The Minimal Phenomenal Experience questionnaire (MPE-92M): Towards a phenomenological profile of "pure awareness" experiences in meditators

Objective

To develop a fine-grained phenomenological analysis of “pure awareness” experiences in meditators.

Methods

An online survey in five language versions (German, English, French, Spanish, Italian) collected data from January to March 2020. A total of 92 questionnaire items on a visual analogue scale were submitted to exploratory and confirmatory factor analysis.

Results

Out of 3627 submitted responses, 1403 were usable. Participants had a median age of 52 years (range: 17–88) and were evenly split between men and women (48.5% vs 50.0%). The majority of meditators practiced regularly (77.3%), were free of diagnosed mental disorders (92.4%) and did not regularly use any psychoactive substances (84.0%). Vipassana (43.9%) followed by Zen (34.9%) were the most frequently practiced meditation techniques. German (63.4%) and English (31.4%) were by far the most frequent questionnaire languages. A solution with 12 factors explaining 44% of the total variance was deemed optimal under joint conceptual and statistical considerations. The factors were named “Time, Effort and Desire,” “Peace, Bliss and Silence,” “Self-Knowledge, Autonomous Cognizance and Insight,” “Wakeful Presence,” “Pure Awareness in Dream and Sleep,” “Luminosity,” “Thoughts and Feelings,” “Emptiness and Non-egoic Self-awareness,” “Sensory Perception in Body and Space,” “Touching World and Self,” “Mental Agency,” and “Witness Consciousness.” This factor structure fit the data moderately well.

Conclusions

We have previously posited a phenomenological prototype for the experience of “pure awareness” as it occurs in the context of meditation practice. Here we offer a tentative 12-factor model to describe its phenomenal character in a fine-grained way. The current findings are in line with an earlier study extracting semantic constraints for a working definition of minimal phenomenal experience.

Relationship between benzodiazepine prescription, aggressive behavior, and behavioral disinhibition: a retrospective study in a Swiss prison

Background

Benzodiazepines are commonly prescribed in prisons amidst the controversies surrounding their potential role in causing behavioral disinhibition and aggressive behavior and their association with use and trafficking of illicit and addictive substances. The present study aimed to (1) ascertain the relationship between benzodiazepine prescription (including their dosage and duration of use) and aggressive behavior and behavioral disinhibition in prison and (2) investigate whether there was an association between benzodiazepine prescription, (including their dosage and duration of use) and using and trafficking illicit and addictive substances during imprisonment.

Methods

Data were extracted from the electronic database of an open Swiss prison (n=1206, 1379 measures) over a 5-year period (20102015). Measures included benzodiazepine prescription, duration of benzodiazepine use and mean dosage, and punishable behaviors (physical and verbal aggression, disinhibited but not directly aggressive behaviors, property damage or theft, substance-related offenses, and rule transgression). We assessed the relationship between benzodiazepine prescription and punishable behaviors after propensity score matching. Logistic regressions were also used to test the relationship of benzodiazepine use duration and dosage with punishable behaviors among participants who received benzodiazepines.

Results

After propensity score matching, benzodiazepine prescription was not significantly associated with any punishable behavior. Among detained persons who took benzodiazepines, there was no significant association of dosage and duration of use with offenses involving illicit or addictive substance use or trafficking.

Conclusions

Our study did not empirically support the occurrence of increased aggressive or disinhibited behaviors or increased risk of substance abuse in detained persons who received benzodiazepines in prison. This suggests a need to reconsider restrictions in prescribing benzodiazepines in the prison setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00504-5.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study

Background

In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims

Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design

Retrospective cohort study

Setting

An open prison with 120 places

Subjects

Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements

Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings

Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions

This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Event-Related Potentials for Diagnosing Children and Adults With ADHD

Objective: The diagnosis of ADHD is based on behavioral criteria, which allow for subjective variability and invite criticism regarding the reality of the disorder. In this situation, more objective criteria would be desirable. We review the scientific literature for diagnostic tests based on event-related potentials (ERPs). Method: Seven studies met the inclusion criteria of reporting the sensitivity and specificity of an ERP-based classifier discriminating participants with ADHD from healthy controls. Study quality was rated using the second version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) system. Results: Overall, study quality was acceptable. The largest biases were lack of representativeness and overfitting. Sensitivities and specificities ranged from 57% to 96%, and 63% to 92%, respectively. However, no two studies used the same diagnostic test. Conclusion: There is a serious lack of coordination in worldwide efforts to find more objective ERP-based criteria for the diagnosis of ADHD. Concerted action is needed.

[ICD-11 posttraumatic stress disorder (PTSD) in male prisoners]

THEORETICAL BACKGROUND

The eleventh version of the ICD, expected to be published in 2018, leads to changed criteria for post-traumatic stress disorder (PTSD) according to the online beta version. Such changes are likely to affect previously known features of PTSD, including the prevalence rate. Little is known about the prevalence of ICD-11 PTSD in imprisoned men. The present study examined this issue in this high-risk group for trauma disorders, as male prisoners are known to be more often affected by traumatic events compared to the general population.

METHOD

In n = 49 men imprisoned in Switzerland, cross-sectional and standardized self-assessment procedures (ACE, Cidi list, IES-R) were used to record traumatic events and possible trauma symptoms. The frequency of ICD-11 PTSD was calculated using the diagnostic heuristic of Hyland et al. (2017), on the basis of which ICD-11 PTSD is estimated by means of the IES-R.

RESULTS

Overall, 88 % of the detained men examined had been traumatized during childhood and / or life span; 78 % reported at least one event on the ACE, on average 1.5, with 25 % reporting four or more events. Emotional abuse was reported most frequently (51 %). Furthermore, 71 % reported at least one event on the Cidi list, on average 1.8, with 45 % reporting serious physical threat. The analysis of ICD-11 PTSD was carried out with n = 34 inmates after exclusion of those without a traumatic event and those who did not complete the IES-R, and ICD-11 PTSD was estimated at 26.5 %.

CONCLUSION

The study shows that imprisoned men are likely to be a high risk group for the development of PTSD even according to the new ICD. Considering the high prevalence of traumatic events and the numerous negative consequences for mental as well as physical health, specific psychotherapeutic programs and a trauma-informed imprisonment are necessary.

Status quo of German-speaking medical students' attitudes toward and knowledge about central aspects of forensic psychiatry across four European countries

While forensic psychiatry is of increasing importance in mental health care, limited available evidence shows that attitudes toward the discipline are contradictory and that knowledge about it seems to be limited in medical students. We aimed to shed light on this subject by analyzing medical students' central attitudes toward and their association with knowledge about forensic psychiatry as well as with socio-demographic and education-specific predictor variables. We recruited N = 1345 medical students from 45 universities with a German language curriculum across four European countries (Germany, Switzerland, Austria and Hungary) by using an innovative approach, namely snowball sampling via Facebook. Students completed an online questionnaire, and data were analyzed descriptively and multivariably by linear mixed effects models and multinomial regression. The results showed overall neutral to positive attitudes toward forensic psychiatry, with indifferent attitudes toward the treatment of sex offenders, and forensic psychiatrists' expertise in the media. Whereas medical students knew about the term 'forensic psychiatry', they showed a lack of specific medico-legal knowledge. Multivariable models on predictor variables revealed statistically significant findings with, however, small estimates and variance explanation. Therefore, further research is required along with the development of a refined assessment instrument for medical students to explore both attitudes and knowledge in forensic psychiatry.

Predicting Medical Students' Current Attitudes Toward Psychiatry, Interest in Psychiatry, and Estimated Likelihood of Working in Psychiatry: A Cross-Sectional Study in Four European Countries

Psychiatry as a medical discipline is becoming increasingly important due to the high and increasing worldwide burden associated with mental disorders. Surprisingly, however, there is a lack of young academics choosing psychiatry as a career. Previous evidence on medical students' perspectives is abundant but has methodological shortcomings. Therefore, by attempting to avoid previous shortcomings, we aimed to contribute to a better understanding of the predictors of the following three outcome variables: current medical students' attitudes toward psychiatry, interest in psychiatry, and estimated likelihood of working in psychiatry. The sample consisted of N = 1,356 medical students at 45 medical schools in Germany and Austria as well as regions of Switzerland and Hungary with a German language curriculum. We used snowball sampling via Facebook with a link to an online questionnaire as recruitment procedure. Snowball sampling is based on referrals made among people. This questionnaire included a German version of the Attitudes Toward Psychiatry Scale (ATP-30-G) and further variables related to outcomes and potential predictors in terms of sociodemography (e.g., gender) or medical training (e.g., curriculum-related experience with psychiatry). Data were analyzed by linear mixed models and further regression models. On average, students had a positive attitude to and high general interest in, but low professional preference for, psychiatry. A neutral attitude to psychiatry was partly related to the discipline itself, psychiatrists, or psychiatric patients. Female gender and previous experience with psychiatry, particularly curriculum-related and personal experience, were important predictors of all outcomes. Students in the first years of medical training were more interested in pursuing psychiatry as a career. Furthermore, the country of the medical school was related to the outcomes. However, statistical models explained only a small proportion of variance. The findings indicate that particularly curriculum-related experience is important for determining attitudes toward psychiatry, interest in the subject and self-predicted professional career choice. We therefore encourage the provision of opportunities for clinical experience by psychiatrists. However, further predictor variables need to be considered in future studies.

Interpersonal Sensitivity as a Mediator Between Cumulative Childhood Traumatic Events and Adult Sexual Disturbance

Previous research has shown that cumulative childhood traumatic events are stronger predictors of sexual disturbances than childhood sexual abuse. Additional factors are likely to influence this relationship. Whereas socio-interpersonal factors such as interpersonal sensitivity have repeatedly been shown to be salutogenic in the aftermath of traumatic events, the specific underlying mechanisms are little understood. The aim of the present study was to examine the relationship between cumulative childhood traumatic events and adult sexual disturbances (i.e., the avoidance of sexual contacts, disruptive sexual behavior, poor sexual boundaries, decreased regulation of sexual impulses) and to investigate the role of interpersonal sensitivity as a potential mediator. The sample comprised 100 adult psychiatric in-patients. As expected, cumulative childhood traumatic events were found to be strong predictors of sexual disturbances, with interpersonal sensitivity partially mediating this relationship.

Online Survey of Medical and Psychological Professionals on Structured Instruments for the Assessment of Work Ability in Psychiatric Patients

Objective: To evaluate perceived needs and difficulties related to instruments for assessing work ability in individuals with mental disorders. Method: We conducted an online survey of 104 German-speaking medico-legal experts (forensic psychiatric and psychology experts, insurance physicians) and therapists. Results: The large majority of respondents reported they would welcome a standardized, structured instrument for the assessment of work ability. High predictiveness, inter-rater agreement, comprehensibility for laymen, and symptom validity were desired in roughly equal measure as the main characteristic of such an instrument. More women than men, and more medico-legal experts than therapists, considered symptom validation as always necessary. Pain, personality, and affective disorders were perceived to be the most difficult disorders in the context of work ability assessments. Conclusion: Our survey documents professionals' wish for a structured assessment of work ability in both medico-legal and therapeutic settings.

Duration of Absence from Work Is Related to Psychopathology, Personality, and Sociodemographic Variables in a Longitudinal Cohort

OBJECTIVE

To examine, in a non-clinical sample, the association of psychopathology, personality, sociodemographic information, and psychosocial indicators of non-occupational functioning with the duration of absence from work in the past 12 months.

METHOD

A longitudinal community cohort of 591 adults from Switzerland was analyzed using multilevel ordered logistic regression, with several alternative models as robustness checks. Psychopathology was assessed using the total score (Global Severity Index) of the Symptom Check List-90 Revised.

RESULTS

The highest psychopathology levels were associated with absences of 3 or more week duration, largely independently of age. Extraversion and being divorced, widowed or separated also corresponded with longer absences from work in some analyses. No effect of sex was found. Most effects tested were not statistically significant and estimates showed large uncertainty.

CONCLUSION

Although tentative, our results suggest a possible influence of psychopathology on work participation. It may thus be desirable in insurance-medical appraisals of work ability to include instruments for measuring psychopathology.

Could Google Trends Be Used to Predict Methamphetamine-Related Crime? An Analysis of Search Volume Data in Switzerland, Germany, and Austria

Objective

To compare the time trends of Google search interest in methamphetamine and criminal offences related to this drug.

Methods

Google Trends data for the search term "meth" was compared to methamphetamine-related crime statistics (incl. use, possession, and dealing) in Switzerland, Germany, and Austria for the years 2004–2016. Google data was availably monthly. Crime data was available yearly, and monthly values were imputed.

Results

On the country level, internet search trends for "meth" roughly paralleled relevant criminal activity. State-level data, which was available for Austria, showed more heterogeneity. Cross-correlations for yearly data almost always peaked at a lag time of 0 and coefficients were mostly between 0.7 and 1.0 on the country level, and between 0.5 to 1.0 on the state level. Monthly cross-correlations based on imputed values were substantially lower, ranging from 0 to 0.6.

Conclusions

These results encourage the further evaluation by law enforcement authorities of Google search activity as a possible predictor of methamphetamine-related crime. However, several limitations, in particular the crude temporal resolution of available crime data, precluded a detailed assessment of the relationship between internet search trends and the development of methamphetamine-related crime in central Europe.

Changes in cocaine consumption are associated with fluctuations in self-reported impulsivity and gambling decision-making

BACKGROUND

In cross-sectional studies, cocaine users generally display elevated levels of self-reported and cognitive impulsivity. To what extent these impairments are stable v. variable markers of cocaine use disorder, and, thus, are pre-existing or drug-induced, has not yet been systematically investigated.

METHOD

We conducted a longitudinal study with cocaine users who changed or maintained their consumption intensity, measuring self-reported impulsivity with the Barratt Impulsiveness Scale (BIS-11), and cognitive impulsivity with the Rapid Visual Processing task (RVP), Iowa Gambling task (IGT), and Delay Discounting task (DD) at baseline and at 1-year follow-up. We assessed 48 psychostimulant-naive controls and 19 cocaine users with decreased, 19 users with increased, and 19 users with unchanged cocaine intake after 1 year as confirmed by hair analysis.

RESULTS

Results of linear multilevel modelling showed significant group × time interactions for the BIS-11 total score and the IGT total card ratio. Increasers showed a trend for elevated scores, whereas decreasers exhibited reduced self-reported impulsivity scores within 1 year. Surprisingly, increasers' IGT performance was improved after 1 year, whereas decreasers' performance deteriorated. By contrast, neither RVP response bias B" nor DD total score showed substantial group × time interactions. Importantly, BIS-11 and DD revealed strong test-retest reliabilities.

CONCLUSION

Self-reported impulsivity (BIS-11) and decision-making impulsivity (IGT) covary with changing cocaine use, whereas response bias and delay discounting remain largely unaffected. Thus, self-reported impulsivity and gambling decision-making were strongly state-dependent in a stimulant-using population and may be suitable to monitor treatment success, whereas delay of gratification was confirmed as a potential endophenotype of stimulant addiction.

Adult attention-deficit/hyperactivity disorder: Associations between subtype and lifetime substance use - a clinical study

ADHD is the one of the most prevalent childhood disorders and has been associated with impairments persisting into adulthood. Specifically, childhood ADHD is an independent clinical risk factor for the development of later substance use disorders (SUD). Moreover, adults who meet diagnostic criteria for ADHD have shown high rates of comorbid SUDs. Few studies, however, have reported on the relationship between ADHD subtypes and SUD in adult samples. The purpose of this study was to characterize a clinical sample of adults with ADHD and to identify possible associations between ADHD subtypes, lifetime substance use, and if ADHD subtypes may be preferentially associated with specific substances of abuse. We recruited 413 adult ADHD patients, performed an evaluation of their ADHD and conducted an interview on their use of psychotropic substances. Complete data was obtained for 349 patients. Lifetime substance abuse or dependence was 26% and occasional use was 57% in this sample. The inattentive subtype was significantly less likely to abuse or be dependent on cocaine than the combined subtype. Our findings underscore the high rate of comorbidity between substance use and ADHD in adults. The more frequent abuse/dependence of cocaine by adult patients with hyperactive-impulsive symptoms should be kept in mind when treating this patient group.

Adult attention-deficit/hyperactivity disorder and nicotine use: a qualitative study of patient perceptions

BACKGROUND

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with high rates of comorbid substance use disorders, and cigarette smoking has a particularly high prevalence in this population. However, there is an ongoing debate as to whether this tobacco use is an attempt at "self-medication" or due to behavioral disinhibition. There is a surprising lack of qualitative studies that investigate the subjective perceptions of adults with ADHD regarding cigarette smoking. The present study was designed to fill this gap in the literature.

METHODS

We recruited twelve adult patients with ADHD and comorbid tobacco use from our ADHD consultation service, an outpatient facility of the Zurich University Psychiatric Hospital. Subjects were interviewed using qualitative methodology, and Mayring's qualitative content analysis was used to evaluate findings.

RESULTS

We identified two explanatory models linking ADHD and tobacco use: smoking as an attempt at self-medication and "smoking as a social behavior". On one hand, subjects considered tobacco a therapeutic aid, reporting positive effects on "inner tension" and cognitive function, and noted possible antidepressant properties as well. On the other hand, subjects considered smoking to enhance social functioning and to have a positive impact on interpersonal relationships. The majority believed that stimulant medications offered only a transient decrease in patterns of tobacco use because their ability to reduce nicotine cravings wore off quickly. Others believed that stimulants had no effect or even reinforced cigarette use.

CONCLUSIONS

Participants had different views about the link between cigarette smoking and ADHD. While the majority thought of nicotine as a sort of therapy, viewing smoking as a way to self-medicate symptoms of ADHD, motivations for nicotine use were also related to self-image, desire to belong to a peer-group, and a drive to undermine perceived social norms. Ultimately, these findings can be used by clinicians to improve treatment alliance and collaboration.

Transcultural validity of the Hypomania Checklist-32 (HCL-32) in patients with major depressive episodes

OBJECTIVES

There is mounting evidence that current diagnostic systems inadequately recognize clinically relevant levels of hypomania in depressed patients, thereby leading to an under-diagnosis of bipolar disorders and the associated risk of treatment that is inappropriate or may actually worsen illness course. The Hypomania Checklist-32 revised version 2 (HCL-32-R2) is a self-rating scale for hypomanic symptoms specifically developed to address this problem. The goal of this study was to assess the transcultural validity of the HCL-32-R2.

METHODS

Measurement invariance of HCL-32-R2 responses from the multinational Bipolar Disorders: Improving Diagnosis, Guidance, and Education (BRIDGE) Study of 5635 patients with major depressive episodes (MDEs) was assessed by exploratory and confirmatory factor analysis across five cultural regions.

RESULTS

Two previously identified factors were reproduced and explained 60% of the variance in test responses. Only three out of 32 items had cross-culturally variable factor loadings. Some moderate measurement invariance was also found with regard to age and gender. In discriminating unipolar from bipolar disorder, the HCL-32-R2 showed a sensitivity of 82% with a specificity of 57% when current DMS-IV criteria for bipolar disorder were used, and substantially higher specificity of 73% when evidence-based modified criteria were applied.

CONCLUSIONS

The psychometric properties of the HCL-32-R2 were largely culture-independent. This finding replicates that of our previous international study and is a step towards validating the HCL-32-R2 as a broadly applicable screening instrument for hypomanic features, facilitating the detection of hidden bipolarity in depressed patients.

A prospective population-based cohort study of the prevalence, incidence and impact of obsessive-compulsive symptomatology

OBJECTIVE

Prospective longitudinal studies of obsessive-compulsive disorder (OCD) and sub-diagnostic obsessive-compulsive symptomatology in the non-clinical population, using age-defined cohorts, are rare. This study aimed to investigate the effect of OC symptoms on distress and psychosocial function and the effect of early-onset OC symptoms.

METHODS

591 subjects drawn from the general population of Zurich, Switzerland were interviewed seven times between 1979 (at age 20/21) and 2008 (age 49/50). Data for socio-demographic variables and psychosocial impairment was also collected and compared with a control-group without OC symptoms drawn from the same population.

RESULTS

The unweighted cumulative one-year rate of OCD in this sample was 5.1% and 21.7% reported some degree of clinically-relevant OC symptomatology (OCD or OCS). OCD appeared more prevalent in females whereas OCS and OC symptoms were more prevalent in males. The weighted cumulative prevalence rates, representative of the general population, for OCD, OCS and OC symptoms were 3.5%, 9.7%, and 11.2%, respectively. We could not identify OCD occurring before the age of 10 years, though sub-threshold cases were reported as early as age 2 years, whereas by the age of 22 years, around two thirds of OCD cases had emerged and no new cases developed OCD after around 37 years. Males were statistically significantly younger than females at onset of any OC symptomatology.

CONCLUSIONS

Clinically-relevant OC syndromes start early and are associated with substantial distress, treatment-seeking activity and in the case of OCD, functional disability.

Mortality of 403 patients with mood disorders 48 to 52 years after their psychiatric hospitalisation

The purpose is to analyse differences in mortality among patients with major depressive disorders (MDD), bipolar-II (BP-II), bipolar-I (BP-I) disorders and mania with or without minor depressive disorders and to identify risk factors of mortality. The sample represents all admissions for depression or mania over 5 years (1959-1963) to the Psychiatric Hospital of Zurich University, serving a large area. 403 patients were included and followed up every 5 years until 1985; thereafter, mortality data were collected repeatedly until 2009 when 352 (87 %) patients had died. Standardised mortality ratios (SMRs) were computed and survival analyses applied. With the exception of BP-II disorder, the three other diagnostic groups showed elevated SMRs. The group with mania had the highest SMR for cardiovascular deaths and the group with MDD the highest for deaths by suicide. Mortality was also high among patients with late-onset MDD. Across the diagnostic spectrum, we found differences in risk factors for mortality, such as a family history of suicides and personality type: more anxious patients with MDD lived longer, and among patients with BP disorders, more tense (aggressive) types had shorter lives. Long-term medication had a protective effect against mortality in patients with MDD during years 1-9 and in patients with BP disorders during years 1-19 after admission. We found marked differences in causes of death and risk factors between subgroups of mood disorders. For the purpose of further research, it would be recommendable to distinguish pure mania from bipolar disorders.

The role played by depression associated with somatic symptomatology in accounting for the gender difference in the prevalence of depression

PURPOSE

A variety of studies suggest the existence of a distinct phenotype of somatic depression, i.e., depression accompanied by significant somatic symptomatology. Previous research suggests that the gender difference in the prevalence of depression is primarily due to a difference in somatic depression. The aim of this study was to compare the gender difference in the prevalence of somatic depression and of depression not accompanied by significant somatic symptomatology (labelled "pure" depression) in two representative samples, the National Comorbidity Survey-Replication (NCS-R) and the Zurich Study.

METHOD

The gender difference in lifetime somatic depression was compared to that of pure depression based on analyses weighted back to the general population in two representative samples. The NCS-R analyses involved a narrow definition of somatic depression with items from the DSM criteria for depression--appetite, sleep, and fatigue. The analysis of the Zurich study added headaches, body image issues, and breathing difficulties to the criteria and comparison to atypical depression.

RESULTS

In both samples, the gender difference in depressive prevalence was due to a large difference in somatic depression with other phenotypes showing little or no gender difference. The gender differences were found to be due to the somatic symptoms rather than the number of symptoms and were much larger for somatic than for atypical depression.

CONCLUSION

The gender difference in the prevalence of depression results from the higher prevalence among women of a specific phenotype, somatic depression.

The role of genetic information in personalized medicine

Personalized medicine is the latest promise of a gene-centered biomedicine to provide treatments custom-tailored to the specific needs of patients. Although surrounded by much hype, personalized medicine at present lacks the empirical and theoretical foundations necessary to render it a realistic long-term perspective. In particular, the role of genetic data and the relationship between causal understanding, prediction, prevention, and treatment of a disease need clarifying. This article critically examines the concept of information in genetics and its relation to modern-day genetic determinism, using pharmacogenetics, personalized medicine's core discipline, as a test case. The article concludes that: (1) genetic knowledge does not constitute a privileged basis for personalized medicine because there is an a priori complete causal parity of genetic and nongenetic resources of development; and (2) prediction, prevention, and treatment all depend on a causal-mechanistic understanding that will follow only from integrating data across the whole gamut of developmental factors-genetic and non-genetic. In a future successful personalized medicine, genes will have no special status, either as determinants of phenotype, markers of disease or as targets of treatment.

Prediction of psilocybin response in healthy volunteers

Responses to hallucinogenic drugs, such as psilocybin, are believed to be critically dependent on the user's personality, current mood state, drug pre-experiences, expectancies, and social and environmental variables. However, little is known about the order of importance of these variables and their effect sizes in comparison to drug dose. Hence, this study investigated the effects of 24 predictor variables, including age, sex, education, personality traits, drug pre-experience, mental state before drug intake, experimental setting, and drug dose on the acute response to psilocybin. The analysis was based on the pooled data of 23 controlled experimental studies involving 409 psilocybin administrations to 261 healthy volunteers. Multiple linear mixed effects models were fitted for each of 15 response variables. Although drug dose was clearly the most important predictor for all measured response variables, several non-pharmacological variables significantly contributed to the effects of psilocybin. Specifically, having a high score in the personality trait of Absorption, being in an emotionally excitable and active state immediately before drug intake, and having experienced few psychological problems in past weeks were most strongly associated with pleasant and mystical-type experiences, whereas high Emotional Excitability, low age, and an experimental setting involving positron emission tomography most strongly predicted unpleasant and/or anxious reactions to psilocybin. The results confirm that non-pharmacological variables play an important role in the effects of psilocybin.

Identifying features of bipolarity in patients with first-episode postpartum depression: findings from the international BRIDGE study

OBJECTIVES

The aims of this study were to assess rates of bipolar spectrum disorders in women experiencing their first episode of postpartum depression, and to find out features indicative of bipolarity in these patients.

METHODS

As part of the international BRIDGE study designed to detect hypo/mania in patients with a major depressive episode, 52 (5.85%) were found to experience a first episode of postpartum (FEPP) depression, whereas 833 (94.13%) had a first episode of nonpostpartum (FENPP) depression. Hypo/mania was assessed using varying definitions of bipolarity, and the two groups compared on sociodemographic, family history and clinical characteristics.

RESULTS

Compared to FENPP depressive patients, women with FEPP depression had higher rates of bipolar disorders, with more hypo/mania in first degree relatives. Psychotic symptoms, atypical features, mixed depression, younger age at onset, high number of prior episodes, episodes of short duration, switches on antidepressants, seasonality of mood episodes as well as mood episodes with free intervals were found to be more frequent in FEPP depressives.

LIMITATIONS

The following are the limitations of this study: centres not randomly selected, recall bias, cross-sectional design, and limited training of participating psychiatrists.

CONCLUSIONS

This study confirms, in women experiencing a first depressive episode, high rates (15 to 50%) of bipolar disorders during the postpartum period and is the first to systematically assess and demonstrate the higher prevalence of identifying features of bipolarity in FEPP versus FENPP depression. Early recognition of bipolarity in these patients may help prevent the harmful consequences of this illness.

Prevalence of mental disorders in the Zurich Cohort Study: a twenty year prospective study

Background — In order to minimise retrospective recall in developing estimates of the prevalence of mental dis-orders in the general population, we conducted a prospective study of a cohort of youth from Zurich, Switzerland. Method — A 20 year prospective study of a community-based cohort aged 19-20 from Zurich Switzerland. The sample was enriched by subjects scoring high on the Symptom Checklist 90 R (Derogatis, 1977). A semi-structured diagnostic interview was administered by clinically experienced psychologists and psychiatrists. The six interviews from 1979 to 1999 assessed diagnoses and sub-threshold manifestations of major diagnostic categories (with the exception of schizophrenia) for the past twelve months, depending on the current DSM versions (DSM-IH, DSM-HI R, DSM-IV). Additional information on symptoms and treatment were collected for the years between the interviews. The reported prevalence rates are weighted for stratified sampling and cumulate the one-year rates of the six interviews. Results — The cumulative weighted prevalence rates for any psychiatric disorder were 48.6% excluding, and 57.7% including tobacco dependence. In addition 29.2% and 21.8%, respectively manifested sub-diagnostic syndromes. Overall there were no significant gender differences. The corresponding treatment prevalence rates were 22.4% and 31.1%, respectively for the diagnostic subjects and 6.9% and 6.1 %, respectively for the sub-diagnostic groups. The total treatment prevalence rate was 37.2% of the population (males 30.0%, females 44.1%). Conclusions — Our findings reveal that psychiatric disorders are quite common in the general population. When the spectra of mental disorders are considered, nearly three quarters of the general population will have manifested at least one of the mental disorders across their lifetime. Limitations — The data are based on a relatively small sample; a single age cohort, and the study was conducted in Zurich, Switzerland. These study features may diminish the generalisability of the findings.

Declaration of Interest: this work was supported by Grant 3200-050881.97/1 of the Swiss National Science Foundation, and Research Scientist Development Awards (MH 46376 and DA00293) from the US National Institutes of Health (Dr. Merikangas).

Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study

CONTEXT

Major depressive disorder, the most common psychiatric illness, is often chronic and a major cause of disability. Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers.

OBJECTIVE

To determine the frequency of bipolar disorder symptoms in patients seeking treatment for a major depressive episode.

DESIGN

Multicenter, multinational, transcultural, cross-sectional, diagnostic study. The study arose from the initiative Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE).

SETTING

Community and hospital psychiatry departments.

PATIENTS

Participants included 5635 adults with an ongoing major depressive episode.

MAIN OUTCOME MEASURES

The frequency of bipolar disorder was determined by applying both DSM-IV-TR criteria and previously described bipolarity specifier criteria. Variables associated with bipolarity were assessed using logistic regression.

RESULTS

A total of 903 patients fulfilled DSM-IV-TR criteria for bipolar disorder (16.0%; 95% confidence interval, 15.1%-17.0%), whereas 2647 (47.0%; 95% confidence interval, 45.7%-48.3%) met the bipolarity specifier criteria. Using both definitions, significant associations (odds ratio > 2; P < .001) with bipolarity were observed for family history of mania/hypomania and multiple past mood episodes. The bipolarity specifier additionally identified significant associations for manic/hypomanic states during antidepressant therapy, current mixed mood symptoms, and comorbid substance use disorder.

CONCLUSIONS

The bipolar-specifier criteria in comparison with DSM-IV-TR criteria were valid and identified an additional 31% of patients with major depressive episodes who scored positive on the bipolarity criteria. Family history, illness course, and clinical status, in addition to DSM-IV-TR criteria, may provide useful information for physicians when assessing evidence of bipolarity in patients with major depressive episodes. Such an assessment is recommended before deciding on treatment.

Sub-clinical psychosis symptoms in young adults are risk factors for subsequent common mental disorders

BACKGROUND

Not all persons identified in the early stages to be at risk for psychosis eventually cross the threshold for a psychotic illness. However, sub-clinical symptoms may not only indicate a specific risk but also suggest a more general, underlying psychopathology that predisposes one to various common mental disorders.

METHODS

Analyzing data from the prospective Zurich Cohort Study, we used two psychosis subscales - "schizotypal signs" and "schizophrenia nuclear symptoms" - derived from the SCL-90-R checklist that measured sub-clinical psychosis symptoms in 1979. We also assessed 10 different diagnoses of common mental disorders through seven interview waves between 1979 and 2008. This 30-year span, covering participant ages of 19/20 to 49/50, encompasses the period of highest risk for the occurrence of such disorders.

RESULTS

Both psychosis scales from 1979, but especially "schizotypal signs", were significantly correlated with most mental disorders over the subsequent test period. Higher values on both subscales were associated with an increasing number of co-occurring disorders.

CONCLUSIONS

Our data demonstrate that sub-clinical psychosis generally represents a risk factor for the development of common mental disorders and a liability for co-occurring disorders. This refers in particular to dysthymia, bipolar disorder, social phobia, and obsessive-compulsive disorder. Proneness to psychosis could signal a fundamental tendency toward common mental disorders.

Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study

OBJECTIVE

To determine the prevalence, impact, and stability of different subtypes of headache in a 30 year prospective follow-up study of a general population sample.

DESIGN

Prospective cohort study.

SETTING

Canton of Zurich, Switzerland.

PARTICIPANTS

591 people aged 19-20 from a cohort of 4547 residents of Zurich, Switzerland, interviewed seven times across 30 years of follow-up.

MAIN OUTCOME MEASURES

Prevalence of headache; stability of the predominant subtype of headache over time; and age of onset, severity, impact, family history, use of healthcare services, and drugs for headache subtypes.

RESULTS

The average one year prevalences of subtypes of headache were 0.9% (female:male ratio of 2.8) for migraine with aura, 10.9% (female:male ratio of 2.2) for migraine without aura, and 11.5% (female:male ratio of 1.2) for tension-type headache. Cumulative 30 year prevalences of headache subtypes were 3.0% for migraine with aura, 36.0% for migraine without aura, and 29.3% for tension-type headache. Despite the high prevalence of migraine without aura, most cases were transient and only about 20% continued to have migraine for more than half of the follow-up period. 69% of participants with migraine and 58% of those with tension-type headache manifested the same predominant subtype over time. However, the prospective stability of the predominant headache subtypes was quite low, with substantial crossover among the subtypes and no specific ordinal pattern of progression. A gradient of severity of clinical correlates and service use was present across headache subtypes; the greatest effect was for migraine with aura followed by migraine without aura, and then tension-type headache and unclassified headaches.

CONCLUSIONS

These findings highlight the importance of prospective follow-up of people with headache. The substantial longitudinal overlap among subtypes of headache shows the developmental heterogeneity of headache syndromes. Studies of the causes of headache that apply diagnostic nomenclature based on distinctions between discrete headache subtypes may not capture the true nature of headache in the general population.

Reappraisal of the interplay between psychosis and depression symptoms in the pathogenesis of psychotic syndromes: results from a twenty-year prospective community study

The interplay of psychotic and affective symptoms is a crucial challenge in understanding the pathogenesis of psychosis. In this study, we analyzed the interplay between two subclinical psychosis symptoms dimensions, and one depression symptoms dimension, using longitudinal data from Zurich. The Zurich study started in 1979 with a representative sample of 591 participants who were aged 20/21. Follow-up interviews were conducted at age 23, 28, 30, 35, and 41. The psychiatric symptoms were assessed with a semi-structured interview and the SCL 90-R. In this study, we analyzed three SCL-90-R subscales: the depression symptoms dimension and two distinct symptoms dimensions of subclinical psychosis, one representing a schizophrenia nuclear symptom dimension, the other representing a schizotypal symptoms dimension. Modeling was done with hybrid latent growth models, thereby including simultaneous and cross-lagged effects. The interplay between the two subclinical psychosis symptoms dimensions and the depression symptoms dimension includes several intertwined pathways. The schizotypal symptoms dimension has strong direct effects on the schizophrenia nuclear symptoms dimension, but also on the depression symptoms dimension. The latter has for its part an effect on the schizophrenia nuclear symptoms dimension. The main driving force within the dynamic interplay between depression and psychosis symptoms is a schizotypal symptoms dimension, which represents social and interpersonal deficiencies, ideas of reference, suspiciousness, paranoid ideation, and odd behavior. It does not only directly influence subclinical nuclear schizophrenia symptoms but also the symptoms of depression.

Childhood adversity and chronicity of mood disorders

To evaluate the potential impact of early childhood problems on the chronicity of mood disorders. A representative cohort from the population was prospectively studied from ages 19/20 to 39/40. Unipolar (UP) and bipolar disorders (BP) were operationally defined applying broad Zurich criteria for bipolarity. Chronicity required the presence of symptoms for more days than not over 2 years prior to an interview, or almost daily occurrence for 1 year. A family history and a history of childhood problems were taken at ages 27/28 and 29/30. Data include the first of multiple self-assessments with the Symptom-Checklist-90 R at age 19/20, and mastery and self-esteem assessed 1 year later. A factor analysis of childhood problems yielded two factors: family problems and conduct problems. Sexual trauma, which did not load on either factor, and conduct problems were unrelated to chronicity of UP or BP or both together. In contrast, childhood family problems increased the risk of chronicity by a factor of 1.7. An anxious personality in childhood and low self-esteem and mastery in early adulthood were also associated with chronicity. Childhood family problems are strong risk factors for the chronicity of mood disorders (UP and BP). The risk may be mediated partly by anxious personality traits, poor coping and low self-esteem.

Subjective distress predicts treatment seeking for depression, bipolar, anxiety, panic, neurasthenia and insomnia severity spectra

OBJECTIVE

To examine correlates of mental health treatment seeking such as gender, diagnosis, impairment, distress and mastery.

METHOD

Longitudinal epidemiological data from the Zurich Study of common psychiatric syndromes, including unipolar and bipolar depression, panic, anxiety, neurasthenia and insomnia, were utilized. In longitudinal Generalized Estimating Equations, treatment seeking was regressed on measures of subjective distress and impairment, childhood family problems, mastery and number of comorbid diagnoses.

RESULTS

Approximately half of all treated participants across all six syndromes suffered from subthreshold disorders. Meeting full or subthreshold diagnostic criteria was associated with treatment seeking for insomnia. Being female was associated with treatment seeking for depression. The only variable highly and consistently associated with treatment seeking, across all syndromes, was subjective distress. Treated participants reported high levels of distress, work and social impairment in both diagnostic and subthreshold groups.

CONCLUSION

Subjective distress may be a better indicator of treatment seeking than symptom count.

Psychometric evaluation of the altered states of consciousness rating scale (OAV)

BACKGROUND

The OAV questionnaire has been developed to integrate research on altered states of consciousness (ASC). It measures three primary and one secondary dimensions of ASC that are hypothesized to be invariant across ASC induction methods. The OAV rating scale has been in use for more than 20 years and applied internationally in a broad range of research fields, yet its factorial structure has never been tested by structural equation modeling techniques and its psychometric properties have never been examined in large samples of experimentally induced ASC.

METHODOLOGY/PRINCIPAL FINDINGS

The present study conducted a psychometric evaluation of the OAV in a sample of psilocybin (n = 327), ketamine (n = 162), and MDMA (n = 102) induced ASC that was obtained by pooling data from 43 experimental studies. The factorial structure was examined by confirmatory factor analysis, exploratory structural equation modeling, hierarchical item clustering (ICLUST), and multiple indicators multiple causes (MIMIC) modeling. The originally proposed model did not fit the data well even if zero-constraints on non-target factor loadings and residual correlations were relaxed. Furthermore, ICLUST suggested that the "oceanic boundlessness" and "visionary restructuralization" factors could be combined on a high level of the construct hierarchy. However, because these factors were multidimensional, we extracted and examined 11 new lower order factors. MIMIC modeling indicated that these factors were highly measurement invariant across drugs, settings, questionnaire versions, and sexes. The new factors were also demonstrated to have improved homogeneities, satisfactory reliabilities, discriminant and convergent validities, and to differentiate well among the three drug groups.

CONCLUSIONS/SIGNIFICANCE

The original scales of the OAV were shown to be multidimensional constructs. Eleven new lower order scales were constructed and demonstrated to have desirable psychometric properties. The new lower order scales are most likely better suited to assess drug induced ASC.

Smoking and psychiatric disorders: have subthreshold disorders been overlooked?

INTRODUCTION

The association between smoking and mental disorders has been confirmed by several studies using cross-sectional and retrospective designs. The present study illustrates the need for differentiating subthreshold psychiatric disorders in the analysis.

METHODS

The analysis is based on cumulative ("lifetime") prevalences of mental disorders and smoking in the Zurich study. This is a longitudinal community study with a stratified sample of 591 participants and six interviews from 1979 to 1999.

RESULTS

The percentage of lifetime smokers in the Zurich study was higher both in persons with a lifetime psychiatric diagnosis (72%) and in persons with subthreshold disorders (60%) than in those without any diagnosis (40%).

DISCUSSION

The association between smoking and mental disorders turned out to be clearly stronger if subthreshold mental disorders were appropriately considered in the analyses. Constructing appropriate reference groups is as crucial for the analysis of mental disorders and their outcomes as constructing adequate diagnostic groups.

Adult versus adolescent onset of smoking: how are mood disorders and other risk factors involved?

AIMS

To examine the strength of association between smoking and mood disorders and the association between smoking and its traditional risk factors, comparing those who started smoking in adolescence with those who started smoking in early adulthood.

DESIGN AND PARTICIPANTS

The analyses relied on prospective data from the Zurich Study. This longitudinal community study started in 1979 with a stratified sample of 591 participants aged 20/21 years, weighted towards those with mental disorders. Follow-up interviews were conducted at ages 23, 28, 30, 35 and 41.

MEASUREMENTS

In this analysis the adult versus adolescent onset of smoking was regressed on the cumulative prevalence of mood disorders, personality characteristics measured by the Freiburg Personality Inventory, common risk factors such as parental smoking, conduct and school problems, troubles with the family and basic socio-demographic variables (sex, education).

FINDINGS

In the Zurich Study cohort we found that 61.6% were former or current smokers, of whom 87% started smoking before the age of 20 and 13% after the age of 20. Adolescent onset of smoking was associated strongly with later major depression, dysthymia or bipolar disorders and, furthermore, with parental smoking, extroverted personality and discipline problems and rebelliousness in youth. However, only depression and dysthymia were associated with adult onset smoking and other risk factors associated with smoking were not so associated in this group.

CONCLUSIONS

Correlates of smoking onset in adolescence are mainly not applicable to the onset of smoking in young adulthood. Smoking onset beyond adolescence is an open research issue.

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.

Does psychomotor agitation in major depressive episodes indicate bipolarity? Evidence from the Zurich Study

BACKGROUND

Kraepelin's partial interpretation of agitated depression as a mixed state of "manic-depressive insanity" (including the current concept of bipolar disorder) has recently been the focus of much research. This paper tested whether, how, and to what extent both psychomotor symptoms, agitation and retardation in depression are related to bipolarity and anxiety.

METHOD

The prospective Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults (N = 591) (aged 20 at first interview) by six interviews over 20 years (1979-1999). Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 (five interviews) on the basis of the observed and reported behaviour within the interview section on depression. Psychiatric diagnoses were strictly operationalised and, in the case of bipolar-II disorder, were broader than proposed by DSM-IV-TR and ICD-10. As indicators of bipolarity, the association with bipolar disorder, a family history of mania/hypomania/cyclothymia, together with hypomanic and cyclothymic temperament as assessed by the general behavior inventory (GBI) [15], and mood lability (an element of cyclothymic temperament) were used.

RESULTS

Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety. Longitudinally, agitation and retardation were significantly associated with each other (OR = 1.8, 95% CI = 1.0-3.2), and this combined group of major depressives showed stronger associations with bipolarity, with both hypomanic/cyclothymic and depressive temperamental traits, and with anxiety. Among agitated, non-retarded depressives, unipolar mood disorder was even twice as common as bipolar mood disorder.

CONCLUSION

Combined agitated and retarded major depressive states are more often bipolar than unipolar, but, in general, agitated depression (with or without retardation) is not more frequently bipolar than retarded depression (with or without agitation), and pure agitated depression is even much less frequently bipolar than unipolar. The findings do not support the hypothesis that agitated depressive syndromes are mixed states.

LIMITATIONS

The results are limited to a population up to the age of 40; bipolar-I disorders could not be analysed (small N).

Impact of Childhood Adversity and Premorbid Personality on the Onset and Course of Major Bipolar Disorder

Background:

Clinical studies have demonstrated the great clinical relevance of long-term depression (LTD). Our study aims to characterise long-term bipolar disorder (LTBP) in comparison with episodic (non-chronic) bipolar major depressive episodes (EBP) 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). LTBP, which was assessed from age 27/28 to 40/41, was defined as threshold or subthreshold depressive syndrome plus hypomanic symptoms, present for more days than not over the past year, plus work or social impairment.

Results:

The cumulative incidence of LTBP was 6.3%, and of episodic BP 15.3%. The two groups did not differ in mean age of onset (13.7 vs. 13.1 years). Age of onset was significantly earlier in subjects with a positive FH of depression and was inversely correlated with the somatisation score of the SCL-90R as assessed at age 19/20. The age of onset increased with increasing levels of childhood family problems in subjects with a positive FH, but decreased in subjects without an FH of depression. Chronic BP was associated with early childhood adversity and low self-esteem and, at a trend-level, with no family history of depression.

Conclusions:

The results are surprising and counter-intuitive, a genetic disposition seeming to be correlated more with periodicity than with chronicity.

Are hypomanics the happier normals?

BACKGROUND

Not much is known about hypomanic states in subjects free of major and minor depressive mood disorders. Our aim was to identify and characterise a group of such "pure" hypomanics in relation to a normal control group.

METHODS

Data were obtained from the Swiss Zurich study, a stratified epidemiological sample of young adults from the general population, followed from age 20 to 40. "Pure" hypomania was defined as a period of increased activity and decreased need for sleep with consequences (e.g. legal trouble or reactions by others). Minor and major mood disorders were excluded.

RESULTS

Twenty-three subjects were identified as pure hypomanics. They overlapped minimally with and were clearly different from subjects with DSM-IV defined hypomanic episodes, most of whom had a bipolar disorder. Pure hypomanics were characterised by physical and social overactivity, elevated and irritable mood, as well as increases in extraversion, sexual interest, and risk-taking behaviors. They had higher monthly incomes and were more often married than controls. Subjective distress due to hypomanic symptoms was virtually absent. Quality of life and treatment rates for mood and anxiety were not different from controls, although sleep disturbances, substance abuse and binge eating were more frequent.

LIMITATIONS

The subsample identified was small. Due to the focus of the study on pathology, some positive aspects of hypomania may have been missed.

CONCLUSIONS

The existence of a group of pure hypomanics presenting a mixed picture of clinically relevant and irrelevant characteristics supports the concept of a continuum from normal to pathological mood states.

Diagnosis and course of affective psychoses: was Kraepelin right?

Kraepelin's basic attitude to the classification of psychoses was data-oriented and flexible. In his latter years he was close to revising his own celebrated dichotomy between manic-depressive insanity and dementia praecox in order to take account of a large group of intermediate psychoses, which today are called schizo-affective. His concept of a continuum from healthy to ill has stood the test of time and corresponds to modern epidemiological findings. Kraepelin's unitarian concept of manic-depressive insanity did not survive. It was differentiated and broken down into several subgroups, and a proportional diagnostic spectrum with a continuum from mania via bipolar disorders to depression has recently even been proposed. Bipolar disorders would in that case be comorbid disorders of mania plus depression. In contrast to Kraepelin's unitarian view the long-term prognosis of subgroups of mood disorders varies considerably. Overall it is nevertheless astonishing how much of Kraepelin's legacy has survived.

Prevalence, course, and comorbidity of insomnia and depression in young adults

STUDY OBJECTIVES

(1) To describe the prevalence and prospective course of insomnia in a representative young-adult sample and (2) to describe the cross-sectional and longitudinal associations between insomnia and depression.

DESIGN

Longitudinal cohort study.

SETTING

Community of Zurich, Switzerland.

PARTICIPANTS

Representative stratified population sample.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The Zurich Study prospectively assessed psychiatric, physical, and sleep symptoms in a community sample of young adults (n=591) with 6 interviews spanning 20 years. We distinguished 4 duration-based subtypes of insomnia: 1-month insomnia associated with significant distress, 2- to 3-week insomnia, recurrent brief insomnia, and occasional brief insomnia. The annual prevalence of 1-month insomnia increased gradually over time, with a cumulative prevalence rate of 20% and a greater than 2-fold risk among women. In 40% of subjects, insomnia developed into more chronic forms over time. Insomnia either with or without comorbid depression was highly stable over time. Insomnia lasting 2 weeks or longer predicted major depressive episodes and major depressive disorder at subsequent interviews; 17% to 50% of subjects with insomnia lasting 2 weeks or longer developed a major depressive episode in a later interview. "Pure" insomnia and "pure" depression were not longitudinally related to each other, whereas insomnia comorbid with depression was longitudinally related to both.

CONCLUSIONS

This longitudinal study confirms the persistent nature of insomnia and the increased risk of subsequent depression among individuals with insomnia. The data support a spectrum of insomnia (defined by duration and frequency) comorbid with, rather than secondary to, depression.

Is depression a risk factor for heart complaints? Longitudinal aspects in the Zurich study

BACKGROUND

The objective of this longitudinal study was to assess the association between major depression and heart complaints in a population of young and healthy adults.

METHODS

Starting at the age 20/21, participants of the Zurich Study underwent 6 structured, psychological interviews during a span of 20 years. We evaluated longitudinal data from 277 persons who participated in all 6 interviews including questions about heart complaints.

RESULTS

Over 20 years, heart complaints were reported by two thirds of participants, and the frequency of depression was 11.4%. At the age of 40/ 41, heart complaints were significantly associated with earlier heart complaints and major depression, both more often in women. Recurrent brief depression showed a tendency, but neither minor depression nor depressive symptoms were predictive for later heart complaints.

CONCLUSIONS

This study suggests that major depression is a predictor for heart complaints at the age of 40 and that the severity of depressive disorder in younger age has an effect on subsequent heart complaints. Follow-up data will help to elucidate whether these subjective heart complaints show any correlation with a later coronary heart disease.

Are behavioral problems in childhood and adolescence associated with bipolar disorder in early adulthood?

Several recent studies have found an association between conduct problems and bipolar disorder in adolescents. However, prospective studies are rare and most do not apply multivariable analysis strategies to control for important variables (e.g. socio-demographics). The aim of this study was to test the association between certain conduct problems and bipolar disorders. The sample consisted of 591 adolescents (male and female) representative for 2,600 persons from the Canton of Zurich in Switzerland. Data were prospectively collected through an interviewing procedure, with the first screening taking place at the age of 19-20. The incidence rate was computed using sampling weights, and risk factors of bipolar II disorder were estimated using a multivariable logistic regression model. The 9-year incidence rate of bipolar II disorder in the canton of Zurich was 8.4% (n = 65). Adolescents and children showing behavior such as repeated running away from home and physical fighting were 2.6-3.5 times more likely to experience a bipolar II disorder than those with no indication of conduct problems. Sensitivity analysis showed that the conduct problems were not the result of low socio-economic status.

Psychotic experiences in the general population: a twenty-year prospective community study

PURPOSE

Recent work suggested that psychosis might be expressed at subclinical levels. However, the determinants of subclinical psychotic symptoms, the degree of continuity over the life span, and the impact on functioning remain unclear. Thus we analyzed the prevalence, determinants, patterns and impact of subclinical psychotic symptoms in a community cohort over a 20-year period.

METHODS

The Zurich Study - a longitudinal community study - started in 1979 with a sample of 591 participants aged 20/21 years. Follow-up interviews were conducted at age 23, 28, 30, 35 and 41. Symptoms were assessed with a semi-structured interview and the SCL90-R. In this analysis, items of the SCL90-R symptom dimensions "paranoid ideation" and "psychoticism" were examined.

RESULTS

Two distinct symptom dimensions of subclinical psychosis became evident, one representing schizophrenia nuclear symptoms, the other representing schizotypal signs. Cannabis use in adolescence was associated specifically with schizophrenia nuclear symptoms, whereas childhood adversity as well as chronic physical or mental disorders in parents contributed to schizotypal signs. Individuals with a persistently high level of either of the two identified symptom dimensions over 20 years experienced significant deficiencies in social achievement and functioning.

CONCLUSIONS

Expression of psychotic symptoms in populations is continuous and characterized by differing levels of severity and persistence. A small group of individuals displays persistence of subclinical psychotic symptoms over a period of 20 years. The causes of and pathways to clinical psychotic disorder can be studied long before the disorder becomes clinically relevant.

Parsing the clinical phenotype of depression: the need to integrate brief depressive episodes

OBJECTIVE

To expand the concept of recurrent brief depression (RBD) to brief depression (BD) and to test its clinical relevance.

METHOD

Subjects (N = 591) were studied prospectively six times from ages 20/21 to 40/41 years. RBD was defined according to DSM-IV as episodes under 2 weeks with about monthly recurrence and work impairment. BD embraces RBD and brief depressive episodes with a frequency of 1-11 per year.

RESULTS

Pure BD and pure major depressive episodes (MDE) did not differ in treatment rates, family history of mood and anxiety disorders or comorbidity with bipolar spectrum and anxiety disorders but they differed in work impairment, suicide attempt rates and distress self-ratings. The combination of BD + MDE identified a very severe group of MDE, comparable with combined depression (MDE + RBD) and double depression (MDE + dysthymia).

CONCLUSION

Our data argue for the use of BD as a diagnostic specifier for severe MDE. RBD remains an important independent subgroup.

The spectra of neurasthenia and depression: course, stability and transitions

BACKGROUND

Neurasthenia has had a chequered history, receiving changing labels such as chronic fatigue or Gulf war syndrome. Neurasthenia is recognized by ICD-10, but not by DSM-IV. Its course, longitudinal stability and relationship to depression is not well understood.

METHODS

In a stratified community sample (n = 591), representative of 2600 persons of the canton of Zurich, Switzerland, neurasthenia and depression were assessed in six structured interviews between ages 20 and 41. Course, stability and comorbidity were examined. A severity spectrum of neurasthenia and depression from symptoms to diagnosis was taken into account.

RESULTS

The annual prevalence of a neurasthenia diagnosis increased from 0.7% to 3.8% from age 22-41, while mere symptoms became less prevalent. Intraindividual courses improved in 40% and deteriorated in about 30% of symptomatic cases. The most frequent symptoms overall, besides criterial exhaustion, were increased need for sleep, over-sensitivity, nervousness and difficulty concentrating. Cross-sectional associations and overlap with depression were strong. Longitudinal stability of ICD-neurasthenia was low.

CONCLUSIONS

Neurasthenia is intermittent, overlaps significantly with depression, and shows improvement and deterioration over time to roughly equal measures.

Melancholia and atypical depression in the Zurich study: epidemiology, clinical characteristics, course, comorbidity and personality

OBJECTIVE

A comparison of psychiatric, psychological and somatic characteristics in specified subgroups of major depressive episodes (MDE).

METHOD

In a stratified community sample of young adults investigated prospectively from age 20/21 to 40/41, we defined four MDE subgroups: i) DSM-IV melancholia or atypical depression (the 'combined group'), ii) pure melancholia, iii) pure atypical depression, and iv) unspecified MDE.

RESULTS

The cumulative incidence rates of the four groups were 4.1%, 7.1%, 3.5% and 8.2% respectively. Women were over-represented in the combined and atypically depressed group. In 56 of 117 (47.9%) cases, melancholia was longitudinally associated with atypical MDE (n = 84) (OR = 11.9).

CONCLUSION

Melancholic MDE was more severe than atypical MDE although the two groups shared many characteristics. The longitudinal overlap of melancholia with atypical depression in almost half of all cases calls for comparative analyses of combined, pure and unspecified MDE.

Does long-term medication with lithium, clozapine or antidepressants prevent or attenuate dementia in bipolar and depressed patients?

Background. Recent preclinical research suggests that lithium, clozapine, and possibly even antidepressants, have neurotrophic and neuroprotective properties. However, it remains unclear whether their long-term use can prevent the development of dementia or attenuate its severity in patients with major mood disorders. Method. Subjects included patients with bipolar disorder (N=220) and major depressive disorder (N=186) admitted between 1959 and 1963 and followed from 1965 to 1985. The presence of dementia was assessed clinically using ICD-9 criteria, and functioning was determined with the Global Assessment Schedule (GAS). Long-term medication with lithium, clozapine and antidepressants was documented. Results. In the total sample, the occurrence of dementia correlated only with age. In a restricted analysis of the 88 patients with dementia, age became non-significant and lithium showed a trend to an inverse correlation with the severity of dementia. In the subgroup of bipolar demented patients, both lithium and clozapine medication were inversely related to the severity of dementia. Conclusions. The results are consistent with an attenuating effect of lithium and possibly clozapine on the development of severe dementia. Limitations. The sample of patients with dementia was small and the results are based on a naturalistic study. Dementia was only assessed once, without the use of cognitive measures.

The use of complementary and alternative medicine in the general population: results from a longitudinal community study

BACKGROUND

Many patients with psychological or physical problems are interested in non-medical approaches. The reasons for the growing popularity of complementary and alternative medicine (CAM) are not well understood considering that evidence of the effectiveness of conventional therapies is greater than ever before. We have examined data from the Zurich Study to determine trends and predictors of CAM use in Switzerland.

METHOD

The Zurich Study is a longitudinal community study that was started in 1979 with a sample of 591 participants born in 1958 and 1959. In 1999, the last of six interview waves with face-to-face interviews was conducted. CAM use was analyzed with data from interviews in 1993 and 1999. Polytomous logistic regression analysis focused on the personal, demographic and sociocultural background of CAM users.

RESULTS

CAM use in the last 12 months was reported by 21.9% of the participants in 1993 and by 29.5% in 1999. CAM use among those exhibiting either physical or psychological problems was in the ratio of two to one. There was a trend from alternative variants of CAM (homeopathy) to complementary ones (massage, osteopathy, acupuncture). The vast majority of CAM use was in addition to conventional therapies. Predictors of CAM use were, among others, attribution of physical complaints to stress and other psychological variables, very low education level in parents, and lacking political interest.

CONCLUSIONS

Besides the sociocultural background, characteristics such as the psychological attribution style play an important role in CAM use. CAM use in Switzerland is mainly of a complementary rather than an alternative nature.

How ubiquitous are physical and psychological complaints in young and middle adulthood? A longitudinal perspective

OBJECTIVES

To investigate continuity and change of self-reported physical and psychological complaints in young adults over a period of 20 years.

STUDY DESIGN AND SETTING

The Zurich Study--a long-term panel survey in psychiatric epidemiology--is based on a stratified sample of 591 subjects born in 1958 (women) and 1959 (men). The sample strata combine SCL-90-R high-scorers and low-scorers in a 2:1 ratio. Up to now, the Zurich Study has included six interviews between 1979 and 1999, i.e. 20 years of life in young adults. We analysed the longitudinal frequency data of a variety of physical and psychological complaints, as well as information about subjective suffering and use of professional help. The analyses utilised on the McNemar's test, the Q-test and Markov chain models.

RESULTS

Sleep disorders, depression, menstruation, backache, headache, stomach and bowel complaints yielded cumulative prevalence rates of 80% or higher. Physical and psychological complaints systematically differ with respect to the change patterns between 1979 and 1999. Moreover, strong differences were found in view of subjective suffering and use of professional help.

CONCLUSIONS

Even though many self-reported physical and psychological complaints are very common in young adulthood, the underlying dynamics and the implications largely differ. It seems to be crucial whether respondents use somatic glasses or psychological lenses.

Is the association of alcohol use disorders with major depressive disorder a consequence of undiagnosed bipolar-II disorder?

BACKGROUND

There is emerging evidence that there is a spectrum of expression of bipolar disorder. This paper uses the well-established patterns of comorbidity of mood and alcohol use disorder to test the hypothesis that application of an expanded concept of bipolar-II (BP-II) disorder might largely explain the association of alcohol use disorders (AUD) with major depressive disorder (MDD).

METHOD

Data from the Zurich study, a community cohort assessed over 6 waves from ages 20/21 to 40/41, were used to investigate the comorbidity between mood disorders and AUD. Systematic diagnostic criteria were used for alcohol abuse, alcohol dependence, MDD, and BP-II. In addition to DSM criteria, two increasingly broad definitions of BP-II were employed.

RESULTS

There was substantially greater comorbidity for the BP-II compared to major depression and for alcohol dependence compared to alcohol abuse. The broadest concept of BP-II explained two thirds of all cases of comorbidity of AUD with major depressive episodes (MDE). In fact, the broader the definition of BP-II applied, the smaller was the association of AUD with MDD, up to non-significance. In the majority of cases, the onset of bipolar manifestations preceded that of drinking problems by at least 5 years.

CONCLUSIONS

The findings that the comorbidity of mood disorders with AUD was primarily attributable to BP-II rather than MDD and that bipolar symptoms usually preceded alcohol problems may encourage new approaches to prevention and treatment of AUD.