Family study of chronic depression in a community sample of young adults

Challenges in the treatment of dysthymia: a narrative review

INTRODUCTION

Despite its milder severity, the chronic nature of dysthymia leads to significant impairments and functional limitations. The treatment of dysthymia has received considerably less research attention compared to major depressive disorder (MDD).

AREAS COVERED

The authors have conducted a comprehensive review on the treatment of dysthymia. Their primary objective was to identify therapeutic options that have demonstrated genuine efficacy. To do this, they searched the PubMed database, without any time restrictions, to retrieve original studies. The samples were exclusively comprised individuals diagnosed with dysthymia according to the diagnostic criteria outlined in DSM-III, DSM-III-R, DSM-IV, or DSM-IV-TR.

EXPERT OPINION

Within the realm of dysthymia treatment, several antidepressants, including imipramine, sertraline, paroxetine, minaprine, moclobemide, and amineptine, in addition to the antipsychotic agent amisulpride, have demonstrated superiority over placebo. In certain studies, psychotherapeutic interventions did not distinguish themselves significantly from pharmacological treatments and failed to exhibit greater efficacy than a placebo. However, these findings remain inconclusive due to the limited number of studies and substantial methodological limitations prevalent in a significant proportion of them. Limitations include factors like small sample sizes, the absence of placebo comparisons, and a lack of study blinding.

The influence of the gut-brain axis on anxiety and depression: A review of the literature on the use of probiotics

This review aims to argue how using probiotics can improve anxiety and depressive behaviour without adverse effects, also exploring the impact of postbiotics on it. Specifically, probiotics have drawn more attention as effective alternative treatments, considering the rising cost of antidepressant and anti-anxiety drugs and the high risk of side effects. Depression and anxiety disorders are among the most common mental illnesses in the world's population, characterised by low mood, poor general interest, and cognitive or motor dysfunction. Thus, this study analysed published literature on anxiety, depression, and probiotic supplementation from PubMed and Scopus, focusing on the last twenty years. This study focused on the effect of probiotics on mental health as they have drawn more attention because of their extensive clinical applications and positive impact on various diseases. Numerous studies have demonstrated how the gut microbiota might be critical for mood regulation and how probiotics can affect host health by regulating the gut-brain axis. By comparing the different works analysed, it was possible to identify a strategy by which they are selected and employed and, at the same time, to assess how the effect of probiotics can be optimised using postbiotics, an innovation to improve mental well-being in humans.

Classification of recurrent major depressive disorder using a new time series feature extraction method through multisite rs-fMRI data

BACKGROUND

Major depressive disorder (MDD) has a high rate of recurrence. Identifying patients with recurrent MDD is advantageous in adopting prevention strategies to reduce the disabling effects of depression.

METHOD

We propose a novel feature extraction method that includes dynamic temporal information, and inputs the extracted features into a graph convolutional network (GCN) to achieve classification of recurrent MDD. We extract the average time series using an atlas from resting-state functional magnetic resonance imaging (fMRI) data. Pearson correlation was calculated between brain region sequences at each time point, representing the functional connectivity at each time point. The connectivity is used as the adjacency matrix and the brain region sequences as node features for a GCN model to classify recurrent MDD. Gradient-weighted Class Activation Mapping (Grad-CAM) was used to analyze the contribution of different brain regions to the model. Brain regions making greater contribution to classification were considered to be the regions with altered brain function in recurrent MDD.

RESULT

We achieved a classification accuracy of 75.8 % for recurrent MDD on the multi-site dataset, the Rest-meta-MDD. The brain regions closely related to recurrent MDD have been identified.

LIMITATION

The pre-processing stage may affect the final classification performance and harmonizing site differences may improve the classification performance.

CONCLUSION

The experimental results demonstrate that the proposed method can effectively classify recurrent MDD and extract dynamic changes of brain activity patterns in recurrent depression.

Differences in White Matter Structural Networks in Family Risk of Major Depressive Disorder and Suicidality: A Connectome Analysis

Background

Depression and suicide are leading global causes of disability and death and are highly familial. Family and individual history of depression are associated with neurobiological differences including decreased white matter connectivity; however, this has only been shown for individual regions. We use graph theory models to account for the network structure of the brain with high levels of specialization and integration and examine whether they differ by family history of depression or of suicidality within a three-generation longitudinal family study with well-characterized clinical histories.

Methods

Clinician interviews across three generations were used to classify family risk of depression and suicidality. Then, we created weighted network models using 108 cortical and subcortical regions of interest for 96 individuals using diffusion tensor imaging derived fiber tracts. Global and local summary measures (clustering coefficient, characteristic path length, and global and local efficiencies) and network-based statistics were utilized for group comparison of family history of depression and, separately, of suicidality, adjusted for personal psychopathology.

Results

Clustering coefficient (connectivity between neighboring regions) was lower in individuals at high family risk of depression and was associated with concurrent clinical symptoms. Network-based statistics showed hypoconnected subnetworks in individuals with high family risk of depression and of suicidality, after controlling for personal psychopathology. These subnetworks highlighted cortical-subcortical connections including between the superior frontal cortex, thalamus, precuneus, and putamen.

Conclusions

Family history of depression and of suicidality are associated with hypoconnectivity between subcortical and cortical regions, suggesting brain-wide impaired information processing, even in those personally unaffected.

The Reliability and Validity of Response-Based Measures of Attention Bias

Background

Attention bias to threat is a fundamental transdiagnostic component and potential vulnerability factor for internalizing psychopathologies. However, the measurement of attentional bias, such as traditional scores from the dot-probe paradigm, evidence poor reliability and do not measure intra-individual variation in attentional bias.

Methods

The present study examined, in three independent samples, the psychometric properties of a novel attentional bias (AB) scoring method of the dot-probe task based on responses to individual trials. For six AB scores derived using the response-based approach, we assessed the internal consistency, test-retest reliability, familial associations, and external validity (using Social Anxiety Disorder, a disorder strongly associated with attentional bias to threatening faces).

Results

Compared to traditional AB scores, response-based scores had generally better internal consistency (range of Cronbach's alphas: 0.68-0.92 vs. 0.41-0.71), higher test-retest reliabilities (range of Pearson's correlations: 0.26-0.77 vs. -0.05-0.35), and were more strongly related in family members (range of ICCs: 0.11-0.27 vs. 0-0.05). Furthermore, three response-based scores added incremental validity beyond traditional scores and gender in the external validators of current and lifetime Social Anxiety Disorder.

Conclusions

Findings indicate that response-based AB scores from the dot-probe task have better psychometric properties than traditional scores.

Prevalence of depression and its potential contributing factors in patients with enterostomy: A meta-analytical review

OBJECTIVE

In patients with intestinal pathologies, the placement of a stoma bag affects multiple aspects of their perceived quality of life. This meta-analysis aims to evaluate the prevalence of depression among patients with enterostomy and to determine the underlying factors that could explain the potential heterogeneity of this prevalence.

METHODS

Relevant published studies were identified by searching PubMed, Embase, PsycINFO, Cochrane, CINAHL, Scopus, and Web of Science until May 2022. The random-effects model was used to determine the pooled prevalence of depression among patients with enterostomy using cross-sectional studies from various countries. Meta-regression and subgroup analysis were performed to identify factors contributing to heterogeneity. Quality assessment of the included studies was conducted using the Newcastle-Ottawa scale for nonrandomized studies.

RESULTS

The pooled prevalence of depressive symptoms among patients with enterostomy, as calculated using the random-effects model, was 41.6% (95% confidence interval [CI]: 25.4-59.7%, Q-value = 145.794, df = 8, p < 0.001, tau^∧2 = 1.124, I^∧2 = 94.513). The meta-regression found that mean age and gender were not significant moderators for the observed heterogeneity in prevalence. Subgroup analysis according to the indications for enterostomy formation showed that the prevalence of depression was highest in patients with colorectal cancer, at 34.4% (95% CI: 27.2-42.4%). Subgroup analysis by region showed that patients in Africa had the highest prevalence of depression, at 88.2% (95% CI: 76.1-94.6%), compared to other regions. Subgroup analysis by stoma indication was not significant.

CONCLUSION

This meta-analysis reports that the pooled prevalence of depression among patients with enterostomy is 41.6%. Indications for enterostomy formation, as well as geographical region, were identified as potential sources of heterogeneity. These findings highlight the need for appropriate psychosocial support and interventions at different stages of enterostomy placement.

ADHD and depression: investigating a causal explanation

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is associated with later depression and there is considerable genetic overlap between them. This study investigated if ADHD and ADHD genetic liability are causally related to depression using two different methods.

METHODS

First, a longitudinal population cohort design was used to assess the association between childhood ADHD (age 7 years) and recurrent depression in young-adulthood (age 18-25 years) in N = 8310 individuals in the Avon Longitudinal Study of Parents and Children (ALSPAC). Second, two-sample Mendelian randomization (MR) analyses examined relationships between genetic liability for ADHD and depression utilising published Genome-Wide Association Study (GWAS) data.

RESULTS

Childhood ADHD was associated with an increased risk of recurrent depression in young-adulthood (OR 1.35, 95% CI 1.05-1.73). MR analyses suggested a causal effect of ADHD genetic liability on major depression (OR 1.21, 95% CI 1.12-1.31). MR findings using a broader definition of depression differed, showing a weak influence on depression (OR 1.07, 95% CI 1.02-1.13).

CONCLUSIONS

Our findings suggest that ADHD increases the risk of depression later in life and are consistent with a causal effect of ADHD genetic liability on subsequent major depression. However, findings were different for more broadly defined depression.

Depression risk factors and affect dynamics: An experience sampling study

Affect dynamics reflect individual differences in how emotional information is processed, and may provide insights into how depressive episodes develop. To extend prior studies that examined affect dynamics in currently depressed individuals, the present study tested in 68 non-depressed young adults whether three well-established risk factors for major depressive disorder (MDD) - (a) past episodes of MDD, (b) family history of MDD, and (c) reduced neurophysiological responses to reward - predicted mean levels, instability, or inertia (i.e., inflexibility) of positive affect (PA) and/or negative affect (NA). Momentary PA and NA were assessed up to 6 times per day for 14 days (mean number of surveys completed = 45.89). MDD history and family history of MDD were assessed via semi-structured interview, and neurophysiological responses to reward were indexed using the Reward Positivity, an event-related potential related to depression. After adjusting for current depressive symptoms, results indicated that (a) past episodes of MDD predicted higher mean levels of NA, (b) family history of MDD predicted greater PA inertia, and (c) blunted reactivity to reward predicted greater NA inertia. Collectively, these results suggest that elevated mean levels of NA and inflexibility of PA and NA may be potential mechanisms that confer risk for depression.

Offspring of Mothers With Histories of Chronic and Non-chronic Depression: Symptom Trajectories From Ages 6 to 15

Several studies have reported that individuals with chronic depression have higher rates of depressive disorders, and particularly chronic depression, in their first-degree relatives, compared to those with non-chronic (episodic) major depression. In addition, a few studies have suggested that offspring of parents with chronic depression have elevated rates of depression and other psychopathology. Most of this work uses the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines chronicity as persistence for at least 2 years. An alternative is a life-course, approach, which evaluates overall course since first onset. We examined the trajectories of depressive, anxiety, and externalizing symptoms in a community sample of 577 offspring of mothers with histories of chronic depression, non-chronic (or episodic) major depression, and no depression using prospective, multi-informant assessments from age 6 to age 15. Offspring of mothers with a history of depression exhibited higher levels of depression, anxiety, and externalizing symptoms than offspring of mothers who were never depressed. Moreover, the effects of maternal depression on offspring depression, anxiety, and externalizing symptoms were more pronounced for mothers with histories of chronic than non-chronic depression, particularly when the life-course approach to classifying chronicity was used. These data suggest that research that combines chronic and non-chronic depressions includes significant heterogeneity that may hinder understanding of etiology and reduce the likelihood of developing a cumulative and replicable literature. In addition, these findings have significant implications for prevention and treatment.

Distress Tolerance as a Familial Vulnerability for Distress-Misery Disorders

Low perceived distress tolerance (DT), a trait-like individual difference factor reflecting one's perceived ability to withstand aversive affective states, has been linked with current internalizing and substance use disorders (SUDs). However, perceived DT has not been systematically evaluated as a familial, transdiagnostic vulnerability factor for internalizing and SUDs. The current study tested whether perceived DT runs in families and whether it is reduced among individuals with versus without remitted internalizing/SUD psychopathology. Perceived DT and internalizing/SUDs were measured in 638 individuals (nested within 256 families). Analyses also adjusted for the effects of neuroticism to test whether DT was a specific vulnerability factor independent of temperamental negative affect. Analyses revealed that perceived DT was lower in individuals with remitted distress (i.e., major depression, generalized anxiety disorder, posttraumatic stress disorder) but not fear disorders (i.e., panic disorder, social anxiety disorder, specific phobia, obsessive-compulsive spectrum disorders) relative to healthy controls, and the effect of distress-misery disorder history remained significant when adjusting for neuroticism. Perceived DT was not significantly different among individuals with versus without a remitted SUD. There were no effects for comorbid SUD and distress-misery disorders. Finally, perceived DT was also significantly correlated within families, suggesting that it runs in families. Overall, results suggest that independent of neuroticism, low perceived DT is a familial vulnerability for distress (but not fear or substance use) disorders.

Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications

Persistent depressive disorder is a chronic mood disorder that is common and often more disabling than episodic major depression. In DSM-5, the term subsumes several chronic depressive presentations, including dysthymia with or without superimposed major depressive episodes, chronic major depression, and recurrent major depression without recovery between episodes. Dysthymia can be difficult to detect in psychiatric and primary care settings until it intensifies in the form of a superimposed major depressive episode. Although information is scarce concerning the cause of persistent depressive disorder including dysthymia, the causation is likely to be multifactorial. In this narrative Review, we discuss current knowledge about the nosology and neurobiological basis of dysthymia and persistent depressive disorder, emphasising a dimensional perspective based on course for further research. We also review new developments in psychotherapy and pharmacotherapy for persistent depressive disorder, and propose a tailored, modular approach to accommodate its multifaceted nature.

Double trouble: Do symptom severity and duration interact to predicting treatment outcomes in adolescent depression?

Studies suggest that depression severity and duration interact to predict outcomes in depression treatment. To our knowledge, no study has explored this question in a sample with a placebo control, two therapies, and their combination nor with adolescents. We used data from the Treatment of Adolescent Depression Study (N=439), in which adolescent were randomized to placebo (PBO), cognitive-behavioral therapy (CBT), antidepressants medications (MEDs), or their combination (COMB). We explore the interaction between depression severity, chronicity, and treatments (vs. placebo) in predicting outcomes. There was interaction between severity and chronicity when comparing COMB and CBT with PBO, but not MEDs. In non-chronic depression, the effects of CBT were inversely related to severity to the point that CBT appeared iatrogenic with more severe depression. In chronic depression, the effects of CBT did not vary by severity, but the relative effects of COMB grew, being smallest in milder, more dysthymic-like depression, and largest in chronic-severe depression. These findings support calls to classify depression by severity and chronicity as well efforts to risk stratify patients to different intensity of care according to these variables.

Neuroimaging Biomarkers for Predicting Treatment Response and Recurrence of Major Depressive Disorder

The acute treatment duration for major depressive disorder (MDD) is 8 weeks or more. Treatment of patients with MDD without predictors of treatment response and future recurrence presents challenges and clinical problems to patients and physicians. Recently, many neuroimaging studies have been published on biomarkers for treatment response and recurrence of MDD using various methods such as brain volumetric magnetic resonance imaging (MRI), functional MRI (resting-state and affective tasks), diffusion tensor imaging, magnetic resonance spectroscopy, near-infrared spectroscopy, and molecular imaging (i.e., positron emission tomography and single photon emission computed tomography). The results have been inconsistent, and we hypothesize that this could be due to small sample size; different study design, including eligibility criteria; and differences in the imaging and analysis techniques. In the future, we suggest a more sophisticated research design, larger sample size, and a more comprehensive integration including genetics to establish biomarkers for the prediction of treatment response and recurrence of MDD.

Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball

BACKGROUND

Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group.

METHODS

After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions.

RESULTS

Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls.

LIMITATIONS

The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate.

CONCLUSIONS

These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.

Effect of Parenting and Peer Stressors on Cognitive Vulnerability and Risk for Depression among Youth

Parenting behaviors influence clinical depression among youth, but little is known about the developmental processes that may account for this association. This study investigated whether parenting is associated with the onset of clinical depression and depressive symptoms through negative cognitive style, particularly under conditions of high exposure to stressors, in a community sample of children and adolescents (N = 275; 59% girls). Observational methods were used to assess positive and negative parenting during a laboratory social-evaluative stressor task. Depressive symptoms and clinical depressive episodes were repeatedly assessed over an 18-month prospective follow-up period. Results supported a conditional indirect effect in which low levels of observed positive parenting during a youth stressor task were indirectly associated with an increased likelihood of experiencing an episode of depression and worsening depressive symptoms over the course of the study through youth negative cognitive style, but only for youth who also experienced a high number of peer stressors. These findings elucidate mechanisms through which problematic parenting may contribute to risk for the development of clinical depression during the transition into and across adolescence. Implications for depression interventions are discussed.

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.

Differences between chronic and nonchronic depression: Systematic review and implications for treatment

BACKGROUND

There is still uncertainty if and to what extent chronic depression (CD) presents with specific features especially in contrast to the nonchronic course of major depressive disorder (non-CD). This systematic review aims to summarize the existing literature regarding sociodemographic factors, psychopathology, and course of disease in patients with CD in comparison to patients with non-CD.

METHODS

A structured database search (MEDLINE, PsycINFO, Web of Science, CENTRAL) was performed. All studies comparing CD with non-CD patients were included. Twenty-eight studies, including cohort studies, cross-sectional studies, and observational studies, were identified in which both subgroups were diagnosed according to DSM-IV or DSM-5, respectively. Primary outcome were group comparisons focused on sociodemographic factors, childhood adversity, onset of the disorder, comorbidities, severity and course of the depressive symptoms, and specific psychopathology.

RESULTS

Patients with CD had an earlier onset of depressive symptoms, higher rates of psychiatric comorbidities, and a complicated treatment course (e.g., higher rates of suicidality) compared to non-CD. We also found some evidence for specific features in the psychopathology of CD patients (submissive and hostile interpersonal styles) in contrast to non-CD patients. Results were inconsistent with regard to childhood maltreatment. No differences were found regarding the severity of depressive symptoms and most sociodemographic factors.

CONCLUSION

Despite some inconsistencies, the results of this review verified important differences between CD and non-CD. However, future research is needed to characterize especially the specific psychopathology of CD in comparison to non-CD patients to develop more tailored treatment strategies.

The influence of family factors on time to suicidal ideation onsets during the adolescent developmental period

Family factors are associated with suicidal behavior in youth, but little is known about how the joint influence of multiple family factors prospectively predicts onsets of suicidal ideation (SI) in adolescence, a developmental period characterized by increases in SI and risk for suicide. This study investigated whether parent history of SI interacted with either positive or negative parent-child relationship quality to longitudinally predict time to SI onsets during the transition into and across adolescence. Specifically, we used a longitudinal, multi-wave design and survival analyses to examine whether the interaction between these family factors prospectively predicted time to emergence of SI onsets (assessed at 6 month intervals over 3 years) in a community sample of youth ages 8 to 15 (N = 238; 57% girls). Results supported an interaction effect, such that more negative relationship quality with parents predicted earlier emergence of SI among those youth whose parents had no history of SI. However, negative parent relationship quality did not amplify risk among youth with parent history of SI; all youth with a parent history of SI were more likely to experience earlier emergence of SI regardless of level of negative relationship quality. Findings did not support an interaction between low levels of parent-child positive relationship quality and parent history of ideation. Implications for the role of family factors in the etiology and prevention of SI are discussed.

Affective and cognitive reactivity to mood induction in chronic depression

BACKGROUND

Chronic depression (CD) is strongly associated with childhood maltreatment, which has been proposed to lead to inefficient coping styles that are characterized by abnormal affective responsiveness and dysfunctional cognitive attitudes. However, while this notion forms an important basis for psychotherapeutic strategies in the treatment of CD, there is still little direct empirical evidence for a role of altered affective and cognitive reactivity in CD. The present study therefore experimentally investigated affective and cognitive reactivity to two forms of negative mood induction in CD patients versus a healthy control sample (HC).

METHODS

For the general mood induction procedure, a combination of sad pictures and sad music was used, while for individualized mood induction, negative mood was induced by individualized scripts with autobiographical content. Both experiments included n = 15 CD patients versus n = 15 HC, respectively. Interactions between affective or cognitive reactivity and group were analyzed by repeated measurements ANOVAs.

RESULTS

General mood induction neither revealed affective nor cognitive reactivity in the patient group while the control group reported the expected decrease of positive affect [interaction (IA) affective reactivity x group: p = .011, cognitive reactivity x group: n.s.]. In contrast, individualized mood induction specifically increased affective reactivity (IA: p = .037) as well as the amount of dysfunctional cognitions in patients versus controls (IA: p = .014).

LIMITATIONS

The experiments were not balanced in a crossover design, causal conclusions are thus limited. Additionally, the differences to non-chronic forms of depression are still outstanding.

CONCLUSIONS

The results suggest that in patients with CD, specific emotional activation through autobiographical memories is a key factor in dysfunctional coping styles. Psychotherapeutic interventions aimed at modifying affective and cognitive reactivity are thus of high relevance in the treatment of CD.

Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model - are we there yet?

A number of factors (biogenic amine deficiency, genetic, environmental, immunologic, endocrine factors and neurogenesis) have been identified as mechanisms which provide unitary explanations for the pathophysiology of depression. Rather than a unitary construct, the combination and linkage of these factors have been implicated in the pathogenesis of depression. That is, environmental stressors and heritable genetic factors acting through immunologic and endocrine responses initiate structural and functional changes in many brain regions, resulting in dysfunctional neurogenesis and neurotransmission which then manifest as a constellation of symptoms which present as depression.

Attachment representations, patterns of emotion regulation, and social exclusion in patients with chronic and episodic depression and healthy controls

BACKGROUND

The experience of social exclusion (ostracism) is linked to the etiology and maintenance of depression. Most individuals experience emotional stress in states of social exclusion. Insecurely attached individuals, especially with an unresolved trauma, show maladaptive coping in response to social stress. The present study examines (a) the differences with regards to attachment representations in episodic (ED) and chronic depressive (CD) inpatients and (b) how ostracism affects their emotional reactions.

METHODS

Patients with CD (n=29) and ED (n=23) and healthy control subjects (n=29) were interviewed using the Adult Attachment Projective Picture System (AAP), a valid measure to assess attachment representation; and played a virtual ball tossing game simulating social exclusion (Cyberball). Multiple depression-related risk and protective factors were considered. We hypothesized that CD patients show the most severe attachment disorganization and are emotionally most affected by the social exclusion situation. Moreover, we explored the interaction between ostracism and attachment.

RESULTS

Contradicting our hypotheses, ED and CD individuals were almost akin with regards to their attachment insecurity/disorganization and reactions to Cyberball. An emotionally altered reaction to social exclusion was identified in the insecure-disorganized depressive subgroup.

LIMITATIONS

Small sample size hampering further subgroup analyses. The ED sample may include single CD subjects with recent manifestation.

CONCLUSIONS

The pattern of emotion regulation in the depressive groups matches with findings from clinical studies, including attachment research. The relationship between attachment representations and ostracism should be further investigated in larger samples of depressive individuals.

The recovery index: A novel approach to measuring recovery and predicting remission in major depressive disorder

BACKGROUND

Clinicians view "recovery" as the reduction in severity of symptoms over time, whereas patients view it as the restoration of premorbid functioning level and quality of life (QOL). The main purpose of this study is to incorporate patient-reported measures of functioning and QOL into the assessment of patient outcomes in MDD and to use this data to define recovery.

METHOD

Using the STAR*D study of patients diagnosed with MDD, this present analysis grades patients' MDD severity, functioning level, and QOL at exit from each level of the study, as well as at follow-up. Using Item Response Theory, we combined patient data from functioning and QOL measures (WSAS, Q-LES-Q) in order to form a single latent dimension named the Recovery Index.

RESULTS

Recovery Index - a latent measure assessing impact of illness on functioning and QOL - is able to predict remission of MDD in patients who participated in the STAR*D study.

CONCLUSIONS

By incorporating functioning and quality of life, the Recovery index creates a new dimension towards measuring restoration of health, in order to move beyond basic symptom measurement.

Pericardial adipose tissue and the metabolic syndrome is increased in patients with chronic major depressive disorder compared to acute depression and controls

OBJECTIVE

Major depressive disorder (MDD) is associated with an estimated fourfold risk for premature death, largely attributed to cardiovascular disorders. Pericardial adipose tissue (PAT), a fat compartment surrounding the heart, has been implicated in the development of coronary artery disease. An unanswered question is whether people with chronic MDD are more likely to have elevated PAT volumes versus acute MDD and controls (CTRL).

METHODS

The study group consists of sixteen patients with chronic MDD, thirty-four patients with acute MDD, and twenty-five CTRL. PAT and adrenal gland volume were measured by magnetic resonance tomography. Additional measures comprised factors of the metabolic syndrome, cortisol, relative insulin resistance, and pro-inflammatory cytokines (interleukin-6; IL-6 and tumor necrosis factor-α, TNF-α).

RESULTS

PAT volumes were significantly increased in patients with chronic MDD>patients with acute MDD>CTRL. Adrenal gland volume was slightly enlarged in patients with chronic MDD>acute MDD>CTRL, although this difference failed to reach significance. The PAT volume was correlated with adrenal gland volume, and cortisol concentrations were correlated with depression severity, measured by BDI-2 and MADRS. Group differences were found concerning the rate of the metabolic syndrome, being most frequent in chronic MDD>acute MDD>CTRL. Further findings comprised increased fasting cortisol, increased TNF-α concentration, and decreased physical activity level in MDD compared to CTRL.

CONCLUSION

Our results extend the existing literature in demonstrating that patients with chronic MDD have the highest risk for developing cardiovascular disorders, indicated by the highest PAT volume and prevalence of metabolic syndrome. The correlation of PAT with adrenal gland volume underscores the role of the hypothalamus-pituitary-adrenal system as mediator for body-composition changes. Metabolic monitoring, health advices and motivation for the improvement of physical fitness may be recommended in depressed patients, in particular in chronic depression.

Course of depression in a 10-year prospective study: Evidence for qualitatively distinct subgroups

The course of depressive disorders can vary considerable, with some individuals exhibiting a chronic course and poor outcomes, while others have a more episodic course and better outcomes. However, it is unclear whether degree of chronicity is continuous or reflects qualitatively distinct subgroups. Using data from a 5-wave, 10-year, naturalistic study of 127 depressed outpatients, we examined whether depression chronicity lies on a continuum or manifests natural boundaries. Spline regression was used to test 7 continuous and discontinuous models of the relationship between depression during the first follow-up interval and multiple outcomes at subsequent follow-ups. In order to further validate the findings, we also created empirically derived subgroups based on the results of the spline regression analyses and compared them on baseline clinical characteristics and long-term outcomes. There was a clear and consistent discontinuity indicating that for higher levels of chronicity during the first 30-month period, depression was linearly related to outcome; in contrast, for lower levels of chronicity, depression in the initial interval was unrelated to subsequent outcomes. The findings were strikingly consistent across the 4 follow-up evaluations using multiple outcomes and goodness-of-fit indices. In addition, the chronic group--as defined by the first follow-up period--exhibited more baseline chronic depression, anxiety and personality disorders, family history of dysthymia, and childhood adversity, and was more likely to attempt suicide and be hospitalized during follow-up, than the nonchronic group. Results suggest that there are qualitatively distinct classes of patients with more and less chronic depressions, and support the utility of longitudinal course as a means of parsing depression into more homogeneous subgroups.

Theory of Mind in Depressive Disorders: A Review of the Literature

BACKGROUND

Theory of mind (ToM) is the ability to infer the mental states of others in order to understand and predict their behaviour. This ability is thought to be essential to social functioning and interpersonal relationships. As major depression is characterized by considerable social and interpersonal difficulties, exploration of the quality of ToM functioning can be particularly relevant in this and in related disorders. We aim to review the current state of research on ToM in depressive disorders in order to find out the extent to which ToM impairment is associated with these illnesses.

METHODS

An internet database search was carried out to collect all publications on the subject.

RESULTS

A total of 32 publications in English met our inclusion criteria: (a) 17 studies on ToM in major depression, (b) 4 studies on ToM in psychotic depression, (c) 3 studies on ToM in dysphoria or mild depression, (d) 4 studies on ToM in euthymic major depression, (e) 2 studies on ToM in chronic versus episodic depression, and (f) 2 studies on ToM in another psychiatric disorder with comorbid major depression.

CONCLUSIONS

Despite an increased interest in the research of the topic in recent years, no firm conclusions can be drawn, as the reviewed articles present some conflicting results. Acutely depressed patients have been found to be impaired on tasks involving both ToM social-perceptual and social-cognitive components. On the other hand, a number of studies have not reported significant between-group differences between depressed patients and healthy controls or have found minimal differences. Further research is needed in order to confirm and extend these results.

Parental depression and child cognitive vulnerability predict children's cortisol reactivity

Risk for depression is expressed across multiple levels of analysis. For example, parental depression and cognitive vulnerability are known markers of depression risk, but no study has examined their interactive effects on children's cortisol reactivity, a likely mediator of early depression risk. We examined relations across these different levels of vulnerability using cross-sectional and longitudinal methods in two community samples of children. Children were assessed for cognitive vulnerability using self-reports (Study 1; n = 244) and tasks tapping memory and attentional bias (Study 2; n = 205), and their parents were assessed for depression history using structured clinical interviews. In both samples, children participated in standardized stress tasks and cortisol reactivity was assessed. Cross-sectionally and longitudinally, parental depression history and child cognitive vulnerability interacted to predict children's cortisol reactivity; associations between parent depression and elevated child cortisol activity were found when children also showed elevated depressotypic attributions as well as attentional and memory biases. Findings indicate that models of children's emerging depression risk may benefit from the examination of the interactive effects of multiple sources of vulnerability across levels of analysis.

Premorbid risk factors for major depressive disorder: are they associated with early onset and recurrent course?

Premorbid risk for major depressive disorder (MDD) and predictors of an earlier onset and recurrent course were examined in two studies in a large, community-based sample of parents and offspring, prospectively assessed from late childhood into adulthood. In Study 1 (N = 2,764 offspring and their parents), parental psychiatric status, offspring personality at age 11, and age 11 offspring internalizing and externalizing symptoms predicted the subsequent development of MDD, as did poor quality parent-child relationships, poor academic functioning, early pubertal development, and childhood maltreatment by age 11. Parental MDD and adult antisocial behavior, offspring negative emotionality and disconstraint, externalizing symptoms, and childhood maltreatment predicted an earlier onset of MDD, after accounting for course; lower positive emotionality, trait anxiety, and childhood maltreatment predicted recurrent MDD, after accounting for age of onset. In Study 2 (N = 7,146), we examined molecular genetic risk for MDD by extending recent reports of associations with glutamatergic system genes. We failed to confirm associations with MDD using either individual single nucleotide polymorphism based tests or gene-based analyses. Overall, results speak to the pervasiveness of risk for MDD, as well as specific risk for early onset MDD; risk for recurrent MDD appears to be largely a function of its often earlier onset.

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.

[The temporal relationship between anxiety and depression during the school transition between primary and high-school]

Depression and anxiety are among the most prevalent disorders in the adolescent population. An increase of the prevalence of these disorders is taking place during adolescence, this developmental period being experienced in synchronicity with the high school transition. Also, some studies suggested the existence of a developmental trend between the onset of anxiety and depression. This longitudinal study explored the temporal relationship between anxiety and depression during the transition from primary to high school.

GOALS

first, this study examined whether the presence of anxiety in grade 6 (Time 1) increases the risk of depression in grade 8 (Time 2). Then a subgroup of comorbid students, who presented anxiety and depression, was compared with a subgroup of anxious ones on the presence of cognitive distortions. It was assessed whether cognitive distortions in the anxious group in Time 1 influenced the development of comorbidity between anxiety and depression in Time 2.

METHOD

146 students from 12 public schools, 62 girls and 84 boys (mean = 11.22 years) participated in this study. This sub sample was drowned from a larger sample of 499 students, in a 9 years longitudinal study (2003-2012). Participants completed the questionnaire and were met for an interview at the beginning of each school year. Parents consent was obtained. In Time 1, students were divided into two subgroups, anxious and non-anxious students. At time 2, two subgroups of students were constituted, either anxious or comorbid anxious and depressed students. Depression was controlled at time 1.The Dominic Interactive for Adolescents (Valla, 2000) was used to measure the presence of anxiety and depression. The correlation (.34 to .62) between the three anxiety scales (separation anxiety, generalized anxiety and phobia) allowed to create an unique anxiety score. Cognitive distortions (related to dependence, achievement and self control) were measured by the Dysfunctional Attitudes Scale (Weisseman & Beck, 1978).

RESULTS

The hierarchical log linear analyse revealed a tendency between the presence of anxiety in Time 1 and the development of depression in Time 2, only for girls (p=.08), so that 25% of anxious girls at Time 1 became depressive at Time 2, compare to 0% of non anxious girls. For boys, whether anxiety is present or not, the two subgroups presented the same risk to develop depression. Then, results of a Manova analysis revealed that anxious students at time 1 already adopted cognitive distortions related to dependency and to achievement, usually associated with depression. At time 2, the result of the Manova revealed that comorbid students presented more cognitive distortions related to dependency then the anxious students. However, non significant results were found for the longitudinal analyse, which did not supported the existence of a predicting link between the presence of depressogenous cognitive distortions at Time 1 in the anxious subgroup of students and the emergence of comorbidity at Time 2.

CONCLUSION

The results of the present study testified the importance to prevent depression, especially for anxious school girls. Anxiety seems to have a different role for girls and boys. A trend was observed between the presence of an anxiety disorder in Grade 6 and the development of a depressive disorder 2 years later, among girls only. This result raises the importance to understand the role of anxiety in girls to reduce their risk to develop a depressive disorder. Our results also showed that anxious students in grade 6, already presented cognitive distortions related to dependency and achievement which are associated with depression while comorbid students in the second year of high school presented more cognitive distortions related to dependency only, when they were compared with the anxious group.

The serotonin transporter linked polymorphic region and brain-derived neurotrophic factor valine to methionine at position 66 polymorphisms and maternal history of depression: associations with cognitive vulnerability to depression in childhood

Preliminary work indicates that cognitive vulnerability to depression may be associated with variants of the serotonin transporter promoter polymorphism (5-HTTLPR) and the valine to methionine at position 66 (val66met) polymorphism of the brain-derived neurotrophic factor (BDNF) gene; however, existing reports come from small samples. The present study sought to replicate and extend this research in a sample of 375 community-dwelling children and their parents. Following a negative mood induction, children completed a self-referent encoding task tapping memory for positive and negative self-descriptive traits. Consistent with previous work, we found that children with at least one short variant of the 5-HTTLPR had enhanced memory for negative self-descriptive traits. The BDNF val66met polymorphism had no main effect but was moderated by maternal depression, such that children with a BDNF methionine allele had a heightened memory for negative self-descriptive traits when mothers had experienced depression during children's lifetimes; in contrast, children with a methionine allele had low recall of negative traits when mothers had no depression history. The findings provide further support for the notion that the 5-HTTLPR is associated with cognitive markers of depression vulnerability and that the BDNF methionine allele moderates children's sensitivity to contextual factors.

A comparison of vulnerability factors in patients with persistent and remitting lifetime symptom course of depression

BACKGROUND

Research has suggested fundamental differences between patients with persistent and those with remitting courses of depression. This study investigated whether patients with different lifetime symptom course configurations differ in early risk and cognitive vulnerability factors.

METHODS

Patients with at least three previous episodes who were currently in remission were categorized based on visual timelines of their lifetime symptom course and compared with regard to a number of different indicators of vulnerability including questionnaire measures of childhood trauma and experiential avoidance.

RESULTS

Of the N=127 patients, n=47 showed a persistent course of the disorder with unstable remissions and symptoms most of the time, and n=59 showed a course with more stable, lasting remissions. Group comparisons indicated that patients with a more persistent course were significantly more likely to have suffered from childhood emotional abuse, and reported higher levels of experiential avoidance as well as related core beliefs. Experiential avoidance partially mediated the effect of childhood emotional abuse on persistence of symptoms.

LIMITATIONS

The study is cross-sectional and does not allow conclusions with regard to whether differentiating variables are causally related to chronicity. Self-report measures may be subject to reporting biases.

CONCLUSIONS

The results highlight the detrimental effects of childhood adversity and suggest that experiential avoidance may play an important role in mediating such effects.

Neural activity in relation to empirically derived personality syndromes in depression using a psychodynamic fMRI paradigm

OBJECTIVE

The heterogeneity between patients with depression cannot be captured adequately with existing descriptive systems of diagnosis and neurobiological models of depression. Furthermore, considering the highly individual nature of depression, the application of general stimuli in past research efforts may not capture the essence of the disorder. This study aims to identify subtypes of depression by using empirically derived personality syndromes, and to explore neural correlates of the derived personality syndromes.

MATERIALS AND METHODS

In the present exploratory study, an individually tailored and psychodynamically based functional magnetic resonance imaging paradigm using dysfunctional relationship patterns was presented to 20 chronically depressed patients. RESULTS from the Shedler-Westen Assessment Procedure (SWAP-200) were analyzed by Q-factor analysis to identify clinically relevant subgroups of depression and related brain activation.

RESULTS

The principle component analysis of SWAP-200 items from all 20 patients lead to a two-factor solution: "Depressive Personality" and "Emotional-Hostile-Externalizing Personality." Both factors were used in a whole-brain correlational analysis but only the second factor yielded significant positive correlations in four regions: a large cluster in the right orbitofrontal cortex (OFC), the left ventral striatum, a small cluster in the left temporal pole, and another small cluster in the right middle frontal gyrus.

DISCUSSION

The degree to which patients with depression score high on the factor "Emotional-Hostile-Externalizing Personality" correlated with relatively higher activity in three key areas involved in emotion processing, evaluation of reward/punishment, negative cognitions, depressive pathology, and social knowledge (OFC, ventral striatum, temporal pole). RESULTS may contribute to an alternative description of neural correlates of depression showing differential brain activation dependent on the extent of specific personality syndromes in depression.

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.

Predicting relapse in major depressive disorder using patient-reported outcomes of depressive symptom severity, functioning, and quality of life in the Individual Burden of Illness Index for Depression (IBI-D)

BACKGROUND

Patients with Major Depressive Disorder (MDD) often experience unexpected relapses, despite achieving remission. This study examines the utility of a single multidimensional measure that captures variance in patient-reported Depressive Symptom Severity, Functioning, and Quality of Life (QOL), in predicting MDD relapse.

METHODS

Complete data from remitted patients at the completion of 12 weeks of citalopram in the STAR*D study were used to calculate the Individual Burden of Illness index for Depression (IBI-D), and predict subsequent relapse at six (n=956), nine (n=778), and twelve months (n=479) using generalized linear models.

RESULTS

Depressive Symptom Severity, Functioning, and QOL were all predictors of subsequent relapse. Using Akaike information criteria (AIC), the IBI-D provided a good model for relapse even when Depressive Symptom Severity, Functioning, and QOL were combined in a single model. Specifically, an increase of one in the IBI-D increased the odds ratio of relapse by 2.5 at 6 months (β=0.921 ± 0.194, z=4.76, p<2 × 10(-6)), by 2.84 at 9 months (β=1.045 ± 0.22, z=4.74, p<2.2 × 10(-6)), and by 4.1 at 12 months (β=1.41 ± 0.29, z=4.79, p<1.7 × 10(-6)).

LIMITATIONS

Self-report poses a risk to measurement precision. Using highly valid and reliable measures could mitigate this risk. The IBI-D requires time and effort for filling out the scales and index calculation. Technological solutions could help ease these burdens. The sample suffered from attrition. Separate analysis of dropouts would be helpful.

CONCLUSIONS

Incorporating patient-reported outcomes of Functioning and QOL in addition to Depressive Symptom Severity in the IBI-D is useful in assessing the full burden of illness and in adequately predicting relapse, in MDD.

The categorisation of dysthymic disorder: can its constituents be meaningfully apportioned?

BACKGROUND

Since its introduction in DSM-III, the validity of dysthymia has been debated. Our objective is to further examine the concept of dysthymia in an outpatient sample, and explore whether its constituents can be meaningfully apportioned.

METHODS

318 patients attending the Black Dog Institute Depression Clinic were assessed by the Mini-International Neuropsychiatric Interview, and completed several self-report measures, in addition to a clinical assessment by an Institute psychiatrist. The characteristics of patients with major depressive disorder (MDD), dysthymic disorder and double depression were examined. Latent Class Analysis (LCA) and Latent Profile Analysis (LPA) were then conducted with the aim of detecting distinct classes based on depressive symptomatology and personality domains, respectively. Finally, clinicians' formulations of the study patients were examined.

RESULTS

Depression groups mainly differed on parameters of severity. Although LCA and LPA analyses indicated the presence of distinct classes, these only moderately correlated with the MINI-diagnosed groups. Finally, there was evidence for considerable heterogeneity within clinicians' formulations of dysthymia.

LIMITATIONS

Inadequate sample numbers for various measures limited the power of the LPA and our sample was weighted to patients with a more severe depressive condition which may affect the detection of a distinct 'dysthymic' personality profile.

CONCLUSIONS

Despite employing a variety of techniques, we were unable to obtain a clear homogeneous picture of dysthymia. Rather, there was evidence for a distinct heterogeneity in clinician-derived diagnoses. These findings allude to the questionable discriminant validity of dysthymia and may encourage future research and discussion on this important topic.

Contrasting chronic with episodic depression: an analysis of distorted socio-emotional information processing in chronic depression

BACKGROUND

The specific features that differentiate chronic and episodic depression are widely unknown. This study compares the chronic and episodic form of depression with regard to two domains of socio-emotional information processing: Decoding of other people's emotional states (Theory of Mind) and the perception of own emotions (alexithymia).

METHOD

This study compares 30 chronically and 29 episodically depressed patients by tapping into Theory of Mind deficits with a multi-method approach and by assessing alexithymic deficits. Furthermore, a retrospective assessment of adverse relational childhood experiences is administered.

RESULTS

The observed results reveal distorted information processing in only one of the two domains: Chronically depressed patients scored higher in alexithymia than episodically depressed patients, while no group differences in the domain of Theory of Mind were found. Moreover, alexithymia was found to mediate the influence of adverse relational childhood experiences on depression type (chronic vs. episodic).

LIMITATIONS

Due to the reliance on retrospective and self-report data, results should be interpreted with due caution. In addition, the cross-sectional design limits causal conclusions.

CONCLUSIONS

These results suggest a potentially central role of the deficient perception of own emotions in causing or maintaining chronic depression. Derived practical implications include a focus on the perception of own emotions in the psychotherapy of chronic depression. If future research continues to uncover systematic differences in the psychopathology of chronic and episodic depression, chronicity should be more strongly considered when classifying unipolar depressive disorders.

Phenomenological differences between acute and chronic forms of major depression in inpatients

BACKGROUND

Chronic forms of depression are highly prevalent especially in inpatient settings. Defined only by episode duration greater than 2 years, heterogeneous diagnoses like dysthymic disorder, double depression, major depression and recurrent major depression are included. Chronic depression is considered difficult to treat, although its distinguishing characteristics remain unclear.

AIMS

The purpose of the present study was empirically to approach proposed differences between acute and chronic forms of depression.

METHODS

80 psychiatric inpatients positively screened for depression and diagnosed with the Composite International Diagnostic Interview (CIDI), completed a set of questionnaires regarding symptom severity (a simplified version of the Beck Depression Inventory), dysfunctional attitudes (Dysfunctional Attitudes Scale), ruminative response style (Response Styles Questionnaire, Why Ruminate Scale) and interpersonal problems (Inventory of Interpersonal Problems; IIP).

RESULTS

30 patients were diagnosed with chronic forms of depression; 34 patients with acute depression. Patients did not differ regarding symptom severity, ruminative response styles, all but one subscales of the IIP or presence of comorbid post-traumatic stress disorder. However, chronic depression did show higher dysfunctional attitudes than acute depression, and reported higher rates of socially avoidant behavior.

CONCLUSIONS

In line with previous findings, acute and chronic forms of depression differed in dysfunctional attitudes, which might actually reflect a distinguishing pattern of chronicity. Chronic depression patients also reported higher socially avoidant behavior, which might be crucial to focus in treatment. Surprisingly, other variables that are assumed to characterize chronic depression could not be confirmed as distinguishing features. Future research should take etiological aspects into account.

Epidemiology of chronic and nonchronic major depressive disorder: results from the national epidemiologic survey on alcohol and related conditions

BACKGROUND

Burden related to major depressive disorder (MDD) derives mostly from long-term occurrence of symptoms. This study aims to examine the prevalence, sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization of chronic major depressive disorder (CMDD) compared to nonchronic major depressive disorder.

METHODS

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalence of CMDD within the population meeting criteria for MDD was 26.5% and 24.0%, respectively. Individuals reporting a chronic course of MDD were socioeconomically and educationally disadvantaged, tended to be older, report loss of spouse or history of divorce, live in rural areas, have public assistance, low self-esteem, worse overall health and more likely to report comorbidities, most importantly dysthymia, generalized anxiety disorder, avoidant, and dependant personality disorder. Individuals with chronic MDD were more likely to report familial but not childhood onset risk factors for MDD. Those suffering CMDD were more likely to seek and receive mental health care than other forms of MDD, even though it took longer to start treatment.

CONCLUSION

Chronic course of MDD is related to still worse socioeconomic conditions, educational achievement, more comorbidities, and family risk factors, although other courses of MDD carried greater risk of unmet treatment.

Risk factors for chronic depression--a systematic review

BACKGROUND

One of five patients with an acute depressive episode develops chronic depression. Risk factors for a current depressive episode to become chronic are insufficiently known. This review was conducted to examine which factors represent a risk factor for the development of chronic depression for patients diagnosed with a depressive episode.

METHOD

Medline, Psycinfo, ISI Web of Science, CINHAL and BIOSIS Previews were searched up until September 2007, complemented by handsearching in the December 1987 to December 2007 issues of Journal of Affective Disorders and investigating reference lists of included articles and existing reviews. On the basis of a formal checklist, two investigators independently decided which studies to include or exclude.

RESULTS

25 relevant primary studies with a total of 5192 participants were included in the systematic review. Overall the methodological quality of the included studies was found to be sufficient. Data synthesis was performed via vote counting. The following risk factors were identified: younger age at onset, longer duration of depressive episode, and family history of mood disorders. Psychological comorbidity i.e. anxiety disorders, personality disorders and substance abuse, low level of social integration, negative social interaction and lower severity of depressive symptoms repeatedly appeared concurrently with chronic depression.

LIMITATIONS

Most included studies were cross-sectional thus drawing causal conclusions with regard to risk factors proved to be difficult.

CONCLUSION

Risk factors for a current depressive episode to become chronic were identified. To date only few significant longitudinal studies on this topic are available.

Psychopharmacology of depression in children and adolescents

Although much debate continues about the prevalence of depressive disorders in prepubertal children, depression clearly is common in adolescents, increasing rapidly throughout the teen years. All physicians who work with young patients must to be able to recognize and treat these disorders. This article provides a brief overview of depressive disorders in children and adolescence, including their clinical presentation, prevalence, etiology, course, and prognosis. Psychopharmacological treatment options are reviewed in detail, including practical information for medication management including patient education, making the decision to treat with medication, selection of specific medications, strategies for nonresponsive patients, and decisions about stopping medication.

Serotonin transporter gene polymorphisms and chronic illness of depression

Clinical course of depression is variable. The serotonin transporter gene is one of the most studied genes for depression. We examined the association of serotonin transporter gene polymorphisms with chronicity and recurrent tendency of depression in Korean subjects. This cross-sectional study involved 252 patients with major depression. Patients were genotyped for s/l polymorphisms in 5-HTT promoter region (5-HTTLPR), s/l variation in second intron of the 5-HTT gene (5-HTT VNTR intron2). Chronicity was associated with 5-HTTLPR. Patients with l/l had higher rate of chronicity than the other patients (l/l vs s/l or s/s; odds ratio, 4.45; 95% confidence interval, 1.59-12.46; P=0.005; logistic regression analysis). Recurrent tendency was not associated with 5-HTTLPR. Chronicity and recurrent tendency were not associated with 5-HTT VNTR intron2. These results suggest that chronic depression is associated with 5-HTTLPR.

The epidemiology of chronic major depressive disorder and dysthymic disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To examine the prevalence of chronic major depressive disorder (CMDD) and dysthymic disorder, their sociodemographic correlates, patterns of 12-month and lifetime psychiatric comorbidity, lifetime risk factors, psychosocial functioning, and mental health service utilization.

METHOD

Face-to-face interviews were conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093).

RESULTS

The 12-month and lifetime prevalences were greater for CMDD (1.5% and 3.1%, respectively) than for dysthymic disorder (0.5% and 0.9%, respectively). Individuals with CMDD and dysthymic disorder shared most sociodemographic correlates and lifetime risk factors for major depressive disorder. Individuals with CMDD and dysthymic disorder had almost identically high rates of Axis I and Axis II comorbid disorders. However, individuals with CMDD received higher rates of all treatment modalities than individuals with dysthymic disorder.

CONCLUSIONS

Individuals with CMDD and dysthymic disorder share many sociodemographic correlates, comorbidity patterns, risk factors, and course. Individuals with chronic depressive disorders, especially those with dysthymic disorder, continue to face substantial unmet treatment needs.

Chronic Depression

Traditionally, non-bipolar depression has been viewed as an episodic, remitting condition. However, with the recognition that depressions can persist for many years, the current diagnostic classification system includes various forms of chronic depression. The distinction between chronic and nonchronic depressions is useful for reducing the heterogeneity of the disorder. Individuals with chronic depression differ from those with nonchronic depression on a variety of clinically and etiologically significant variables, including comorbidity, impairment, suicidality, history of childhood maltreatment, familial psychopathology, and long-term course. In contrast, there is little support for current distinctions between different forms of chronic depression. This suggests that it may be simpler to collapse the existing forms of chronic depression in the current classification system into a single category. However, there is growing evidence that other characteristics, such as age of onset and a childhood history of early adversity, may provide meaningful approaches to subtyping chronic depression.

Low level of parental bonding might be a risk factor among women with prolonged depression: a preliminary investigation

AIMS

The aim of the present study was to determine whether or not the effect of parenting by the father and mother on outcomes for depression may be different between male and female subjects.

METHODS

A total of 115 patients were involved in this investigation: 74 had states of depression that continued for more than 2 years, and 41 had symptoms that remitted within 4 months. The Parental Bonding Instrument (PBI) was used to test for gender differences in the PBI score, the level of education, and the age at which the depression began, using an unpaired t-test.

RESULTS

It is suggested that female patients with low paternal care and low levels of education have a higher likelihood of showing symptoms of prolonged depression in a primary episode. No relationship was found among prolongation of depression, educational level, and parental care in male patients. Furthermore, comparing the PBI quadrants established by Parker showed that female patients who were exposed to paternal care as 'Affectionless Control', had a tendency towards a higher risk of prolonged depression than female patients who received 'Optimal Parenting'.

CONCLUSION

Especially in female patients, the prolongation of depression is likely a result of low levels of paternal care and low education.

Independent associations between personality traits and clinical characteristics of depression

Few studies have examined age of onset and chronicity of depression in the same subject sample. The present study sought to determine whether personality traits related to early onset depression were different from those related to chronic depression. We tested the associations between personality self-reports and clinical characteristics of depression by conducting multiple and logistic regression analyses to determine whether personality uniquely predicted clinical characteristics and whether clinical characteristics uniquely predicted personality, after adjusting for depression severity. We also analyzed data at 6-month follow-up to determine whether age of onset and chronicity maintained their associations with personality. The study found that low levels of positive personality traits had unique associations with chronicity of depression, whereas elevated levels of negative personality traits had unique associations with an earlier onset of depression. Furthermore, associations were generally maintained over time, suggesting that associations between personality and these depression subtypes are stable.

Long-term depression versus episodic major depression: results from the prospective Zurich study of a community sample

BACKGROUND

Clinical studies have demonstrated a great clinical relevance of long-term depression (LTD). Our study aims to characterise LTD in comparison with episodic (non-chronic) major depressive episodes (MDE) on the basis of data from a community sample.

METHOD

The Zurich Cohort Study is a prospective study of young adults followed from age 20/21 to 40/41 with six interviews. The stratified sample consisted of two thirds high scorers and one third lower scorers on the Symptom Checklist-90 R (SCL-90-R). LTD was assessed from age 27/28 to 40/41 and defined as being symptomatic more days than not over 2 years plus the presence of work impairment. MDE and dysthymia were defined by DSM-III-R criteria.

RESULTS

The cumulative incidence of LTD was 5.7%, and of episodic MDE 20.9%. In both groups we found a similar preponderance of women. LTD subjects reported disturbed memory, feelings of inferiority, hopelessness, fear of everyday tasks, fear of being alone and thoughts of dying significantly more often than subjects with episodic MDE. Subjects with LTD had an earlier age of onset. 82% of them were treated over lifetime for depression compared to 61% with MDE. LTD subjects were less often married, less often in fulltime employment, more often unemployed, and more often receiving social benefits. LTD was comorbid with cardiac and respiratory syndromes, and LTD subjects were more frequently treated for insomnia and pain. They suffered significantly more from social phobia and benzodiazepine abuse; there was also a statistical trend to greater comorbidity with panic attacks, agoraphobia, obsessive-compulsive syndrome, binge eating and neurasthenia. Somatic and psychological well-being were also reduced.

CONCLUSIONS

LTD is common, clinically more serious than episodic MDE and highly comorbid.

LIMITATIONS

The sample is relatively small with an attrition rate of 38.5% over 20 years. The results cannot be generalised to persons over 40 years of age and may be dependent on the definition of LTD.

The long-term course of depression: development of an empirical index and identification of early adult outcomes

BACKGROUND

Research on the long-term course of major depressive disorder (MDD) is hindered by the absence of established course criteria and by idiosyncratic definitions of chronicity. The aims of this study were to derive an empirical index of MDD course, to examine its predictive validity, and to identify the adulthood outcomes associated with a chronic course.

METHOD

Indicators for a MDD course factor were rationally selected and subjected to principal components (PCA) and confirmatory factor analyses (CFA) among 426 subjects with a lifetime history of MDD by age 30. Scores on the index prior to age 19 were examined as predictors of course from age 19 to 30. Associations between the index and outcomes of interest at age 30 were examined.

RESULTS

Three indicators loaded highly on a chronic course index and displayed adequate internal consistency: early onset age, number of episodes, and duration of ill time. Predictive validity of the index was supported. A more chronic course was associated with greater symptom severity, greater likelihood of treatment utilization, and greater psychosocial impairment in multiple domains. Treatment utilization interacted with chronicity to predict relatively few outcomes and did not reduce the negative impact of a chronic course.

CONCLUSIONS

The course of MDD through early adulthood is best represented by a composite of early onset age, number of episodes, and duration of ill time. A chronic course through early adulthood is associated with numerous indicators of psychosocial impairment. Mental health treatment utilization in a naturalistic setting does not appear to reduce the negative impact of chronic MDD.

Classification of depressive disorders in the DSM-V: proposal for a two-dimension system

The number of categories and specifiers for mood disorders has increased with each successive edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM). Many of these categories and specifiers can be viewed as an effort to map the various permutations of severity and chronicity that characterize the depressive disorders. However, this has resulted in a system that (a) is unnecessarily complex and unwieldy, (b) has created problems with artificial distinctions between categories and artifactual comorbidity, and (c) at the same time obscures what may be more fundamental distinctions. A potentially useful and more parsimonious approach to capturing much of the heterogeneity of depressive disorders is to classify the depressive disorders along 2 dimensions, 1 reflecting severity and the other, chronicity. Considerations in the development of these dimensions are discussed, and a set of examples is presented. Although further research and discussion are needed to determine the optimal form of these dimensions, the next edition of the DSM should consider replacing many of the existing categories and specifiers for depressive disorders with the simpler approach of classifying depressive disorders using the 2 dimensions of severity and chronicity.

Familiality of major depressive disorder and gender differences in comorbidity

OBJECTIVE

Gender differences exist in the prevalence and psychiatric comorbidity of major depressive disorder (MDD). This study investigates whether familiality of MDD contributes to observed gender differences in comorbidity.

METHOD

Familial (f-MDD) and non-familial (nf-MDD) MDD cases from a population sample were assessed for comorbid dysthymia, anxiety disorders and alcohol-related disorders using the Composite International Diagnostic Interview (CIDI). Logistic regression analyses were performed to examine the effect of f-MDD on gender differences in comorbidity, adjusted for confounders.

RESULTS

Women with f-MDD reported significantly more comorbid dysthymia and generalized anxiety disorder (GAD) than their male counterparts; women with nf-MDD reported significantly more comorbid simple phobias and agoraphobia than their male counterparts. Gender differences in comorbid panic disorder and alcohol-related disorders occurred independently of the familial load. Adjustment for age of onset, severity and recurrence of MDD did not change these results.

CONCLUSION

Models to explain comorbidity patterns of MDD differ by gender. Familiality of MDD should be taken into account.