Diagnosis Of Major Depressive Episode Research Articles

Cognitive restructuring and improvement of symptoms with cognitive-behavioural therapy and pharmacotherapy in patients with depression

BackgroundSince 1960, psychological theories of maladaptivebehavior began to change their focus from enviornmentto expectation, control, decision and helplessness on theindividual level. After 1965, M.E.P. Seligman introducesthe concept of learned helplessness representing a givingup reaction determined by the belief that whatever youdo it doesn’t matter.According to theory [1] there are at least three typesof inferences that people can make and this, changes theway people develop or not hopelessness followed by thesimptoms of depressive lack of hope when confrontedwith negative life events [2]: 1) inference on the motivewhy certain events occur (inferated cause or causal attri-bution); 2) inference on the consequences which mightresult from events taking place (inferated consequences)and 3) inference on oneself given by events that havehappened to oneself at some point (inference of perso-nal characteristics).In this study we will investigate the efficiency of cog-nitive-behavioural and pharmaco-therapeutical interven-tions in changing depression symptoms and improvingcognitive, emotional disfunctions and perception ofsocial support.We investigate the relation between depression and dis-funtional causal attributions, perception of social support,self esteem, emotions and reaction to daily life stress.Materials and methodsPharmacotherapeutical group (PT). The study included13 patients diagnosed with depression and at the firsthospitalization they got disthimia or major depressiveepisode diagnosis, beeing subsequently treated.Cognitive-behavioural therapy group (CBT) had12 participants.Control group (C), 13 participants, was selectedconsidering their scores on SCL-90, DEP scale.In diagnosis phase, subjects were given to fill in a set ofscales similar to psychiatric patients, and it was appliedagain after 6-7 weeks and at the end of intervention. Agroup with high scores on BDI and SCL-90, indicating thepresence of depression symptoms were tested only in pretestand posttest phases without beeing subjected to any thera-peutical intervention. Participant admited into the studyformed three groups: pharmacotherapeutical group (PT),psychotherapeutical group (CBT) and control group (C).Psychiatric patients were administrated with anti-depressive medication. The psychotherapeutical groupfollowed 18-20 sessions of therapy (onehour average ses-sion) over a period of 15 weeks; twice a week in the firsttwo and once a week for the remaining.In this study we used the following scales: SCL-90;ASQ; SGC; SERV; POMS and SMSSP.Attributional Style Questionnaire (A.S.Q) is an instru-ment that measures the “explaning style” patterns repre-senting the tendency of selecting certain causalexplanations for favorable or unfavorable events.Symptom Check List 90-R [3] is an instrument whichevaluates the gravity of the symptoms reported bypatients. The internal consistency of its subscales is situ-ated between .75 and .86 and for ISG it is .97. Test-ret-est trust quotient of the two testing phases (T1 and T2)is between .77 and .87.Multidimensional Scale of Perceived Social Supportis an instrument projected to mesure the way people

Increased soluble TNF receptor 2 in antidepressant-free patients with late-life depression

Increased pro-inflammatory state has been implicated in the pathophysiology of major depressive disorder. The aim of this study was to determine serum levels of TNF-α and soluble TNF-α receptors 1 and 2 (sTNFR1 and sTNFR2) in anti-depressant free depressed elderly patients as compared to healthy controls. Sixty-seven older adults (28 with major depression and 39 controls) were enrolled to this study. Participants were assessed by the SCID and diagnosis of major depressive episode was made according to the DSM-IV criteria. Serum TNF-α, sTNFR1 and sTNFR2 were determined by ELISA. Anti-depressant free patients with late-life depression showed an increased level of the sTNFR2 as compared to controls ( p = 0.03). No significant differences were found in serum TNF-α and sTNFR1 levels ( p = 0.1 and p = 0.4, respectively). There was no correlation between serum levels of these inflammatory markers and the severity of depression. Our findings provide additional evidence of the involvement of abnormal pro-inflammatory state in late-life depression.

Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?

The objectives of this study were: (1) to examine Composite International Diagnostic Interview (CIDI) period prevalence and comorbidity for depression and anxiety disorder in a cohort of women assessed during the first 6-8 months postpartum and (2) to examine the benefits of combining the Edinburgh Postnatal Depression Scale (EPDS) with a simple "interval symptom" question to optimize screening postpartum. Women aged over 18 (N = 1,549) were assessed during late pregnancy and reviewed at approximately 2, 4, and 6-8 months postpartum using the EPDS and an "interval symptom" question. The latter asked about any depressive symptoms in the interval since the last EPDS. Women who scored >12 on the EPDS and/or positive on the "interval symptom" question were then administered the CIDI. A further 65 randomly selected women that screened negative were also administered the CIDI. Loss to postnatal follow-up was very significant, and returns rates were inconsistent across the three postnatal time points. Almost 25% of those who screened positive did not complete a CIDI. For screen-positive status, a total of 314 (24.4%) of those that returned questionnaires (N = 1,289) screened positive at least once across the 6- to 8-month interval. Of these, 79 were lost to follow-up; thus, 235 (74.8%) completed a CIDI. In this group, 34.7% had been positive both on the EPDS and the "interval" question, 15.9% on the EPDS alone, and 49.4% on the "interval" question alone. For the CIDI diagnosis and estimated 6- to 8-month period CIDI prevalence, among those 235 women who screened positive and completed a CIDI, 67.2% met the criteria for a CIDI diagnosis, as did 16.9% of those who screened negative. The breakdown in CIDI diagnoses in the 235 women was 32.8% major depression (± anxiety disorder); 26.4% minor depression alone; and 8.1% with a primary anxiety disorder (approximately half with minor depression). Put another way, 20.4% of these women had an anxiety disorder (approximately two thirds with comorbid depression) and 37.7% of women with a major depressive episode (MDE) had a comorbid anxiety disorder. The estimated 6- to 8-month prevalence rate for a CIDI diagnosis of anxiety or depression (major or minor) was 29.2% (95% CI 26.7%-31.7%). The use of the "interval symptom" question alone was 1.7 times more likely to identify positive CIDI cases than the EPDS alone. Almost 40% of postnatal women with a diagnosis of MDE have a comorbid diagnosis of anxiety disorder. The estimated 6- to 8-month period prevalence for CIDI cases of anxiety and depression was 29.2%. Screening for anxiety and depression using the EPDS alone was associated with a lesser capacity to identify CIDI caseness than a simple "interval symptom" question (for the 2 months prior) which almost doubled the yield. This paper demonstrates that combining the EPDS with the "interval symptom" question improves detection of CIDI caseness.

Dr Corruble and Colleagues Reply

To the Editor: We thank Dr Clayton for her comment about our article. We particularly appreciate her synthetic clinical description, based on a large number of publications, of the relationship between bereavement and depressive symptoms over time. One of the questions raised by this literature is whether, when, and how bereaved people with depressive symptoms should be recognized and treated as having major depressive episodes (MDE). Our results tend to show that the DSM-IV bereavement exclusion for MDE, instead of giving the ability to identify a self-limited “normal” depressive syndrome, may lead to the exclusion of individuals with symptoms of major depression that are more severe than those of typical MDE patients. Keeping the MDE bereavement exclusion criterion could indeed result in patients’ failing to be correctly diagnosed, living with prolonged and unnecessary suffering, and not getting appropriate treatment. We think that our results could be interpreted in 2 different ways. A first hypothesis would be that the investigators of this study may have skipped the bereavement exclusion E criterion for MDE. However, the involved clinicians were specifically trained before the beginning of the study about the DSM MDE criteria and were asked, during the protocol, to check individually each DSM-IV MDE diagnosis criterion. Thus, this hypothesis might not be the most likely, although it would be difficult to rule out. The second hypothesis, which could be more relevant, is that the bereavement exclusion criterion may not be applicable in the real life of office-based clinical practice. Difficulties in applying this exclusion criterion might be due to its polythetic presentation, as it includes not only symptom cues, but also functional impairment and time period features. Before modifying or deleting the bereavement exclusion E criterion for MDE is proposed, obtaining prospective data about the outcome of individuals excluded from the diagnosis of MDE due to the bereavement exclusion criterion would be useful. Whatever the outcome of the MDE bereavement exclusion criterion in the DSM-V (modification or deletion), we do agree with the proposition of Dr Clayton that the V code for bereavement should be maintained. The V code for bereavement and MDE bereavement exclusion criterion are 2 separate issues, but could complement each other in the direction suggested by Dr Clayton. This recommendation would be in agreement with our data and would contribute to solving the issue of the controversial MDE bereavement exclusion criterion.

PW01-39 - Characteristics of patients with hypomanic symptoms presenting a current major depressive episode identified with the HCL-32 patient questionnaire

ObjectivesTo evaluate the extent of hypomanic symptoms in patients presenting with a current major depressive episode (MDE) and to identify characteristics differentiating patients with hypomanic symptoms from those with pure unipolar depression, using the HCL-32 self-assessment tool.MethodsThis cross-sectional diagnostic study was performed in eighteen countries. Community- and hospital- based psychiatrists included consecutively all consulting adult patients with a diagnosis of MDE and completed a questionnaire on sociodemographic variables, diagnosis, medical history, treatment and comorbid psychiatric disorders. Each patient completed the Hypomania Self-Rating Scale (HCL-32 R2), and those scoring ≥14 were assigned a diagnosis of bipolar disorder. The frequency of study variables in the bipolar disorder (BD) and unipolar depression subgroups were compared.ResultsA total of 5635 patients were included. Overall, 1645(39%) had received a diagnosis of BD, 703(16%) fulfilled DSM-IV-TR criteria for BD and 2942(54%) scored ≥14 on the HCL-32. Patients scoring ≥14 on the HCL-32 were significantly more likely to have experienced a mood switch in response to antidepressants (OR:3.4), a family history of bipolarity (OR:2.4), comorbid substance abuse (OR:2.1) or borderline personality disorder (OR:1.7) and current mixed-state symptoms (OR:1.5).ConclusionsIn patients with DSM-IV MDE self-assessed, hypomanic symptoms were present in 54% of patients, whereas only 16% fulfilled DSM-IV criteria for bipolar disorder. However, these patients presented features recognised to be associated with bipolar disorder. The presence of bipolarity in patients presenting with a major depressive disorder may be frequent and use of this questionnaire would contribute to improve awareness and prompt better diagnosis.

Family childhood experiences reports in depressed patients: comparison between 2 time points

Research has shown some discrepancies in the reports of experiences from childhood when an individual is depressed, because a depressed mood may have biasing effects on autobiographical memory. The present study sought to clarify this issue by examining whether there is temporal stability in the report of childhood experiences in depressed subjects, or rather, if these experiences are influenced by the mood at the time of report. The study therefore carries implications for the credibility of childhood reports of depressed adults, for the validity of the questionnaire used – Family Background Questionnaire (FBQ), adapted from Melchert (1991) – and for the conclusions it might yield. We hypothesized that the report of the same childhood family experiences across the year would not be influenced by the mood disorder. To test this prediction, we solicited reports of family experiences in 25 depressed subjects (76% women and 24% men) across the course of one year. The diagnosis of Major Depressive Episode at the outset of the study was confirmed in all subjects with the use of Structured Clinical Interview for DSM-IV Axis I and the Beck Depression Inventory (BDI) to quantify level of depressive mood (M=19.80, SD=10.68). The report of childhood and family experiences was collected with the FBQ (Melchert, 1991; Melchert & Sayger, 1998), which consists of 124 items comprising 14 subscales. As hypothesized, results demonstrated that the reporting of childhood experiences in dthe family after approximately 1 year was not influenced by mood state of depression, which reinforces the reliability of childhood reports and the adequate reliability of the FBQ. However, there were significant differences between the first and second moment in the mood of the subjects (BDI), with a significant mood improvement after one year. These results are consistent with those of other authors which confirms that the use of questionnaires with more objective and specific items reduce the risk of biased responses on self-reporting childhood experiences.

Utility of the twelve-item World Health Organization Disability Assessment Schedule II (WHO-DAS II) for discriminating depression “caseness” and severity in Spanish primary care patients

The 12-item WHO-DAS II was developed to assess the activity limitations and participation restrictions experienced by individuals irrespective of medical diagnosis. In this paper we examine the known-groups' validity of the instrument by evaluating its ability to discriminate between patients with/without major depression, patients with depression with/without medical comorbidity, and patients with depression with different depression severity. The participants were 3,615 PC patients from 17 regions of Spain, with a first-time diagnosis of major depressive episode according to the general practitioner. The 12-item WHO-DAS II, the PHQ-9, and a chronic medical conditions checklist were administered during the consultation. The statistical analyses indicated that the 12-item WHO-DAS II was able to discriminate between patients with/without depression and between those with different depression severity. The ROC analysis revealed that with a cutoff score >or=50, the instrument correctly classified 70.4% of the sample (area under the ROC curve = .76; sensitivity = 71.4%; specificity = 67.6%). Overall, our results support the discriminant validity of the 12-item WHO-DAS II for major depression, being quite recommendable its use in epidemiological research.

Validity of the Brazilian version of the Geriatric Depression Scale (GDS) among primary care patients

The aim of the present study was to determine the validity of the Brazilian version of the Geriatric Depression Scale (GDS) with 30 (GDS-30), 15 (GDS-15), 10 (GDS-10), 4 (GDS-4) and 1 (GDS-1) items and to calculate the optimum cutoff points for identifying depression among elderly primary care subjects. A cross-sectional study was carried out involving 220 elderly patients recruited from four primary care clinics in northeastern Brazil. The following measurements were obtained: sociodemographic variables, Katz scale of independence in activities of daily living, and the GDS with 30, 15, 10, 4 and 1 item(s). A psychiatrist blinded to the results of the GDS applied the mood module of the Structured Clinical Interview for the DSM-IV for the diagnosis of major depressive episodes as the "gold standard." The use of the cut-off point of 10/11 for the GDS-30 produced sensitivity and specificity rates of 92.0% (95% CI: 70-98) and 79% (95% CI: 73-85), respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 49% and 98%, respectively. The optimum cut-off point for the GDS-15 was 4/5, at which sensitivity was 87% (95% CI: 71-95) and specificity was 82% (95% CI: 76-91), PPV was 51% and NPV was 97%. At the cut-off point of 3/4 the sensitivity, specificity, PPV and NPV for the GDS-10 were 76% (95% CI: 60-89), 81% (95% CI: 75-87), 46% (95% CI: 33-59%), and 94% (95% CI 89-97%), respectively. The optimum cut-off point for the GDS-4 was 0/1, at which sensitivity was 84% (95% CI: 68-93%); specificity was 75% (95% CI; 68-91%); PPV was 41% and NPV was 96%. For the GDS-1, sensitivity was 47%, specificity was 96%; PPV was 69% and NPV was 90%. The GDS-30, GDS-15, GDS-10 and GDS-4 proved to be good screening instruments for depression in primary care clinics in Brazil, whereas the GDS-1 failed to perform adequately.

Association between Obesity and Depression in Canadians

To determine the age and sex variations in the associations between obesity and depression. This analysis was based on data from 59,652 adults >or=18 years of age in the provinces of Nova Scotia, Quebec, Saskatchewan, Alberta, and British Columbia, who participated in the Canadian Community Health Survey conducted in 2005. The survey included a set of 27 questions about symptoms of depression, which were taken from the Composite International Diagnostic Interview. Based on these questions, depression scores were calculated and used to define depression, which corresponds to a 90% likelihood of a positive diagnosis of major depressive episode. Body weight and height were based on self-report. The prevalence of depression was 5.3% in adults living in the five provinces and was higher in women than in men. People with abnormal body weight tended to have an increased risk of depression. On average, obesity and being underweight were associated with approximately 30% and 40% increases in depression, respectively. Particularly in women, depression was more markedly associated with obesity in the 18-39 year age group (OR 1.67, 95% CI 1.29-2.15) and with being underweight in the 40-59 year age group (OR 2.23, 95% CI 1.45-3.42) than other age groups. Obesity is associated with an increased risk of depression in younger women.

Importance of retardation and fatigue/interest domains for the diagnosis of major depressive episode after stroke: a four months prospective study

Post-stroke major depressive episode is very frequent, but underdiagnosed. Researchers have investigated major depressive episode symptomatology, which may increase its detection. This study was developed to identify the depressive symptoms that better differentiate post-stroke patients with major depressive episode from those without major depressive episode. We screened 260 consecutive ischemic stroke patients admitted to the neurology clinic of a university hospital. Seventy-three patients were eligible and prospectively evaluated. We assessed the diagnosis of major depressive episode using the Structured Clinical Interview for DSM-IV and the profile of depressive symptoms using the 31-item version of the Hamilton Depression Rating Scale. For data analysis we used cluster analyses and logistic regression equations. Twenty-one (28.8%) patients had a major depressive episode. The odds ratio of being diagnosed with major depressive episode was 3.86; (95% CI, 1.23-12.04) for an increase of one unit in the cluster composed by the domains of fatigue/interest and retardation, and 2.39 (95% CI, 1.21-4.71) for an increase of one unit in the cluster composed by the domains of cognitive, accessory and anxiety symptoms. The domains of eating/weight and insomnia did not contribute for the major depressive episode diagnosis. The domains of retardation and interest/fatigue are the most relevant for the diagnosis of major depressive episode after stroke.

Depression in adult Nigerians: Results from the Nigerian Survey of Mental Health and Well-being

Background Community-based studies of the rates and profile of depression among Africans are still sparse. Methods As part of the World Mental Health Surveys initiative, a clustered multi-stage sampling of households in 21 of Nigeria's 36 states (representing 57% of the national population) was implemented to select adults aged 18 years and over ( N = 6752) for face-to-face interviews using the Composite International Diagnostic Interview (CIDI 3.0). Diagnosis of major depressive episode (MDE) was based on the criteria of the Diagnostic and Statistical Manual, 4th edition. Results Lifetime and 12-month estimates of MDE were 3.1% (standard error 0.3) and 1.1% (s.e. 0.1), receptively. Increasing age was associated with higher estimates of positive responses to stem (screen) questions for depression and of lifetime disorders among stem-positive respondents. The mean age of onset was about 29.2 years. The median (inter quantile range, IQR) duration of an episode among lifetime cases was 1.0 (2.0–2.4) year and the median (IQR) number of lifetime episodes was 1.5 (2.0–2.8). MDE was highly comorbid with anxiety disorders, musculoskeletal conditions, chronic pain and ulcer. The odds ratio of lifetime suicide attempt among persons with lifetime MDE was 11.6 (95% confidence interval, 3.9–34.9). Over 25% of 12-month cases were rated as severely disabled in the performance of usual roles. Only 16.9% (s.e. 5.0) of 12-month cases had received any treatment. Limitations All data were based on self-reports. Conclusion MDE, defined according to DSM-IV, is a risk factor for mental and physical comorbidity as well as disability in Nigerians. Age-related telescoping or denial may partly explain the low rates in this young population.

Ethyl-eicosapentaenoic acid for the treatment of psychological distress and depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized clinical trial

Background:Psychological distress (PD) and depressive symptoms are commonly observed during menopausal transition. Studies suggest that omega-3 (n–3) fatty acids may help alleviate depression.Objective: The objective was to compare enriched ethyl-eicosapentaenoic acid (E-EPA) supplementation with placebo for the treatment of PD and depressive symptoms in middle-aged women.Design: Women with moderate-to-severe PD (n= 120) were randomly assigned to receive 1.05 g E-EPA/d plus 0.15 g ethyl-docosahexaenoic acid/d (n= 59) or placebo (n= 61) for 8 wk. The main outcomes were 8-wk changes in PD scores [Psychological General Well-Being Schedule (PGWB)] and depressive scales [20-item Hopkins Symptom Checklist Depression Scale (HSCL-D-20) and the 21-item Hamilton Depression Rating Scale (HAM-D-21)].Results: At baseline, women with PD were mildly to moderately depressed, and 24% met the major depressive episode (MDE) criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. After 8 wk, outcomes improved in both groups, but no significant differences were noted between them. Stratification analyses for MDE diagnosis at baseline indicated that differences in adjusted 8-wk changes between the E-EPA group without MDE (n= 46) and the placebo group (n= 45) were 8.0 (95% CI: 0.6, 15.3; P= 0.034) for the PGWB, −0.2 (95% CI: −0.01, −0.4; P= 0.040) for the HSCL-D-20, and −2.7 (95% CI: −0.3, −5.1; P= 0.030) for the HAM-D-21. Differences in adjusted 8-wk changes between the E-EPA group with MDE (n= 13) and the placebo group (n= 16) were not significant.Conclusions: To our knowledge, this is the first trial of n–3 supplementation in the treatment of PD and depressive symptoms in middle-aged women. In women with PD without MDE at baseline, the 8-wk changes in PD and depressive scales improved significantly more with E-EPA than with placebo. This trial was registered at >http://www.controlled-trials.comas ISRCTN69617477.

P02-89 Suicidal attempts in primary care: Prevalence and correlates in a Tunisian area

Aims:This study aimed to determine prevalence and correlates of suicidal attempts in an adult primary care population in Sousse (Tunisia).Method:Sampling followed a stratified multistage probability cluster design from witch a representative sample of adult primary care population of Sousse was obtained. The sample was composed of 1249 subjects aged 18 years or more. Subjects were interviewed by trained clinicians using the Tunisian version of Composite International Diagnostic Interview 2.1.General and clinical characteristics of subjects who had reported previous suicidal attempts were compared with those of the remainder using t test and Chi-2 test.Results:Mean age in our sample was 43.4 ± 17.62 years, with female gender (70.9%) and urban residency (67.8%) predominance. 62.3% of participants were married, 27.3% celibates and 10.4% divorced or widowed. 68.4% of them had low educational level and 70% were out of work during the last 12 months. Suicidal attempts were found in 2.9% of participants. They were correlated to less than 40 years age (p=0.036) and to the diagnosis of major depressive episodes (p< 10-3), recurrent major depressive disorder (p=0.005) and dysthymic disorder (p< 10-3). Among major depressive episodes, only severe ones were associated to higher prevalence of suicidal attempts (p< 10-3).Conclusion:Prevalence of suicidal attempts in Sousse primary care population was 2.9%. It was correlated to low age and to depressive disorders.

P02-200 Preliminary study of mental health consultation-liaison activities with Primary Health Care teams in university community health care center in Brazil

Aims:This preliminary study describe the experience of mental health consultation-liaison activities delivered by a psychiatric community nurse and a psychiatrist with Primary Health Care (PHC) teams in a university community health center in city of Ribeirao Preto, State of Sao Paulo, Brazil.Method:This is a descriptive exploratory study, carried out from March to May 2008, from the record of the activities in weekly consultation meetings with four PHC teams.Results:The activities developed including discussions of issues and cases, joint consultations and home visits with PHC teams. Fifty-one joint consultations/home visits and twenty-six discussions of cases/issues were made. The clients were predominantly female and aged over 18 years; diagnoses of major depressive episode, generalized anxiety disorder and alcohol unhealthy use was common. Psychotic and bipolar disorders were also discussed and evaluated. The main complaints were related to: changes in sleep, appetite and energy; difficulty in relationships (including family and work); aggression and violence (including physical and sexual abuse); difficulty of adherence to treatment, and other psychiatric symptoms. The referrals were made mostly for ambulatory psychotherapy and ambulatory adult and child mental health specialized care.Conclusion:The joint activities between the specialized and PHC teams to enable full attention to health of patients and the development of interdisciplinary work. This work is challenging because it put on the agenda of health the borders between the levels of assistance, knowledge, practices and goals of different professional groups.

Generalizability of Clinical Trial Results for Major Depression to Community Samples

Although emerging data indicate that sample composition may influence the effectiveness of mental health interventions, the extent to which subjects in clinical trials represent affected community samples remains unknown. The goal of this study was to assess the proportion of community-dwelling adults with major depressive episode (MDE) who would meet eligibility criteria for a traditional efficacy trial in patients with MDE. We applied a standard set of exclusion criteria used in clinical trials in patients with MDE to the 2001-2002 National Epidemiologic Survey for Alcohol and Related Conditions (NESARC), the largest psychiatric epidemiologic study in the United States to date (N = 43,093). Because individuals who seek treatment for a disorder may systematically differ from those who do not, we applied the criteria first to all individuals with a current diagnosis of MDE (N = 3119) (diagnosed according to DSM-IV) and then to the subsample of individuals who sought treatment (N = 1359). Among the full sample of individuals with MDE, 75.8% were excluded by one or more study eligibility criteria. Approximately two thirds (66.9%) of the subsample of those who sought treatment were excluded. The percentage of subjects excluded by individual study criteria ranged from 2.4% to 47.4% in the overall sample and 0% to 38.4% in the treatment-seeking sample. For both groups, the presence of comorbid, nondepressive, non-substance use Axis I disorders and the duration of the depressive episode excluded the largest percentage of individuals. The design of traditional clinical trials tends to exclude a majority of individuals with MDE. Selection of exclusion criteria may have a powerful influence on the generalizability of study results. Clinical trials should explain the rationale for their exclusion criteria and estimate the impact of eligibility criteria on the generalizability of trial results.

Nondysphoric Depression Following Stroke

Nondysphoric Depression Following Stroke

Researchers Link Normal Grief to Major Depression

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessResearchers Link Normal Grief to Major DepressionJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:3 Aug 2007https://doi.org/10.1176/pn.42.15.0028aFor some time now, psychiatric scientists have been making forays into the nether world of bereavement, and their efforts seem to be leading to some clarification of what grief for a loved one is and what it is not.Normal grief for a loved one, for example, does not seem to be the same as complicated or traumatic grief. The latter is characterized by persistent difficulty in accepting the death, recurrent pangs of intense grief, preoccupation with thoughts and images of the deceased, and avoidance of reminders of the loss (Psychiatric News, July 6, 2005; April 6).Also, the depression stemming from complicated grief does not seem to be the same as major depression.On the other hand, depression stemming from normal grief seems to be very closely related to major depression, two psychiatrists now conclude. Sidney Zisook, M.D., a professor of psychiatry at the University of California at San Diego, and Kenneth Kendler, M.D., a professor of psychiatry and human genetics at Virginia Commonwealth University, presented data backing their theory in the June Psychological Medicine.Zisook and Kendler searched all English-language reports in Medline up to November 2006 to identify published data about key characteristics that define bereavement depression and standard major depression. They then compared characteristics for both types of depression.Several of their results indicated that bereavement depression might be a separate disorder from major depression. For example, although women are more vulnerable to major depression, men may be equally as vulnerable to bereavement depression.Most of their analysis, however, suggested that bereavement depression is closely related to major depression. For instance, bereavement depression, like major depression, is more common in younger adults than in older ones, more likely to occur in individuals with a personal or family history of major depression, more likely to occur in persons in poor health than in good health, and more likely to occur in those with little social support.Furthermore, both bereavement depression and major depression are accompanied by heightened adrenocortical activity, impaired immune responses, and sleep disturbances. And bereavement depression has clinical characteristics similar to those of major depression—impaired psychosocial function, comorbidity with a number of anxiety disorders, and symptoms of worthlessness and suicidality.“Overall, the prevailing evidence more strongly supports similarities than differences between bereavement-related depression and standard major depression,” Zisook and Kendler concluded.These findings have important clinical implications, Zisook and Kendler believe. For example, DSM-IV-TR guidelines for diagnosing depression indicate that bereavement depression can only be diagnosed as major depression if it exceeds two months or if specific symptoms, such as suicidal ideation, morbid preoccupation with worthlessness, or psychomotor retardation, are present. Yet if bereavement depression is the same as major depression these guidelines may be invalid.On the other hand, if depression following the death of a loved one should be largely excluded from the definition of major depression, then should depression following other types of losses, say a divorce or bankruptcy, also be excluded from it? Currently, “DSM-IV-TR singles out bereavement as the only stressful life event that excludes the diagnosis of major depressive episode when all other features are present,” Zisook and Kendler noted.“The ideal study to test the validity of the bereavement exclusion,” they pointed out, “would compare individuals with depressive syndromes beginning within two months of the loss of a loved one...[to individuals with] major depressive episodes of similar duration and symptom profile whose onset is unrelated to the death of a loved one.” But “Unfortunately, we found no such studies in the literature,” they said.What about treatment? “The ultimate decision of when, whether, and how to treat the depression,” Zisook told Psychiatric News,“ should be made on the basis of considerations generally used for other, nonbereavement-related depressions, such as past history of depression and response to treatment, severity and chronicity of the episode, comorbidity, anxiety level, suicidal ideation, effects on functioning, supports, et cetera. The decision should not be based on time since the death of a loved one.”Zisook and Kendler's review was not supported by outside funding.An abstract of “Is Bereavement-Related Depression Different Than Non-Bereavement-Related Depression?” is posted at<http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1018312>.▪ ISSUES NewArchived

A dimensional model of psychopathology among homeless adolescents: suicidality, internalizing, and externalizing disorders.

The present study examined associations among dimensions of suicidality and psychopathology in a sample of 428 homeless adolescents (56.3% female). Confirmatory factor analysis results provided support for a three-factor model in which suicidality (measured with lifetime suicidal ideation and suicide attempts), internalizing disorders (assessed with lifetime diagnoses of major depressive episode and post-traumatic stress disorder), and externalizing disorders (indicated by lifetime diagnoses of conduct disorder, alcohol abuse, and drug abuse) were positively intercorrelated. The findings illustrate the utility of a dimensional approach that integrates suicidality and psychopathology into one model.

Increased Plasma Concentration of Brain-Derived Neurotrophic Factor With Electroconvulsive Therapy

The therapeutic mechanism of electroconvulsive therapy (ECT) is unknown. Animal research supports a neurotrophic effect of ECT. To investigate a neurotrophic effect in humans, we examined whether plasma concentration of brain-derived neurotrophic factor (BDNF) increases in patients receiving ECT for major depression. We conducted a prospective, self-controlled study of 15 patients with a DSM-IV diagnosis of major depressive episode who were referred for ECT at the University of Maryland Medical Center (Baltimore, Md.) between January 2004 and September 2005. Plasma BDNF concentration was measured by enzyme-linked immunosorbent assay before and during an acute course of ECT. Depression severity was measured using the 21-item Hamilton Rating Scale for Depression (HAM-D). ECT resulted in a significant increase in plasma BDNF (Z = 2.897, p = .004) from a pre-ECT median of 84.9 pg/mL to a post-ECT median of 141.2 pg/mL. This change was accompanied by a significant decrease in HAM-D score (Z = 3.411, p = .001) from a pre-ECT median of 30.0 to a post-ECT median of 9.0. BDNF increased in 13 (86.7%) of 15 subjects. This is the first report of an increase in plasma BDNF concentration in patients receiving ECT. These preliminary results encourage further investigation of a neurotrophic mechanism for the antidepressant effect of ECT.

Antidepressant treatment during pregnancy: Pros and cons

Background:The prevalence of mood disorders (anxiety and depression) during pregnancy seems to be similar to the women of the same group without pregnancy. Women with recurrent depression and euthimic women who discontinued antidepressants medication during pregnancy are particularly at high risk for depressive illness. Data about perinatal effects of SSRI antidepressants are gradually accumulating and are controversial. Two meta-analyses and some controlled studies don't find increased risk for major malformations in SSRI-exposed newborn. However, other studies find an increased risk of congenital malformations, poor birth outcomes and neonatal complications.Neonatal morbidity in infant newborn of women treated with antidepressant drugs. We examine the relation between the pharmacological treatment of the maternal anxiety/depression during the pregnancy and acute morbidity in infant newborns.Material and MethodsStudy group of 66 infant newborn of pregnant women with a diagnoses of major depressive episode or defined anxiety disorders according to DSM-IV, who were in treatment with antidepressant drugs during pregnancy. Control group: 120 newborn of healthy pregnant women, who did not receive any treatment, and were contemporary of the same gestational age and sex. Criteria of exclusion: demonstrated toxic consumption (alcohol, cocaine, cannabis, opiates, drug of synthesis). Studied variables: Type of childbirth and analgesia; Weight and age of gestation; pH of umbilical artery and Apgar test; Presence of malformations; Morbidity; Feeding; Withdrawal syndrome.Results:Infant newborn of mothers exposed to the antidepressant treatment suffered from more pathology than those of the control group (16/66 vs. 14/114; 24.2% vs.12.3%; p=0.038). Two smaller malformations in the study group were observed, a preauricular appendix (group A) and one moderate pielocilicilar ectasy (group C), both in mothers who received paroxetine (2/60; 3.3% vs. 0/114; 0%, p=0.05, Fisher p=0.118, NS). Only one infant newborn displayed compatible clinical signs with moderate withdrawal syndrome (irritability, vomits) from a mother treated with venlafaxine. No case of convulsions was observed. Breast feeding was less frequent in the group of antidepressant treated mothers (38/66, 57.6% vs. 86/116, 74,1%, p=0.032).Conclusions:The treatment with antidepressant drugs during pregnancy is necessary for some women. The clinician must weigh the relative risks of various treatment options and take into account individual patient wishes. Although the antidepressant drugs suppose an increased risk for the newborn, it could be assumable for the benefit that represents maintain the mother in an euthimic situation. We propose to discuss the clinical management, as well as, the accuracy of the psychiatric and obstetric controls to minimize the neonatal complications.