Recurrently situational (reactive) depression: a study of course, phenomenology and familial psychopathology

Revisiting the theoretical and methodological foundations of depression measurement

Depressive disorders are among the leading causes of global disease burden, but there has been limited progress in understanding the causes and treatments for these disorders. In this Perspective, we suggest that such progress crucially depends on our ability to measure depression. We review the many problems with depression measurement, including limited evidence of validity and reliability. These issues raise grave concerns about common uses of depression measures, such as diagnosis or tracking treatment progress. We argue that shortcomings arise because depression measurement rests on shaky methodological and theoretical foundations. Moving forward, we need to break with the field's tradition that has, for decades, divorced theories about depression from how we measure it. Instead, we suggest that epistemic iteration, an iterative exchange between theory and measurement, provides a crucial avenue for depression measurement to progress.

The Long-Term Impact of Parental Mental Health on Children's Distress Trajectories in Adulthood

Using six waves of data from the Panel Study of Income Dynamics (2007-2017) and the Childhood Retrospective Circumstances Study (2014) (n=3,240), this paper estimates how childhood experiences with parental mental health problems shape trajectories of children's own distress in adulthood. Findings indicate that those who experience poor parental mental health have consistently greater distress than their non-exposed counterparts throughout adulthood. More severe and longer exposures to parental mental health problems corresponds to even greater distress in adulthood. The gender of the parent afflicted does not predict differences in adult mental health, but those individuals exposed to both maternal and paternal poor mental health have the greatest distress in adulthood. Together, results suggest that parental mental health during children's formative years is a significant predictor of life course distress and that heterogeneity in this experience corresponds to unique mental health trajectories.

Impact, Diagnosis, Phenomenology, and Biology

This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.

Molecular Genetic Analysis Subdivided by Adversity Exposure Suggests Etiologic Heterogeneity in Major Depression

OBJECTIVE

The extent to which major depression is the outcome of a single biological mechanism or represents a final common pathway of multiple disease processes remains uncertain. Genetic approaches can potentially identify etiologic heterogeneity in major depression by classifying patients on the basis of their experience of major adverse events.

METHOD

Data are from the China, Oxford, and VCU Experimental Research on Genetic Epidemiology (CONVERGE) project, a study of Han Chinese women with recurrent major depression aimed at identifying genetic risk factors for major depression in a rigorously ascertained cohort carefully assessed for key environmental risk factors (N=9,599). To detect etiologic heterogeneity, genome-wide association studies, heritability analyses, and gene-by-environment interaction analyses were performed.

RESULTS

Genome-wide association studies stratified by exposure to adversity revealed three novel loci associated with major depression only in study participants with no history of adversity. Significant gene-by-environment interactions were seen between adversity and genotype at all three loci, and 13.2% of major depression liability can be attributed to genome-wide interaction with adversity exposure. The genetic risk in major depression for participants who reported major adverse life events (27%) was partially shared with that in participants who did not (73%; genetic correlation=+0.64). Together with results from simulation studies, these findings suggest etiologic heterogeneity within major depression as a function of environmental exposures.

CONCLUSIONS

The genetic contributions to major depression may differ between women with and those without major adverse life events. These results have implications for the molecular dissection of major depression and other complex psychiatric and biomedical diseases.

Structure of major depressive disorder in adolescents and adults in the US general population

BACKGROUND

Although techniques such as latent class analysis have been used to derive empirically based subtypes of depression in adult samples, there is limited information on subtypes of depression in youth.

AIMS

To identify empirically based subtypes of depression in a nationally representative sample of US adolescents, and to test the comparability of subtypes of depression in adolescents with those derived from a nationally representative sample of adults.

METHOD

Respondents included 912 adolescents and 805 adults with a 12-month major depressive disorder, selected from the National Comorbidity Survey Adolescent Supplement and the National Comorbidity Survey Replication samples respectively. Latent class analysis was used to identify subtypes of depression across samples. Sociodemographic and clinical correlates of derived subtypes were also examined to establish their validity.

RESULTS

Three subtypes of depression were identified among adolescents, whereas four subtypes were identified among adults. Two of these subtypes displayed similar diagnostic profiles across adolescent and adult samples (P = 0.43); these subtypes were labelled 'severe typical' (adults 45%, adolescents 35%) and 'atypical' (adults 16%, adolescents 26%). The latter subtype was characterised by increased appetite and weight gain.

CONCLUSIONS

The structure of depression observed in adolescents is highly similar to the structure observed in adults. Longitudinal research is necessary to evaluate the stability of these subtypes of depression across development.

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

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

Do reasons for major depression act as causes?

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

Genes, environment, and individual differences in responding to treatment for depression

A principal weakness of evidence-based psychiatry is that it does not account for the individual variability in therapeutic response among individuals with the same diagnosis. The aim of personalized psychiatry is to remediate this shortcoming and to use predictors to select treatment that is most likely to be beneficial for an individual. This article reviews the evidence that genetic variation, environmental exposures, and gene-environment interactions shape mental illness and influence treatment outcomes, with a primary focus on depression. Several genetic polymorphisms have been identified that influence the outcome of specific treatments, but the strength and generalizability of such influences are not sufficient to justify personalized prescribing. Environmental exposures in early life, such as childhood maltreatment, exert long-lasting influences that are moderated by inherited genetic variation and mediated through stable epigenetic mechanisms such as tissue- and gene-specific DNA methylation. Pharmacological and psychological treatments act on and against the background of genetic disposition, with epigenetic annotation resulting from previous experiences. Research in animal models suggests the possibility that epigenetic interventions may modify the impact of environmental stressors on mental health. Gaps in evidence are identified that need to be bridged before knowledge about cause can inform cure in personalized psychiatry.

Adjustment disorders: the state of the art

Adjustment disorders are common, yet under-researched mental disorders. The present classifications fail to provide specific diagnostic criteria and relegate them to sub-syndromal status. They also fail to provide guidance on distinguishing them from normal adaptive reactions to stress or from recognized mental disorders such as depressive episode or post-traumatic stress disorder. These gaps run the risk of pathologizing normal emotional reactions to stressful events on the one hand and on the other of overdiagnosing depressive disorder with the consequent unnecessary prescription of antidepressant treatments. Few of the structured interview schedules used in epidemiological studies incorporate adjustment disorders. They are generally regarded as mild, notwithstanding their prominence as a diagnosis in those dying by suicide and their poor prognosis when diagnosed in adolescents. There are very few intervention studies.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Does major depressive disorder change with age?

BACKGROUND

The authors used results from a 20-year, high-intensity follow-up to measure the influence of ageing, and of age at onset, on the long-term persistence of symptoms in major depressive disorder (MDD).

METHOD

Subjects who completed a 20-year series of semi-annual and then annual assessments with a stable diagnosis of MDD or schizo-affective disorder other than mainly schizophrenic (n=220) were divided according to their ages at intake into youngest (18-29 years), middle (30-44 years) and oldest (>45 years) groups. Depressive morbidity was quantified as the proportion of weeks spent in major depressive or schizo-affective episodes. General linear models then tested for effects of time and time x group interactions on these measures. Regression analyses compared the influence of age of onset and of current age.

RESULTS

Analyses revealed no significant time or group x time effects on the proportions of weeks in major depressive episodes in any of the three age groups. Earlier ages of onset were associated with greater symptom persistence, particularly in the youngest group. The proportions of weeks ill showed intra-individual stability over time that was most evident in the oldest group.

CONCLUSIONS

These results indicate that the persistence of depressive symptoms in MDD does not change as individuals move from their third to their fifth decade, from their fourth to their sixth decade, or from their sixth to their eighth decade. An early age of onset, rather than youth per se, is associated with greater morbidity over two decades.

Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care

Epidemiological studies have identified high prevalence rates of anxiety and depression in North America [e.g., J. of Nerv. Ment. Dis. 182 (1994) 290]. However, only a small percentage of these individuals access effective treatment. The undertreatment of anxiety and depression is a major public health issue and is associated with significant personal, social, and economic burden. This article describes the existing discrepancy between prevalence of anxiety and depression and access to effective treatment for adults and children, the contributors to this discrepancy, and suggests various means through which access to effective treatment may be enhanced. We begin with a brief overview of the prevalence and associated personal, societal, and systemic burdens of anxiety and depression. This is followed by a review of current rates of access to treatment and possible individual, provider, and systemic barriers to accessing treatment. Recommendations for bridging the gap between the high rates of these disorders and limited accessibility of effective care are then presented.

Endogenous, reactive and neurotic depression -- diagnostic stability and long-term outcome

BACKGROUND

No larger long-term study has been conducted of outcomes of patients diagnosed with endogenous, reactive or neurotic depression and using survival methods in the analyses.

SAMPLING AND METHODS

All patients who had had their first-ever discharge in the period from 1970 to 1994 with a diagnosis of endogenous, reactive or neurotic depression according to ICD-8 were identified in a nationwide register of admissions to psychiatric wards. Patients were followed up to 1999 and the long-term diagnostic stability, the risk of relapse leading to readmission and the risk of suicide was analysed in the three groups.

RESULTS

The diagnostic stability over time of the diagnosis of reactive depression and neurotic depression was low. Patients with neurotic depression had a substantially greater risk of relapse leading to readmission compared to patients with endogenous depression, and patients with reactive depression had less risk of relapse. No differences were found in the risk of completed suicide between the three groups of patients during long-term follow-up.

CONCLUSIONS

The study does not provide evidence for re-establishing prior diagnostic systems of depressive disorders based on the presence or absence of neurotic characteristics or on the presence or absence of a psychic trauma as in ICD-8.

Inflationary tendencies in judging the yield of depression research

The mood around mood disorders is one of optimism. Progress in diagnosis and treatment is generally felt to be considerable. Zeitgeist rests on convictions. In this case the main supporting convictions are the following: depression is a very frequent disorder and its diagnosis has improved greatly; we dispose of more or less specific agents to control depression: biological psychiatric research made great strides, particularly in the field of affective disorders; new antidepressants are properly tested before being clinically introduced. Each of these convictions is critically analysed. It is concluded that each of these claims is either a half-truth or not true. Apparently reality awareness and reality testing are out of balance. This harms the prospects of research, particularly biological research. Ways to avoid the stalemate are discussed.

Psychopathology in the relatives of depressed-abused children

OBJECTIVE

To determine if the type of symptomatology abused children manifest is related to family history of psychopathology.

METHOD

Lifetime history of psychopathology was assessed in the relatives of 26 preadolescents--13 depressed abused (MDD-AB) and 13 depressed nonabused (MDD-NA) children. Rates of disorder in the relatives of these children were compared to published rates of psychopathology in relatives of 27 normal control (NC) children. Data were obtained on 104 first-degree relatives (MDD-AB = 25, MDD-NA = 29, NC = 50) and 503 second-degree relatives (MDD-AB = 127, MDD-NA = 117, NC = 259). The Schedule for Affective Disorders and Schizophrenia was used to assess psychopathology in parents, and Family History method was used to obtain lifetime psychiatric data for all other relatives.

RESULTS

When compared to first-degree relatives of NC children, first-degree relatives of MDD-AB children had approximately a nine-fold increased risk for major depression, and a three- to nine-fold increased risk for other disorders associated with the familial subtype of affective illness known as Depression Spectrum Disease (e.g., antisocial personality, alcohol and substance dependence). Similar findings were reported in second-degree relatives, and comparisons between the relatives of MDD-NA and NC children.

CONCLUSION

The findings extend results of prior research and (1) suggest familial vulnerability factors influence the symptom profile of abused children; and (2) highlight the value of incorporating psychiatric formulations into multidisciplinary models of child abuse research and treatment programs.

Personality dimensions and depression: review and commentary

OBJECTIVES

The relationship between dimensionally assessed personality and the onset, features, and course of depressive illness will be critically examined and considered in relation to 4 hypothesized models: predisposition or vulnerability: pathoplasty: complication or scar: and spectrum or continuity.

METHOD

Studies that have used clinically depressed adult patients to explore the relationship between personality dimensions and depression will be reviewed.

RESULTS

Higher-order personality factors that have shown a significant and consistent association with major depressive illness include neuroticism, extraversion (negative relationship), and the factors of Cloninger's Tridimensional Personality Model. Neuroticism appears to be the most powerful predictor of depression. Lower-order factors showing a significant and consistent relationship with depressive illness include dependency, self-criticism, obsessionality, and perfectionism. The links between depression and dependency and self-criticism have the strongest empirical support.

CONCLUSIONS

Several personality dimensions are significantly associated with depressive illness, but the evidence that unequivocally demonstrates a true personality predisposition for depression is modest. Measures of personality may prove to be clinically useful for treatment selection.

The relationship between perceived stress and self-reported illness-related absenteeism

PURPOSE

To investigate the association between perceived stress and illness-related work absenteeism.

DESIGN

A standardized health profile questionnaire developed by Johnson & Johnson Advanced Behavioral Technologies, Inc., was used to collect demographic and personal health data between June 1988 and January 1993. Chi-square, odds ratio, and stepwise regression tests were used to analyze perceived stress and self-reported absenteeism data.

SETTING

Worksite health promotion programs in 250 U.S. companies.

SUBJECTS

Subjects consisted of 79,070 employees.

MEASURES

Stress data, grouped as low, moderate, and high, were correlated with absenteeism data grouped by annual days missed (None, 1 to 2, 3 to 4, and 5+).

RESULTS

Significant relationships were found (p < or = .05) between high stress and absenteeism for both genders. Female workers reported higher stress levels and absenteeism than men. Those with high stress were 2.22 more likely to be absent 5+ days per year than those with low stress. Work, finances, and family were the highest stress sources. Greatest absenteeism predictors were health, legal, social, and financial stress.

CONCLUSIONS

These data primarily represented self-selected white workers and may not apply to all employees. However, if high stress relates to absenteeism, these data may provide valuable information for program design in stress management.

Familial depression versus depression identified in a control group: are they the same?

Subjects who meet the criteria for an affective syndrome possibly are aetiologically heterogeneous. An approach to this possibility involves examining affectively ill subjects obtained by different methods of ascertainment. This study compares depressed and manic subjects who are related to affectively ill probands with affectively ill subjects who were obtained from a study of a control population, and, therefore, were less likely to be familial. The subjects were identified in a large collaborative study of depression where both family members as well as controls were personally interviewed and followed up for 6 years after admission to the study. Data were obtained on subtypes of affective disorder using the Research Diagnostic Criteria and information was gathered about psychiatric hospitalizations, suicide attempts, alcoholism and psychological functioning prior to admission. Similar assessments were made for the comparison groups for the 6 year period between intake and follow-up. Relatives of bipolar I/schizoaffective manic probands were more likely to show mania than affectively ill controls or relatives of unipolar/schizoaffective depressed probands. Affectively ill controls were less likely to be hospitalized and less likely to suffer from an incapacitating depression. They were also likely to have functioned in a more healthy fashion than the affectively ill relatives of the bipolars and unipolars, in the 5 years before admission to the study. In the 6 year follow-up, both the subjects themselves and raters assessed the depressed controls as functioning better than the affectively ill relatives of the probands. Further, assessment of global adjustment during the 6 year period was worse for the relatives of affectively ill probands than for the depressed controls. Length of major depression was longer in relatives of bipolar and unipolar probands than in controls. Though all of the subjects in this study met research criteria for an affective illness, there were marked differences in the qualitative aspects of these illnesses with the relatives of affectively ill probands, who functioned less well and had longer and more severe episodes and more hospitalizations.