Somatoform disorders in DSM-IV: mental or physical disorders?

OBJECTIVE: To examine analytically the question of whether the characterization of somatoform disorders (SFDs) in Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) provides adequate grounds for classifying them as mental disorders rather than as physical disorders. METHODS: Analytical examination. RESULTS: There are prima facie grounds for classifying SFDs as physical disorders since they are characterized by physical symptoms. The characterization of SFDs in DSM-IV does not provide adequate grounds for classifying them as mental disorders. CONCLUSION: The spectrum of SFDs is drawn too widely in DSM-IV. At least some of the conditions now listed as SFDs in DSM-IV should be either given a dual diagnosis or classified simply as physical disorders.     

On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice

BACKGROUND: Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients. METHOD: 1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder. RESULTS: No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion. CONCLUSION: In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.     

The effects of breathing-related sleep disorders on mood disturbances in the general population

BACKGROUND: Results of clinical studies suggest that there may be a relationship between breathing-related sleep disorders and depressive disorders. This study aims to assess the impact of breathing-related sleep disorder on major depressive disorder in the general population. METHOD: A cross-sectional telephone survey was carried out between 1994 and 1999 in the general population of the United Kingdom, Germany, Italy, Portugal, and Spain. A total of 18,980 randomly selected subjects aged 15 to 100 years and representative of the general population of their respective countries participated in the study. The questionnaire included a series of questions about sleep quality, breathing-related sleep disorder symptoms, mental disorders, and medical conditions. Data are presented using point prevalence. RESULTS: 2.1% of the subjects were found with obstructive sleep apnea syndrome at the time of the interview, and 2.5% had some other type of DSM-IV breathing-related sleep disorder diagnosis. The association of DSM-IV breathing-related sleep disorder diagnosis and major depressive disorder diagnosis was found in 0.8% of the sample. As many as 18% of individuals with a major depressive disorder diagnosis also have a DSM-IV breathing-related sleep disorders diagnosis, and 17.6% of subjects with a DSM-IV breathing-related sleep disorders diagnosis have a major depressive disorder diagnosis. Multivariate models showed that even after controlling for obesity and hypertension, the odds of having a DSM-IV breathing-related sleep disorders diagnosis was 5.26 for individuals with a major depressive disorder diagnosis. CONCLUSION: About 800 of 100,000 individuals have both a breathing-related sleep disorder and a major depressive disorder. The identification of 1 of these 2 disorders should prompt the investigation of the other disorder since nearly a fifth of them have the other disorder.     

Prevalence and risk factors for depression in a rural setting. Results from the North Wales arm of the ODIN project

BACKGROUND: Depressive disorders are common, and result in high individual and societal costs. The majority of research assessing depression has occurred in urban areas. There is a paucity of research examining the prevalence of and risk factors for depression in rural general practice. AIM: The aim of this study was to examine the prevalence of and risk factors for depression in a rural area of North Wales in the context of a large multi-centre European study. METHOD: One thousand nine hundred and ninety-nine people randomly selected from a health authority database underwent a two-phase screening method to identify depression. The first phase involved patients completing a self-rating postal questionnaire (the Beck Depression Inventory or BDI). In the second phase, those scoring above cut-off underwent detailed diagnostic interview (Schedules of Clinical Assessment in Neuropsychiatry or SCAN). The SCAN diagnostic interview can generate either DSM-IV or ICD-10 diagnoses; the DSM-IV classification system was used here. RESULTS: One thousand two hundred and thirty-nine (63 %) people responded to the initial screening questionnaire. The prevalence rate for all DSM-IV depressive disorders was calculated to be 6.1 % (95 % CI 4.1, 9.0) whereas the prevalence rate for DSM-IV major depressive disorder was 5.1 % (CI 3.37, 7.66). Multivariate analysis indicated that several variables were related to BDI caseness, including gender, employment status, social support and negative life events. CONCLUSION: Levels of reported depression are relatively low in North Wales compared to those observed in a neighbouring urban area using comparable data collection methods. A number of factors traditionally associated with increased risk from depression were predictive of scoring above cut-off on the BDI in a rural North Wales sample.     

Generalized anxiety disorder in patients with major depression: is DSM-IV's hierarchy correct?

OBJECTIVE: DSM-III imposed a hierarchical relationship in the diagnosis of anxiety disorders in depressed patients, stipulating that anxiety disorders could not be diagnosed if their occurrence was limited to the course of a mood disorder. In the subsequent versions of the DSM this hierarchy was eliminated for all anxiety disorders except generalized anxiety disorder. The authors examined the validity of this remaining hierarchical relationship between mood and anxiety disorders. METHOD: Psychiatric outpatients with major depressive disorder (N=332) were evaluated with a semistructured diagnostic interview and completed paper-and-pencil questionnaires on presentation for treatment. To study the validity of the DSM-IV hierarchical relationship between generalized anxiety disorder and mood disorders, the authors made a diagnosis of modified generalized anxiety disorder for patients with major depressive disorder who met all the criteria for generalized anxiety disorder except for the exclusion criterion. The analyses compared the characteristics of three nonoverlapping groups of patients with DSM-IV major depressive disorder: 1) those with coexisting DSM-IV generalized anxiety disorder, 2) those with coexisting modified generalized anxiety disorder, and 3) those with neither DSM-IV nor modified generalized anxiety disorder. RESULTS: Compared to the depressed patients without generalized anxiety disorder, the depressed patients with DSM-IV and modified generalized anxiety disorder had higher levels of suicidal ideation; poorer social functioning; a greater frequency of other anxiety disorders, eating disorders, and somatoform disorders; higher scores on most subscales of a multidimensional self-report measure of DSM-IV axis I disorders; a greater level of pathological worry; and a higher morbid risk for generalized anxiety disorder in first-degree family members. The two generalized anxiety disorder groups did not differ from each other. CONCLUSIONS: The findings question the validity of the DSM-IV hierarchical relationship between major depressive disorder and generalized anxiety disorder and suggest that the exclusion criterion should be eliminated.     

Noncardiac chest pain and psychopathology in children and adolescents

OBJECTIVE: We sought to examine the prevalence of DSM-IV psychiatric disorders in children and adolescents with complaints of noncardiac chest pain (NCCP). METHOD: We assessed 27 youngsters (ages 8-17 years) referred to a pediatric cardiology practice with complaints of NCCP. Each child and a parent were interviewed using the Anxiety Disorders Interview Schedule for Children. RESULTS: Sixteen youngsters (59%) were diagnosed with a current DSM-IV disorder. Fifteen (56%) had a current anxiety disorder, nine of whom were diagnosed with panic disorder. One participant was diagnosed with a depressive disorder. CONCLUSION: Results of this preliminary study suggest that DSM-IV anxiety disorders may be common in youngsters with NCCP. No evidence was found for high prevalence of depression in this sample. Larger controlled studies are needed to determine the prevalence and impact of psychopathology in youngsters with NCCP.     

Toward a clinical delineation of dysphoric hypomania - operational and conceptual dilemmas

OBJECTIVE: Unlike dysphoric mania, we are unaware of any formal studies of dysphoric hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states. METHODS: In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (> or =2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric hypomania had to last at least 1 week. RESULTS: Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) 'pure' BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH. CONCLUSIONS: The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.     

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.     

How should mood disorders be modelled?

Classification of any mental disorder is likely to have clinical utility only if it is based on a valid underlying model. The depressive disorders have long provoked debates as to whether a categorical or a dimensional model is all explanatory. This paper will argue that no single (categorical or dimensional) model is likely to be valid, and that a mix of models is required to classify, diagnose and shape management decisions for the mood disorders. After reviewing limitations to the dimensionally based official classificatory systems (DSM-IV and ICD-10), and noting some of the consequences, a set of alternative strategies is outlined. In essence, identifying syndromal 'fuzzy sets' from phenotypic and aetiological clustering, a model that occurs in the rest of medicine.     

Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review

Objective: Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. Method: This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. Results: Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. Conclusion: Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.     

Clinical epidemiology in patients admitted at Mathari Psychiatric Hospital,Nairobi, Kenya

BACKGROUND: Knowledge of types and co-morbidities of disorders seen in any facility is useful for clinical practice and planning for services. AIM: To study the pattern of co-morbidities of and correlations between psychiatric disorders in in-patients of Mathari Hospital, the premier psychiatric hospital in Kenya. STUDY DESIGN: Cross-sectional. METHODS: All the patients who were admitted at Mathari Hospital in June 2004 and were well enough to participate in the study were approached for informed consent. Trained psychiatric charge nurses interviewed them using the Structured Clinical Interview for DSM-IV Axis I disorders Clinical Version (SCID-I). Information on their socio-demographic profiles and hospital diagnoses was extracted from their clinical notes using a structured format. RESULTS: Six hundred and ninety-one patients participated in the study. Sixty-three percent were male. More than three quarters (78%) of the patients were aged between 21 and 45 years. More than half (59.5%) of the males and slightly less than half (49.4%) of the females were single. All the patients were predominantly of the Christian faith. Over 85% were dependants of another family member and the remainder were heads of households who supported their own families. Schizophrenia, bipolar I disorder, psychosis, substance use disorder and schizo-affective disorder were the most common hospital and differential diagnoses. Of the anxiety disorders, only three patients were under treatment for post-traumatic stress disorder (PTSD). Nearly a quarter (24.6%) of the patients were currently admitted for a similar previous diagnosis. Schizophrenia was the most frequent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-fourth edition) diagnosis (51%), followed by bipolar I disorder (42.3%), substance use disorder (34.4%) and major depressive illness (24.6%). Suicidal features were common in the depressive group, with 14.7% of this group reporting a suicidal attempt. All DSM-IV anxiety disorders, including obsessive-compulsive disorders, were highly prevalent although, with the exception of three cases of PTSD, none of these anxiety disorders were diagnosed clinically. Traumatic events were reported in 33.3% of the patients. These were multiple and mainly violent events. Despite the multiplicity of these events, only 7.4% of the patients had a PTSD diagnosis in a previous admission while 4% were currently diagnosed with PTSD. The number of DSM-IV diagnoses was more than the total number of patients, suggesting co-morbidity, which was confirmed by significant 2-tailed correlation tests. CONCLUSION: DSM-IV substance use disorders, major psychiatric disorders and anxiety disorders were prevalent and co-morbid. However, anxiety disorders were hardly diagnosed and therefore not managed. Suicidal symptoms were common. These results call for more inclusive clinical diagnostic practice. Standardized clinical practice using a diagnostic tool on routine basis will go a long way in ensuring that no DSM-IV diagnosis is missed. This will improve clinical management of patients and documentation.     

The relationship between depressive personality disorder and major depressive disorder: a population-based twin study

OBJECTIVE: One of the most important controversies regarding depressive personality disorder is the overlap with mood disorders. The aim of this study was to estimate the genetic and environmental sources of covariance between depressive personality disorder and major depressive disorder and to what extent genetic, shared, and unique environmental factors are specific to each disorder. METHOD: A total of 2,801 young adult twins from the Norwegian Institute of Public Health Twin Panel were assessed at personal interview for depressive personality disorder and major depressive disorder with the Structured Interview for DSM-IV Personality and the Composite International Diagnostic Interview. Bivariate Cholesky models were fitted to the data by using the Mx statistical program. RESULTS: In the best-fitting model, the covariation between depressive personality disorder and major depressive disorder were accounted for by genetic and unique environmental factors only. A model that did not include genetic factors specific to major depressive disorder was rejected. The authors found no clear evidence for gender differences in sources of comorbidity of depressive personality disorder and major depressive disorder. CONCLUSIONS: Although depressive personality disorder and major depressive disorder share a substantial proportion of genetic and environmental risk factors, the results from this study support the hypothesis that the two disorders are distinct entities with overlapping, but not identical, etiologies.     

Course of hypochondriasis in an international primary care study

Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.     

The validity of the associated symptom criteria for DSM-IV generalized anxiety disorder

In light of the poor reliability and discriminant validity of the DSM-III-R criteria for generalized anxiety disorder (GAD), extensive modifications were implemented in the development of the DSM-IV criteria. This study compares the discriminant validity of the DSM-III-R and DSM-IV criteria for GAD using data from a study of the familial aggregation of anxiety disorders and alcoholism. Based on information from a semi-structured diagnostic interview, both the DSM-III-R and DSM-IV associated symptom criteria were applied to characterize directly interviewed spouses and relatives of probands. The criterion-related and discriminant validity of the DSM-IV revised criteria were assessed according to the following clinical criteria: lifetime and concurrent comorbidity with depressive disorder and lifetime comorbidity with panic disorder. Subjects who met the DSM-IV associated symptom with and without comorbid depression were then compared on rates of treatment, psychotropic medication use, impairment, age at onset and presence of a psychosocial stressor at onset. No differences were found in the discriminant validity of the DSM-III-R versus DSM-IV definitions of GAD. It is postulated that the lack of difference in validity between the two diagnostic systems is due to the low prevalence of autonomic hyperactivity symptoms associated with GAD. Implications for the nosology of GAD and its relationship with other anxiety disorders are discussed. Copyright © 1999 Whurr Publishers Ltd.     

Prevalence of DSM-IV disorders in Chinese adolescents and the effects of an impairment criterion

Purpose

To provide preliminary prevalence estimates of common DSM-IV (Diagnostic and Statistical Manual of Mental Disorders—4th Edition) disorders in a sample of Hong Kong Chinese adolescents.

Methods

541 Chinese adolescents were recruited from Grades 7, 8 and 9 of 28 mainstream high schools in Hong Kong (mean age=13.8 years; SD=1.2). The adolescents and their parents were separately administered the Youth and Parent versions of DISC-IV (Diagnostic Interview Schedule for Children-Version 4), respectively.

Results

Based upon both symptom and impairment criteria, as required by DSM-IV, the overall prevalence estimate of DSM-IV disorders in our sample of Chinese adolescents was 16.4%. Estimates for such individual disorders/diagnostic groupings as anxiety disorders, depressive disorders, attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), and substance use disorders were 6.9, 1.3, 3.9, 6.8, 1.7, and 1.1%, respectively. These rates were largely compatible with those reported in previous studies with perhaps lower rates of generalized anxiety disorder (GAD), depressive disorders, CD, and substance use disorders, but a higher rate of ODD. The rate of ADHD was somewhat higher, but this might reflect the current DSM-IV diagnostic practice. The rate of anxiety disorders was not as high as predicted from some previous questionnaire surveys. The application of an impairment criterion had discernible impacts on prevalence estimates, greater on anxiety and substance use disorders, but smaller on depressive and disruptive behavior disorders. There was a lack of gender difference in rates of ODD and CD.

Discussion and conclusion

While the findings reported here are broadly compatible with those of other studies, there may be cross-cultural differences in rates of some individual disorders, e.g., GAD, depressive disorders, ODD, CD, and substance use disorders, as well as in gender difference regarding rates of ODD and CD. However, exact comparison between studies is confounded by methodological differences in sample characteristics, measures, and case definition. Standardization of methodology in epidemiological surveys should allow more precise identification of any within- or between-culture variations in prevalence estimation.     

Emerging themes in the revision of the classification of somatoform disorders

Abstract

The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on ‘medically unexplained’ symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.     

Challenging the unipolar–bipolar division: Does mixed depression bridge the gap?

BACKGROUND: Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the categorical splitting of mood disorders in bipolar disorders and unipolar depressive disorders, and may support a continuum between these disorders. Study aim was to find if there were a continuum between hypomania (defining BP-II) and depression (defining MDD), by testing mixed depression as a 'bridge' linking these two disorders. A correlation between intradepressive hypomanic symptoms and depressive symptoms could support such a continuum, but other explanations of a correlation are possible. METHODS: Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed, cross-sectionally, with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive hypomanic symptoms) and the Family History Screen, by a mood disorders specialist psychiatrist in a private practice. Patients presented voluntarily for treatment of depression when interviewed drug-free and had many subsequent follow-ups after treatment start. Mixed depression (depressive mixed state) was defined as the combination of MDE (depression) and three or more DSM-IV intradepressive hypomanic symptoms (elevated mood and increased self-esteem were always absent by definition), a definition validated by Akiskal and Benazzi. RESULTS: BP-II, versus MDD, had significantly lower age at onset, more recurrences, atypical and mixed depressions, bipolar family history, MDE symptoms and intradepressive hypomanic symptoms. Mixed depression was present in 64.5% of BP-II and in 32.1% of MDD (p=0.000). There was a significant correlation between number of MDE symptoms and number of intradepressive hypomanic symptoms. A dose-response relationship between frequency of mixed depression and number of MDE symptoms was also found. CONCLUSIONS: Differences on classic diagnostic validators could support a division between BP-II and MDD. Presence of intradepressive hypomanic symptoms by itself, and correlation between intradepressive hypomanic symptoms and depressive symptoms could instead support a continuum. Other explanations of such a correlation are possible. Depending on the method used, a BP-II-MDD continuum could be supported or not.     

Cerebral haemodynamics and depression in the elderly

BACKGROUND: Evidence from epidemiological and neuroimaging studies suggests that cerebrovascular disease is associated with depressive disorders in the elderly, but the extent to which it contributes to the pathogenesis of late life depression is unclear. OBJECTIVE: To investigate the relation between cerebral haemodynamics and depression in a population based study, using transcranial Doppler ultrasonography. METHODS: Cerebral blood flow velocity and CO2 induced vasomotor reactivity in the middle cerebral artery were measured in 2093 men and women who participated in the Rotterdam study. All subjects were screened for depressive symptoms using the Center of Epidemiological Studies Depression scale, and those with a score of 16 or over had a psychiatric work up. In a semistructured interview, diagnoses of depressive disorders according to the DSM-IV and subthreshold depressive disorder were established. Analyses of covariance controlled for age, sex, stroke, cognitive score, and cardiovascular risk factors were used to compare means of haemodynamic variables. RESULTS: Subjects with depressive symptoms had reduced blood flow velocities (mean difference, -2.9 cm/s; 95% confidence interval (CI), -5.0 to -0.8; p = 0.008) and lower vasomotor reactivity (mean difference -0.5%/kPa; 95% CI, -1.0 to -0.05; p = 0.03). Blood flow velocity was reduced most in subjects suffering from a DSM-IV depressive disorder (mean difference, -4.9 cm/s; 95% CI, -8.5 to -1.4; p = 0.006). The overall reduction in vasomotor reactivity was accounted for by subjects with subthreshold depressive disorder. CONCLUSIONS: Depression in late life is associated with cerebral haemodynamic changes that can be assessed by transcranial Doppler ultrasonography. The observed reduction in cerebral blood flow velocity could be a result of reduced demand in more seriously depressed cases with a DSM-IV disorder, whereas reduced CO2 induced cerebral vasomotor reactivity is a possible causal factor for subthreshold depressive disorder.     

Frequency and patterns of mental health services utilization among adolescents with anxiety and depressive disorders

The main aim of this study was to examine the frequency and patterns of mental health services utilization among 12- to 17-year-old adolescents with anxiety and depressive disorders. Another aim was to examine the factors associated with the use of mental health services. The study population comprised 1,035 adolescents randomly recruited from 36 schools. Anxiety and depressive disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Only 18.2% of the adolescents who met DSM-IV criteria for anxiety disorders, and 23% of those with depressive disorders, used mental health services. Among adolescents with anxiety disorders, mental health services utilization was associated with past suicide attempt, older age, the presence of comorbid disorders, as well as parental anxiety and depression. The only factor that predicts the use of mental health service among adolescents with depressive disorder was a history of suicide attempt. The implication of the results in terms of tailoring services for children and adolescents with anxiety and depressive disorders are discussed.