Moderating effect of indoleamine 2,3-dioxygenase (IDO) activation in the association between depressive symptoms and carotid atherosclerosis: evidence from the Young Finns study

Background

Depression and inflammation have been suggested to be involved in the atherosclerotic processes, but empirical evidence is mixed. We tested the hypothesis that depressive symptoms are associated with atherosclerosis only when combined with other risk factors, such as inflammation indicated by indoleamine 2,3-dioxygenase (IDO) activation.

Methods

Participants were 544 women and 442 men (aged 24-39 years) who participated in the Young Finns Study medical examinations in 2001 and 2007. At baseline (in 2001), IDO activity (tryptophan and kynurenine ratio) and other biological and behavioral risk factors were assessed and depressive symptoms were determined using a modified 21-item Beck Depression Inventory. Carotid atherosclerosis was measured on the basis of carotid intimamedia thickness (IMT) at baseline and again in 2007.

Results

In women, IDO activity moderated the association between depressive symptoms and IMT (p = 0.02), so that a longitudinal association between depressive symptoms and IMT was found only in combination with high IDO activity (B = 0.21, p = 0.009). This association was robust to adjustment for other risk factors except body mass index and lipids which largely removed the association.

Limitations

The results of this study need to be confirmed using larger data sets and studies using clinical cut-off point for depression.

Conclusions

These data suggest that depressive symptoms are associated with preclinical y carotid atherosclerosis only if they are linked to inflammation, and that this association is present only in women. Underlying mechanisms are unknown but probably relate to adiposity.     

Job strain, burnout, and depressive symptoms: a prospective study among dentists

BACKGROUND: Burnout has been presented as an antecedent of depression, but longitudinal data are lacking. We investigated whether burnout mediates the association between job strain and depressive symptoms. METHODS: Two surveys were conducted. In 2003, 71% of Finnish dentists were reached, and the response rate of the 3-year follow-up was 84% (n=2555). Burnout was measured with the Maslach Burnout Inventory and depressive symptoms with the Beck Depression Inventory. The sequences 'job strain-burnout-depressive symptoms' and 'job strain-depressive symptoms-burnout' were investigated with logistic regression analyses. RESULTS: Of the burnout sufferers without depressive symptoms at baseline, 23% reported depressive symptoms at follow-up. The adjusted odds ratio of burnout for depressive symptoms was 2.6 (95% CI 2.0-3.5). The effect of job strain on depressive symptoms had an OR of 3.4 (95% CI 2.0-5.7), but it disappeared when adjusted for burnout. Of those who had depressive symptoms without burnout at baseline, 63% had burnout at follow-up. The adjusted odds ratio of depressive symptoms for burnout was 2.2 (95% CI 1.4-3.4). The effect of job strain on burnout had an OR of 27.9 (95% CI 6.5-120.2) for the men and 4.9 (95% CI 2.5-9.6) for the women. These effects remained significant after adjustment for depressive symptoms. LIMITATIONS: The study was conducted among one occupational group. CONCLUSIONS: There is a reciprocal relationship between burnout and depressive symptoms. Job strain predisposes to depression through burnout. In comparison, job strain predisposes to burnout directly and via depression.     

Type-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up

BACKGROUND: Chronic heart failure (CHF) is a debilitating condition associated with poor outcome, including increased anxiety. However, anxiety and its determinants have not yet been studied systematically in CHF. We examined whether type-D personality and depressive symptoms would predict clinically significant anxiety at 1-year follow-up. METHODS: Consecutive patients with systolic CHF (n=149; 79% men; mean age 66+/-8.6) completed the type-D Scale (DS14), the Beck Depression Inventory, and the Anxiety Sensitivity Index at baseline. A clinical interview (Hamilton Anxiety Rating Scale) was used to assess clinically significant anxiety at 1-year follow-up. RESULTS: At 12 months follow-up, 26% (9/35) of type-D patients had clinically significant anxiety versus only 6% (7/114) of the non type-Ds (p=0.001). In univariable analyses, type-D personality (OR=5.3; p=0.002) and anxiety sensitivity (OR=4.5; p=0.009), but not depressive symptoms (p=0.27) predicted clinically significant anxiety. Type-D remained an independent predictor of anxiety at 1 year (OR=5.7; p=0.01), controlling for depressive symptoms, anxiety sensitivity, socio-demographic and clinical variables. Adding type-D in a hierarchical logistic regression model, comprising standard and psychological risk factors, enhanced the level of prediction of clinically significant anxiety substantially (-2LL=75.16 chi(2)=26.46; p=0.009). CONCLUSIONS: Type-D personality, but not depressive symptoms predicted 1-year clinically significant anxiety. The type-D scale could be used to identify CHF patients at high risk of anxiety, as these patients may be at an increased risk of adverse prognosis and impaired quality of life.     

Two-year prospective study of major depressive disorder in HIV-infected men

OBJECTIVE: The risks and factors contributing to major depressive episodes in HIV infection remain unclear. This 2-year prospective study compared cumulative rates and predictors of a major depressive episode in HIV-infected (HIV+) men (N=297) and uninfected (HIV-) risk-group controls (N=90). METHODS: By design participants at entry were without current major depression, substance dependence or major anxiety disorder. Standardized neuromedical, neuropsychological, neuroimaging, life events, and psychiatric assessments (Structured Clinical Interview for DSM III-R) were conducted semi-annually for those with AIDS, and annually for all others. RESULTS: Lifetime prevalence of major depression or other psychiatric disorder did not differ at baseline between HIV+ men and controls. On a two-year follow-up those with symptomatic HIV disease were significantly more likely to experience a major depressive episode than were asymptomatic HIV+ individuals and HIV-controls (p<0.05). Episodes were as likely to be first onset as recurrent depression. After baseline disease stage and medical variables associated with HIV infection were controlled, a lifetime history of major depression, or of lifetime psychiatric comorbidity (two or more psychiatric disorders), predicted subsequent major depressive episode (p<0.05). Neither HIV disease progression during follow-up, nor the baseline presence of neurocognitive impairment, clinical brain imaging abnormality, or marked life adversity predicted a later major depressive episode. LIMITATIONS: Research cohort of men examined before era of widespread use of advanced anti-HIV therapies. CONCLUSIONS: Symptomatic HIV disease, but not HIV infection itself, increases intermediate-term risk of major depression. Prior psychiatric history most strongly predicted future vulnerability.     

Dispositional optimism and the risk of depressive symptoms during 15 years of follow-up: the Zutphen Elderly Study

OBJECTIVE: It is unclear whether the personality trait of dispositional optimism, defined in terms of generalized positive outcome expectancies, life engagement, and a future orientation, has a protective effect on the development of depression in community-dwelling elderly men. METHODS: We included 464 men aged 64 to 84 years (mean 70.8; SD 4.6) with complete data at baseline and at 5 years of follow-up in a prospective cohort study with a follow-up period of 15 years. In 1985, 1990, 1995 and 2000 dispositional optimism was assessed using a 4-item questionnaire, and in 1990, 1995 and 2000 depressive symptoms were assessed by the Zung self-rating depression scale (SDS). Logistic regression was used to estimate odds ratios for the development of depressive symptoms (i.e., Zung SDS > or = 50). RESULTS: The cumulative incidence for depressive symptoms was 44% (n = 202) after 15 years follow-up. Dispositional optimism predicted for a lower cumulative incidence of depressive symptoms with an odds ratio of 0.23 (95% confidence interval 0.15-0.36; high vs. low optimism). The protective effect remained unaffected after multivariate adjustment for age, self-rated health, cardiovascular disease, education, and physical activity. In men free of depressive symptoms in 1990, the protective effect of dispositional optimism persisted. LIMITATION: The dispositional optimism scale has not been validated against the 'Life Orientation Test'. CONCLUSIONS: Dispositional optimism protects against the development of depressive symptoms during 15 years of follow-up in elderly community-dwelling men.     

Anxiety but not depression is associated with elevated blood pressure in a community group of French elderly

OBJECTIVE: This study examined whether anxiety and depression were independently associated with elevated blood pressure in elderly persons. METHOD: The study group consisted of 1389 subjects aged 59 to 71 years recruited from the electoral rolls of the city of Nantes (France). Subjects completed the Center for Epidemiologic Studies-Depression scale (CES-D) and the Spielberger Inventory scales to assess depressive symptoms and anxiety symptoms, respectively. Data were collected on sociodemographic characteristics, smoking and drinking habits, medical history, and drug use. Two measures of systolic and diastolic blood pressure were taken after a 10-minute rest. Body mass index was computed from weight and height measurements. Subjects taking antihypertensive drugs (N = 281) were excluded from the present analysis. RESULTS: Depression and anxiety scores were significantly correlated (r = .61 in men; r = .65 in women; p<.001). In univariate analyses, anxiety scores were correlated with systolic and diastolic blood pressure in men, but not in women; blood pressure was not associated with depressive symptoms in either sex. Multivariate logistic regressions, controlling for possible confounders, showed that in both men and women, the risk of high blood pressure increased with increasing anxiety scores; odds ratios for high blood pressure were less than 1 in subjects with depressive symptomatology. CONCLUSIONS: This study suggested that anxiety but not depression was independently associated with an increased risk for high blood pressure.     

Depressive symptoms decline among persons on HIV protease inhibitors

OBJECTIVE: To ascertain whether initiation of protease inhibitors was associated with a change in depressive symptoms among persons infected with HIV. METHODS: Study subjects included men and women who were enrolled in the HIV/AIDS Drug Treatment Program and who had completed an annual participant survey before and after initiating triple combination therapy with a protease inhibitor. Depressive symptoms were assessed using the Centre for Epidemiologic Studies-Depression scale (CES-D). Statistical analyses to determine the change in CES-D total and subscale scores before and after protease inhibitor use were conducted using parametric and multivariate methods. RESULTS: Our analysis was restricted to 453 participants. Of these 234 (52%) were depressed at baseline (CES-D score > or = 16). Compared with nondepressed participants, depressed participants were slightly younger (p = .048), less likely to be employed (p < .001) and more likely to have an annual income less than $10,000 per annum (p < .001). After adjusting for CD4 count, employment status, income, age, and CES-D total or subscale score at baseline, we found a significant improvement in total scale score (p = .001) and depressive mood (p = .002), positive affects (p = .005), and somatic symptoms (p = .011) subscale scores at follow-up. There was no significant change in the interpersonal relations score over the study period. CONCLUSION: Our findings indicate that in addition to conferring impressive clinical benefits, protease inhibitor use is associated with a significant improvement in HIV-positive individuals' mental health.     

Depression and risk of heart failure among the elderly: a prospective community-based study

OBJECTIVE: Although the association between depression and the incidence of coronary heart disease has been established in many studies, the impact of depression on the incidence of heart failure has not been previously investigated. METHODS: We examined the effect of depression (assessed by means of the Center for Epidemiological Studies Depression Scale (CES-D) with a cutoff point of > or =21) on the incidence of heart failure in a community sample of persons aged > or =65 years who were participants in the New Haven cohort of the Established Populations for Epidemiological Studies in the Elderly. RESULTS: At baseline 2501 individuals were free of heart failure. Of these, 188 (132 women and 56 men) scored as depressed. Depressed participants were significantly more likely to have hypertension, diabetes, and mobility-related functional limitations and were less likely to be male or married. During the 14-year follow-up period, 313 participants (146 men and 167 women) developed heart failure, defined as hospital admission for heart failure or mortality with heart failure as the underlying cause of death. After adjusting for baseline differences in demographic and comorbidity factors and functional status using Cox regression, depression tended to be associated with a greater risk of heart failure (hazard ratio (HR) = 1.52, 95% confidence interval (CI) = 0.94-2.43, p =.09). This effect was significant in women (HR = 1.96, 95% CI = 1.11-3.46, p =.02) but not in men (HR = 0.62, 95% CI = 0.23-1.71, p =.05 for the interaction term between sex and depression). CONCLUSIONS: Depression is an independent risk factor for heart failure among elderly women but not elderly men.     

Depressive symptoms in peripheral arterial disease: a follow-up study on prevalence, stability, and risk factors

BACKGROUND: Depressive symptoms are associated with poor prognosis in coronary artery disease, but there is a paucity of research on these symptoms in peripheral arterial disease (PAD). We examined the clinical correlates and 18-month course of depressive symptoms in PAD patients. METHODS: 166 patients with symptomatic lower-extremity PAD (39% women; M age=64.9 +/- 10 years) completed the 10-item Center for Epidemiological Studies Depression scale. A score > or =4 indicates clinically relevant depressive symptoms. Depressive symptoms were re-assessed at 6, 12, and 18 months follow-up. Ankle-brachial index (ABI) and treadmill walking distance were used to assess PAD severity. RESULTS: At baseline, depressive symptoms (CES-D > or =4) were present in 16% of the patients. Depressed patients performed worse regarding pain free (p=0.003) and maximum (p=0.005) walking distance. After adjusting for age, sex, education, ABI, psychotropic medication use, cardiovascular risk factors, and comorbidity, depressive symptoms remained stable in initially depressed patients. Using mixed modelling, three subgroups were identified in the total sample. The majority of PAD patients did not have depressive symptoms (58%), but there were two groups who persistently experienced either subclinical (27%) or clinically manifest (15%) depressive symptoms. LIMITATIONS: Only baseline data of ABI and treadmill walking performance were available. CONCLUSIONS: Depressive symptomatology was present in a substantial number of PAD patients, tended to be stable, and was associated with reduced walking distance. These apparently evident results are overlooked thus far in this patient group and deserve further attention in research and clinical care.     

Depressive symptoms, cynical hostility, and weight change: A 3-year follow-up among middle-aged men and women

In this article we examine, in a 3-year follow-up, whether depressive symptoms and cynical hostility predict weight change. A cardiovascular risk factor survey was carried out for a stratified random sample of a population aged between 45 to 64 years in 1992. A follow-up survey was conducted three years later for 119 male and 166 female participants of the baseline survey. Using similar methodology, body mass index (BMI), depression (Beck depression inventory), cynical hostility (cynical distrust scale), and several health-related factors were measured in both surveys. Higher depression scores at the baseline predicted both weight gain (> 2 BMI units) and weight loss (> 1 BMI unit) during the follow-up. Cynical hostility did not predict weight change. An increase in depression scores predicted weight loss. Women with depressive symptoms in the least educated group lost weight, and women with depressive symptomsin the most educated group gained weight. These results emphasize the assessment of depressive symptoms in a normal population that is interested in losing weight or preventing obesity.     

Minor depressive disorder in the context of miscarriage

BACKGROUND: Although minor depressive disorder is of considerable clinical and public health importance, it has received limited research attention relative to major depressive disorder. This study examines the incidence rate and relative risk for minor depressive disorder following miscarriage. METHODS: Using a cohort design we tested whether miscarrying women are at increased risk for an episode of minor depression (diagnosed based on research criteria proposed in Appendix B of DSM-IV) in the 6 months following loss. The miscarriage cohort consisted of women attending a medical center for spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230). RESULTS: Among miscarrying women, 5.2% experienced an episode of minor depression, compared with 1.0% of community women. The overall relative risk for an episode of minor depression for miscarrying women was 5.2 (95% confidence interval, 1.2-23.6). Relative risk did not vary by length of gestation at the time of loss or attitude toward the pregnancy. The majority of episodes in miscarrying women began within 1 month following loss. Limitations: Minor depression was relatively rare in both study cohorts. The resulting limits on statistical power reduced our ability to identify factors, such as sociodemographic or reproductive history variables that might moderate the effect of miscarriage on risk for minor depression. CONCLUSIONS: These results, in the context of prior work showing increased risks of major depression and depressive symptoms following miscarriage, lend some support to the conceptualization of minor depressive disorder as part of a continuum of symptom severity. Miscarrying women should be evaluated for depression at their follow-up medical visits.     

The incidence of first-onset depression in a population followed from the age of 70 to 85.

BACKGROUND: Due to the limited data available, it is not clear whether the incidence of first-onset depression varies with age in the elderly. METHODS: A representative sample of individuals born 1901-2 (N = 392) was examined at the ages of 70, 75, 79, 81, 83 and 85 years by psychiatrists using a semi-structured schedule. Information on depressive episodes was also collected from self-report and examination of case records. Depression was diagnosed according to the DSM-III-R criteria. RESULTS: The incidence of depression was 12 per 1,000 person-years in men and 30 per 1,000 person-years in women between the ages of 70 and 85 (sex difference P = 0.001). The incidence increased from 17 per 1,000 person-years (men 8.7, women 23.2, P = 0.007) between the ages of 70 and 79 to 44 per 1,000 person years (men 27.0, women 52.8, P = 0.166) between 79 and 85 (age difference: RR 2.6, P < 0.001; men RR 3.1, P = 0.036; women RR 2.3, P = 0.003). A diagnosis of depression was associated with increased mortality and refusal rate during the 15-year follow-up. Previous episodes of depression were associated with an increased risk of further episodes. The prevalence of depression increased from 5.6% at the age of 70 to 13.0% at the age of 85. The lifetime prevalence of depression was 23% in men and 45% in women. CONCLUSIONS: Both the incidence and prevalence of depression increased with age in this longitudinally followed birth cohort, and the incidence was higher in women than in men.     

Depression and risk of sudden cardiac death after acute myocardial infarction: testing for the confounding effects of fatigue

OBJECTIVES: This study examined the impact of depressive symptoms and social support on 2-year sudden cardiac death (SCD) risk, controlling for fatigue symptoms. METHODS: Myocardial infarction (MI) patients (N = 671) participating in the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial completed measures of depression, hostility, and social support. RESULTS: After controlling for significant biological predictors, psychosocial predictors of increased SCD risk in the survival analysis were greater social network contacts (RR = 1.04; 95% CI = 1.01-1.06; p < .007), lower social participation (RR = 0.98; 95% CI = 0.96-1.00; p < .05), and, in placebo-treated patients, elevated depressive symptoms (RR = 2.45; 95% CI = 1.14-5.35; p < .02). Fatigue was associated with SCD (RR = 1.31; 95% CI = 1.11-1.53; p < .001), and, when included in the model, diminished the influence of depression (RR = 1.73; 95% CI = 0.75-3.98; p = .20). When the cognitive-affective depressive symptoms were examined separately from somatic symptoms, there was a trend for an association between cognitive-affective symptoms and SCD in placebo-treated patients after controlling for fatigue (RR = 1.09; 95% CI = 0.99-1.19, p < .06). CONCLUSIONS: Symptoms of depression and fatigue overlap in patients with MI. The trend for the cognitive-affective symptoms of depression to be associated with SCD risk, even after controlling for dyspnea/fatigue, suggests that the association between depression and mortality after AMI cannot be entirely explained as a confound of cardiac-related fatigue. The independent contribution of social participation suggests a role of both depressive symptomatology and social factors in influencing mortality risk after MI.     

Mortality risk varies according to gender and change in depressive status in very old adults

OBJECTIVE: We aimed to evaluate whether gender and different patterns of change in depressive status over 2 years were associated with different risks of mortality in the subsequent 6 years. METHODS: Depression (CES-D) was assessed in 1947 participants in 1992 and a smaller proportion of the sample in 1994. The mortality risk at July 30, 2000, associated with depression and change in depression was estimated using proportional hazards models. RESULTS: After controlling for demographic variables, smoking, alcohol, and medical conditions, depression was associated with mortality for men but not women. In men, incident depression was associated with mortality after controlling for all other variables. Chronic depression and remitted depression were also associated with mortality, but this effect was explained by medical conditions. In women, change in depressive status was not associated with mortality. CONCLUSIONS: Depression confers a greater risk of mortality for men than women with incident depression in old age representing the greatest risk for men. The course of depressive illness must be considered when evaluating mortality risk.     

Suicidality and sleep disturbances

STUDY OBJECTIVES: A growing body of research indicates that sleep disturbances may be specifically linked to suicidal behaviors. It remains unclear, however, whether this link is largely explained by depressive symptoms. The present study investigated the relationship between suicidality, depression, and sleep complaints in a clinical outpatient setting. DESIGN AND SETTING: Upon admission, 176 outpatients completed measures on sleep disturbances, suicidal symptoms, and depression. Several sleep disturbances were evaluated with regard to suicidal ideation, including insomnia, nightmares, and sleep-related breathing symptoms. MEASUREMENTS AND RESULTS: Regression analyses revealed that insomnia and nightmare symptoms were associated with both depressive symptoms and suicidality. Sleep-related breathing symptoms were associated with depressive symptoms, but did not show an association with suicidal ideation. After controlling for depressive symptoms, only nightmares demonstrated an association with suicidal ideation. This relationship emerged as a nonsignificant trend (P = .06). Nightmares were particularly associated with suicidality among women compared with men. Posthoc analyses revealed that, after controlling for sex and depressive symptoms, nightmare symptoms were significantly associated with suicidality (P = .04). CONCLUSIONS: Although insomnia and nightmares were significantly associated with depressive and suicidal symptoms, after controlling for additional variables, such as depression and sex, only nightmares remained associated with suicidality. This association was slightly stronger among women compared with men.     

Symptoms of depression as a prospective risk factor for stroke

OBJECTIVE: The objective of this study was to assess baseline levels of depression as a risk factor for stroke among white and black men and women. METHODS: A population-based cohort of 6095 stroke-free white and black men and women aged 25 to 74 years in the NHANES I Epidemiologic Followup Study were followed for an average of 16 years to a maximum of 22 years. The association between stroke and baseline self-reported depressive symptomatology was analyzed using Cox proportional hazards models adjusting for baseline age, race, sex, education, smoking status, body mass index, alcohol use, nonrecreational physical activity, serum cholesterol level, history of diabetes, history of heart disease, and systolic blood pressure. Hospital records and death certificates were used to identify stroke cases; a total of 483 cases were identified. RESULTS: In age-adjusted models for all persons, white men, white women, and black persons of both sexes, depression was predictive of stroke. In risk-adjusted models for all persons (relative risk (RR) = 1.73, 95% confidence interval (CI) = 1.30-2.31) and for white men (RR = 1.68, 95% CI = 1.02-2.75), depression remained predictive of stroke. For white women, depression (RR = 1.52, 95% CI = 0.97-2.38) reached borderline significance (p = .07). For black persons, depression (RR = 2.60, 95% CI = 1.40-4.80) demonstrated a higher risk of stroke. A series of supplemental analyses also supported the association between depression and stroke. CONCLUSIONS: Depression is predictive of stroke across all strata. This nationally representative study gives evidence of a prospective association between depression and stroke.     

Prediction of the three-year course of recurrent depression in primary care patients: different risk factors for different outcomes

BACKGROUND: The objectives of this study are: (1) identification of predictors for the three-year course of recurrent depression in the rarely studied, but relevant sample of primary care patients, and (2) investigation whether different outcome indicators, time to recurrence, proportion depression-free time and mean severity of depressive symptoms during follow-up, are associated with different risk factors. METHODS: Depression course was established by assessing 110 patients three-monthly with the Composite International Diagnostic Interview and the BDI, during a three-year period. Eight (groups of) predictors, assessed at baseline, were examined: socio-demographics, parental depression, history and severity of depression, anxiety, coping potential, social dysfunctioning and physical functioning. RESULTS: Time to recurrence was predicted by number of previous episodes (OR=1.91). Both proportion depressive disorder-free time and mean depression severity during follow-up were predicted by: severity of depression (B=-.19 and .21 respectively), anxiety (B=-.32 and .33), social dysfunctioning (B=-.21 and .22) and physical functioning (B=.24 and -.39). Mean severity was additionally predicted by: educational level (B=-.21), duration of the longest prior episode (B=.32), and coping potential (B=-.40). Coping potential and number of previous episodes were marginally significant predictors for all three outcomes. LIMITATIONS: Although substantial, sample size was restricted. CONCLUSION: Different outcome variables are predicted by different risk factors. Restriction to one outcome may lead to missing important determinants of the depression course. Number of prior episodes and coping potential seem to warrant special attention from the GP.     

The natural history of late-life depression: results from the Amsterdam Study of the Elderly (AMSTEL)

BACKGROUND: This study examines whether risk factors related to incidence of depression are also related to prognosis, and whether a vulnerability-stress model can be established for prognosis. METHODS: A prospective model for prognosis of depression (chronic or remitted course) in later life was studied in 236 depressed community-living elderly. Subjects were interviewed at baseline, and at follow-up 3 years later. Bivariate and multivariate relationships between risk factors and chronic depression (GMS-AGECAT) were assessed. Effect modification was studied between stressors and two types of vulnerability: vulnerability through a personal history of depression, and gender. RESULTS: A personal history of depression, baseline functional limitations and incident anxiety syndrome predicted chronic depression, whereas life-events occurring between assessments, and changes in physical, functional or cognitive status did not. In subjects without a previous history, functional disabilities, male gender and receiving instrumental support correlated with a poor prognosis. The prognosis for subjects with a personal history of depression was not affected by other factors. In women, the development of chronicity was more strongly associated with a personal history than in men, whereas in men recent psychosocial and health-related characteristics were more important than in women. LIMITATIONS: Because the study consisted of two measurements with a 3-year interval, depressive episodes with a short duration may be under-represented. CONCLUSIONS: In the elderly, the impact of risk factors on the course of depression is modified by longstanding vulnerability characteristics, such as a personal history of depression and gender. More recent life stresses are related to prognosis in subjects without a personal history, and in men.     

A follow-up study of DSM-III-R generalized anxiety disorder with syndromal and subsyndromal major depression

OBJECTIVE: The authors examined the long-term outcome of generalized anxiety disorder with depressive symptoms utilizing both categorical and dimensional analyses. METHOD: Thirty-nine out-patients with a DSM-III-R diagnosis of generalized anxiety disorder (GAD) with depressive symptoms, both with (n=23) and without (n=16) syndromal major depression (MD) participated in an 11-week clinical trial. Approximately 18 months after initial screening, these individuals were once again evaluated using a structured diagnostic interview and a battery of rating scales. RESULTS: Three distinct groups were discernible at follow-up. Twenty-three (60%) of the patients remained syndromal for GAD; 10 patients (43%) were in partial remission from GAD; six (15%) were asymptomatic. Of the 23 patients who were syndromal for MD at baseline, 13 (56%) remained syndromal for MD at follow-up. All of the patients who were syndromal for MD at follow-up remained syndromal for GAD as well. CONCLUSIONS: Outcomes in this study were quite divergent, though they support the concept of GAD as a chronic illness in most patients, with or without MD. The presence or absence of MD versus subsyndromal depression at baseline appeared to have relatively little impact upon the outcome. Patients with subsyndromal anxiety and depressive symptoms may be at special risk for syndromal disorders over time.