Gender differences in patients presenting with a single depressive episode according to ICD-10

Abstract Background It is unsure whether men and women present with different subtypes of depression. The aim of the study was to compare the prevalence of subtypes of a single depressive episode according to ICD-10 for men and women in a nationwide sample of all patients treated in psychiatric in- or outpatient settings. Methods All patients who got a diagnosis of a single depressive episode in a period from 1994 to 2002 at the end of the first outpatient treatment ever or at the first discharge from psychiatric hospitalisation ever in Denmark were identified in a nationwide register. Results A total of 18,192 patients got a diagnosis of a single depressive episode at the first outpatient contact ever and 8,396 patients got a diagnosis of a single depressive episode at the first psychiatric hospitalisation ever. Significantly more women were treated as outpatients than as inpatients (68 % vs. 60.4 %). In outpatient settings, women slightly more often presented with milder types of depression than with severe depression, but no gender difference was found in the severity of depressive episodes among hospitalised patients. No differences were found between genders in the prevalence of depression with vs. without melancholic or psychotic symptoms in either of the settings. Women were treated for longer periods in both settings. Conclusions The distributions of the subtypes of a single depressive episode are remarkably similar for male and female patients with first contact to the psychiatric health care system.     

Gender differences in the phenomenology of bipolar disorder

OBJECTIVES: To investigate gender differences in the phenomenology of episodes in bipolar disorder as according to ICD-10. METHODS: All patients who got a diagnosis of a manic episode/bipolar disorder in a period from 1994 to 2002 at the first outpatient treatment ever or at the first discharge from psychiatric hospitalization ever in Denmark were identified in a nationwide register. RESULTS: Totally, 682 outpatients and 1037 inpatients got a diagnosis of a manic episode/bipolar disorder at the first contact ever. Significantly more women were treated as outpatients than as inpatients. Women were treated for longer periods as inpatients but not as outpatients. In both settings, the prevalence of depressive versus manic/mixed episodes was similar for men and women and the severity of manic episodes (hypomanic /manic without psychosis/manic with psychosis) and the severity of depressive episodes (mild/moderate/severe without psychosis/severe with psychosis) did not differ between genders. The prevalence of psychotic symptoms at first contact was the same for both genders. Among patients treated in outpatient settings more men than women presented with comorbid substance abuse and among patients treated during hospitalization more women than men presented with mixed episodes. CONCLUSIONS: Besides differences in the prevalence of mixed episodes and comorbid substance abuse few gender differences are found among patients presenting with a manic episode/bipolar disorder at first contact in psychiatric inpatient or outpatient hospital settings.     

Gender differences in subtypes of late-onset depression and mania

BACKGROUND: It is currently not known whether elderly men and women present with different subtypes of depression and mania/bipolar disorder. The aim of this study was to compare the prevalence of subtypes of a single depressive episode and mania/bipolar disorder according to the ICD-10 for elderly men and women in a nationwide sample of all out- and inpatients in psychiatric settings. METHODS: All patients older than 65 years who received a diagnosis of a single depressive episode and mania/bipolar disorder in the period from 1994 to 2002 at the end of their first outpatient treatment or at their first discharge from psychiatric hospitalization in Denmark were identified in a nationwide register. RESULTS: A total of 9837 patients aged more than 65 years received a diagnosis of a single depressive episode (69.9% were women) and 443 a diagnosis of mania/bipolar disorder (61.6% were women) at the end of their first contact with psychiatric health care. Slightly more women than men received a diagnosis of mild (70.8%) or moderate depression (67.4%) compared to severe depression (65.9%). Men more often presented with a single depressive episode with comorbid substance abuse or comorbid somatic illness. No gender differences were found in the prevalence of depression with or without melancholic or psychotic symptoms. Men more often presented with mania/bipolar disorder with comorbid substance abuse. CONCLUSIONS: The distributions of the subtypes of a single depressive episode or mania/bipolar disorder are remarkably similar for male and female patients aged over 65 years with first contact with the psychiatric health-care system.     

Diagnostic subtypes of bipolar disorder in older versus younger adults

OBJECTIVE: To investigate differences in diagnostic subtypes of bipolar disorder as according to ICD-10 between patients whose first contact with psychiatric health care occurs late in life (over 50 years of age) and patients who have first contact earlier in life (50 years of age or below). METHODS: From 1994 to 2002 all patients who received a diagnosis of a manic episode or bipolar disorder at initial contact with the mental healthcare system, whether outpatient or inpatient, were identified in Denmark's nationwide register. RESULTS: A total of 852 (49.6%) patients, who were over age 50, and 867 patients, who were 50 or below, received a diagnosis of a manic episode or bipolar disorder at the first contact ever. Older inpatients presented with psychotic symptoms (35.4%) significantly less than younger inpatients (42.6%) due specifically to a lower prevalence of manic episodes with psychotic symptoms. Conversely, older inpatients more often presented with severe depressive episodes with psychotic symptoms than younger inpatients (32.0% versus 17.0%). Among outpatients, no significant differences were found between patients older than 50 years and patients 50 years of age or younger. However, a bimodal distribution of age at first outpatient contact was found with an intermode of 65 years and outpatients older than 65 years more often presented with severe depressive episodes with psychosis. CONCLUSIONS: Bipolar patients who are older at first psychiatric hospitalization (>50 years) present less with psychotic manic episodes and more with severe depressive episodes with psychosis than younger patients. The distribution of age at first outpatient contact is bimodal with an intermode of 65 years and outpatients older than 65 years more often present with severe depressive episodes with psychosis.     

Severity of depressive episodes during the course of depressive disorder

BACKGROUND: It is not clear whether the severity of depressive episodes changes during the course of depressive disorder. AIMS: To investigate whether the severity of depressive episodes increases during the course of illness. METHOD: Using a Danish nationwide case register, all psychiatric in-patients and out-patients with a main ICD-10 diagnosis of a single mild, moderate or severe depressive episode at the end of first contact were identified. Patients included in the study were from the period 1994-2003. RESULTS: A total of 19 392 patients received a diagnosis of a single depressive episode at first contact. The prevalence of severe depressive episodes increased from 25.5% at the first episode to 50.0% at the 15th episode and the prevalence of psychotic episodes increased from 8.7% at the first episode to 25.0% at the 15th episode. The same pattern was found regardless of gender, age at first contact and calendar year. CONCLUSIONS: The increasing severity of depressive episodes emphasises the importance of early and sustained prophylactic treatment.     

Subtypes of depressive episodes according to ICD-10: prediction of risk of relapse and suicide

BACKGROUND: The long-term predictive ability of the ICD-10 subtypes of depression with melancholic syndrome and depression with psychosis has not been investigated. SAMPLING AND METHODS: All patients in Denmark who had a diagnosis of a single depressive episode at their first ever discharge during a period from 1994 to 1999 were identified. The risk of relapse leading to readmission and the risk of committing suicide were compared for patients discharged with an ICD-10 diagnosis of a single depressive episode with and without melancholic syndrome and for patients with and without psychotic symptoms, respectively. RESULTS: In all, 1,639 patients had a diagnosis of depressive episode without psychotic symptoms, 1,275 patients a diagnosis with psychotic symptoms, 293 a diagnosis without melancholic syndrome, and 248 a diagnosis with melancholic symptoms at first discharge. The risk of relapse leading to readmission was greater for patients with psychotic symptoms than for patients without, but no difference was found between the two groups in the risk of committing suicide during follow-up. No differences were found in the risk of relapse leading to readmission or suicide between patients with and without melancholic syndrome. CONCLUSIONS: The ICD-10 categorization into depression with and without psychotic symptoms seems to be clinically and prognostically useful, whereas the ICD-10 subtyping into melancholic and non-melancholic syndrome does not seem to have any long-term predictive value.     

Emergence of psychosis and depression in the longitudinal evaluation of Alzheimer's disease

Prospective psychiatric evaluations were performed as part of a longitudinal study of 32 demented patients who met criteria for the histopathological diagnosis of Alzheimer's disease at the time of death. Psychosis and major depressive disorder emerged in 15 (47%) and 7 (22%) patients, respectively, none of whom had a history of either behavioral disorder prior to the onset of dementia. The prevalence of psychosis increased with increasing dementia severity, was associated with more rapid cognitive decline, and once present was often persistent. In this regard, the emergence of psychosis in the context of Alzheimer's disease appears to be a poor prognostic sign. In contrast to its relationship to cognitive impairment, psychosis was not associated with an increased mortality rate.     

First self‐perceived signs and symptoms in emerging psychosis compared with depression

Aim: To investigate differences between the early symptoms of schizophrenia and depressive disorders. Methods: Sixty‐one individuals with an at‐risk mental state (ARMS), 17 of whom later made the transition to psychosis, 37 patients with a first episode of psychosis and 16 controls with depressive disorders were interviewed about first self‐perceived signs and symptoms. Results: In ARMS and first episode of psychosis, on average, first self‐perceived signs or symptoms had occurred about 5–6 years before the interview. In ARMS, including transition to psychosis, ‘loss of energy’ and ‘difficulties concentrating’ were the most frequently recalled first signs. There was much overlap for the four most frequently mentioned symptoms in the three groups. As compared with ARMS, controls with depressive disorders significantly more often recalled ‘depression’ and ‘social isolation’ as the very first signs of disease. Conclusions: Clinicians should consider the development of self‐recalled first signs over time carefully when assessing suspected early prodromal stages of schizophrenia and beginning depressive disorder.     

Intervenir précocement dans les stades débutants du trouble bipolaire : pourquoi,quand et comment

ObjectivesBipolar disorder (BD) is a chronic and severe psychiatric disease. There are often significant delays prior to diagnosis, and only 30 to 40 % of patients will experience complete remission. Since BD occurs most often at a young age, the disorder can seriously obstruct future socio-professional development and integration. Vulnerability-stress model of BD is considered to be the result of an interaction between vulnerability genes and environmental risk factors, which leads to the onset of the disorder most often in late adolescence or early adulthood. The clinical “staging” model of BD situates the subject in a clinical continuum of varying degrees of severity (at-risk status, first episode, full-blown BD). Given the demonstrated effectiveness of early intervention in the early stages of psychotic disorder, we posit that early intervention for early stages of BD (i.e. at-risk status and first episode mania or hypomania) would reduce the duration of untreated illness and optimize the chances of therapeutic response and recovery.MethodsWe conducted a narrative review of the literature to gather updated data on: (1) features of early stages: risk factors, at-risk symptoms, clinical specificities of the first manic episode; (2) early screening: targeted populations and psychometric tools; (3) early treatment: settings and therapeutic approaches for the early stages of BD.Results(1) Features of early stages: among genetic risk factors, we highlighted the diagnosis of BD in relatives and affective temperament including as cyclothymic, depressive, anxious and dysphoric. Regarding prenatal environmental risk, we identified peripartum factors such as maternal stress, smoking and viral infections, prematurity and cesarean delivery. Later in the neurodevelopmental course, stressful events and child psychiatric disorders are recognized as increasing the risk of developing BD in adolescence. At-risk symptoms could be classified as “distal” with early but aspecific expressions including anxiety, depression, sleep disturbance, decreased cognitive performance, and more specific “proximal” symptoms which correspond to subsyndromic hypomanic symptoms that increase in intensity as the first episode of BD approaches. Specific clinical expressions have been described to assess the risk of BD in individuals with depression. Irritability, mixed and psychotic features are often observed in the first manic episode. (2) Early screening: some individuals with higher risk need special attention for screening, such as children of people with BD. Indeed, it is shown that children with at least one parent with BD have around 50 % risk of developing BD during adolescence or early adulthood. Groups of individuals presenting other risk factors, experiencing an early stage of psychosis or depressive disorders should also be considered as targeted populations for BD screening. Three questionnaires have been validated to screen for the presence of at-risk symptoms of BD: the Hypomanic Personality Scale, the Child Behavior Checklist-Paediatric Bipolar Disorder, and the General Behavior Inventory. In parallel, ultra-high risk criteria for bipolar affective disorder (“bipolar at-risk”) distinguishing three categories of at-risk states for BD have been developed. (3) Early treatment: clinical overlap between first psychotic and manic episode and the various trajectories of the at-risk status have led early intervention services (EIS) for psychosis to reach out for people with an early stage of BD. EIS offers complete biopsychosocial evaluations involving a psychiatric examination, semi-structured interviews, neuropsychological assessments and complementary biological and neuroimaging investigations. Key components of EIS are a youth-friendly approach, specialized and intensive care and client-centered case management model. Pharmaceutical treatments for at-risk individuals are essentially symptomatic, while guidelines recommend the use of a non-antipsychotic mood stabilizer as first-line monotherapy for the first manic or hypomanic episode. Non-pharmacological approaches including psychoeducation, psychotherapy and rehabilitation have proven efficacy and should be considered for both at-risk and first episode of BD.ConclusionsEIS for psychosis might consider developing and implementing screening and treatment approaches for individuals experiencing an early stage of BD. Several opportunities for progress on early intervention in the early stages of BD can be drawn. Training first-line practitioners to identify at-risk subjects would be relevant to optimize screening of this population. Biomarkers including functional and structural imaging measures of specific cortical regions and inflammation proteins including IL-6 rates constitute promising leads for predicting the risk of transition to full-blown BD. From a therapeutic perspective, the use of neuroprotective agents such as folic acid has shown particularly encouraging results in delaying the emergence of BD. Large-scale studies and long-term follow-up are still needed to achieve consensus in the use of screening and treatment tools. The development of specific recommendations for the early stages of BD is warranted.     

Negative symptoms in first episode non-affective psychosis

OBJECTIVE: To determine the prevalence of negative symptoms and to examine secondary sources of influence on negative symptoms and the role of specific negative symptoms in delay associated with seeking treatment in first episode non-affective psychosis. METHOD: One hundred and ten patients who met Diagnostic Statistical Manual-IV (DSM-IV) criteria for a first episode of schizophrenia spectrum psychoses were rated for assessment of negative, positive, depressive and extrapyramidal symptoms, the premorbid adjustment scale and assessment of demographic and clinical characteristics including duration of untreated psychosis (DUP). RESULTS: Alogia/flat affect and avolition/anhedonia were strongly influenced by parkinsonian and depressive symptoms, respectively. A substantial proportion (26.8%) of patients showed at a least moderate level of negative symptoms not confounded by depression and Parkinsonism. DUP was related only to avolition/anhedonia while flat affect/alogia was related to male gender, diagnosis of schizophrenia, age of onset and the length of the prodrome. CONCLUSION: Negative symptoms that are independent of the influence of positive symptoms, depression and extra pyramidal symptoms (EPS) are present in a substantial proportion of first episode psychosis patients and delay in seeking treatment is associated mainly with avolition and anhedonia.     

Health-related quality of life and psychiatric comorbidity in first episode psychosis

BACKGROUND: Quality of life (QOL) has been increasingly recognized as an important outcome measure in the care of patients with severe mental illnesses. This study seeks to evaluate the health-related QOL in patients with first episode psychosis and comparing those with psychiatric comorbidity to those without in an Early Psychosis Intervention Program. METHODS: Overall, 131 patients with first episode psychosis were evaluated on their principal Axis I diagnosis and any other comorbid diagnosis, severity of psychopathology, insight, social/occupational functioning, and QOL, respectively. RESULTS: Patients with psychiatric comorbidity scored lower on Positive and Negative Symptom Scale positive symptom subscale (z = -2.84, P <.01), had a greater awareness of their mental illness (z = -3.44, P <.001) and its social consequences (z = -3.24, P < 0.001), but lower ratings on the overall QOL (z = -3.06, P < 0.01) as well as in the individual domains (physical, psychological health, social relationships, environment, all P < .05) compared with patients without any psychiatric comorbidity. On multivariate analysis, being single and the presence of psychiatric comorbidity were associated with a poorer QOL in the various subdomains. CONCLUSIONS: The association of psychiatric comorbidity with poorer QOL warrants attention. The differences in the clinical correlates may provide potential targets for early identification and highlight needs that are significant to these patients with first episode psychosis and psychiatric comorbidity.     

Psychiatric comorbidity in first episode psychosis: the Early Psychosis Intervention Program (EPIP) experience

OBJECTIVE: To determine the prevalence rates of psychiatric comorbidity in a hospitalized Asian patient group with first episode psychosis and examine its clinical correlates. METHOD: Seventy-nine consecutively admitted patients with first episode psychosis were assessed using the Structured Clinical Interview for DSM-IV-axis I disorders (patient edition), Positive and Negative Symptom Scale (PANSS), Scale to assess Unawareness of Mental Disorders (SUMD) and Global Assessment of Functioning (GAF) scales. RESULTS: Psychiatric comorbidity was present in 36.7% (n = 29) of the patients. Patients with psychiatric comorbidity were younger (P < 0.05), had an earlier onset of illness (P < 0.05) and better insight on social consequences and flat affect items (P < 0.05) on the SUMD. No significant differences were found between the two groups with and without psychiatric comorbidity in gender, ethnicity, marital status, length of education, employment status, living arrangements, duration of hospitalization and untreated psychosis as well as total PANSS and GAF scores. CONCLUSION: Psychiatric comorbidity is common thus calling for a greater awareness in clinicians of these conditions, which are often under-recognized, under-diagnosed and untreated.     

Nosology, diagnostic challenges, and unmet needs in managing bipolar disorder

The spectrum of bipolar disorders includes the subtypes of bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder not otherwise specified (NOS). Because depression is the most pervasive symptom of bipolar disorder, this condition is frequently misdiagnosed as unipolar major depressive disorder. As a result, patients often experience substantive delays in receiving the correct diagnosis and appropriate treatment. To help meet this important diagnostic challenge, various markers have been identified that have predictive value for a bipolar outcome, including early onset of depression, family history of bipolar disorder, atypical depressive symptoms, and the presence of psychosis. Unmet needs in the management of bipolar disorder include an enhanced diagnostic process, more options for treating bipolar depressive episodes, and safer, more tolerable medications for long-term maintenance treatment.     

Late life psychosis

Psychoses in late life are serious psychiatric disorders. They include schizophrenia (both late onset schizophrenic patients and the more prevalent early onset schizophrenic patients living into middle and old age), delusional disorder, psychosis in patients with dementia, psychosis in patients with depression, and miscellaneous psychoses. This article reviews some of the more recent and interesting findings in late life psychoses. A need for further research is stressed.     

Comorbid psychiatric disorders in late life depression.

In late life depression, common comorbid psychiatric disorders are alcohol use, anxiety, and personality disorders. Elderly depressed patients are three to four times more likely to have an alcohol use disorder compared with nondepressed elderly subjects, with a prevalence of 15%-30% in patients with late life major depression. While the presence of a comorbid alcohol use disorder may worsen the prognosis for geriatric depression, limited data suggest that successful treatment of depression combined with reducing alcohol use leads to the best possible outcomes. Most studies show that the overall prevalence of anxiety disorders, particularly panic disorder and obsessive-compulsive disorder, is low in geriatric depression, but generalized anxiety disorder may not be uncommon. It remains unclear if the presence of a comorbid anxiety disorder impacts on the treatment and prognosis of late life major depression. Personality disorders occur in 10%-30% of patients with late life major depression or dysthymic disorder, particularly in patients with early onset depressive illness. Cluster C disorders, including the avoidant, dependent, and obsessive-compulsive subtypes predominate, while Cluster B diagnoses, including borderline, narcissistic, histrionic and antisocial, are rare. Overall, the research database on comorbid psychiatric disorders in major and nonmajor late life depression is relatively sparse. Since comorbid psychiatric disorders affect clinical course and prognosis, and may worsen long-term disability in late life depression, considerably more research in this field is needed.     

The prevalence of mixed episodes during the course of illness in bipolar disorder

Objective: To investigate the prevalence of mixed episodes during the course of illness in bipolar disorder. Method: A total of 1620 patients with an ICD‐10 diagnosis of bipolar affective disorder at the first psychiatric contact were identified in a period from 1994 to 2003 in Denmark and the prevalence of mixed, depressive and hypomanic/manic episodes were calculated at each episode. Results: The prevalence of mixed episodes increased from the first episode to the tenth episode, however, only for women (6.7% of the first episodes leading to psychiatric care compared with 18.2% of the tenth episodes). For men, the prevalence of mixed episodes was constantly low. At all episodes, the presence of a current mixed episode increased the risk substantially of getting a future mixed episode. Conclusion: Clinicians should pay more attention to mixed episodes, especially among women, as they may represent an increasing treatment challenge as the illness progress.     

Effect of age at onset on the course of major depressive disorder

OBJECTIVE: This report assesses whether age at onset defines a specific subgroup of major depressive disorder in 4,041 participants who entered the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. METHOD: The study enrolled outpatients 18-75 years of age with nonpsychotic major depressive disorder from both primary care and psychiatric care practices. At study entry, participants estimated the age at which they experienced the onset of their first major depressive episode. This report divides the population into five age-at-onset groups: childhood onset (ages <12), adolescent onset (ages 12-17), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late adult onset (ages > or =60). RESULTS: No group clearly stood out as distinct from the others. Rather, the authors observed an apparent gradient, with earlier ages at onset associated with never being married, more impaired social and occupational function, poorer quality of life, greater medical and psychiatric comorbidity, a more negative view of life and the self, more lifetime depressive episodes and suicide attempts, and greater symptom severity and suicidal ideation in the index episode compared to those with later ages at onset of major depressive disorder. CONCLUSIONS: Although age at onset does not define distinct depressive subgroups, earlier onset is associated with multiple indicators of greater illness burden across a wide range of indicators. Age of onset was not associated with a difference in treatment response to the initial trial of citalopram.     

Depressive disorders among epileptic patients attending a specialised outpatient clinic

The overall prevalence of psychiatric disorders in epileptic patients is estimated between 19 and 62%. Depressive disorders may be the most common psychiatric disorders and the main reason for psychiatric hospitalisation and taking psychotropic drugs. The underdiagnosis and undertreatment of depressive disorders among epileptic patients represent a problem of considerable magnitude. The aim of the present study was to evaluate the prevalence of depressive disorders among patients with primary epilepsy and to determine the risk factors of the occurrence of the depressive illness. The survey was conducted in a outpatient epilepsy clinic in the Ibn Rochd University Hospital Centre in Casablanca. All patients with idiopathic or cryptogenic epilepsy aged 15 Years and above, were eligible, except for patients with severe physical and mental disabilities. Neurologists diagnosed the epilepsy based on clinical criteria with electroencephalograms data. The depressive disorders met a psychiatrist's evaluation of an ICD-10 criterion. Ninety-two subjects participated in the survey, 57.6% were men and the mean age was 30.3 +/- 10.8 Years. The epilepsy age of onset was 16.3 +/- 11.4 Years with an average duration of 14.1 +/- 9.2 Years. The prevalence of depressive disorders among epileptic patients in our survey was 18.5%. According to sex, the prevalence was 23.1% in women and 15.1% in men. The depressed patients were compared with the remaining patients without depression with regard to seizure variables and sociodemographic characteristics. The epilepsy-depression and epilepsy-control groups did not differ significantly in the duration of epilepsy or in the type of anticonvulsant therapy (mono versus polytherapy). Three variables were significantly different between the two groups. The mean age in the epilepsy-depression group was significantly higher (34.4 +/- 9.6 Years versus 29.4 +/- 10.9, p<0.03), the mean age of epilepsy age of onset was also higher in the epilepsy-depression group than in the epilepsy-control group (21.8 +/- 11.9 Years versus 15.04 +/- 11.0, p<0.03) and the seizure frequency per week was more important among depressed epileptic patients (2.4 + 5.2 seizures versus 0.4 + 1.5, p<0.007). The present survey confirms the findings of previous studies that the prevalence of the comorbidity between epilepsy and depression is common in specialised outpatient units. The detection and the treatment of depressive disorders among the epileptic patients remains a very great challenge in the management of the epileptic illness. It will improve the quality of life of these patients. A closer involvement of psychiatric and psychological treatment in patient management is necessary.