Clinical and socio-demographic correlates of anxious distress in Asian outpatients with major depressive disorder

Background: Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties.

Aims: This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD.

Methods: Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery–Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support.

Results: The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment.

Conclusions: Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.     

Diurnal mood variation in outpatients with major depressive disorder

Background: Diurnal mood variation (DMV) with early morning worsening is considered a classic symptom of melancholic features of major depressive disorder (MDD) according to the Diagnostic and Statistical Manual. This report used data from the sequenced treatment alternatives to relieve depression study to determine whether DMV was associated with treatment outcome to citalopram. Methods: Two thousand eight hundred and seventy‐five outpatients with nonpsychotic MDD were evaluated during a 14‐week trial of the selective serotonin reuptake inhibitor citalopram. Participants were divided into three groups: those with “classic” DMV (early morning worsening), those with any form of DMV (morning, afternoon, or evening worsening), and those with no DMV. Participants with classic DMV and those with any form of DMV were compared to those with no DMV in terms of baseline sociodemographic and clinical characteristics, treatment outcomes, and treatment features. Results: Minor baseline clinical characteristics and treatment feature differences were found between participants with and without DMV. Participants with classic morning DMV had slightly higher response rates than those without DMV. However, no differences were found in response or remission between either group of participants with DMV and those with no DMV. Conclusion: DMV does not appear to be associated with a unique prominent pattern of response to selective serotonin reuptake inhibitor treatment in patients with depression, and does not appear to be a serotonergically modulated process. Further evaluation is necessary to determine if this relationship holds true for dopaminergic and noradrenergic antidepressant agents, such as dual‐acting agents or antidepressant medication combinations. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

抑郁症门诊患者中未识别出的双相障碍者的临床特征（英文）

背景双相障碍常未被识别或被误诊为单相抑郁。明确未被识别或被误诊的双相障碍者的临床特征有助于减少错误分类。目的调查门诊抑郁症患者中未被识别的双相障碍者的比例,并分析未被识别的双相障碍者的临床特征。方法使用32项轻躁狂症状清单（Hypomania Checklist-32,HCL-32）、心境障碍问卷（Mood Disorder Questionnaire,MDQ）和简明国际神经精神访谈（Mini International Neuropsychiatric Interview,MINI）对目前被诊断为抑郁症的100例门诊患者进行调查。对被重新诊断为双相障碍与仍然被诊断为抑郁症的患者的临床特征进行比较分析。结果共有29例（29%）抑郁症门诊患者被诊断为双相障碍;其中双相Ⅰ型6例,双相Ⅱ型23例。与未更改诊断的抑郁症者相比,被重新诊断为双相障碍者年龄轻、起病早、发病次数多、受教育程度高,多为复发性抑郁且多伴精神病性症状。多因素Logistic回归分析显示年龄（OR=0.55,95%CI=0.34~0.89）和精神病性症状（OR=9.12,95%CI=1.56~53.26）是双相障碍的独立危险因素。结论在门诊抑郁症患者中未被识别的双相障碍比例较高,尤其是双相Ⅱ型。与单相抑郁相比,诊断为抑郁症而为未被识别的双相障碍者年龄轻,更可能伴有精神病性症状。     

Relevance of anger and irritability in outpatients with major depressive disorder

INTRODUCTION: Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder. METHODS: A total of 222 newly admitted consecutive outpatients with major depressive disorder (mean age 48.9 years, 64.4% females) were enrolled in the study. They had no comorbid axis I or II DSM-IV disorder, and they received no treatment with antidepressants in the preceding 2 months. They were assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. Principal component analysis was performed on SVARAD items. RESULTS: We obtained a three-factor solution accounting for 47.4% of total variance. The factors were interpreted as 'anger/irritability', 'depression', and 'anxiety', respectively. The anger/irritability dimension was clinically relevant in 23% of patients. Anger/aggressiveness was especially frequent (21.6%), whereas psychomotor activation was infrequent (0.9%). DISCUSSION: In depressive disorders, there are psychopathological dimensions other than depressed mood and anxiety that deserve greater clinical recognition and research. Our study suggests that one of these symptom clusters includes anger, irritability, aggressiveness, and hostility. The relevance of this dimension was not related to concurrent pharmacological treatment. Misdiagnosis of bipolar II disorder is also unlikely to explain our findings. Possibly, personality factors might at least partly explain the occurrence of anger and aggressiveness in several depressed patients. Attachment theory suggests that anger might also be conceived as part of the protest-despair-detachment reaction to a loss, either actual or symbolic.     

Prevalence of major depressive disorder in the general population of South Korea

INTRODUCTION: Previous epidemiological studies have reported a high prevalence of major depressive disorder (MDD) in North America and Western Europe. However, little information exists on MDD in Asian countries. This study investigates the prevalence of MDD and its characteristics in the general population of South Korea. METHODS: A representative sample of the South Korean general population composed of 3719 non-institutionalized individuals aged 15 years or older was interviewed by telephone using the Sleep-EVAL system. The participation rate was 91.4%. The interviews covered sociodemographic characteristics, health care utilization, physical illnesses and Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) psychiatric disorders. RESULTS: A depressive mood, i.e., feeling sad, downcast, having the blues or having lost interest in things formerly pleasant was reported by 20.9% of the sample without significant difference between men and women and among age groups. DSM-IV MDD was found in 3.6% (95% CI: 3.0-4.2%) of the sample. The prevalence of MDD was comparable among age groups. Shift workers were more likely to have MDD than daytime workers. Factor significantly associated with MDD were: being a woman, being a light or heavy smoker, perceiving one's health as being average or poor, doing physical activities at least three times per week in the evening, having a BMI below 18.5 kg/m2 and perceiving one's life as being moderately or highly stressful. CONCLUSIONS: Prevalence of MDD in Korea is higher than what it was previously estimated to be two decades ago. The number of individuals seeking help for depression was very low, and only a small number of MDD subjects received appropriate treatment for their condition.     

Frequency of anxiety disorders in psychiatric outpatients with major depressive disorder

OBJECTIVE: The authors determined the frequency of anxiety disorders in a large group of depressed outpatients seeking treatment. METHOD: The Structured Clinical Interview for DSM-IV was administered to 373 depressed outpatients. RESULTS: More than one-half of the patients met the full criteria for a current anxiety disorder, and more than one-half of the patients with an anxiety disorder had more than one. When partial remissions and anxiety disorder diagnoses classified as "not otherwise specified" were included, two-thirds of the patients had a current anxiety disorder and three-quarters had a lifetime history of an anxiety disorder. CONCLUSIONS: The majority of patients with a principal diagnosis of unipolar major depressive disorder have a comorbid anxiety disorder. Because antidepressant medications have differential efficacies for anxiety disorders, knowledge of the presence of a comorbid anxiety disorder in a depressed patient may have treatment implications.     

Bupropion in the treatment of outpatients with asthma and major depressive disorder

OBJECTIVE: Depressive disorders are common in asthma. Despite the high prevalence, antidepressant therapy in asthma patients with depression remains under-investigated. The objective of this pilot study was to investigate the use of bupropion for depression and anxiety in depressed asthma patients. METHOD: We conducted a 12-week open-label study of bupropion in 18 depressed asthma patients. Participants were assessed with the Hamilton Rating Scale for Depression (HAM-D-17), Hamilton Rating Scale for Anxiety (HAM-A), Inventory of Depressive Symptomatology--Self-Report (IDS-SR), Asthma Control Questionnaire (ACQ) and spirometry at baseline and weeks 1, 2, 4, 8, and 12. RESULTS: Significant baseline to exit improvements were observed on the HAM-D-17 (mean change = 4.72, SD = 7.78, p = 0.02) and the HAM-A (mean change = 2.12, SD = 3.97, p = 0.04). Based on the HAM-D-17 scores, 27.8% of the patients were responders and 16.7% were remitters. Significant correlations were found between changes in ACQ score and HAM-D-17 r = 0.73, p = 0.001), ACQ score and IDS-SR r = 0.58, = 0.012), and FEV1% Predicted and HAM-D-17 r = -0.66, p = 0.006). CONCLUSIONS: Bupropion treatment was associated with significant improvements in depression and anxiety symptoms in asthma patients. Improvements in asthma correlated significantly with improvements in depression.     

An open trial of reboxetine in HIV-seropositive outpatients with major depressive disorder

BACKGROUND: The prevalence of major depressive disorder (MDD) in human immunodeficiency virus (HIV)-seropositive patients is higher than in the general population. The treatment of comorbidities of HIV infection, such as depression, is an important target in the clinical management of these patients. The use of antidepressants in HIV patients can be complicated by the pharmacokinetic interaction between antidepressants and antiretroviral agents. Several antidepressants and antiretrovirals are metabolized by cytochrome P450 (CYP450). Reboxetine is a noradrenergic antidepressant that is not metabolized by CYP450 and may offer a valuable option in the treatment of MDD in HIV-seropositive patients. METHOD: Twenty HIV-infected outpatients with MDD according to DSM-IV criteria were treated with reboxetine, 8 mg/day, for 12 weeks within an open trial design. Outcome measures included the Montgomery-Asberg Depression Rating Scale (MADRS) and a side effect profile. Data were gathered from July 2000 to March 2001. RESULTS: Seventy-five percent of patients (N = 15) completed the trial. All patients who completed the trial had an improvement equal to or higher than a 50% reduction in their MADRS scores at endpoint. The most frequent adverse effects were insomnia, sweating, and shivering. CONCLUSION: Within this open trial, reboxetine was found to be effective in reducing depressive symptoms in HIV illness. The rate of dropout (25%) suggests that reboxetine may be well tolerated in this population.     

Prevalence and correlates of alpha-delta sleep in major depressive disorders

Objective. Major depressive disorder is associated with sleep disturbances. An electroencephalographic pattern of alpha wave intrusion in delta wave sleep (alpha-delta sleep) is observed in some subjects with major depressive disorder. The treatment-resistant symptoms in major depressive disorder, nonrestorative sleep and fatigue, are associated with alpha-delta sleep. The objective of this study is to identify the prevalence and clinical correlates of alpha-delta sleep in major depressive disorder.Design. Retrospective studySetting. Sleep Disorders Center, Cleveland Clinic, Cleveland, OhioParticipants. Polysomnograms were conducted on 150 subjects 18 years of age or older (75 with and 75 without major depressive disorder) were reviewed.Measurements. The percent of delta waves with alpha intrusion was collected and analyzed.Results. Subjects with major depressive disorder compared to nondepressed subjects had a higher sleep efficiency (83.0±9.6; 78.1±8.2%), shorter rapid eye movement latency (85.0±44.5; 189.9±25.6 min), less slow wave sleep (8.3±3.0; 13.5±6.2%), and greater rapid eye movement (24.7±7.0; 19.2±8.2%), and all of these findings were statistically significant. Patients with major depressive disorder had higher alpha-delta sleep (23.4±14.2%; 2.3±6.7%, p<0.01). Patients with major depressive disorder were categorized into high and low alpha-delta sleep based on percentage of alpha-delta sleep present in slow wave sleep (alpha-delta sleep was present ≥15% or ≤15% of slow wave sleep, respectively). Patients with major depressive disorder with high alpha-delta sleep were at 3.15 greater odds (1.22-8.14; p=0.018) to have excessive daytime sleepiness.Conclusion. Patients with major depressive disorder have a higher prevalence of alpha-delta sleep. Alpha-delta sleep is associated with daytime sleepiness in patients with major depressive disorder. Study limitations include the retrospective nature of the project and the fact that the principle investigator, who scored and interpreted alpha intrusion, was not blind to group membership.     

Neuroanatomic correlates of psychopathologic components of major depressive disorder

BACKGROUND: The Hamilton Depression Rating Scale (HDRS) is widely used to measure the severity of depression in mood disorders. Total HDRS score correlates with brain metabolism as measured by fludeoxyglucose F 18 ([(18)F]-FDG) positron emission tomography. The HDRS comprises distinct symptom clusters that may be associated with different patterns of regional brain glucose metabolism. OBJECTIVE: To examine associations between HDRS component psychopathologic clusters and resting glucose cerebral metabolism assessed by [(18)F]-FDG positron emission tomography.Patients We evaluated 298 drug-free patients who met the DSM-III-R criteria for major depressive disorder. MAIN OUTCOME MEASURES: Five principal components were extracted from the 24-item HDRS for all subjects and ProMax rotated: psychic depression, loss of motivated behavior, psychosis, anxiety, and sleep disturbance. The [(18)F]-FDG scans were acquired in a subgroup of 43 drug-free patients in twelve 5-minute frames. Voxel-level correlation maps were generated with HDRS total and factor scores. RESULTS: Total HDRS score correlated positively with activity in a large bilateral ventral cortical and subcortical region that included limbic, thalamic, and basal ganglia structures. Distinct correlation patterns were found with the 3 individual HDRS factors. Psychic depression correlated positively with metabolism in the cingulate gyrus, thalamus, and basal ganglia. Sleep disturbance correlated positively with metabolism in limbic structures and basal ganglia. Loss of motivated behavior was negatively associated with parietal and superior frontal cortical areas. CONCLUSIONS: Different brain regions correlate with discrete symptom components that compose the overall syndrome of major depression. Future studies should extend knowledge about specific regional networks by identifying responsible neurotransmitters related to specific psychopathologic components of mood disorders.     

Insight and correlates among outpatients with depressive disorders

The aims of this study were to explore the levels of insight in patients with depressive disorders and to examine the factors that influenced insight. Using the Mood Disorders Insight Scale, we evaluated 247 patients with depressive disorders to determine their levels of insight with respect to their awareness of the illness, the attribution of symptoms, and their belief in the necessity of treatment. The relationships between insight and the severity of depressive symptoms, the level of self-stigma, sociodemographic characteristics, and the course of the illness were examined. The results reveal that 91 (36.8%) subjects had impaired insight into awareness of their illness, 92 (37.2%) had impaired insight into attribution of symptoms, and 39 (15.8%) had impaired insight into the need for treatment. A younger age and more severe depression symptoms were significantly associated with insight into awareness of the illness. More severe depression symptoms and a higher education were associated with intact insight with respect to attribution of symptoms. Those who have a major depressive disorder were more likely to have intact insight into the need for treatment than those with depressive disorder that was not otherwise specified. Analysis of our results indicates that depressive patients with factors predicting impaired insight may benefit from intervention to improve their insight, and this should advance their recovery.     

The neural correlates of anhedonia in major depressive disorder.

BACKGROUND: Anhedonia is a relative lack of pleasure in response to formerly rewarding stimuli. It is an important diagnostic feature of major depressive disorder (MDD), and predicts antidepressant efficacy. Understanding its neurobiological basis may help to target new treatments and predict treatment outcomes. Using a novel paradigm, we aimed to explore the correlations between anhedonia severity and magnitude of neural responses to happy and sad stimuli in regions previously implicated in studies of human reward processing and depressive anhedonia. METHODS: Neural responses to happy and sad emotional stimuli (autobiographical prompts and mood congruent facial expressions) were measured using blood oxygen level dependent (BOLD) functional magnetic resonance imaging in twelve MDD individuals with varying degrees of anhedonia. RESULTS: In response to happy stimuli, anhedonia, but not depression severity per se, was positively and negatively correlated with ventromedial prefrontal cortex (VMPFC) and amygdala/ventral striatal activity, respectively. State anxiety independently contributed to a VMPFC-subcortical dissociation of response to happy (but not sad) stimuli, which was similar, but different, to anhedonia. CONCLUSIONS: These findings suggest that anhedonia and state anxiety are associated with dysfunction within neural systems underlying the response to, and assessment of, the rewarding potential of emotive stimuli in MDD, and highlight the importance of employing a symptom-dimension-based approach in the examination of the neurobiology of depression.     

Comorbidities and factors related to discontinuation of pharmacotherapy among outpatients with major depressive disorder

Objective

Although many studies have researched adherence to pharmacotherapy among patients with major depressive disorder (MDD), the effects of chronic depression, anxiety comorbidities, migraine, and other factors on adherence have rarely been studied. This study investigated which comorbidities and factors independently predicted discontinuation of pharmacotherapy among psychiatric outpatients with MDD.

Methods

One hundred thirty-five subjects (34 men, 101 women) with MDD were enrolled. MDD and anxiety comorbidities were diagnosed using the Structured Clinical Interview for DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision), migraine was diagnosed based on the International Classification of Headache Disorders, 2nd Edition, and depression severity was evaluated using the Hamilton Depression Rating Scale. Six months later, subjects' reasons for discontinuation were investigated, and Cox proportional hazards regression and logistic regression were used to investigate the independent factors predicting discontinuation.

Results

Subjects with chronic depression, migraine, panic/agoraphobia, or posttraumatic stress disorder attended follow-up for longer before discontinuation than those without. Chronic depression and greater age independently predicted a longer follow-up before discontinuation. Concern about and intolerance of the side effects of antidepressants and lack of insight into MDD independently predicted discontinuation within 2 months. “Self-reported recovery” was the most common reason for discontinuation; however, 53.8% of the subjects who cited this reason did not reach full remission.

Conclusions

The impact of the duration of depression (chronic depression) on adherence may be more important than the severity of depression, anxiety comorbidities, and migraine. Education of MDD patients and society in general to improve understanding of MDD and antidepressants is needed to enhance adherence to pharmacotherapy.     

A comparison of fluoxetine and imipramine in the treatment of outpatients with major depressive disorder

A double-blind clinical trial was undertaken to evaluate the clinical efficacy and safety of fluoxetine compared with imipramine in the treatment of 59 outpatients suffering from major depressive disorder. The mean scores of all depression rating scales showed that the drugs had comparable efficacy. The side effect profile of imipramine was found to be mainly anticholinergic, which was not the case for fluoxetine, where it was mainly found to be gastrointestinal, such as nausea and diarrhoea. In both groups the total number of adverse events reported were the same. Fluoxetine treatment resulted in weight loss, whereas imipramine treatment resulted in a slight but significant weight increase.     

Prevalence of major depressive disorder in Nigerian college students with alcohol-related problems

OBJECTIVES: The study aimed to estimate the prevalence of major depressive disorder (MDD) among Nigerian college students with alcohol-related problems (ARP) and compare the estimated prevalence with their counterparts without ARP. METHOD: A cross-sectional survey of a representative sample of students (n=2658) in six colleges in Osun state, Western Nigeria. The students were independently assessed for ARP and MDD with the Mini International Neuropsychiatric Interview (MINI). RESULTS: The current (2 weeks) prevalence of MDD in college students with alcohol dependence is 23.8%; alcohol abuse 17.2% and hazardous use 12.4%. Compared with total abstainers, major depressive disorder is significantly more likely to be associated with diagnosis of alcohol dependence (OR 3.14, 95% CI 1.42-6.96), alcohol abuse (OR 2.27, 95% CI 1.38-3.72) and hazardous use (OR 1.64, 95% CI 1.12-2.38), but less associated with alcohol users without ARP (OR 0.93, 95% CI 0.69-1.25). CONCLUSION: Nigerian college students with ARP are significantly more at risk of depressive disorders than those without ARP. Early recognition and treatment of depression are important considerations when planning preventive strategies for alcohol-related problems in college students.     

Narrative therapy for adults with major depressive disorder: Improved symptom and interpersonal outcomes

Abstract

This study investigated depressive symptom and interpersonal relatedness outcomes from eight sessions of manualized narrative therapy for 47 adults with major depressive disorder. Post-therapy, depressive symptom improvement (d=1.36) and proportions of clients achieving reliable improvement (74%), movement to the functional population (61%), and clinically significant improvement (53%) were comparable to benchmark research outcomes. Post-therapy interpersonal relatedness improvement (d=.62) was less substantial than for symptoms. Three-month follow-up found maintenance of symptom, but not interpersonal gains. Benchmarking and clinical significance analyses mitigated repeated measure design limitations, providing empirical evidence to support narrative therapy for adults with major depressive disorder.     

Prevalence of major depressive disorder among Chinese-Americans in primary care

An epidemiological study in Los Angeles showed that Chinese Americans had lower rates of depression compared to the U.S. national estimates. This study surveys the prevalence of major depressive disorder (MDD) among Asian-Americans in the primary care setting. A two-phase epidemiological survey was performed in the primary care clinic of a community health center in Boston, MA, which provides treatment to under-served Asian-Americans. Participants were Chinese Americans in the waiting area of the primary care clinic, 18 years of age or older, who spoke any one the four commonly used Chinese dialects. The Chinese version of the Beck Depression Inventory (CBDI) was used for initial screening. All consenting patients who screened positive (CBDI >/= 16) and a fraction of those who screened negative (CBDI < 16) were interviewed by a bilingual and bicultural psychiatrist with the Structured Clinical Interview for DSM-III-R, patient version, for confirmation of the diagnosis of MDD. There were 815 in the primary care clinic that were approached, of which 503 patients (62% female, mean age 50 +/- 17 years) filled out the CBDI in the initial phase of depression screening. Extrapolating the results from the SCID-P interviews, the prevalence of MDD among Asian-Americans in the primary care setting was estimated to be 19.6% +/- 0.06. MDD is common among Asian-Americans in primary care settings. The prevalence of MDD is comparable to or higher than those found in the U.S. nonminority populations.