Long-term Outcome Of Depression Research Articles

The combined DEX-CRH test in treatment course and long-term outcome of major depression

Neuroendocrine studies strongly suggest that the hypothalamic–pituitary–adrenocortical (HPA) system plays a crucial role in the development and course of depression. The interaction between the disease process and HPA system function in long-term course, however, is unclear. Since improvement of HPA system deterioration has been demonstrated to be associated with treatment response, the question has arisen whether the course of therapy response as reflected by, for example, early improvement or response (after 1 or 2 weeks of therapy) is also based on HPA system dysfunction and whether the course of HPA regulation during treatment is only a state marker or has additional predictive implications for long-term outcome. In order to elucidate these questions a long-term study was carried out to investigate whether HPA system disturbance is associated (1) with the course of treatment response, predominantly early treatment response, during acute depression and (2) with the long-term course of depression, i.e. number of episodes. Twenty patients with affective disorders who participated in earlier controlled antidepressant treatment studies over 6 weeks were enrolled in an exploratory follow-up study. Using the combined DEX/CRH test it was demonstrated that (1) early improvement, early treatment response and beneficial treatment outcome after 6 weeks were associated with a lower HPA system activity and that (2) in long-term course of depression the HPA system deterioration increases in parallel with the number of previous episodes. These findings suggest that HPA system alterations are closely related to treatment response and long-term outcome of depression.

NMDA receptor involvement in imipramine withdrawal-associated effects on swim stress, GABA levels and NMDA receptor binding in rat hippocampus

Abrupt antidepressant withdrawal after chronic treatment is associated with a stress response that may negatively affect the long-term outcome of depression, the neurochemical correlates, of which, remain undetermined. Prolonged depression involves the stress-related release of glucocorticoids and glutamate, while response to antidepressants involves γ-amino butyric acid (GABA) and the glutamate N-methyl-D-aspartate (NMDA) receptor. Here, imipramine (IMI) was administered to rats for three weeks followed by acute withdrawal for seven days. Levels of GABA in the hippocampus (HC), and effects on swim stress immobility (SSI), were determined. Furthermore, glutamate/NMDA receptor binding properties were determined using [ 3H]-CGP-39653. Finally, the ability of dizocilpine (MK801), a glutamate NMDA antagonist, to reverse IMI withdrawal was determined. Chronic IMI (15 mg/kg ip) significantly reduced SSI together with a slight but insignificant decrease in HC GABA levels. However, IMI significantly reduced specific binding (B max) of [ 3H]-CGP-39653. Withdrawal of IMI for 7 days resulted in a loss of efficacy on SSI, a slight increase in GABA and a significant reversal of IMI effects on [ 3H]-CGP-39653 binding. MK801 (0.2 mg/kg ip) alone for seven days caused a significant decrease in SSI, a significant suppression of HC GABA, and significantly decreased [ 3H]-CGP-39653 B max. MK801 during IMI-withdrawal significantly decreased GABA, prompted recovery on SSI, though not significantly, but significantly reversed withdrawal effects on [ 3H]-CGP-39653 B max. In conclusion, acute antidepressant discontinuation is associated with subtle changes on HC GABA, a resurgence of NMDA receptor density and a loss of its anti-immobility response. These responses are reversed by a NMDA antagonist suggesting that abrubt antidepressant discontinuation mobilises glutamate activity.

Does age predict the long-term outcome of depression treated with ECT? (a prospective study of the long-term outcome of ECT-treated depression with respect to age).

Sixty-three subjects with DSM-III-R major depression with melancholia or psychosis were followed up 2-4 years after index treatment with electroconvulsive therapy. There was a twofold increase in likelihood of improved outcome with an additional 20 years of age.

Fragile states of mind: neuroticism, vulnerability and the long-term outcome of depression.

This paper considers the extent to which vulnerability to the outcome of major affective disorder is conferred through personality deviance. Results are based upon a 12 year longitudinal follow-up study of 80 patients with a primary depressive disorder, originally selected from a consecutive series seeking care at a hospital in Scotland. The study included detailed clinical course assessments in association with the formal application of diagnostic criteria. Assessments on recovery from the index episode included measures of self-confidence and of neuroticism. Experience of selected severe loss events over the study period was also determined. Limited self-confidence was strongly related, unlike neuroticism, to the subsequent first recurrence of affective disorder. Relationships between psychosocial, clinical and demographic factors and long-term outcome revealed psychosocial factors, in particular neuroticism and a lack of self-confidence, to have the greatest prognostic significance. These results reveal the heightened risk over the long-term of a poor outcome for depressive disorder consequent upon measures of personality deviance and of exposure to adversity. While giving only limited support to narrowly defined psychosocial models of depression, they clarify the risk gradients involved and through this may provide a firmer basis than hitherto for relapse prevention.

Future imperfect: the long-term outcome of depression.

During 1976, 80 patients with a primary depressive illness were selected from a consecutive series of referrals to the Royal Edinburgh Hospital for a short-term follow-up study. This paper concerns the 12-year longitudinal assessment of the survivors. During the follow-up, mortality risk for the sample was almost doubled. Of the series, 35% had experienced a recurrence within 2 years of the initial interview, and just over 60% within the entire study time of 12 years. The risk of recurrence was enhanced for those aged over 45 years at index, for those with a history of depressive disorder and for those who had not engaged in parasuicidal behaviour during the index episode. The observed effect of previous episodes was largely accounted for by age. The chance of recurrence was not affected by whether the treatment of the index episode included ECT, or by whether diagnosis was 'endogenous' or 'neurotic'. Application of the Lee-Murray outcome criteria showed that about one-third of the Edinburgh series experienced a very poor outcome. Results are presented concerning the prediction of long-term outcome as represented by the Depression Outcome Scale (DOS), a measure specially constructed for this study.

The Stirling County Study: Then and now

The Stirling County Study was started more than 40 years ago. In the context of the field of community-based psychiatric epidemiology as a whole, the Stirling Study is reviewed using three time periods. The early years are illustrated by comparison of the Lundby, Midtown, and Stirling Studies. This period ended in critical reviews which emphasized the absence of agreement about psychiatric diagnosis and which suggested that prevalence was over-estimated especially by Stirling and Midtown, both of which gave a current overall rate of about 20%. During the middle years effort in the Stirling Study and in psychiatric epidemiology generally was concentrated on issues of reliability and validity of diagnosis. The recent years are illustrated by comparison with the Epidemiologic Catchment Area Program, the Edmonton Epidemiologic Survey, and the National Comorbidity Survey. A current overall rate of approximately 20% can no longer be thought of as an over-estimation since it has appeared in numerous studies. Similarities and differences across studies will, however, continue to draw attention. In terms of similarities, the findings from the Stirling Study from 1952–1970 seem to support a “birth cohort” effect for depression which has been commonly but retrospectively reported in the newer studies. While recent findings from the Stirling Study are not yet available, it is possible that peak prevalence has moved downward from older to younger people as time has moved forward from 1952 to 1992. In terms of differences, results about depression in the Stirling Study are unusual in that they suggest equal vulnerability for men and women. This finding is worthy of attention because long-term outcome of depression was much worse for men than women in terms of association with death and in the liklihood of remaining chronically or recurrently depressed.

Electroconvulsive Therapy for Major Depression in the Oldest Old: Effects of Medical Comorbidity on Post-Treatment Survival

This is a longitudinal study of 65 patients who were 80 years old or older at the time they were hospitalized for depression. Thirty-seven were treated with ECT and 28 with medication. Survival after 1, 2, and 3 years in the ECT group was 73.0%, 54.1%, and 51.4%, respectively. Survival after 1, 2, and 3 years in the non-ECT group was 96.4%, 90.5%, and 75.0%, respectively. The relatively high mortality rate in the ECT group in this study suggests that patients over 80 who undergo ECT have more severe physical illness than those who can be treated successfully with medication. Medical comorbidity is a major determinant of long-term outcome of depression in the oldest old.

Outcome of Depression and Anxiety in Primary Care

We evaluated the long-term outcome of depression and anxiety and associated disability among primary-care attenders with common psychiatric disorders and symptoms (n = 201) using binary and multicategorical, interview-based outcome measures of psychiatric illness and disability. A two-stage design was used. In the first stage, 1994 consecutive attenders of 25 general practitioners were screened on psychiatric illness with the General Health Questionnaire and by their physicians. A stratified random sample (n = 292) with differing probabilities was selected for second-stage interview (Present State Examination and Groningen Disability Schedule). Patients with psychiatric symptoms (n = 201) were reassessed 1 (n = 182) and 3 1/2 (n = 154) years later. At 1- and 3 1/2-year follow-ups, many cases no longer met the criteria of their baseline diagnosis and disability levels had substantially dropped. However, partial remission, not full recovery, was the rule, and was associated with residual disability. Depression had better outcomes than anxiety and mixed anxiety-depression. We concluded that a multicategorical, rather than a binary, outcome measure better reflects patient outcomes, since it highlights partial remission, mild symptoms, and residual disability, and as such, stresses the need to supplement short-term treatment. A multicategorical caseness model may be advantageous for research and clinical practice. We suggest a dynamic-equilibrium model to account for residual symptoms and disability. This study is a follow-up to two earlier reports on the recognition, treatment, and 1-year course of common psychiatric illnesses in general practice.

Diagnosis, Personality and the Long-term Outcome of Depression

Patients diagnosed in the late 1960s as suffering from either endogenous or neurotic depression, or as presenting with depression but discharged with another neurotic diagnosis, were followed for 15 years. Diagnosis at index admission did not predict overall outcome, but patients with endogenous depression, an apparently stable diagnosis, had longer index admissions, were readmitted sooner, but spent less time ill than patients in either of the neurosis groups. Personality abnormality accounted for 20% of the variance in outcome in the neurotic groups and only 2% of the variance in the endogenous group. Thus there is evidence that endogenous and neurotic depression are two illnesses and that, in the neuroses particularly, prognosis will depend on the extent to which these personality abnormalities are modified by treatment.

Life stressors, social resources, coping, and the 4-year course of unipolar depression.

Little is known about the effects of psychosocial factors on the long-term course of unipolar depression. This article examines the 4-year stability and change in life stressors, social resources, and coping, and their effect on the course of treated unipolar depression among 352 men and women. Depressed patients were assessed at treatment intake and at 1-year and 4-year follow-ups. Over the 4 years, patients improved in symptom outcomes, the quality of social resources, and coping responses; there were some declines in life stressors. Life stressors, social resources, and coping were related to patient functioning concurrently, after controlling for demographics, initial treatment, and initial dysfunction severity. Preintake medical conditions and family conflict consistently predicted poorer long-term outcomes. The findings imply that medical conditions and family conflict are important risk factors that predict poorer long-term outcome of depression.

Personality and the prediction of long-term outcome of depression.

In a follow-up study of 150 women who had undergone treatment on an outpatient basis for acute depression, it was found that the most important predictor of their long-term clinical outcome (8, 20, and 48 months after the acute episode) was personality as measured by the Neuroticism Scale of the Maudsley Personality Inventory (MPI-N). Age, race, social class, marital status, religion, number of previous depressions or suicide attempts, diagnosis, history of early deaths of or separations from significant others, history of neurotic traits as a child, amount and type of stress in the 6 months before onset, and severity and pattern of pretreatment symptoms were not predictive of outcome.