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

PTEN in prefrontal cortex is essential in regulating depression-like behaviors in mice

Chronic stress is an environmental risk factor for depression and causes neuronal atrophy in the prefrontal cortex (PFC) and other brain regions. It is still unclear about the molecular mechanism underlying the behavioral alterations and neuronal atrophy induced by chronic stress. We here report that phosphatase and tensin homolog deleted on chromosome ten (PTEN) is a mediator for chronic stress-induced depression-like behaviors and neuronal atrophy in mice. One-month chronic restraint stress (CRS) up-regulated PTEN signaling pathway in the PFC of mice as indicated by increasing levels of PTEN, p-MEK, and p-ERK but decreasing levels of p-AKT. Over-expression of Pten in the PFC led to an increase of depression-like behaviors, whereas genetic inactivation or knockdown of Pten in the PFC prevented the CRS-induced depression-like behaviors. In addition, systemic administration of PTEN inhibitor was also able to prevent these behaviors. Cellular examination showed that Pten over-expression or the CRS treatment resulted in PFC neuron atrophy, and this atrophy was blocked by genetic inactivation of Pten or systemic administration of PTEN inhibitor. Furthermore, possible causal link between Pten and glucocorticoids was examined. In chronic dexamethasone (Dex, a glucocorticoid agonist) treatment-induced depression model, increased PTEN levels were observed, and depression-like behaviors and PFC neuron atrophy were attenuated by the administration of PTEN inhibitor. Our results indicate that PTEN serves as a key mediator in chronic stress-induced neuron atrophy as well as depression-like behaviors, providing molecular evidence supporting the synaptic plasticity theory of depression.

A critical analysis of debates on grief and depressive disorder in the age of the Diagnostic and Statistical Manual of Mental Disorders

Since the incorporation of the major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, and until its update in the DSM-IV-TR, the DSM classification system considered it necessary to include the criterion of "bereavement exclusion", with the aim of differentiating normal sadness linked to a loss, from a mental disorder, such as the major depressive disorder. In its latest version (DSM-5), this exception was removed, giving rise to a controversy that continues to this day. The debate has set those who are in favor of maintaining this exclusion and extending it to other stressors against those who have intended to eradicate it. Our hypothesis is that these positions account for two qualitatively diverse clinical and epistemological matrices, linked to major transformations in health sciences and in psychiatry. We show that this debate involved a profound renewal of the meaning of psychiatric practice, a change in the function of diagnosis and in the way of conceiving the etiology of mental disorders, as well as a reformulation of the patient's suffering status for the medical act.

Neuroticism's prospective association with mental disorders halves after adjustment for baseline symptoms and psychiatric history, but the adjusted association hardly decays with time: a meta-analysis on 59 longitudinal/prospective studies with 443 313 participants

BACKGROUND

This meta-analysis seeks to quantify the prospective association between neuroticism and the common mental disorders (CMDs, including anxiety, depression, and substance abuse) as well as thought disorders (psychosis/schizophrenia) and non-specific mental distress. Data on the degree of confounding of the prospective association of neuroticism by baseline symptoms and psychiatric history, and the rate of decay of neuroticism's effect over time, can inform theories about the structure of psychopathology and role of neuroticism, in particular the vulnerability theory.

METHOD

This meta-analysis included 59 longitudinal/prospective studies with 443 313 participants.

RESULTS

The results showed large unadjusted prospective associations between neuroticism and symptoms/diagnosis of anxiety, depression, and non-specific mental distress (d = 0.50-0.70). Adjustment for baseline symptoms and psychiatric history reduced the associations by half (d = 0.10-0.40). Unadjusted prospective associations for substance abuse and thought disorders/symptoms were considerably weaker (d = 0.03-0.20), but were not attenuated by adjustment for baseline problems. Unadjusted prospective associations were four times larger over short (<4 year) than long (⩾4 years) follow-up intervals, suggesting a substantial decay of the association with increasing time intervals. Adjusted effects, however, were only slightly larger over short v. long time intervals. This indicates that confounding by baseline symptoms and psychiatric history masks the long-term stability of the neuroticism vulnerability effect.

CONCLUSION

High neuroticism indexes a risk constellation that exists prior to the development and onset of any CMD. The adjusted prospective neuroticism effect remains robust and hardly decays with time. Our results underscore the need to focus on the mechanisms underlying this prospective association.

Self-reported physical symptoms in intensive care unit (ICU) survivors: pilot exploration over four months post-ICU discharge

CONTEXT

Survivors of critical illness must overcome persistent physical and psychological challenges. Few studies have longitudinally examined self-reported physical symptoms in intensive care unit (ICU) survivors.

OBJECTIVES

To describe prevalence and severity of self-reported symptoms in 28 adult medical ICU survivors during the first four months post-ICU discharge and their associations with family caregiver responses.

METHODS

Patients completed the Modified Given Symptom Assessment Scale. Caregivers completed the Shortened 10-item Center for Epidemiologic Studies Depression Scale, Brief Zarit Burden Score, Pittsburgh Sleep Quality Index, and the Caregiver Health Behavior form. Data at ICU discharge (two weeks or less), and two and four months post-ICU discharge were analyzed.

RESULTS

Across the time points, most patients reported one or more symptoms (88.5-97%), with sleep disturbance, fatigue, weakness, and pain the most prevalent. For these four symptoms with the highest prevalence, there were: 1) moderate correlations among symptom severity at two and four months post-ICU discharge; and 2) no difference in prevalence or severity by patients' disposition (home vs. institution), except worse fatigue in patients at home at two weeks or less post-ICU discharge. Patients' overall symptom burden showed significant correlation with caregivers' depressive symptoms two weeks or less post-ICU discharge. There were trends of moderate correlations between patients' overall symptom burden and caregivers' health risk behaviors and sleep quality at two and four months post-ICU discharge.

CONCLUSION

In our sample, sleep disturbance, fatigue, weakness, and pain were the four key symptoms during first four months post-ICU discharge. Future studies focusing on these four symptoms are necessary to promote quality in post-ICU symptom management.

Validity and clinical utility of the current operational characterization of major depression

The operational definition of major depression has remained more or less the same in the past 40 years. An appraisal of currently available research data leads to the conclusion that further evidence is needed about (1) where to fix the boundary between cases and non-cases in order to improve the clinical utility of the diagnosis, (2) the validity and clinical utility of the construct of melancholia as a qualitatively distinct subtype of depression, and (3) the validity and clinical utility of a 'contextual' exclusion criterion. Furthermore, we need a more precise description of individual depressive symptoms, an exploration of the predictive value of these symptoms and of clusters of them, especially concerning clinical outcome and treatment response, and a clearer operationalization of the impairment criterion.

Patterns of depressive symptoms in caregivers of mechanically ventilated critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge: a pilot study

OBJECTIVE

To examine trajectories of depressive symptoms in caregivers of critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge and explore patient and caregiver characteristics associated with differing trajectories.

DESIGN

Longitudinal descriptive study.

SETTING

Medical intensive care unit in a tertiary university hospital.

SUBJECTS

Fifty caregivers and 47 patients on mechanical ventilation for ≥4 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Caregivers completed measures assessing depressive symptoms (Short version Center for Epidemiologic Studies-Depression Scale 10-items), burden (Brief Zarit Burden Interview), and health risk behaviors (caregiver health behaviors) during intensive care unit admission, at intensive care unit discharge, and 2 months postintensive care unit discharge. Group-based trajectory analysis was used to identify patterns of change in shortened Center for Epidemiologic Studies-Depression Scale scores over time. Two trajectory groups emerged: 1) caregivers who had clinically significant depressive symptoms (21.0±4.1) during intensive care unit admission that remained high (13.6±5) at 2 months postintensive care unit discharge (high trajectory group, 56%); and 2) caregivers who reported scores that were lower (10.6±5.7) during intensive care unit admission and decreased further (5.7±3.6) at 2 months postintensive care unit discharge (low trajectory group, 44%). Caregivers in the high trajectory group tended to be younger, female, an adult child living with financial difficulty, and less likely to report a religious background or preference. More caregivers in the high trajectory group reported greater burden and more health risk behaviors at all time points; patients tended to be male with poorer functional ability at intensive care unit discharge. Caregivers' responses during intensive care unit admission did not differ in regard to number of days patients were on mechanical ventilation before enrollment.

CONCLUSION

Findings suggest two patterns of depressive symptom response in caregivers of critically ill adults on mechanical ventilation from intensive care unit admission to 2 months postintensive care unit discharge. Future studies are necessary to confirm these findings and implications for providing caregiver support.

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.

Placing symptoms in context: the role of contextual criteria in reducing false positives in Diagnostic and Statistical Manual of Mental Disorders diagnoses

PURPOSE

The Diagnostic and Statistical Manual of Mental Disorders (DSM) definition of mental disorder requires that symptoms be caused by a dysfunction in the individual; when dysfunction is absent, symptoms represent normal-range distress or eccentricity and, if diagnosed as a mental disorder, are false positives. We hypothesized that because of psychiatry's lack of direct laboratory tests to distinguish dysfunction from normal-range distress, the context in which symptoms occur (eg, lack of imminent danger in a panic attack) is often essential to determining whether symptoms are caused by a dysfunction. If this is right, then the DSM diagnostic criteria should include many contextual criteria added to symptom syndromes to prevent dysfunction false positives. Despite their potential importance, such contextual criteria have not been previously reviewed. We, thus, systematically reviewed DSM categories to establish the extent of such uses of contextual criteria and created a typology of such uses.

RESULTS

Of 111 sampled categories, 68 (61%) used context to prevent dysfunction false positives. Contextual criteria fell into 7 types: (1) exclusion of specific false-positive scenarios; (2) requiring that patients experience preconditions for normal responses (eg, requiring that individuals experience adequate sexual stimulation before being diagnosed with sexual dysfunctions); (3) requiring that symptoms be disproportionate relative to circumstances; (4) for childhood disorders, requiring that symptoms be developmentally inappropriate; (5) requiring that symptoms occur in multiple contexts; (6) requiring a substantial discrepancy between beliefs and reality; and (7) a residual category.

CONCLUSIONS

Most DSM categories include contextual criteria to eliminate false-positive diagnoses and increase validity of descriptive criteria. Future revisions should systematically evaluate each category's need for contextual criteria.

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

Depression in children and adolescents two months after the death of a parent

BACKGROUND

This study examined depressive symptoms in bereaved children and adolescents two months after the death of a parent.

METHODS

Participants were 325 children and adolescents bereaved of a parent approximately two months prior to the study. They were compared to 129 non-bereaved community controls and 110 non-bereaved depressed controls. Participants and their parents were interviewed regarding the child's depressive symptoms. Possible moderating factors for depression in bereaved children were examined.

RESULTS

25% of the bereaved participants experienced a major depressive episode (MDE) compared to 1% of the community controls. An additional 24% of the bereaved participants experienced a sub-syndromal depressive episode, defined as 3 or 4 depressive symptoms, compared to 4% of the community controls. Factors correlated with occurrence of MDE in the bereaved children in exploratory analyses were (1) history of MDE in the child and (2) history of alcoholism in a parent. Guilt/worthlessness, psychomotor disturbance, and low energy in the context of an MDE predicted membership in the depressed control group over the bereaved group.

LIMITATIONS

The relationship between an MDE in the bereaved child and parent history of alcoholism is exploratory, as the p-value for this correlation was greater than the α adjusted for multiple comparisons. The bereaved child's history of MDE was based on the child's and parent's memories of depressive symptoms.

CONCLUSIONS

The death of a parent is a risk factor for depressive symptoms and depressive episodes in children and adolescents two months after the death.

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.