Sub-grouping non-melancholic depression from manifest clinical features

Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder

Subtyping depression is important in order to further delineate biological causes of depressive syndromes. The aim of this study was to evaluate clinical and outcome characteristics of distinct subtypes of depression and to assess proportion and features of patients fulfilling criteria for more than one subtype. Melancholic, atypical and anxious subtypes of depression were assessed in a naturalistic sample of 833 inpatients using DSM-IV specifiers based on operationalized criteria. Baseline characteristics and outcome criteria at discharge were compared between distinct subtypes and their overlap. A substantial proportion of patients (16%) were classified with more than one subtype of depression, 28% were of the distinct anxious, 7% of the distinct atypical and 5% of the distinct melancholic subtype. Distinct melancholic patients had shortest duration of episode, highest baseline depression severity, but were more often early improvers; distinct anxious patients had higher NEO-Five Factor Inventory (NEO-FFI) neuroticism scores compared with patients with unspecific subtype. Melancholic patients with overlap of anxious features had worse treatment outcome compared to distinct melancholic and distinct anxious subtype. Distinct subtypes differed in only few variables and patients with overlap of depression subtypes may have independent clinical and outcome characteristics. Studies investigating biological causes of subtypes of depression should take influence of features of other subtypes into account.

The Major Depressive Disorder Hierarchy: Rasch Analysis of 6 items of the Hamilton Depression Scale Covering the Continuum of Depressive Syndrome

OBJECTIVES

Melancholic features of depression (MFD) seem to be a unidimensional group of signs and symptoms. However, little importance has been given to the evaluation of what features are related to a more severe disorder. That is, what are the MFD that appear only in the most depressed patients. We aim to demonstrate how each MFD is related to the severity of the major depressive disorder.

METHODS

We evaluated both the Hamilton depression rating scale (HDRS-17) and its 6-item melancholic subscale (HAM-D6) in 291 depressed inpatients using Rasch analysis, which computes the severity of each MFD. Overall measures of model fit were mean (±SD) of items and persons residual = 0 (±1); low χ2 value; p>0.01.

RESULTS

For the HDRS-17 model fit, mean (±SD) of item residuals = 0.35 (±1.4); mean (±SD) of person residuals = -0.15 (±1.09); χ2 = 309.74; p<0.00001. For the HAM-D6 model fit, mean (±SD) of item residuals = 0.5 (±0.86); mean (±SD) of person residuals = 0.15 (±0.91); χ2 = 56.13; p = 0.196. MFD ordered by crescent severity were depressed mood, work and activities, somatic symptoms, psychic anxiety, guilt feelings, and psychomotor retardation.

CONCLUSIONS

Depressed mood is less severe, while guilt feelings and psychomotor retardation are more severe MFD in a psychiatric hospitalization. Understanding depression as a continuum of symptoms can improve the understanding of the disorder and may improve its perspective of treatment.

Subtypes of depression in cancer patients: an empirically driven approach

Purpose

This study aimed to (1) identify subgroups of cancer patients with distinct subtypes of depression before the start of psychological care, (2) examine whether socio-demographic and medical characteristics distinguished these subtypes, and (3) examine whether people with distinct subtypes reported differential courses of depression during psychological care.

Method

This naturalistic, longitudinal study included cancer patients who sought psychological care at specialized psycho-oncology institutions in the Netherlands. Data were collected before psychological care (T1) and three (T2) and nine (T3) months thereafter. Latent class analysis was performed to identify depression subtypes in 243 patients at T1.

Results

Before starting psychological care, three depressive subtypes were identified, differing in severity and type of symptoms. Class 1 (47 %) with mild depression reported mostly concentration and sleep problems and fatigue. Class 2 (41 %), with slightly higher levels of depression, reported similar concentration and sleep problems and fatigue as class 1, and additionally depressed mood. Class 3 (12 %), with severe depression, reported mainly a depressed mood and, to a lesser extent but still elevated, fatigue and concentration problems. None of socio-demographic and medical characteristics significantly distinguished these subtypes. These subtypes significantly predicted the course of depression over time, with class 1 reporting moderate improvements, class 2 large improvements, and class 3 the largest improvements.

Conclusions

Results indicate the presence of three subtypes of depression in cancer patients before starting psychological care. Our findings suggest that psychological interventions could be tailored to respond to the specific subtype of depression experienced by each individual.

Identifying patterns of anxiety and depression in children with chromosome 22q11.2 deletion syndrome: comorbidity predicts behavioral difficulties and impaired functional communications

BACKGROUND

Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a complex genetic disorder with a variable clinical presentation that can include cardiac, neural, immunological, and psychological issues. Previous studies have measured elevated anxiety and depression in children with 22q11.2DS. Comorbity of anxiety and depression is well established in the pediatric literature but the nature of comorbidity patterns has not been empirically established in children with 22q11.2DS. Comorbidity of anxiety and depression has important implications for treatment and prognosis, and may be a marker of risk in this population of children at high-risk for developing schizophrenia.

METHOD

Participants were 131 boys and girls ages 8-14 with (n=76) and without (n=55) 22q11.2DS and their mothers. Children and mothers independently completed self- and parent-report measures of anxiety and depression. Mothers also completed measures of behavioral functioning including the Behavioral Assessment for Children, 2nd ed. (BASC-2). Cluster analyses were conducted to test if theoretically based groupings of anxiety and depression could be identified. We hypothesized four psychological profiles based on child- and mother-reports: low/no anxiety and low/no depression, higher depression and low/no anxiety, higher anxiety and no/low depression, and a comorbid profile of higher anxiety and higher depression. BASC-2 subscale scores were then compared across subgroups of children to determine if a comorbid profile would predict greater behavioral difficulties.

RESULTS

In the full sample of children both with and without 22q11.2DS, cluster analyses of self and maternal reported anxiety and depression revealed the expected subgroups: (1) a group of children with higher anxiety/lower depression (anxious); (2) a group with primary depression (lower anxiety/higher depression (depressed)); (3) a comorbid group with higher anxiety/higher depression (comorbid); and, (4) a lowest anxiety/lowest depression group (NP). Mothers' reports produced highly similar groupings. Furthermore, the 22q11.2DS youth were more likely to be in anxiety, depressed or comorbid clusters than the typically developing (TD) youth. Children with 22q11.2DS comorbid for anxiety and depression exhibited the worst functional outcomes (e.g., poor poorer functional communication, and reduced daily life activities).

CONCLUSIONS

Anxiety, comorbid with depression may be of particular concern in children with 22q11.2DS who arguably carry a greater burden on their stress coping resources than children without a complex genetic disorder. Furthermore, the manifestation of negative mood, anxiety and difficult behavior is likely to reverberate between the child and her or his environment. This can lead to negative interactions with family, peers, and teachers, which in turn further taxes coping resources. Comorbidity of anxiety and depression within a vulnerable population highlights the need for the development of tailored interventions.

Dependency and self-criticism: relationship with major depressive disorder, severity of depression, and clinical presentation

Dependency and self-criticism have been proposed as personality dimensions that confer vulnerability to depression. In this study we set out to investigate the diagnostic specificity of these personality dimensions and their relationship with gender differences, severity of depression, and specific depressive symptoms. Levels of dependency and self-criticism as measured by the Depressive Experiences Questionnaire (DEQ) were compared among patients with major depressive disorder (MDD; n=93), mixed psychiatric patients (n=43), university students (n=501), and community adults (n=253). Associations with severity of depression and specific depressive symptoms were also explored. Results showed that dependency was more specifically associated with MDD, whereas self-criticism did not differ between depressed and mixed psychiatric patients. In line with the gender incongruence hypothesis, women with MDD and other psychiatric disorders had higher levels of self-criticism compared to men, whereas men with MDD had higher levels of dependency compared to women. Severity of depression was more clearly linked to self-criticism than to dependency, particularly in patients with MDD. Finally, both dependency and self-criticism were related to theoretically predicted clusters of depressive symptoms, especially after we controlled for shared variance between self-critical and dependent symptoms, respectively. Limitations of this study include the cross-sectional design, which limited the ability to draw causal conclusions. In addition, this study relied exclusively on self-reported personality and mood. Overall, findings of this study suggest that both dependency and self-criticism are associated with MDD, severity of depression, and specific depressive symptoms, and that gender-incongruent personality traits may be associated with increased risk for depression and other disorders.

Depression research and treatment: Are we skating to where the puck is going to be?

This paper critically reviews empirical findings regarding current key assumptions underlying the nature and treatment of depression which heavily rely on the DSM approach. This review shows that empirical evidence provides little support for these assumptions. In response to these findings, an etiologically based, biopsychosocial, dynamic interactionism model of depression is proposed. This model could foster further integration in research on depression and assist in the development of guidelines for the treatment of depression that are better informed by research findings and more congruent with complex clinical realities.

Toward a validation of a tripartite concept of a putative anxious temperament: psychometric data from a French national general medical practice study

BACKGROUND

Although generalized anxiety disorder (GAD) is currently described as a time-limited state mental disorder, emerging evidence suggests that it is best considered as an exaggeration of a putative "anxious temperament" (AT). It is presently unknown whether it is a distinct or unitary construct of a melange of anxious traits related to Cluster-C personality disorders.

METHODS

As part of a Franco-American collaborative study, we developed the 15-item Operational Criteria for Anxious Personality (OCAP), expanding criteria sets developed earlier by one of us (H.S.A.). The study, which was conducted in the French primary care medical sector, included 1112 young adults (18-40 years), seeking help for isolated anxious complaints, never treated before-and without any diagnosable disorder on the axis I of DSM-IV. As previous papers have reported the preliminary validity of OCAP, especially concurrent validity with the State-Trait Anxiety Inventory (STAI) (Speilberger), in this report, we focus on its full psychometric properties.

RESULTS

The present data indicate a normal distribution of AT items, a satisfactory Chronbach's coefficient (0.64), and the presence at intake of three different subtypes of AT: "anxious-avoidant," "anxious-phobic," and "anxious-sensitive." After a prospective 6-month follow-up, the major criteria of AT were stable in 80% of cases, and for specific AT items, the stability rate varied between 65% and 80%; much of the unstable items were accounted by improvement during naturalistic treatment. The latter could explain the different factor structure obtained at follow-up, which tended to be less heterogeneous, and represented by one global factor.

LIMITATION

We used a categorical (yes/no) rather than a Likert-type gradation of frequency and intensity of anxiousness items and relatively low number of items, especially for those involving worrying about one's own health or that of one's loved ones.

CONCLUSIONS

Anxiousness as a temperamental dimension appears to involve putative subtypes along "worrying," "phobic," "sensitive" (and "avoidant") dimensions.

Examining the utility of a temperament model for modelling non-melancholic depression

OBJECTIVE

Depression is currently modelled dimensionally, along severity, duration and recurrency dimensions. An alternative model allows dimensional expressions of temperament and personality to influence risk to onset as well as persistence. Here, we examine the utility of a temperament model.

METHOD

A questionnaire assessing temperament dimensions and a number of depression variables was administered to a large routine general practice sample and with the temperament measure also completed by a small clinical sample.

RESULTS

'Anxious worrying' and 'irritable' dimensions were identified as internalizing and externalizing expressions of a trait anxiety dimension, three other 'temperament' dimensions (i.e. 'introversion', 'self-centred' and 'obsessive') were refined, while a 'self-blame' dimension intruded into the factor analytic solution. High scores on the 'anxious worrying' dimension were associated with all depression parameters. The 'irritable', 'introversion' and 'self-blame' dimensions were less clearly linked with depression variables, while higher scores on the 'self-centred' and 'obsessional' dimensions did not appear to increase the chance of depression onset, persistence or recourse to treatment.

CONCLUSION

A temperament-based approach appears to have some conceptual utility in modelling depression, and particularly, the non-melancholic disorders. It is likely, however, to require complementing with refined at-risk personality dimensions.

Latent class analysis of child behavior checklist anxiety/depression in children and adolescents

OBJECTIVE

Comorbidity of psychiatric problems such as anxiety and depression poses challenges to treatment and research. This study tested whether problem items from the Anxious/Depressed scale of the Child Behavior Checklist (CBCL) can be separated into distinct anxiety and depression classes or are continuously distributed throughout a population.

METHOD

A CBCL was completed by a parent or guardian of each of 1,987 children and adolescents selected to represent nonreferred children in the United States, as well as by a parent or guardian of each of a demographically matched sample of 1,987 clinically referred children and adolescents. Problem items from the Anxious/Depressed scale of the CBCL were subjected to latent class analysis.

RESULTS

Analyses revealed three levels of problem presentation in both samples. Children in the nonreferred sample were classified as having no problems, mild problems, or moderate anxiety/depression problems. Children and adolescents in the referred group were classified as having mild, moderate, or severe levels of problems. No pure anxiety or depression classes were found, only classes containing a mixture of both anxiety and depressive problems. Age, gender, and sample differences were found in class groupings, with nonreferred adolescent girls showing elevated levels of problems.

CONCLUSIONS

Results suggest that the comorbid conditions of anxiety and depression, as assessed by the CBCL anxiety/depression problem items, can be thought of as part of the same continuum of problems. Implications for assessment and treatment utilization are discussed.