scores predicted medication and symptom levels over time. Results indicate that previous episodes of depression, but not episodes of mania, correlated with increased scores on the Insight and the Enjoyment of Mania subscales. Scores on the Nonbiological Attributions subscale predicted lower levels of lithium as well as increased depressive symptoms over time. Although the current study includes limited measurement of treatment engagement and a small sample size, this easily administered scale may help treatment planning for those with bipolar disorder.

Life events as predictors of mania and depression in bipolar I disorder

To date, few prospective studies of life events and bipolar disorder are available, and even fewer have separately examined the role of life events in depression and mania. The goal of this study was to prospectively examine the role of negative and goal-attainment life events as predictors of the course of bipolar disorder. One hundred twenty-five individuals with bipolar I disorder were interviewed monthly for an average of 27 months. Negative and goal-attainment life events were assessed with the Life Events and Difficulties Schedule. Changes in symptoms were evaluated using the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Scale. The clearest results were obtained for goal-attainment life events, which predicted increases in manic symptoms over time. Negative life events predicted increases in depressive symptoms within regression models but were not predictive within multilevel modeling of changes in depressive symptoms. Given different patterns for goal attainment and negative life events, it appears important to consider specific forms of life events in models of bipolar disorder.

Differences in emotional experience and emotion regulation as a function of age and psychiatric condition

In this study, self-reported experiences of negative affectivity and emotional regulation in a sample of older and younger adults with and without psychiatric co-morbidity were evaluated. Study participants were divided into four separate groups (younger nonpsychiatric = YN; younger psychiatric = YP; older non-psychiatric = ON; and older psychiatric = OP). Findings indicated that, as hypothesized, individuals in the OP and YP groups reported more negative affect intensity and reactivity and more maladaptive emotion regulation than individuals in the ON and YN groups. Contrary to hypotheses, when collapsed across psychiatric conditions, older adults did not report significantly less negative affect intensity and reactivity than younger adults. A significant age by psychiatric group interaction effect on negative affect intensity occurred such that individuals in YN and ON groups reported similar levels of negative affect intensity and individuals in the YP group reported more negative affect intensity than individuals in the OP group. The finding that older adults with Axis I and Axis II diagnoses differ in their symptom reports from younger adults with similar diagnoses suggests there may be important assessment and intervention issues related to the interaction of aging and psychopathology. Clinical implications and directions for future studies are discussed.

Anxiety symptom focus in sessions of cognitive therapy for depression

The comorbid patient presents an especially difficult problem to a therapist who is attempting to implement a short-term, focused therapy. The current study investigates the effect of comorbid anxiety on cognitive therapy for depression. Participants were a subset of patients (N=24) assigned to the cognitive therapy arm of a large, randomized, controlled trial of treatment for depression. From intake assessments, patients were classified as having low or high levels of comorbid anxiety. Two videotapes of each patient's therapy sessions were coded. Irrespective of intake anxiety level, more time and effort spent addressing anxiety in session was found to predict less improvement in both depression and anxiety symptoms over the course of treatment.

Family treatment for bipolar disorder: family impairment by treatment interactions

OBJECTIVE

There is a clear need for psychosocial treatments to supplement pharmacotherapy for bipolar disorder. In this study, the efficacy of 2 forms of adjunctive family intervention were compared to pharmacotherapy alone. In addition to evaluating overall differences between treatments, a chief goal was to examine whether family impairment levels moderated the effects of family intervention on outcome.

METHOD

Ninety-two patients diagnosed with bipolar I disorder (according to DSM-III-R) were randomly assigned to receive (1) pharmaco-therapy alone, (2) family therapy + pharmacotherapy, or (3) multi-family psychoeducational group + pharmacotherapy. Treatments and assessments continued for up to 28 months. Primary outcome measures were number of episodes per year and percentage of time symptomatic throughout the entire follow-up period. The study was conducted from September 1992 through March 1999.

RESULTS

No significant main effects were found for treatment condition. Thus, for the total sample, the addition of a family intervention did not improve outcome. However, there were significant treatment condition by family impairment interactions (p < .05). In patients from families with high levels of impairment, the addition of a family intervention (family therapy or psycho-educational group) resulted in a significantly improved course of illness, particularly the number of depressive episodes (p < .01) and proportion of time spent in a depressive episode (p < .01). These effects were relatively large (Cohen d = 0.7-1.0), with patients receiving either family intervention having roughly half the number of depressive episodes and amount of time spent depressed as those receiving pharmaco-therapy alone. In contrast, for patients from low-impairment families, the addition of a family intervention did not improve course of illness.

CONCLUSIONS

Our findings build on previous literature suggesting the importance of treatment matching within the mood disorders and suggest that the utility of adding family interventions for bipolar patients and their families may depend upon the family's level of impairment.

Functional impairment as a predictor of short-term symptom course in bipolar I disorder

OBJECTIVES

Most prior research has focused on functional impairment as a consequence, rather than a predictor, of mood symptoms in bipolar disorder (BD). Yet the majority of this research has been cross-sectional, thus limiting conclusions regarding directionality of effects. Indeed, just as functional impairment may represent an important outcome of BD, it may also serve as a risk factor for future affective symptoms or episodes. Thus, the primary aim of this study was to evaluate functional impairment as a predictor of mood symptoms in BD.

METHODS

Ninety-two patients with bipolar I disorder, recruited from hospital settings, were administered the Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, and UCLA Social Attainment Survey (SAS) at baseline and at four-month follow-up.

RESULTS

Overall, patients evidenced a moderate level of functional impairment at both time points. Whereas baseline functional impairment was not associated with subsequent manic symptoms, baseline functional impairment was significantly predictive of depressive symptom levels at four-month follow-up. When individual SAS subscales were evaluated, impaired romantic relationship functioning and activity involvement were each significantly predictive of subsequent depressive symptoms, whereas baseline peer functioning was not.

CONCLUSIONS

The study results suggest that functional impairment may be predictive of subsequent depressive, but not manic, symptoms over a relatively short-term follow-up period. Future studies that evaluate illness course over longer follow-up periods would be useful to further clarify the potential bidirectional relationship between depression and functional impairment in BD.

Dysthymic disorder and double depression: prediction of 10-year course trajectories and outcomes

We sought to identify baseline predictors of 10-year course trajectories and outcomes in patients with dysthymic disorder and double depression. Eighty-seven outpatients with early-onset (<21 years) dysthymic disorder, with or without superimposed major depression, were assessed five times at 30-month intervals for 10 years. Baseline evaluations included semi-structured diagnostic interviews for Axis I and II psychopathology and childhood adversity. Direct interview and family history data were collected on first-degree relatives. Follow-up assessments included the Longitudinal Follow-up Evaluation and Hamilton Depression Rating Scale. Using mixed effects growth curve models, univariate predictors of depression severity and functional impairment at 10-year outcome included older age, less education, concurrent anxiety disorder, greater familial loading for chronic depression, a history of a poorer maternal relationship in childhood, and a history of childhood sexual abuse. In addition, longer duration of dysthymic disorder also predicted greater impairment 10 years later. Predictors of a poorer trajectory of depressive symptoms over time included ethnicity and personality disorders; predictors of a poorer trajectory of social functioning included familial loading of chronic depression and quality of the childhood maternal relationship. Thus, demographic, clinical, family history, and early adversity variables all contribute to predicting the long-term trajectory and outcome of DD. These variables should be routinely assessed in clinical evaluations and can provide clinicians with valuable prognostic information.

Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy

Although cognitive behavior therapy has been found to be very effective in the treatment of body dysmorphic disorder (BDD), there still remain a number of challenges that clinicians face in the treatment of individuals with BDD. In this article, we discuss issues related to comorbid depression, suicidality, substance use disorders, personality disorders as well as the role of early life experiences, delusional intensity of beliefs, and motivation to change. The aim of this review is to provide a treatment aid to clinicians by offering specific recommendations for improved care based on the available literature as well as our clinical experience.

Assessment of depressive symptom severity among patients with co-occurring bipolar disorder and substance dependence

BACKGROUND

We examined a modified version of the Hamilton Depression Rating Scale (HDRS) among treatment-seeking patients with co-occurring bipolar disorder and substance dependence in order to elucidate key features of depression in this specific population of patients.

METHODS

Patients with current bipolar disorder and substance dependence who were prescribed mood stabilizers (n=105) completed a 27-item version of the HDRS that was subjected to item and principal components analyses. Preliminary validity analysis consisted of comparing the derived total and component scores to the depressed mood indicators from the Addiction Severity Index (ASI).

RESULTS

Eleven items representing two related components labeled "melancholia" and "anxiety" were retained. The 11-item HDRS total and component scores were higher for those who reported serious depression, serious anxiety, cognitive problems, and suicidal ideation on the ASI than for those who did not report these problems.

LIMITATIONS

We conducted the analyses with a relatively small sample of patients who were primarily white and were diagnosed with bipolar I disorder, thus limiting the generalizability of findings. Moreover, we obtained limited data regarding construct validity of the 11-item scale.

CONCLUSIONS

Our psychometric evaluation of the HDRS led us to retain 11 items representing primarily melancholic and neurovegetative symptoms of depression. These findings suggest that sample-specific item characteristics of the HDRS need to be evaluated prior to using this scale to assess depressive symptom severity among patients with complex diagnostic and treatment characteristics.

Coping and thought suppression as predictors of suicidal ideation in depressed older adults with personality disorders

Suicide rates are higher among older adults than any other age group and suicidal ideation is one of the best predictors of completed suicide in older adults. Despite this, few studies have evaluated predictors of suicidal ideation and other correlates of death by suicide (e.g. hopelessness) among older adults. Even fewer studies on this topic have been conducted among samples characterized as poor responders to treatments (e.g. depressed individuals with co-occurring personality disorder). The purpose of this study was to examine coping styles and thought suppression as predictors of a suicide risk composite score in a sample of depressed older adults with co-occurring personality disorders. Based on the extant literature, it was hypothesized that maladaptive coping (i.e. emotional and avoidance coping) and chronic thought suppression would significantly predict suicide risk. The results of this study indicated that elevated emotional coping and thought suppression were associated with increased suicide risk. Contrary to hypotheses, lower avoidance coping was associated with increased risk, although this finding is moderated by Axis II diagnosis Thus, treatments that focus on decreasing emotional coping and chronic thought suppression may result in decreased suicidal ideation and hopelessness for older adults with depression and Axis II pathology.

Time to emergence of severe suicidal ideation among psychiatric patients as a function of suicide attempt history

BACKGROUND

Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories.

METHOD

One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3-, 6-, 12-, and 18-month follow-up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis.

RESULTS

Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single attempters and nonattempters.

CONCLUSIONS

Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.

Correlates of occupational disability in a clinical sample of obsessive-compulsive disorder

OBJECTIVE

This study aimed to examine correlates of occupational disability in a large, clinical sample of individuals with a primary diagnosis of obsessive-compulsive disorder (OCD).

METHODS

A total of 238 individuals with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of OCD were interviewed at entry into an observational study of the course of OCD. Primary was defined as the diagnosis that patients identified as the most problematic over their lifetime.

RESULTS

At the time of interview, 38% of the sample reported being unable to work for psychiatric reasons. Obsessive-compulsive disorder with occupational disability was associated with greater functional impairment in completing household duties, social functioning, and quality of life. Few differences in treatments received were found among individuals with and without occupational disability. Although the number of years on psychotropic medications was similar among the 2 groups, those with disability had been on a greater number of serotonin-reuptake inhibitors over their lifetime. Half of individuals with occupational disability had entered cognitive-behavioral therapy at some point, but only one third had received at least 13 sessions. Regression analyses revealed that OCD severity was the most powerful predictor of occupational disability, followed by depression severity and presence of a lifetime substance use disorder.

CONCLUSIONS

A substantial proportion of individuals in our sample were unable to work. Cognitive-behavioral therapy was underutilized, and reasons for this remain unclear. Comorbid depression and substance use disorders present additional risk factors for disability. Further advances in biologic and psychosocial treatments are needed to improve functioning and the overall prognosis of the disorder.

Development of the Treatment Adherence Survey-patient version (TAS-P) for OCD

This paper reports on the development and initial psychometric evaluation of the Treatment Adherence Survey-patient version (TAS-P), a brief instrument designed to assess patient adherence to Cognitive-Behavioral Therapy (CBT) and pharmacotherapy recommendations for OCD. Eighty individuals with Obsessive Compulsive Disorder (OCD) were administered the TAS-P as part of the intake interview of a prospective, observational study of the course of OCD. Results demonstrated excellent test-retest reliability. Responses on the TAS-P were also significantly correlated with scores on a self-report measure of general treatment adherence and with data collected from a chart-review, demonstrating concurrent validity. Treatment adherence was not explained by demographic variables. However, participants who reported nonadherence to CBT recommendations had more severe OCD symptoms at the time of intake than those who did not endorse CBT nonadherence (mean Y-BOCS = 23.27 +/- 7.5 versus 18.20 +/- 8.0, respectively). Results suggest that the TAS-P is a promising instrument for assessing reasons for nonadherence to recommendations for CBT and pharmacotherapy interventions.

Childhood physical and sexual abuse in depressed patients with single and multiple suicide attempts

Research has shown both childhood physical and sexual abuse to be associated with later suicide attempts, although some studies have not supported these findings. However, few studies have investigated differences in physical and sexual abuse histories among single and multiple suicide attempters. The goals of the current study were two-fold: (a) to replicate previous findings of associations between childhood sexual and physical abuse and suicide attempts, and (b) to explore differences in reports of childhood physical and sexual abuse among single and multiple suicide attempters. While our results supported the findings that individuals with a history of suicide attempts are more likely to report histories of childhood physical and sexual abuse, we did not find a difference in reported abuse between single and multiple suicide attempters. Implications of these findings, as well as implications for future research, are discussed.

Late-onset obsessive compulsive disorder: clinical characteristics and psychiatric comorbidity

There has been little research examining clinical correlates of late-onset OCD in a large sample of individuals with a primary diagnosis of OCD. Using a sample of 293 consecutive subjects with lifetime DSM-IV OCD, we compared subjects with late-onset (after age 30 years) OCD to those with earlier onset on a variety of clinical measures. Symptom severity was examined using the Yale-Brown Obsessive Compulsive Scale. Thirty-three (11.3%) of the 293 subjects with OCD reported onset of OCD on or after age 30 years (mean age of OCD onset of 38.8+/-9.7 years). Subjects with late-onset had significantly shorter durations of illness prior to receiving treatment, less severe obsessinality, and a trend demonstrating a greater likelihood of responding to cognitive behavioral therapy (CBT). Late-onset OCD subjects were also significantly less likely to report contamination, religious, or somatic obsessions. Comorbidity, insight, depressive symptoms, quality of life, and social functioning did not differ between groups. These preliminary results suggest that although onset on or after age 30 years is fairly uncommon among people with OCD, individuals developing OCD later in life have similar clinical characteristics as those with earlier onset and may respond better to CBT.

Dysfunctional cognitions in hospitalized patients with psychotic versus nonpsychotic major depression

Previous research suggests that psychotic major depression (PMD) is associated with greater illness severity and functional impairment as well as poorer treatment response to antidepressants and psychotherapies compared with nonpsychotic major depression. Although patients with PMD exhibit a number of neurobiological abnormalities, little research has been conducted to date on possible psychological factors that are related to illness in this depression subtype. In the current study, baseline data were pooled from 2 clinical trials in which depressed patients (n = 235) were recruited during a psychiatric hospitalization for an acute episode. Twelve percent (n = 28) of this treatment-seeking sample met criteria for PMD and showed elevated levels of depression severity and dysfunctional beliefs compared with individuals with nonpsychotic major depression. However, even after controlling for depression severity and other relevant baseline variables, only a measure of common dysfunctional beliefs differentiated those with vs those without psychotic features. Furthermore, higher levels of depressive cognitions were related to poorer psychosocial functioning and suicidality in PMD patients. Results suggest that elevated levels of common negative cognitions in depressed patients may be associated with the presence of more severe psychotic symptoms. Adapted cognitive-behavioral treatments may be useful for treating patients with PMD specifically.

Discontinuities and cognitive changes in an exposure-based cognitive therapy for depression

Significant shifts or discontinuities in symptom course can mark points of transition and reveal important change processes. The authors investigated 2 patterns of change in depression-the rapid early response and a transient period of apparent worsening that the authors call a depression spike. Participants were 29 patients diagnosed with major depressive disorder who enrolled in an open trial of an exposure-based cognitive therapy. Hierarchical linear modeling revealed an overall cubic shape of symptom change and that both the rapid response and spike patterns predicted lower posttreatment depression. Patients wrote weekly narratives about their depression. Early narratives of rapid responders were coded as having more hope than those of nonrapid responders. The narratives of patients with a depression spike had more cognitive-emotional processing during this period of arousal than those without a spike. Findings are discussed in the context of cognitive-emotional processing theories in depression and anxiety disorders.

Stress reactivity and coping in seasonal and nonseasonal depression

Stress, stress reactivity, and coping skill use were examined in individuals with seasonal depression, nonseasonal depression, and nondepressed controls. Although participants in the two depressed groups reported using more avoidance coping strategies than controls, only participants in the seasonal depressed group reported using more season-specific coping (i.e., light-related strategies) than participants in the nonseasonal depressed and control groups. Individuals in the seasonal depressed group also reporting using acceptance coping strategies less frequently than individuals in the control group. Only participants in the nonseasonal depressed group, however, exhibited greater psychophysiological arousal in reaction to a laboratory stressor (i.e., unsolvable anagram task) when compared to participants in the seasonal and nondepressed control groups. Participants in both depressed groups reported greater impact of negative life events during the past 6 months than did controls. Similarities and differences in the two types of depression may have implications for the conceptualization and treatment of seasonal depression.