Five-year course and outcome of dysthymic disorder: A prospective, naturalistic follow-up study

An update on the pharmacotherapeutic strategies for the treatment of dysthymic disorder: a systematic review

INTRODUCTION

Longer treatment times, more comorbidity, more severe impairments in social, psychological, and emotional functioning, increased healthcare use, and more hospitalizations are all factors that are related to dysthymia. Given the significant prevalence of dysthymia (including persistent depressive disorder) worldwide, its comorbidity with several mental disorders, and the detrimental effects of these comorbidities, it is important to conduct a systematic review to compare the effects of pharmacological acute and maintenance treatments for dysthymia with placebo and standard care in the last 10 years, based on the publication of DSM5.

AREAS COVERED

This systematic review was performed according to PRISMA guidelines. Databases, including PubMed and Cochrane Central Register of Controlled Trials, were searched to assess the effects of pharmacological acute and maintenance treatments for dysthymia in comparison with placebo and treatment as usual.

EXPERT OPINION

Our review shows that SSRIs and SNRIs present efficacy for dysthymia treatment, and L-Acetylcarnitine should be investigated further for this condition in elderly patients. The comparison of antidepressant medication versus placebo showed coherent results based on three studies favoring pharmacotherapy as an effective treatment for participants with dysthymia. However, the scarcity of research on continuation and maintenance therapy in people with dysthymia highlights the need for more primary research.

Association between mental disorders and mortality: A register-based cohort study from the region of Catalonia

We estimated all-cause and cause-specific mortality associated with mental disorder diagnoses using outpatient and inpatient registers from Catalonia. A historical register-based cohort was used, including 516,944 adults diagnosed with psychotic, mood, or anxiety disorders in 2005-2016, and their matched controls. Six psychiatric groups were created using hierarchical rules. Mortality rate ratios (MRRs), calculated with stratified Cox proportional-hazards models adjusted for mental comorbidity, ranged from 2.45 (95%CI = 2.28-2.64) for other non-organic psychoses to 1.11 (95%CI = 1.08-1.15) for anxiety disorders. Higher MRRs were found in males compared to females with non-organic psychoses, other affective and anxiety disorders, and the excess risk of death was higher in younger ages for all the diagnoses except for schizophrenia. Overall, suicide mortality rates were higher for those with mental disorder diagnoses. The highest MRRs due to natural causes were found for metabolic disorders in schizophrenia, infectious diseases in other non-organic psychoses, and respiratory diseases for bipolar, other affective and anxiety disorders. In the most comprehensive study in Southern Europe, excess mortality is observed not only in people with diagnoses of severe mental disorders, but also in those with other mental disorder diagnoses considered less severe, with an important contribution of both natural and unnatural causes.

The associations between suicide-related behaviors, prefrontal dysfunction in emotional cognition, and personality traits in mood disorders

Suicide is a serious public health problem, and it is urgent to identify biomarkers associated with suicide to prevent it. We aimed to clarify the association across suicidal behavior, personality traits, and brain activation by emotional stimulation tasks using near-infrared spectroscopy (NIRS) in patients with mood disorders. 11 mood disorder patients with a history of suicide attempt (MDSA), 18 mood disorder patients with no history of suicide attempt (MDNSA), and 17 healthy individuals were studied. The MDSA patients showed significantly high impulsivity and hopeless compared to healthy subjects, great response to the thread word task in the orbitofrontal cortex (OFC) and dorsolateral prefrontal cortex (DLPFC) compared to MDNSA patients, and the significant correlation between the personality traits and brain activation. The MDNSA did not show the trend. The results suggest that the personality traits and the activation of OFC and DLPFC during the negative emotional cognitive stimuli is associated with suicidal behavior, indicating the findings are involved in the pathophysiology of suicidality in mood disorders.

Distinct Neural Profiles of Frontoparietal Networks in Boys with ADHD and Boys with Persistent Depressive Disorder

Working memory deficits are common in attention-deficit/hyperactivity disorder (ADHD) and depression-two common neurodevelopmental disorders with overlapping cognitive profiles but distinct clinical presentation. Multivariate techniques have previously been utilized to understand working memory processes in functional brain networks in healthy adults but have not yet been applied to investigate how working memory processes within the same networks differ within typical and atypical developing populations. We used multivariate pattern analysis (MVPA) to identify whether brain networks discriminated between spatial versus verbal working memory processes in ADHD and Persistent Depressive Disorder (PDD). Thirty-six male clinical participants and 19 typically developing (TD) boys participated in a fMRI scan while completing a verbal and a spatial working memory task. Within a priori functional brain networks (frontoparietal, default mode, salience), the TD group demonstrated differential response patterns to verbal and spatial working memory. The PDD group showed weaker differentiation than TD, with lower classification accuracies observed in primarily the left frontoparietal network. The neural profiles of the ADHD and PDD differed specifically in the SN where the ADHD group's neural profile suggests significantly less specificity in neural representations of spatial and verbal working memory. We highlight within-group classification as an innovative tool for understanding the neural mechanisms of how cognitive processes may deviate in clinical disorders, an important intermediary step towards improving translational psychiatry.

Depressive Disorder Related Hospitalizations in Portugal Between 2008-2015: a Nationwide Observational Study

Depression is a prevalent disease, being one of the most relevant contributors of disability in the overall global burden of diseases. Hospitalization episodes are important quality indicators in psychiatric care. The primary aim of this study is to analyse depressive disorder related hospitalizations in Portuguese public hospitals and to detail clinical and sociodemographic differences among various subtypes of depression. Admissions with a primary diagnosis of depression in adult patients(> = 18 years) were selected from a national mainland hospitalization database. ICD-9-CM codes were used to select the diagnoses of interest: 296.2 × to 296.3x (Major depressive disorder), 300.4 (Dysthymic disorder) and 311 (Depressive disorder, not elsewhere classified). Birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status, and hospital estimated charges were obtained. A total of 28,569 hospitalizations (22,387 patients) with a primary diagnosis of depression were analysed. In the 8-year period of the study, 19.1% of all hospitalizations with a primary diagnosis of psychiatric disorder were linked to Depression. Major Depressive episodes were the most common (n = 15,384; 53.8%), followed by Depression unspecified episodes (n = 6,793; 23.8%), and Dysthymia (n = 6,392; 22.4%). Most episodes occurred in female patients (70.2%; n = 20,052), with a mean age of 50.6 years, and 37.0% (n = 10,564) of the episodes were associated to other psychiatric comorbidities. Depressive disorders are one of the leading causes of hospitalization in Portuguese psychiatric departments, being responsible for approximately 1 in 5 hospitalizations with a psychiatric diagnosis.

EEG Frontal Asymmetry in Dysthymia, Major Depressive Disorder and Euthymic Bipolar Disorder

In the last few decades, the incidence of mood disorders skyrocketed worldwide and has brought an increasing human and economic burden. Depending on the main symptoms and their evolution across time, they can be classified in several clinical subgroups. A few psychobiological indices have been extensively investigated as promising markers of mood disorders. Among these, frontal asymmetry measured at rest with quantitative EEG has represented the main available marker in recent years. Only a few studies so far attempted to distinguish the features and differences among diagnostic types of mood disorders by using this index. The present study measured frontal EEG asymmetry during a 5-min resting state in three samples of patients with bipolar disorder in a Euthymic phase (EBD, n = 17), major depressive disorder (MDD, n = 25) and persistent depressive disorder (PDD, n = 21), once termed dysthymia. We aimed to test the hypothesis that MDD and PDD lack the typical leftward asymmetry exhibited by normal as well as EBD patients, and that PDD shows greater clinical and neurophysiological impairments than MDD. Clinical scales revealed no symptoms in EBD, and significant larger anxiety and depression scores in PDD than in MDD patients. Relative beta (i.e., beta/alpha ratio) EEG asymmetry was measured from lateral frontal sites and results revealed the typical greater left than right frontal beta activity in EBD, as well as a lack of asymmetry in both MDD and PDD. The last two groups also had lower bilateral frontal beta activity in comparison with the EBD group. Results concerning group differences were interpreted by taking into account both the clinical and the neurophysiological domains.

Depression, trauma and mentalizing: No influence of depressive symptoms on spontaneous theory of mind in a subclinical sample

BACKGROUND

Depressive symptoms are associated with impaired social functioning, arguably because of reduced mentalizing abilities. However, findings in persons with depressive symptoms and/or major depressive disorder (MDD) are presently mixed, finding evidence both for and against the hypothesis of reduced mentalizing abilities.

AIMS

This study investigated spontaneous cognitive mentalizing in 36 age-, sex- and education-matched students with depressive symptoms and 45 comparisons with minimal depressive symptoms.

METHOD

To assess spontaneous mentalizing, we used the implicit theory of mind (ToM) task, which looks specifically at spontaneous computation of false belief.

RESULTS

Bayesian analysis did not support the hypothesis of impaired mentalizing; in fact, it suggested that the results were 3.90 times more likely to have occurred under the null hypothesis. Results remained stable when comparing depressed and non-depressed individuals without maltreatment exposure but were inconclusive in the maltreatment-exposed groups.

CONCLUSION

The findings suggest no effect of spontaneous mentalizing in a high-functioning depressed sample. Moreover, the findings also emphasize the need to control for childhood maltreatment experiences in future ToM and social functioning research, as these may constitute subgroups within depressed samples. Tailored therapy for maltreated depression individuals may be beneficial.

From dysthymia to treatment-resistant depression: evolution of a psychopathological construct

Dysthymia is a psychopathological construct historically described and often reconsidered through the centuries. Its first description is dated back to 400 b.C., when Hippocrates proposed his theory about the 'black bile' and the melancholic temperament. The concept of dysthymia (dys-, 'ill', thymia-, 'emotions') has been largely elaborated in the XIX and XX centuries by Burton, Cullen, Schneider, Kretschmer, Akiskal and other authors, and recently re-formulated in the various editions of the modern Diagnostic and Statistical Manual of Mental Disorders under different diagnostic labels: neurotic depression, dysthymic disorder, persistent depressive disorder. Beyond the nosology, dysthymia issues some other challenges, including the need for further research to characterise the peculiar pathophysiological framework of this syndrome (compared with major depressive disorder) and to better define evidences about tailored-treatment options and their effectiveness.

Depression and suicidal behavior in LGB and heterosexual populations in Serbia and their differences: Cross-sectional study

Background

Sexual identity is a significant risk factor for triggering symptoms of depression, as well as for suicide attempts in lesbian, gay and bisexual (LGB) population compared to the heterosexual population. To the best of our knowledge, data on the mental health of LGB persons in Serbia are lacking, and this is the first study to address this problem. The aim of the study was to examine the association between selected determinants and depression, and selected determinants and suicide attempts in LGB and heterosexual populations in the Republic of Serbia, as well as, their differences.

Methods

We conducted a cross-sectional study in 2015 of 264 heterosexual and LGB respondents using the "snowball sampling" method. We used linear regression analyses to investigate the relationship between socio-demographic variables and different sexual identity categories with PHQ-9 scores. We assessed associations between suicide attempts, and socio-demographic characteristics, sexual identity, depression, and suicidal thoughts using logistic regression.

Results

Depression symptoms were higher in female relative to male participants, in participants who were single, divorced or widowed in comparison to currently married, among people with a middle level of education compared to highly educated, and in respondents identified as bisexual or homosexual in comparison to heterosexual. Homosexual and bisexual participants reported suicidal attempts 27 [Odds Ratio (OR) = 27.31] and six times (OR = 6.40) more often than did heterosexual respondents, respectively. Suicide attempts were less frequently reported by single, divorced or widowed participants in comparison to married (OR = 0.25) and those with middle education (OR = 0.38) compared to highly educated.

Conclusions

The present study showed that LGB persons in Serbia have significantly more symptoms of depression and suicide attempts compared to heterosexuals. Public health interventions should focus on the early detection of depression and on overcoming prejudicial and discriminatory attitudes. Also, intervention should emphasize that homosexuality and bisexuality are normal, equal and morally acceptable expressions of human sexuality.

Effect of Electroacupuncture and Counseling on Sub-Threshold Depression: A Study Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Sub-threshold depression is common and could impair function, as well as increase the risk of developing major depression. Despite evidence of efficacy for electroacupuncture (EA) and counseling in the treatment of sub-threshold depression, the sample size is insufficient and the level of evidence remains low. This study aims to evaluate the effectiveness of sub-threshold depression treatments by comparing the treatment effects among EA, counseling, and combination therapy, as well as to further study their mechanism.

METHODS

This study is a multicenter, randomized, single blind clinical trial that will be conducted in settings at four clinical centers in China. The randomized controlled trial (RCT) will examine the effectiveness of EA intervention, compared with counseling and combination therapy. A total of 138 sub-threshold depression patients (18 to 55 years of age with Beck Depression Inventory (BDI-II) score ≥ 14 points and Hamilton Depression Scale (HAMD-17) score: 7 points ≤ HAMD total score <17 points) will be recruited. The participants will be randomly assigned to receive the above treatments. The interventions will be delivered over a 6-week period (EA: 3 times a week for 6 weeks; 30 min a session. Counseling: once a week for 6 weeks; 50-60 min a session). The primary outcome measure will be the HAMD-17; BDI-II. The secondary outcome measures will be: Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS), and Pittsburgh Sleep Quality Index (PSQI). The assessments will occur at baseline, 2, 4, and 6 weeks and a follow-up period. Recruitment will commence in March 2020 and is anticipated to occur over a 2-year period.

DISCUSSION

This study intends to conduct a multicenter randomized controlled trial to compare the effectiveness among EA, counseling and the combined therapy in the treatment of patients with sub-threshold depression, and to further study the mechanisms of effect.

CHINESE CLINICAL TRIAL REGISTRY REGISTRATION

www.chictr.org.cn/, identifier ChiCTR1900028530.

Desvenlafaxine vs. placebo in the treatment of persistent depressive disorder

INTRODUCTION

Pharmacotherapy of non-major persistent depressive disorder (PDD) is little studied. We report a study of the serotonin-norepinephrine reuptake inhibitor (SNRI) desvenlafaxine (DVLX) for PDD.

METHOD

Non-psychotic, non-bipolar outpatients aged 20-65 having PDD without concurrent major depression (MDD) were randomized double-blind to desvenlafaxine or placebo for 12 weeks. All had Hamilton Depression Rating Scale (HDRS-24) score ≥ 12. Open-label DVLX was offered for 12 weeks following the acute trial.

RESULTS

Seventy-one subjects having mean baseline HDRS-24 20.27 ± 4.77 were eligible, of whom post-RZ data was available for all 59 randomized. The primary 12 week analysis did not differentiate DVLX-treated subjects' mean HDRS scores from those on placebo (6.53 ± 3.98 vs. 8.24 ± 4.96, F = 3.33, df = 1, p = .07). Several secondary analyses yielded statistically significant results, including Responder, CGI and QIDS.

DISCUSSION

As the primary analysis did not reach statistical significance, this is a negative study which does not support the use of DVLX for non-major PDD. Nevertheless, statistically significant secondary analyses suggest the overall negative result could be due to sample size or sampling, suggesting further studies of this medication might be appropriate in this population.

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.

Cognitive Behavioral Analysis System of Psychotherapy as group psychotherapy for chronically depressed inpatients: a naturalistic multicenter feasibility trial

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a relatively new approach in the treatment of chronic depression (CD). Adapted as group psychotherapy for inpatients, CBASP is attracting increasing attention. In this naturalistic multicenter trial, we investigated its feasibility after 10 sessions of CBASP group therapy over a treatment time of at least 5 to a maximum of 10 weeks. Treatment outcome was additionally assessed. Across four centers, 116 inpatients with CD (DSM-IV-TR) attended CBASP group psychotherapy. Feasibility was focused on acceptance, and evaluated for patients and therapists after five (t1) and ten sessions (t2) of group psychotherapy. Observer- and self-rating scales (Hamilton Depression Rating Scale-24 items, HDRS₂₄; Beck Depression Inventory-II, BDI-II; World Health Organization Quality of Life assessment, WHOQOL-BREF) were applied before group psychotherapy (t0) and at t2. Dropouts were low (10.3%). Patients' evaluation improved significantly from t1 to t2 with a medium effect size (d = 0.60). Most of the patients stated that the group had enriched their treatment (75.3%), that the size (74.3%) and duration (72.5%) were 'optimal' and 37.3% wished for a higher frequency. Patients gave CBASP group psychotherapy an overall grade of 2 ('good'). Therapists' evaluation was positive throughout, except for size of the group. Outcome scores of HDRS₂₄, BDI-II, and WHOQOL-BREF were significantly reduced from t0 to t2 with medium to large effect sizes (d = 1.48; d = 1.11; d = 0.67). In this naturalistic open-label trial, CBASP, when applied as inpatient group psychotherapy, was well accepted by patients and therapists. The results point towards a clinically meaningful effect of inpatient treatment with CBASP group psychotherapy on depression and quality of life. Other potential factors that could have promoted symptom change were discussed. A future controlled study could investigate the safety and efficacy of CBASP group psychotherapy for inpatients.

Prevalence of Childhood Affective disorders in Turkey: An epidemiological study

AIM

To determine the prevalence of affective disorders in Turkey among a representative sample of Turkish population.

METHODS

This study was conducted as a part of the "The Epidemiology of Childhood Psychopathology in Turkey" (EPICPAT-T) Study, which was designed by the Turkish Association of Child and Adolescent Mental Health. The inclusion criterion was being a student between the second and fourth grades in the schools assigned as study centers. The assessment tools used were the K-SADS-PL, and a sociodemographic form that was designed by the authors. Impairment was assessed via a 3 point-Likert type scale independently rated by a parent and a teacher.

RESULTS

A total of 5842 participants were included in the analyses. The prevalence of affective disorders was 2.5 % without considering impairment and 1.6 % when impairment was taken into account. In our sample, the diagnosis of bipolar disorder was lacking, thus depressive disorders constituted all the cases. Among depressive disorders with impairment, major depressive disorder (MDD) (prevalence of 1.06%) was the most common, followed by dysthymia (prevalence of 0.2%), adjustment disorder with depressive features (prevalence of 0.17%), and depressive disorder-NOS (prevalence of 0.14%). There were no statistically significant gender differences for depression. Maternal psychopathology and paternal physical illness were predictors of affective disorders with pervasive impairment.

CONCLUSION

MDD was the most common depressive disorder among Turkish children in this nationwide epidemiological study. This highlights the severe nature of depression and the importance of early interventions. Populations with maternal psychopathology and paternal physical illness may be the most appropriate targets for interventions to prevent and treat depression in children and adolescents.

The association between lifetime cannabis use and dysthymia across six birth decades

BACKGROUND

Though high rates of co-occurring cannabis use and depression are well-documented, data regarding the association between cannabis use and dysthymia is scarce. The aim of this cross-sectional study was to explore clinical correlations of cannabis use among individuals with dysthymia, as well as the changes in the association between cannabis use and dysthymia across six decades of birth cohorts.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; 2012-2013; N = 36,309). Participants were divided into six birth cohorts (1940s-1990s), based on their decade of birth, and individuals with dysthymia were further categorized by 3 levels of lifetime cannabis use: non-users, non-CUD users, and CUD-users. We compared rates of co-occurring psychiatric and substance use disorders among cannabis users vs non-users and conducted logistic regression analyses in order to determine the odds of dysthymia among cannabis users across six decades.

RESULTS

Rates of several psychiatric disorders, such as personality disorders, and substance use disorders were higher among individuals with dysthymia who used cannabis compared to those who did not. The interaction between cannabis use (without a CUD) and birth cohort was associated with a decrease in the odds of dysthymia (OR=0.90, 95% CI 0.84-0.97) and remained significant after controlling for confounding variables. Similar changes over time were not demonstrated for CUD users.

LIMITATIONS

Likelihood for recall bias and misclassification based on cross-sectional nature of the study and on respondents' self-reports of symptoms throughout their lifetime.

CONCLUSIONS AND IMPLICATIONS

Our study's findings demonstrate that the association between cannabis use (but not CUDs) and dysthymia has weakened over time. These findings highlight the need for further research examining changes over time in the relationship between cannabis use and associated psychiatric disorders.

Loving Kindness Meditation zur Behandlung der chronischen Depression

Zusammenfassung. Theoretischer Hintergrund: Chronische Depressionen gehen mit einer langwierigen Belastung einher und verursachen hohe Krankheitskosten. Ein möglicher Ansatz zur Behandlung könnte die Loving Kindness Meditation (LKM) sein. Methode: In dieser Pilot-Studie wurde ein LKM-Gruppenprogramm eingesetzt und bezüglich der Effektivität untersucht. N = 2207 Fälle aus Wartelistendaten wurden stufenweise zu der LKM-Gruppe (n = 12) zugeordnet. Zwei Kontrollgruppen (n = 134 und n = 12) wurden gebildet, indem zunächst die Ein-und Ausschlusskriterien angewandt wurden und dann die verbliebene Stichprobe basierend auf der Kovariatenverteilung mittels Propensity Score Matching (PSM) angepasst wurde. Die Gruppen wurden anhand des OQ-30 verglichen. Ergebnisse: Im Prä-Post-Vergleich zeigten sich im OQ-30 signifikante Verbesserungen. Allerdings zeigte sich das so nicht in den symptomspezifischen Instrumenten (BDI-II und HAM-D). Im Vergleich zu der gesamten Wartelistenstichprobe (n = 134) ergaben sich signifikante Verbesserungen im OQ-30. Verglichen mit der PSM-Wartelistenkontrollgruppe zeigten sich marginal signifikante Unterschiede im OQ-30, signifikante Unterschiede konnten bezüglich der Depressionsitems des OQ-30 nachgewiesen werden. In der Interventionsgruppe ergaben sich mehr reliable Verbesserungen im OQ-30 als in den Wartelistenkontrollgruppen. Schlussfolgerung: Die Pilotstudie zeigte eine geringere Abbruchquote als Vorgängerpilotstudien und eine gute Prä-Post Effektstärke im OQ-30, sowie im Vergleich zu den beiden Wartelistekontrollgruppen. Allerdings zeigten sich keine konsistenten Prä-Post Effekte in den Depressionsskalen. Eine weitere umfangreichere Studie mit aktiver Kontrollgruppe wäre nötig, um das Programm hinsichtlich seiner Effektivität, bezüglich des Abbruchs sowie der Heterogenität der Effekte in den Depressionsskalen weiter untersuchen zu können.

Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies

BACKGROUND

Many studies have documented robust relationships between depression and hopelessness and subsequent suicidal thoughts and behaviours; however, much weaker and non-significant effects have also been reported. These inconsistencies raise questions about whether and to what degree these factors confer risk for suicidal thoughts and behaviours.AimsThis study aimed to evaluate the magnitude and clinical utility of depression and hopelessness as risk factors for suicide ideation, attempts and death.

METHOD

We conducted a meta-analysis of published studies from 1971 to 31 December 2014 that included at least one longitudinal analysis predicting suicide ideation, attempt or death using any depression or hopelessness variable.

RESULTS

Overall prediction was weaker than anticipated, with weighted mean odds ratios of 1.96 (1.81-2.13) for ideation, 1.63 (1.55-1.72) for attempt and 1.33 (1.18-1.49) for death. Adjusting for publication bias further reduced estimates. Effects generally persisted regardless of sample severity, sample age or follow-up length.

CONCLUSIONS

Several methodological constraints were prominent across studies; addressing these issues would likely be fruitful moving forward.Declaration of interestNone.

White matter microstructure in boys with persistent depressive disorder

BACKGROUND

Persistent depressive symptoms in children and adolescents are considered a risk factor for the development of major depressive disorder (MDD) later in life. Previous research has shown alterations in white matter microstructure in pediatric MDD but discrepancies exist as to the specific tracts affected. The current study aimed to improve upon previous methodology and address the question whether previous findings of lower fractional anisotropy (FA) replicate in a sample of children with persistent depressive disorder characterized by mild but more chronic symptoms of depression.

METHODS

White matter microstructure was examined in 25 boys with persistent depressive disorder and 25 typically developing children. Tract specific analysis implemented with the Diffusion Tensor Imaging - ToolKit (DTI-TK) was used to probe fractional anisotropy (FA) in eleven major white matter tracts.

RESULTS

Clusters within the left uncinate, inferior fronto-occipital and cerebrospinal tracts showed lower FA in the clinical group. FA in the left uncinate showed a negative association with self-reported symptoms of depression.

CONCLUSIONS

The results demonstrate lower FA in several white matter tracts in children with persistent depressive disorder. These findings support the contention that early onset depression is associated with altered white matter microstructure, which may contribute to the maintenance and recurrence of symptoms.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

Prescribing patterns of psychotropic medications and clinical features in patients with major depressive disorder with and without comorbid dysthymia in China

INTRODUCTION

Little has been reported about the demographic and clinical features of major depressive disorder (MDD) with comorbid dysthymia in Chinese patients. This study examined the frequency of comorbid dysthymia in Chinese MDD patients together with the demographic and clinical correlates and prescribing patterns of psychotropic drugs.

METHODS

Consecutively collected sample of 1178 patients with MDD were examined in 13 major psychiatric hospitals in China. Patients' demographic and clinical characteristics and psychotropic drugs prescriptions were recorded using a standardized protocol and data collection procedure. The diagnosis of dysthymia was established using the Mini International Neuropsychiatric Interview. Medications ascertained included antidepressants, antipsychotics, benzodiazepines, and mood stabilizers.

RESULTS

One hundred and three (8.7%) patients fulfilled criteria for dysthymia. In multiple logistic regression analyses, compared to non-dysthymia counterparts, MDD patients with dysthymia had more depressive episodes with atypical features including increased appetite, sleep, and weight gain, more frequent lifetime depressive episodes, and less likelihood of family history of psychiatric disorders. There was no significant difference in the pattern of psychotropic prescription between the 2 groups.

CONCLUSIONS

There are important differences in the demographic and clinical features of comorbid dysthymia in Chinese MDD patients compared with previous reports. The clinical profile found in this study has implications for treatment decisions.

What was the Mental Disease that Afflicted King Saul?

In this article, the author discusses the case of the biblical King Saul, the first King of Israel, who ruled the country 3,000 years ago. Evaluation of the passages referring to King Saul's disturbed behavior indicates that he was afflicted by a mental disorder. Among many disorders that could have affected the King, manic episode with psychotic phases, major depression with psychotic features, mixed episode, bipolar disorder I, dysthymic disorder later developed into bipolar disorder, or nonspecific psychotic disorder are the most likely. And among these diagnoses, bipolar disorder I is the most acceptable. The author suggests in this article that the roots of contemporary psychiatry can be traced back to biblical times.

Comparative Safety of Pharmacologic Treatments for Persistent Depressive Disorder: A Systematic Review and Network Meta-Analysis

We aimed to compare the safety of antidepressants for the treatment of persistent depressive disorder (PDD) with each other and with placebo. We conducted a systematic electronic search and included randomized controlled trials that investigated antidepressants for the treatment of PDD in adults. Outcomes were the incidence of experiencing any adverse event, specific adverse events and related treatment discontinuations. We analyzed the data using traditional and network meta-analyses. Thirty-four studies that comprised 4,769 patients and examined 20 individual agents in nine substance classes were included. Almost all analyzed substance classes were associated with higher discontinuation rates than placebo including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), antipsychotics, and the serotonin antagonist and reuptake inhibitor (SARI) trazodone. The odds of experiencing any adverse event were significantly higher for TCAs and serotonin noradrenaline reuptake inhibitors (SNRIs) compared to placebo. Pairwise comparisons among the substance classes revealed that more patients receiving TCAs or SNRIs experienced any adverse event and that more patients receiving TCAs or the SARI trazodone discontinued treatment. The complementary treatment with acetyl-l-carnitine showed lower rates of experiencing any adverse event and related discontinuations than all other comparators. TCAs were primarily associated with (anti-)cholinergic and sedating adverse events. SSRIs primarily showed gastrointestinal adverse events. Patients treated with the antipsychotic amisulpride were more likely to manifest weight gain and endocrine adverse events. The comparative evidence for further agents was insufficient or lacking. The identified safety differences may be used to inform the selection among the antidepressants.

Persistent Depression as a Novel Diagnostic Category: Results from the Menderes Depression Study

INTRODUCTION

Persistent depressive disorder (PDD) introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 as a novel diagnostic category represents a consolidation of two separate DSM-IV categories, chronic major depressive disorder (MDD) and dysthymic disorder. The present study aims to investigate the frequency and clinical as well as socio-demographic correlates of PDD in comparison with those of episodic MDD among patients seeking treatment for depressive symptoms.

METHODS

Participants were 140 depressive out-and in-patients under treatment at the psychiatry clinic of the Adnan Menderes University Research Hospital. Each patient was assessed by means of a structured clinical interview (SCID-I) and relevant psychometric instruments including the Hamilton Depression Inventory and Eskin Suicidal Behavior Inventory.

RESULTS

Among the depressive patients, 61% fulfilled the criteria for PDD and 39% for episodic MDD. As compared with patients with episodic MDD, the PDD patients were older (d=.54), lower in educational attainment (d=.55), more likely to have comorbid generalized anxiety disorder (OR=3.7), and more prone to report symptoms of anxiety, hopelessness, pessimism, and somatic complaints. Nevertheless, the PDD patients displayed heterogeneous characteristics with respect to clinical severity and suicidal behavior.

CONCLUSION

Our findings suggest that majority of depressive patients, including those fulfilling the criteria for MDD, have been suffering from a persistent ailment rather than an episodic disorder. Clinicians with a cross-sectional perspective are more likely to diagnose MDD, whereas those with a longitudinal perspective are more likely to identify PDD in the majority of depressive patients. The incorporation of both of these perspectives into DSM-5 in a complementary manner will possibly enhance our insight into depressive disorders and improve our treatment results.

Counselling versus low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression (CLICD): a pilot/feasibility randomised controlled trial

BACKGROUND

Persistent depressive symptoms below the threshold criteria for major depression represent a chronic condition with high risk of progression to a diagnosis of major depression. The evidence base for psychological treatments such as Person-Centred Counselling and Low-Intensity Cognitive Behavioural Therapy for sub-threshold depressive symptoms and mild depression is limited, particularly for longer-term outcomes.

METHODS

This study aimed to test the feasibility of delivering a randomised controlled trial into the clinical and cost effectiveness of Low-Intensity Cognitive Behavioural Therapy versus Person-Centred Counselling for patients with persistent sub-threshold depressive symptoms and mild depression. The primary outcome measures for this pilot/feasibility trial were recruitment, adherence and retention rates at six months from baseline. An important secondary outcome measure was recovery from, or prevention of, depression at six months assessed via a structured clinical interview by an independent assessor blind to the participant's treatment condition. Thirty-six patients were recruited in five general practices and were randomised to either eight weekly sessions of person-centred counselling each lasting up to an hour, or up to eight weeks of cognitive-behavioural self-help resources with guided telephone support sessions lasting 20-30 minutes each.

RESULTS

Recruitment rate in relation to the number of patients approached at the general practices was 1.8 %. Patients attended an average of 5.5 sessions in both interventions. Retention rate for the 6-month follow-up assessments was 72.2 %. Of participants assessed at six months, 71.4 % of participants with a diagnosis of mild depression at baseline had recovered, while 66.7 % with a diagnosis of persistent subthreshold depression at baseline had not developed major depression. There were no significant differences between treatment groups for both recovery and prevention of depression at six months or on any of the outcome measures.

CONCLUSIONS

It is feasible to recruit participants and successfully deliver both interventions in a primary care setting to patients with subthreshold and mild depression; however recruiting requires significant input at the general practices. The evidence from this study suggests that short-term Person-Centred Counselling and Low-Intensity Cognitive Behaviour Therapy are potentially effective and their effectiveness should be evaluated in a larger randomised controlled study which includes a health economic evaluation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60972025 .

The association between depressive symptoms and physical status including physical activity, aerobic and muscular fitness tests in children

OBJECTIVES

The aims of the study were to explore the association between depressive symptoms (DS), physical activity (PA), aerobic and muscular fitness in a sample of children.

METHODS

Four hundred and fifty-six schoolboys aged 7-11-year-old underwent standard anthropometry and various physical fitness tests (e.g., aerobic fitness, strength, speed, power, agility and flexibility). DS and PA were obtained by questionnaires.

RESULTS

After adjustment for potential confounders (e.g., age, socioeconomic status and adiposity), PA was significantly and negatively related to DS (P < 0.05). Among the physical fitness tests, just time in one-mile run/walk was significantly related to DS (P < 0.05).

CONCLUSION

Physical activity and aerobic fitness were significantly correlated with DS; however, no significant relationship was observed between DS and the muscular fitness tests in the children.

Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance

BACKGROUND

Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression.

METHODS

Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance.

RESULTS

Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients.

LIMITATIONS

The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions.

CONCLUSIONS

The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.

Improving work outcomes of dysthymia (persistent depressive disorder) in an employed population

OBJECTIVE

To test the effectiveness of a work-focused intervention (WFI) on the work outcomes of employed adults with dysthymia.

METHOD

This subgroup analysis from a randomized controlled trial compares an initial sample of 167 employees (age: ≥45 years), screened for dysthymia using the PC-SAD without current major depressive disorder randomized to WFI (n=85) or usual care (UC) (n=82). Study sites included 19 employers and five additional organizations. Telephone-based WFI counseling (eight, twice monthly 50-min sessions) provided work coaching and modification, care coordination and cognitive behavioral therapy. Adjusted mixed effects models compared the WFI vs. UC group preintervention to 4-month postintervention change in at-work limitations measured by the Work Limitations Questionnaire. Secondary outcome analysis compared the change in self-reported absences and depression symptom severity (Patient Health Questionnaire PHQ-9 scores).

RESULTS

Work productivity loss scores improved 43.0% in the WFI group vs. 4.8% in UC (difference in change: P<.001). Absence days declined by 58.3% in WFI vs. 0.0% in UC (difference in change: P=.09). Mean PHQ-9 depression symptom severity declined 44.2% in WFI vs. 5.3% in UC (difference in change: P<.001).

CONCLUSION

At 4 months, the WFI was more effective than UC on two of the three outcomes. It could be an important mental and functional health improvement resource for the employed dysthymic population.

Counselling versus Low-Intensity Cognitive Behavioural Therapy for persistent sub-threshold and mild Depression (CLICD): study protocol for a pilot/feasibility randomised controlled trial

Background

Persistent sub-threshold depressive symptoms are important because almost all patients who experience symptoms for more than 2 years go on to develop major depressive episodes. The National Institute for Health and Care Excellence in the United Kingdom recommends research into the efficacy of person centred counselling and low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression.

Methods/design

A two-arm, parallel group, pilot randomised trial to test the key components of trial delivery. The participants will be 50 patients with the diagnosis of persistent sub-threshold depressive symptoms and mild depression, recruited at five general practices in Glasgow, Scotland. Eligible patients will be randomised to receive either Person-Centred Counselling (PCC) or Low-Intensity Cognitive Behavioural Therapy (LI-CBT). The primary outcome measures are recruitment, adherence and retention rates at six months from baseline. The secondary outcome measures are changes at 6 months on GRID-HAMD-17; recovery from, or prevention of, depression according to DSM-IV diagnosis at 6 months; changes at 6 months on the PHQ-9, WSAS, EQ5D, and SF12v2 MH Enhanced.

We will provide estimates, with adequate precision, to help design future studies, of the recruitment rate and the proportion followed-up at 6 months; and identify potential moderators of outcome.

Discussion

Evidence of comparative effectiveness of commonly used psychological treatments such as person-centred counselling and low intensity cognitive behavioural therapy is lacking in patients with sub-threshold and mild depression. This study will provide the information needed to construct a trial comparing these two treatments. This would help to inform early intervention treatment strategies for these conditions.

Trial registration

Current Controlled Trials ISRCTN Register ID: ISRCTN60972025

Schema therapy for patients with chronic depression: a single case series study

BACKGROUND AND OBJECTIVES

This study tested the effectiveness of schema therapy (ST) for patients with chronic depression.

METHODS

Twelve patients with a diagnosis of chronic depression participated. The treatment protocol consisted of 60 sessions, with the first 55 sessions offered weekly and the last five sessions on a biweekly basis. A single case series A-B-C design, with 6 months follow-up was used. Baseline (A) was a wait period of 8 weeks. Baseline was followed by introduction to ST and bonding to therapist (phase B) with individually tailored length of 12-16 sessions, after which further ST was provided (phase C) up to 60 sessions (included the sessions given as introduction). Patients were assessed with Hamilton Rating Scale for Depression three times during baseline, at the end of phase B, then every 12 weeks until the end of treatment and at 6 months follow-up. Secondary outcome measures were the Hamilton Rating Scale for Anxiety and the Young Schema Questionnaire.

RESULTS

At the end of treatment 7 patients (approximately 60%) remitted or satisfactorily responded. The mean HRSD dropped from 21.07 during baseline to 9.40 at post-treatment and 10.75 at follow-up. The effects were large and the gains of treatment were maintained at 6-month follow-up. Only one patient dropped out for reasons not related to treatment.

LIMITATIONS

The lack of control group, the small sample and the lack of a multiple baseline case series.

CONCLUSIONS

This preliminary study supports the use of ST as an effective treatment for chronic depression.

Effect of specific psychotherapy for chronic depression on neural responses to emotional faces

BACKGROUND

Neurofunctional deficits in chronic depression (CD) have been understudied. Specifically there is no known published study of the effects of a specialized psychotherapy for CD (CBASP) on neurofunctional deficits.

METHODS

Ten patients with a DSM-IV diagnosis of CD received a 12 week specialised psychotherapy (CBASP). Controls were healthy matched volunteers. All subjects participated in a prospective study with functional magnetic resonance imaging (fMRI) at baseline and after 12 weeks. During the fMRI scans, subjects performed an implicit and explicit emotional processing task while watching dynamic displays of neutral, positive (happy) and negative (fearful and sad) facial expressions. Effects of treatment were analyzed in a repeated measures design. The analysis was restricted to two anatomically defined regions of interest (ROI): the amygdala and the cingulum.

RESULTS

60% of patients responded to treatment. Patients with CD reported increased arousal to negative emotional expressions. They also showed an increase in left amygdala reactivity during implicit processing of emotional expressions following psychotherapy. We found no significant effect for the cingulum.

LIMITATIONS

The main limitation of our study is the small sample size. Due to the lack of a control group it is also unclear whether the demonstrated effect is specific to the psychotherapy used in this study.

CONCLUSIONS

For the first time our study demonstrates an effect of CBASP on neural processing of facial emotions in CD. It therefore adds to the growing evidence supporting this treatment.

Frontoparietal function in young people with dysthymic disorder (DSM-5: Persistent depressive disorder) during spatial working memory

BACKGROUND

Dysthymic disorder (DD) is a depressive disorder characterised by persistent low and/or irritable mood and has been identified as a major risk factor for developing major depressive disorder (MDD). MDD and DD have been associated with executive function difficulties of working memory and attention. Little is known about how executive function networks in the brain are affected in children and adolescents with MDD and even less in DD. This study used fMRI and two spatial working memory paradigms to investigate associated brain function in young people with DD and an age-, gender- and IQ- matched typically developing group.

METHODS

Nineteen male patients with DD (mean age 11.2±1.5 years) diagnosed according to DSM-IV criteria and 16 typically developing boys (mean age 10.5±1.1 years) performed a mental rotation and a delay-match to sample (DMTS) task while undergoing fMRI. All participants were medication-naïve at the time of testing.

RESULTS

Compared to typically developing young people, the DD group showed less activation in left frontal regions including left ventro- and dorsolateral prefrontal cortices (PFC) during mental rotation. Medial frontal regions including dorsomedial PFC, anterior cingulate cortex and frontal pole also showed relatively reduced activation. During the DMTS task patients showed significantly more activation in the right precuneus and posterior cingulate cortex.

LIMITATIONS

This was a cross-sectional study with a small sample limiting the generalizability of the results.

CONCLUSIONS

The results complement previous findings in adults with MDD that have shown differential activation of left PFC regions during working memory tasks. Additionally, altered function of cortical midline structures in young patients with DD was identified. This supports findings in children, adolescents and adults with MDD suggesting that the pathophysiology of depressive disorders extends to DD as a risk factor for MDD and exhibits continuity over the lifespan.

Depressive symptoms and pain complaints as predictors of later development of depression in Portuguese middle-aged women

Pain complaints and depressive symptoms seem to be risk factors for future depressive episodes. We present a one-year follow-up study on Portuguese women and primary health care (initial sample: n = 503). We used the Center for Epidemiologic Studies Depression Scale (CES-D), a short questionnaire on pain, and clinical interviews. We used forward stepwise logistic regression analysis to define models that enable the prediction of developing a major depressive episode in the one-year follow-up. We concluded that nondepressed women with (a) high scores (≥28) at the CES-D, (b) a high severity of pain index, and (c) fatigue complaints at the baseline were particularly at risk.

Obsessive-compulsive disorder; chronic versus non-chronic symptoms

OBJECTIVE

Understanding chronicity in OCD is hampered by contradictory findings arising from dissimilar definitions of chronic OCD. The purpose of this study was to investigate the magnitude of chronicity in OCD and to examine if chronic OCD is critically different from non-chronic OCD, using a chronicity definition that reflects empirical findings.

METHOD

Baseline data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, in which 379 OCD patients participated, were analyzed. Chronic OCD was defined as "continuous presence of at least moderately severe OCD symptoms during at least two years", and was assessed retrospectively using a Life-Chart Interview.

RESULTS

Application of the chronicity criterion resulted in two groups with highly distinguishable course patterns. The majority of the sample (61.7%) reported a chronic course. Patients with a chronic course reported significantly more severe OCD symptoms, more illness burden, more comorbidity, an earlier OCD onset and more contamination and washing - and symmetry and ordering symptoms. Multivariable logistic regression analysis revealed that chronic OCD was independently associated with more OCD-subtypes (p<0.001), contamination and washing symptoms (p<0.001), earlier OCD onset (p=0.05) and higher severity of compulsions (p<.01).

LIMITATIONS

The findings are based on a cross-sectional survey. Furthermore course was assessed retrospectively, implying the possibility of overestimation of persistence and severity of symptoms.

CONCLUSION

Chronicity is the rule rather than the exception in OCD in clinical samples. Chronic OCD is critically different from non-chronic OCD. Further attempts to break down the heterogeneity of OCD in homogeneous course subtypes should be made to allow for a more precise determination of the pathogenesis of OCD and better treatment.

The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles?

PURPOSE OF REVIEW

Dysthymic disorder and other chronic depressive disorders have recently been merged in DSM-5 into a 'persistent depressive disorder' category. As its introduction in DSM-III, the validity of dysthymic disorder has long been challenged, posing concerns regarding the validity of its successor--persistent depressive disorder. This review aims to present recent findings regarding the validity and utility of dysthymic disorder.

RECENT FINDINGS

Several recent studies raise questions regarding the validity of dysthymic disorder, namely, results indicating a significant overlap between dysthymic disorder and other mood and/or anxiety disorders, failure of such a diagnosis to predict illness outcome and the lack of any validation strategy identifying that it is a depressive entity or subtype.

SUMMARY

Research findings indicate that dysthymic disorder is a heterogeneous diagnosis encompassing many different depressive (and anxiety or personality weighted) conditions, and without clear evidence of its validity as a diagnostic entity. As dysthymic disorder is a key component of DSM-defined persistent depressive disorder--the latter is at similar risk of providing a heterogeneous domain diagnosis, and thus limiting identification of specific causative factors and preferential treatment modality.

Baseline characteristics of depressive disorders in Thai outpatients: findings from the Thai Study of Affective Disorders

BACKGROUND

The Thai Study of Affective Disorders was a tertiary hospital-based cohort study developed to identify treatment outcomes among depressed patients and the variables involved. In this study, we examined the baseline characteristics of these depressed patients.

METHODS

Patients were investigated at eleven psychiatric outpatient clinics at tertiary hospitals for the presence of unipolar depressive disorders, as diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The severity of any depression found was measured using the Clinical Global Impression and 17-item Hamilton Depression Rating Scale (HAMD) clinician-rated tools, with the Thai Depression Inventory (a self-rated instrument) administered alongside them. Sociodemographic and psychosocial variables were collected, and quality of life was also captured using the health-related quality of life (SF-36v2), EuroQoL (EQ-5D), and visual analog scale (EQ VAS) tools.

RESULTS

A total of 371 outpatients suffering new or recurrent episodes were recruited. The mean age of the group was 45.7±15.9 (range 18-83) years, and 75% of the group was female. In terms of diagnosis, 88% had major depressive disorder, 12% had dysthymic disorder, and 50% had a combination of both major depressive disorder and dysthymic disorder. The mean (standard deviation) scores for the HAMD, Clinical Global Impression, and Thai Depression Inventory were 24.2±6.4, 4.47±1.1, and 51.51±0.2, respectively. Sixty-two percent had suicidal tendencies, while 11% had a family history of depression. Of the major depressive disorder cases, 61% had experienced a first episode. The SF-36v2 component scores ranged from 25 to 56, while the mean (standard deviation) of the EQ-5D was 0.50±0.22 and that of the EQ VAS was 53.79±21.3.

CONCLUSION

This study provides an overview of the sociodemographic and psychosocial characteristics of patients with new or recurrent episodes of unipolar depressive disorders.

Clinical features of patients with dysthymia in a large cohort of Han Chinese women with recurrent major depression

Background

Dysthymia is a form of chronic mild depression that has a complex relationship with major depressive disorder (MDD). Here we investigate the role of environmental risk factors, including stressful life events and parenting style, in patients with both MDD and dysthymia. We ask whether these risk factors act in the same way in MDD with and without dysthymia.

Results

We examined the clinical features in 5,950 Han Chinese women with MDD between 30–60 years of age across China. We confirmed earlier results by replicating prior analyses in 3,950 new MDD cases. There were no significant differences between the two data sets. We identified sixteen stressful life events that significantly increase the risk of dysthymia, given the presence of MDD. Low parental warmth, from either mother or father, increases the risk of dysthymia. Highly threatening but short-lived threats (such as rape) are more specific for MDD than dysthymia. While for MDD more severe life events show the largest odds ratio versus controls, this was not seen for cases of MDD with or without dysthymia.

Conclusions

There are increased rates of stressful life events in MDD with dysthymia, but the impact of life events on susceptibility to dysthymia with MDD differs from that seen for MDD alone. The pattern does not fit a simple dose-response relationship, suggesting that there are moderating factors involved in the relationship between environmental precipitants and the onset of dysthymia. It is possible that severe life events in childhood events index a general susceptibility to chronic depression, rather than acting specifically as risk factors for dysthymia.

Persistence of chronic major depression: a national prospective study

BACKGROUND

Chronic major depressive disorder (CMDD) is highly prevalent and associated with high personal and societal cost. Identifying risk factors for persistence and remission of CMDD may help in developing more effective treatment and prevention interventions.

METHODS

Prospective cohort study of individuals participating in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1; n=43,093) and its 3-year follow-up (Wave 2; n=34,653) who met a diagnosis of CMDD at the Wave 1 assessment.

RESULTS

Among the 504 respondents who met criteria for present CMDD at Wave 1, only 63 (11.52%) of them continued to meet criteria of CMDD. A history of childhood sexual abuse, earlier onset of MDD, presence of comorbidity and a history of treatment-seeking for depression predicted persistence of CMDD three years after the baseline evaluation.

LIMITATIONS

Our sample is limited to adults, our follow-up period was only three-years and the diagnosis of CMDD at baseline was retrospective.

CONCLUSIONS

CMDD shows high rates of remission within three years of baseline assessment, although some specific risk factors predict a persistent course. Given the high personal and societal cost associated with CMDD, there is a need to develop and disseminate effective interventions for CMDD.

[Dysthymia in the Clinical Context]

Dysthymia is defined as a chronic mood disorder that persists for at least two years in adults, and one year in adolescents and children. According to DSM IV-TR, Dysthymia is classified into two subtypes: early-onset, when it begins before 21 years-old, and late onset Dysthymia, when it starts after this age. Before age 21, symptoms of conduct disorder, attention deficit disorder and hyperactivity with a few vegetative symptoms are usually present. It is important to distinguish it from other types of depression, as earlier as possible. This would allow providing these patients with the appropriate treatment to attenuate the impact of symptoms, such as poor awareness of self-mood, negative thinking, low self-esteem, and low energy for social and family activities, which progressively deteriorate their life quality. The etiology of Dysthymia is complex and multifactorial, given the various biological, psychological and social factors involved. Several hypotheses attempt to explain the etiology of Dysthymia, highlighting the genetic hypothesis, which also includes environmental factors, and an aminergic hypothesis suggesting a deficiency in serotonin, norepinephrine and dopamine in the central nervous system. From our point of view, dysthymia cannot be conceived as a simple mild depressive disorder. It is a distinct entity, characterized by a chronic depressive disorder which could persist throughout life, with important repercussions on the life quality of both patients and families.

Staging of mental disorders: systematic review

BACKGROUND

The staging method, whereby a disorder is characterized according to its seriousness, extension, development and features, is attracting increasing attention in clinical psychology and psychiatry. The aim of this systematic review was to critically summarize the tools that are available for reproducing and standardizing the clinical intuitions that are involved in a staging formulation.

METHODS

A comprehensive research was conducted on the MEDLINE, PsycINFO, EMBASE and Cochrane databases from inception to May 2012. The following search terms were used: 'stage/staging' AND 'psychiatric disorder/mental disorder/schizophrenia/mood disorder/anxiety disorder/substance use disorder/eating disorder'.

RESULTS

A total of 78 studies were identified for inclusion in the review. We discussed studies addressing or related to the issue of staging in a number of mental disorders (schizophrenia, unipolar depression, bipolar disorder, panic disorder, substance use disorders, anorexia and bulimia nervosa). The literature indicates that disorders have a longitudinal development or a treatment history that can be categorized according to stages. We proposed staging formulations for the above-mentioned psychiatric disorders.

CONCLUSION

Staging models offer innovative assessment tools for clinical psychologists and psychiatrists. Characterizing each stage of an illness demarcates major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same psychiatric diagnosis. A stage 0 to denote an at-risk condition does not appear to be warranted at the current state of research.

Comparison of the Effect of Mindfulness-based Cognitive Therapy Accompanied by Pharmacotherapy With Pharmacotherapy Alone in Treating Dysthymic Patients

BACKGROUND

Dysthimia in adults is a chronic depression disorder which is characterized by a mild depression for at least 2 years. Remarkable psycho-social involvements, greater disturbances in psycho-social functions compared to other forms of depression and lack of definite findings about preferred treatment for this disorder led us to evaluate the effectiveness of Mindfulness based cognitive therapy (MBCT) method adjunct to pharmacotherapy compared with pharmachothrapy alone in treating dysthymia in this thesis.

OBJECTIVES

This study aimed to evaluate the effectiveness of mindfulness-based cognitive therapy on a chronic type of depression disorder called dysthymia.

PATIENTS AND METHODS

This study is a clinical trial of an interventional method which was carried out on dysthymic and double depressed patients who had referred to psychiatric clinics of Shiraz University of Medical Sciences, Shiraz, Iran. In doing so, 50 patients above the age of 18 were selected through convenience sampling and assigned into intervention and control groups. The control group only received medications while the intervention group in addition to receiving medication, participated in 8 sessions of a mindfulness based cognitive therapy course which was held once a week and each session lasted for 2 to 2.5 hours. All the participants filled out Beck Depression Inventory II and five facet mindfulness questionnaire. The data were analyzed using the SPSS statistical software (version 16) and univariate covariance and independent t test statistical methods.

RESULTS

In this study, no statistically significant differences were found between the two groups regarding the demographic characteristics. The mean difference between the two groups was statistically significant for the variables in post-test considering the pre-test. The experimental group participants showed significant improvement in terms of the defined variables; a trend which was not observed in the control group participants.

CONCLUSION

The results of this study show that adding MBCT to pharmacotherapy in treatment of dysthymic patients can cause significant improvement in depression symptoms and mindfulness skills in patients compared to pharmacotherapy alone.

Abnormal functional brain asymmetry in depression: evidence of biologic commonality between major depression and dysthymia

Prior studies have found abnormalities of functional brain asymmetry in patients having a major depressive disorder (MDD). This study aimed to replicate findings of reduced right hemisphere advantage for perceiving dichotic complex tones in depressed patients, and to determine whether patients having "pure" dysthymia show the same abnormality of perceptual asymmetry as MDD. It also examined gender differences in lateralization, and the extent to which abnormalities of perceptual asymmetry in depressed patients are dependent on gender. Unmedicated patients having either a MDD (n=96) or "pure" dysthymic disorder (n=42) and healthy controls (n=114) were tested on dichotic fused-words and complex-tone tests. Patient and control groups differed in right hemisphere advantage for complex tones, but not left hemisphere advantage for words. Reduced right hemisphere advantage for tones was equally present in MDD and dysthymia, but was more evident among depressed men than depressed women. Also, healthy men had greater hemispheric asymmetry than healthy women for both words and tones, whereas this gender difference was not seen for depressed patients. Dysthymia and MDD share a common abnormality of hemispheric asymmetry for dichotic listening.

Frontal brain asymmetry in depression with comorbid anxiety: a neuropsychological investigation

The approach-withdrawal model posits that depression and anxiety are associated with a relative right asymmetry in frontal brain activity. Most studies have tested this model using measures of cortical brain activity such as electroencephalography. However, neuropsychological tasks that differentially use left versus right frontal cortical regions can also be used to test hypotheses from the model. In two independent samples (Study 1 and 2), the present study investigated the performance of currently depressed individuals with or without a comorbid anxiety disorder and healthy controls on neuropsychological tasks tapping primarily left (verbal fluency) or right (design fluency) frontal brain regions. Across both samples, results indicated that comorbid participants performed more poorly than depressed only and control participants on design fluency, while all groups showed equivalent performance on verbal fluency. Moreover, comorbid participants showed "asymmetrical" performance on these two tasks (i.e., poorer design [right frontal] relative to verbal [left frontal] fluency), whereas depressed only and control participants showed approximately symmetrical profiles of performance. Results from these two samples suggest an abnormal frontal asymmetry in neurocognitive performance driven primarily by right frontal dysfunction among anxious-depressed individuals and highlight the importance of considering comorbid anxiety when examining frontal brain functioning in depression.

Parental sexual abuse and suicidal behaviour among women with major depressive disorder

OBJECTIVE

Women with major depressive disorder (MDD) and childhood sexual abuse histories have an increased risk for suicidal behaviours, but it is unclear whether specific abuse characteristics contribute to risk. We aimed to examine the contributions of abuse characteristics to lifetime history of suicide attempts and multiple suicide attempts, independent of posttraumatic stress disorder and borderline personality disorder.

METHOD

Women with MDD and sexual abuse histories (n = 106) were assessed regarding sexual abuse characteristics, psychiatric diagnoses, and suicide attempts.

RESULTS

In multivariate logistic regressions, the odds of having multiple suicide attempts increased 12.27-fold when childhood sexual abuse was perpetrated by a parent figure or a parent, compared with a nonparent.

CONCLUSIONS

Parental perpetration of sexual abuse increases the likelihood of multiple suicide attempts among women outpatients. The relationship of the perpetrator to the abused woman is important in suicide risk evaluation and treatment planning.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00843700.

The influence of the comorbidity between depression and alcohol use disorder on suicidal behaviors in the São Paulo Epidemiologic Catchment Area Study, Brazil

OBJECTIVE

To investigate in a community sample the association of suicide-related cognitions and behaviors ("thoughts of death", "desire for death", "suicidal thoughts", and "suicidal attempts") with the comorbidity of depressive disorders (major depressive episode or dysthymia) and alcohol or substance use disorders.

METHOD

The sample was 1464 subjects interviewed in their homes using the Composite International Diagnostic Interview to generate DSM-III-R diagnosis. Descriptive statistics depicted the prevalence of suicide-related cognitions and behaviors by socio-demographic variables and diagnoses considered (major depressive episode, dysthymia, alcohol or substance use disorders). We performed a multivariate logistic regression analysis to estimate the effect of comorbid major depressive episode/dysthymia and alcohol or substance use disorders on each of the suicide-related cognitions and behaviors.

RESULTS

The presence of major depressive episode and dysthymia was significantly associated with suicide-related cognitions and behaviors. In the regression models, suicide-related cognitions and behaviors were predicted by major depressive episode (OR=range 2.3-9.2) and dysthymia (OR=range 5.1-32.6), even in the presence of alcohol use disorders (OR=range 2.3-4.0) or alcohol or substance use disorders (OR=range 2.7-2.8). The interaction effect was observed between major depressive episode and alcohol use disorders, as well as between dysthymia and gender. Substance use disorders were excluded from most of the models.

CONCLUSION

Presence of major depressive episode and dysthymia influences suicide-related cognitions and behaviors, independently of the presence of alcohol or substance use disorders. However, alcohol use disorders and gender interact with depressive disorders, displaying a differential effect on suicide-related cognitions and behaviors.