Stressful life events, depression and demoralization as risk factors for acute coronary heart disease

BACKGROUND: While the effect of psychological stress and depression on the course of heart disease is commonly recognized, the relationship between recent life events, major depression, depressive symptomatology and the onset of acute coronary heart disease (CHD) has been less considered. The aim of this study was to investigate the presence of stressful life events, major and minor depression, recurrent depression and demoralization in the year preceding the occurrence of a first acute myocardial infarction (AMI) and/or a first episode of instable angina and to compare stressful life events, also related with mood disorders, in patients and healthy controls. METHODS: 97 consecutive patients with a first episode of CHD (91 with AMI and 6 with instable angina) and 97 healthy subjects matched for sociodemographic variables were included. All patients were interviewed with Paykel's Interview for Recent Life Events, a semistructured interview for determining the psychiatric diagnosis of mood disorders (DSM-IV), a semistructured interview for demoralization (DCPR). Patients were assessed while on remission from the acute phase. The time period considered was the year preceding the first episode of CHD and the year before the interview for controls. RESULTS: Patients with acute CHD reported significantly more life events than control subjects (p < 0.001). All categories of events (except entrance events) were significantly more frequent. 30% of patients were identified as suffering from a major depressive disorder; 9% of patients were suffering from minor depression, 20% from demoralization. Even though there was an overlap between major depression and demoralization (12%), 17% of patients with major depression were not classified as demoralized and 7% of patients with demoralization did not satisfy the criteria for major depression. Independently of mood disorders, patients had a higher (p < 0.001) mean number of life events than controls. With regard to life events, the same significant difference (p < 0.001) compared to controls applied to patients with and without mood disorders. CONCLUSIONS: Our findings emphasize, by means of reliable methodology, the relationship between life events and AMI. These data, together with those regarding traditional cardiac risk factors, may have clinical and prognostic implications to be verified in longitudinal studies.     

Life events and depression. Part 1. Effect of sex, age and civil status

This is the first of three articles dealing with some basic aspects of the relationship between life events and depression, and is also one part of a larger study in which the possible impact of stressful events has been studied from a multifactorial point of view. Two-hundred and four patients suffering from a depressive disorder, consecutively admitted to the Department of Psychiatry of the Umeå University have participated in a study of life events carried out by means of a specially constructed life events inventory that was used as a guideline for a semistructured interview.The results of this part of the study show that there are no pronounced differences in the occurrence, or appraisal of life events between male and female patients. The more vulnerable, older patients have experienced significantly fewer life events, even of the fateful type, prior to the onset of depression. No difference was found between patients who were married or lived together with a partner and patients who were unmarried, separated, divorced or widowed except in the categories of events (e.g. ‘conflict’ events) which might have been the very reason for a separation or a divorce. The results are discussed in relation to other findings in the literature.     

The generation of life events in recurrent and non-recurrent depression

BACKGROUND: The stress generation hypothesis proposed by Hammen (1991) holds that depressed individuals generate stressful conditions for themselves, which lead to recurrence. The original test of this hypothesis compared dependent life events in women with recurrent depression to medical and normal controls. Two further research questions emerged from this work: (a) do individuals with a history of many depressive episodes generate more dependent life events than depressives with fewer episodes?; and (b) what is the aetiological relevance of any stress that may be generated? METHODS: The present research tested differences in dependent and independent events between depressed individuals who had experienced: (a) no previous major depressive episodes; (b) one previous episode; and (c) two or more previous episodes. We predicted that, based on the stress generation hypothesis, recurrent depressives would show more dependent events than people without a depression history, and that these generated stressors would be of aetiological importance for precipitating recurrence (i.e. severe events in the 3 months preceding recurrence). RESULTS: Recurrent depressives experienced significantly more total dependent events than first-onset depressives in the 12 months, but not the 3 months, preceding their episode. CONCLUSIONS: Although the findings supported the general premise of stress generation, the aetiological relevance of the generated stress for recurrence requires further study.     

Lack of coordination of nonverbal behaviour between patients and interviewers as a potential risk factor to depression recurrence: vulnerability accumulation in depression

BACKGROUND: Coordination of nonverbal behaviour during interactions is a prerequisite for satisfactory relationships. Lack of coordination may form a risk factor for depression. The 'vulnerability-accumulation hypothesis' assumes that vulnerability to recurrence of depression will increase with increasing experience of depressive episodes. Therefore it is expected that interviewers and patients remitted from a recurrent episode of depression would reach less coordination during a clinical interview compared to interviewers and patients remitted from a first lifetime episode. Moreover, we assumed that prior severity of depression modifies this reciprocal coordination process. METHODS: During discharge interviews, interviewers were videotaped in interaction with remitted patients with unipolar major depression recurrent depression (REC); n=28; first episode (SEP); n=22. Durations and frequencies of nonverbal involvement behaviour was registered during the first 15 min. Involvement of the patients consisted of gesticulating, looking at the interviewer, and general head movements; yes--nodding and hm, hm, yes, yes reflected involvement of the interviewer. Coordination between patients and interviewers was analyzed per 3-min epochs and defined as 'attunement': the absolute difference between patients' and interviewers' involvement. Averaged attunement, its time course and variability (presumably reflecting control of the attunement process) were assessed. RESULTS: The time course of nonverbal attunement differed between the REC and SEP condition. A larger variability of attunement was found in patients remitted from a relatively severely depressed episode, compared to patients remitted from a severe first life time episode. No other significant differences were found. CONCLUSIONS: Partial support was found for the notion that nonverbal vulnerability accumulates in depression and that the severity of prior depression modifies this process.     

Life events in depression. Relationship to subtypes

Life events that had occurred in the 6 months before the onset of depression were recorded in 40 depressed patients and 41 normal controls. The depressed patients had experienced significantly more life events and significantly more undesirable life events than the controls. The 20 patients with a DSM-III diagnosed major depressive episode (MDE) without melancholia had experienced significantly more life events in the 6 months before the onset of depression than the 20 patients with a major depressive episode with melancholia. The patients with MDE without melancholia, but not the MDE with melancholia patients, had also experienced significantly more life events than a group of age- and sex-matched normal controls.     

Bipolar II depression in late life: prevalence and clinical features in 525 depressed outpatients

BACKGROUND: Late-life bipolar II depression has not been well studied. The aim of the present study was to find the prevalence of late-life (50 years or more) bipolar II depression among unipolar and bipolar depressed outpatients, and to compare it with bipolar II depression in younger patients, looking for differences supporting the subtyping of bipolar II depression according to age at onset. METHODS: Consecutive 525 patients presenting for treatment of a major depressive episode were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. RESULTS: Among patients less than 50 years, 53.4% had bipolar II depression. Among patients 50 years or more, 32.9% had bipolar II depression (significant difference). Atypical features were present in 60.9% of bipolar II patients less than 50 years, and in 26.1% of those 50 years or more (significant difference). Bipolar II patients 50 years or more had significantly higher age at onset than those less than 50 years. Bipolar II and unipolar patients 50 years or more were not significantly different, apart from comorbidity. Bipolar II patients less than 50 years had significantly more atypical features than unipolar ones. LIMITATIONS: Single interviewer, single nonblind assessment, cross-sectional assessment, exclusion of substance abuse and severe personality disorder patients, comorbidity not systematically assessed, modification of DSM-IV duration criterion for hypomania. CONCLUSIONS: Findings suggest that bipolar II depression and atypical features are less common in late life. Differences in age at onset and atypical features support the subtyping of bipolar II depression according to age at onset.     

Life events and hippocampal volume in first-episode major depression

BACKGROUND: There are many studies on life events in depression and also several studies examining brain structural changes in the hippocampus of depressed patients. However, only few studies have focused on the association of life events and hippocampal volume in depression. The hypothesis of a significant negative association between life events and hippocampal volumes in first episode depression was examined. METHODS: 28 in-patients with a first episode of major depression were examined with high-resolution magnetic resonance imaging measuring hippocampal volumes. The precourse of depression was assessed with the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and Other Psychoses (IRAOS) and life events by using the Munich Interview for the Assessment of Life Events and Conditions (MEL). RESULTS: A significant negative correlation between major life events three month before the onset of depression and the left hippocampal volume was found for male patients. In female patients no significant association between major life events and hippocampal volumes could be found. CONCLUSIONS: The results support the hypothesis that the hippocampus plays a crucial role in the pathogenesis of major depression in the early phase of the disorder particularly for male patients.     

Self-reported data from patients with bipolar disorder: frequency of brief depression

OBJECTIVE: Patients with bipolar disorder often report depressive symptoms that do not meet the DSM-IV criteria for an episode. Using daily self-reported mood ratings, we studied how changing the length requirement to that typical of recurrent brief depression (2-4 days) would impact the number of depressed episodes. METHOD: 203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software on a home computer (30,348 total days; mean 150 days). Episodes of depression and days of depression outside of episodes were determined. Symptom intensity (mild versus moderate or severe) was investigated within and outside of depressive episodes. RESULTS: Decreasing the minimum duration criterion for an episode of depression to 2 days increased the number of patients with a depressed episode two and a half times (52 to 131), and quadrupled both the number of depressed episodes per patient (0.62 to 2.88) and the number of depressed episodes for all patients (125 to 584). With a 2-day episode length, 34% of days of depression remained outside an episode. The ratio of days with severe symptoms within episodes remained consistent (about 25%) in spite of decreasing the episode length to 2 days. Considering only days with severe symptoms, about 25% remained outside of episodes even with a 2-day length. None of the results distinguished bipolar I from bipolar II disorder. LIMITATIONS: Self-reported data, computer access required, relatively short study length, no control group. CONCLUSION: Brief depressive episodes and single days of depression outside of episodes occur frequently in both bipolar I and bipolar II disorder. Moderate or severe symptoms occur during brief episodes at a ratio similar to that for episodes that meet the DSM-IV criteria.     

Life events and depression: A replication

A study which was first carried out in the United States was repeated in Northern Italy. Life events reported to have occurred 6 months before the onset of illness were compared in 40 outpatients who had a first episode of primary depression, and a matched normal control group. Depressives reported significantly more events than the control groups, and had significantly more of the following: undesirable events, exits from the social field, events which had an ‘objective negative impact’ (rated as being traumatic) and ‘independent events’ (events which were unlikely to be a consequence of the depression); the last 2 were judged by a rater who was unaware whether the event had occurred in a depressed patient or in a control subject. There were no significant differences in desirable events, entrances into the social field and events which were within the subjects' control. These findings replicate previous results and are consistent with the view that certain recent life events play a substantial role as precipitants in some depressed patients.     

Life stress and the long-term treatment course of recurrent depression: III. Nonsevere life events predict recurrence for medicated patients over 3 years

Research has consistently documented the significance of severe life events for onset of major depression. Theory, however, suggests other forms of stress are relevant for depression's recurrence. Nonsevere life events were tested in relation to depression for 126 patients with recurrent depression in a 3-year randomized maintenance protocol. Life stress was assessed every 12 weeks and rated along dimensions of severity, focus, and independence. A significant interaction between specific types of nonsevere life events and medication was found. For medicated patients, subject-focused independent nonsevere life events predicted recurrence; for unmedicated patients, these events predicted fewer recurrences. Other nonsevere life events did not predict recurrence. The findings underscore the potential importance of specific stressors for triggering recurrences of depression.     

Relative memory deficits in recurrent versus first-episode major depression on a word-list learning task.

Although memory deficits are associated with major depressive disorder, few studies have identified which patient characteristics predict impairment. Because recurrent depression appears related to more severe cerebral dysfunction, the present study tested whether recurrent depressed individuals have worse memory function than first-episode depressed individuals. Two groups of young-adult, nonpsychotic, depressed inpatients (20 single episode [SE] and 46 recurrent episode [RE]) were administered the California Verbal Learning Test within a broader battery of neuropsychological tests. The groups were equivalent in age, education, estimated IQ, severity of depression, and demographic composition. The RE group demonstrated memory deficits relative to both the SE group and published norms, but no other significant difference was found across the battery. Data indicate that abnormal memory performance is associated with recurrent depression, whereas memory deficits are not prominent in first-episode depressed individuals.     

Major depression in coronary artery disease patients with vs. without a prior history of depression.

Major depression (MD) is common in patients with coronary artery disease (CAD). Some of these patients have a history of prior depressive episodes, whereas others experience their first episode around the same time that their CAD is diagnosed. The purpose of this study was to determine whether there are systematic differences between these two subgroups of depressed patients. Of 39 patients with recently diagnosed CAD who met DSM-III-R criteria for MD, 17 (44%) had a prior history of MD. This subgroup had a higher proportion of females (p less than 0.003), more severe depression (p less than 0.004), were marginally younger (p = 0.08), and had slightly less severe CAD (p = 0.07) compared with those with no prior history of MD. These results support the hypothesis that there may be two distinctive subtypes of MD in patients with CAD. Additional studies are needed to determine whether these subgroups differ with respect to course, treatment, and relationship to the coronary artery disease.     

The unipolar-bipolar depressive dichotomy and the relationship between afternoon prolactin and cortisol levels

Afternoon prolactin and cortisol levels were measured in 29 patients suffering from a current major depressive episode. Among the 15 unipolar depressed patients the afternoon prolactin and cortisol levels were positively correlated, but 14 bipolar depressed patients did not show a similar relationship, and had prolactin levels lower than the unipolar patients. This finding adds to the growing list of ways in which the neurobiology of bipolar and unipolar depression may differ.     

Vasoactive intestinal polypeptide decreased in cerebrospinal fluid (CSF) in atypical depression. Vasoactive intestinal polypeptide, cholecystokinin and gastrin in CSF in psychiatric disorders

Vasoactive intestinal polypeptide (VIP), cholecystokinin (CCK) and gastrin in the cerebrospinal fluid (CSF) were studied in patients with endogenous depression, non-endogenous depression, mania, schizophrenia and a control group. All patients were classified according to ICD-9 and the group of depressions was further classified according to the Newcastle Rating Scales for depression (Carney et al. 1965) (N-I). In the group of non-endogenously depressed patients, CSF-VIP levels (median 16 pmol/l) were found to be significantly lower than those of controls (median = 32 pmol/l) and endogenous depressives (36 pmol/l). In the non-endogenous group, it appeared that the low CSF-VIP was due to a group of patients who, during a past or present depressive episode, had been diagnosed as suffering from endogenous depression. Moreover, this group was clinically characterized by 'dysphoric/hysterical features', 'reversed diurnal variation' (i.e. worse in the evening), and 'lack of clearly circumscribed episodes'. In many aspects this group seems similar to the atypical depressives described as monoamine oxidase inhibitor responders. Concerning CSF-CCK and CSF-gastrin, no significant differences between the examined groups were demonstrated.     

Factor patterns in depression. A replication study.

A principal component analysis was carried out on symptom ratings and selected history items from 79 depressed patients. Three interpretable factors were obtained. The first was a general factor reflecting severity. The second a bipolar factor contrasting endogenous and neurotic depression, the third a bipolar contrasting anxiety and depressive symptoms. These replicate similar factors found previously in a different sample. The stability and predictive value are emphasized of other factors as well as the endogenous-neurotic dimension.     

Life events and depression. Part 3. Relation to severity of the depressive syndrome

Two hundred and six depressed patients, consecutively treated at the Department of Psychiatry, Umeå University were investigated both concerning the occurrence of life events within defined time limits and the severity of their depressive syndrome. Three different criteria were used to divide the patients according to severity: whether they were in- or out-patients, whether or not they were psychotic according to a classification model (MACM) used at Umeå and, finally, according to the clinical ratings received by those admitted to the hospital. The average number of events experienced by the patients within the time limits set by the study was similar in each of the subgroups taken into account. A weak, but still statistically significant, relation was found between a negative experience of the events and the total score obtained at the ratings. The occurrence of events ‘independent’ of depression did not distinguish between the groups. Thus, the results of this study do not support the opinion maintained by some authors that there is a sizeable positive relation between magnitude of life events and seriousness of illness.     

Female depression before and after menopause

BACKGROUND: There is no clear association between menopause and depression. Aim of the study was to compare female depression with onset before menopause with female depression with onset after menopause, to find out if endocrinological changes had an impact on depression. METHODS: Five hundred and twelve consecutive unipolar and bipolar I/II depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery-Asberg Depression Rating Scale and the Global Assessment of Functioning scale. Patients were divided into patients with depression/mania onset before 40 and after 40. RESULTS: Female depression with onset after 40 had a significantly shorter duration of illness, fewer recurrences, fewer patients with atypical features, fewer bipolar II patients and more unipolar patients than female depression with onset before 40. Male depression with onset after 40 had a significantly shorter duration of illness and fewer patients with atypical features than male depression with onset before 40. CONCLUSIONS: Some features were common to both female and male depression with onset after 40. Female depression with onset after 40 had significantly more unipolar and fewer bipolar II patients, than female depression with onset before 40. Different frequency of unipolar and bipolar II patients suggests that the biology of depression in menopause women may be different from that of women not in menopause, and from that of male depression with onset after 40. Differences may be related to menopause.     

Timing of mother and child depression in a longitudinal study of children at risk

Temporal associations of diagnoses in mothers and children were examined in a 3-year longitudinal study of unipolar, bipolar, and comparison women and their 8- to 16-year-old offspring. There was a significant temporal association between mother and child diagnoses, especially in unipolar families, and most children who experienced a major depressive episode did so in close proximity to maternal depression. Regression analyses indicated that children's own stressful life events, maternal disorder, and the interaction of the two significantly predicted children's changes in depression. Children exposed to high stress but with nonsymptomatic mothers were significantly less depressed subsequent to stressors than those who also had symptomatic mothers. The results are discussed in terms of the reciprocal, interpersonal context of depression.     

The association between the disruption of motor imagery and the number of depressive episodes of major depression

Background

Mental rotation performance may be used as an index of mental slowing or bradyphrenia, and may reflect, in particular, speed of motor preparation. Previous studies suggest depressive patients present the correlates of impaired behavioural performance for mental rotation and psychomotor disturbance. The aim of this study is to compare the mental rotation abilities of patients with a first episode of depression, recurrent depression and healthy control subjects with regard to hand tasks.

Methods

We tested 32 first episode of depression, 38 recurrent depression and 36 healthy control subjects by evaluating the performance of depressed patients with regard to the hand mental rotation tasks.

Results

First, the first episode and recurrent depression subjects were significantly slower and made more errors than controls in mentally rotating hands. Second, the first depressive episode but not the recurrent depression displayed the same pattern of response times to stimuli at various orientations relative to control subjects in the hand task. Third, in particular, recurrent depression subjects were significantly slower and made more errors during the mental transformation of hands than first depressive episode relative to control subjects and the differences were significantly larger in female than male subjects in the mental rotation hand task.

Limitations

Patients were on antidepressant medication.

Conclusions

These results suggest that the impaired behavioural performance for mental representation processing are related to the number of previous episodes. Moreover, the recurrent major depressive episodes may contribute to the reinforcement of cognitive impairments and further the development or maintenance of mental representation dysfunctions, especially in female patients. A deficit on mental rotation in the depressive patients may be potential biomarkers for recurrence chronically.     

Severity of stressful life events in first and subsequent episodes of depression: the relevance of depressive subtype

BACKGROUND: Recent studies have reignited debate concerning the relationship between stressful life events and depressive subtypes, particularly in relation to first versus subsequent episodes. AIMS: To investigate the relationship between stressful life events and variably defined melancholic/non-melancholic depressive subtypes, and the import of such life events to first compared with subsequent episodes across those subtypes. METHOD: Acute and chronic stressful life events were rated in 270 patients with DSM-IV Major Depressive episodes who were allocated to melancholic and non-melancholic groups separately as defined by DSM-III-R, DSM-IV, the Newcastle criteria and the CORE system. RESULTS: Severe stressful life events (both acute and chronic)-as defined by DSM-III-R axis IV-were more likely to occur prior to first rather than subsequent episodes, particularly for those with non-melancholic depression. LIMITATIONS: Dependence or independence of life events was not assessed. Genetic vulnerability to depression was not determined. Life events in first and subsequent depressive episodes were compared cross-sectionally between groups, not prospectively in the same cohort of patients. There were no differences in the number of severe life events-as defined by clinician consensus-between the first and subsequent episodes. CONCLUSIONS: These findings are consistent with other studies in suggesting an enhanced sensitisation of depressed patients to subsequent episodes of depression, but suggest that any such phenomenon is specific to non-melancholic depression, in comparison to one key previous study.