Humiliation, loss and other types of life events and difficulties: a comparison of depressed subjects, healthy controls and their siblings

BACKGROUND: It has been proposed that adverse life events involving loss or humiliation are particularly potent in provoking depressive episodes. We have also previously suggested that experiencing high rates of non-severe events may play a role in the development of resilience to the impact of severe threatening events when these occur. METHOD: The Life Events and Difficulties Schedule (LEDS) (Brown & Harris, 1978) was used to record the life events experienced by 108 depressed probands and their nearest aged siblings as well as 105 healthy control subjects and their nearest aged siblings. All subjects were interviewed using the Schedule for the Clinical Assessment of Neuropsychiatry (SCAN) (Wing et al. 1990). RESULTS: Depressed probands were significantly more likely to have experienced a severe threatening event, loss event, or a humiliation event compared to the other subjects. These events also made up a greater proportion of the total number of events, in the depressed probands. Humiliation events were more frequent in depressed men than depressed women. There were no differences between the four groups for experiencing a non-severe event, although depressed probands also experienced more difficulties than the other three groups. Fifty-six healthy subjects who had not become depressed despite having experienced at least one severe and threatening event, had significantly more non-severe events, than the 116 subjects who were depressed at the time of interview. CONCLUSIONS: The findings support the hypothesis that loss and humiliation events are particularly depressogenic. Experiencing a high rate of non-severe events may be associated with resilience to becoming depressed in the face of a threatening event.     

Relative lack of depressive cognitions in post-myocardial infarction depression

BACKGROUND: Depression has been associated with adverse clinical events in myocardial infarction (MI) patients, but many questions about the nature of post-MI depression remain unanswered. We examined whether depressive cognitions characteristic of depression in psychiatric patients are also present in post-MI patients with major depression (MD). METHODS: Non-depressed (n=40) and depressed (n=40) post-MI patients, and psychiatric outpatients (n=40) treated for clinical depression, matched on age and sex, were interviewed using a structured clinical interview to diagnose DSM-IV MD. All patients also completed the Beck Depression Inventory (BDI) and the Beck Cognition Checklist-Depression subscale (CCL-D). RESULTS: Mean levels of depressive cognitions were considerably higher in depressed psychiatric patients compared with depressed post-MI patients (34.9 versus 28.0; p=.013), and higher in depressed post-MI patients compared with non-depressed post-MI patients (28.0 versus 17.8; p<.0001), adjusted for age, sex, educational level, and marital status. Younger age (p=.024), absence of a partner (p=.016) and depressed psychiatric status (p=.016) were independently associated with depressive cognitions. Psychiatric patients also had higher mean levels of depressive symptoms as compared to depressed post-MI patients (25.1 versus 17.8; p=.001). LIMITATIONS: This study is based on a cross-sectional design. CONCLUSIONS: The symptom presentation of MD in post-MI patients is both quantitatively and qualitatively different from that seen in psychiatric patients, suggesting that depressive symptoms in post-MI patients differ in content from those in psychiatric patients. These findings could have important consequences for the design and contents of therapeutic programs for treating depression in post-MI patients.     

Social rhythm disruption and stressful life events in the onset of bipolar and unipolar episodes

BACKGROUND: An association between social rhythm disruption (SRD) and onset of manic episodes has recently been observed. Whether other types of bipolar (depressive and cycling) or unipolar depressive episodes are similarly related to SRD is unclear, as is the association between severely threatening life events and onset of bipolar manic, depressed and cycling episodes. METHODS: Bipolar patients with purely manic (N= 21), purely depressed (N = 21) and cycling (N = 24) episodes, and 44 patients with recurrent unipolar depression, were interviewed with the Bedford College Life Events and Difficulties Schedule. The presence of severe and SRD events during the year prior to index episode onset was then determined. RESULTS: More manic than cycling and unipolar subjects experienced SRD events during 8- and 20-week pre-onset periods, and severe events during 20-week pre-onset periods. Controlling for age and prior number of episodes left most findings unchanged. An earlier finding of more manic subjects with SRD events in an 8-week pre-onset versus control period was also replicated. CONCLUSIONS: It appears that manic onsets are influenced by stressful life events, especially those involving SRD, in a unique manner compared to onsets of other types of bipolar and unipolar episodes. Onset of bipolar cycling episodes, in contrast, seems to be relatively unaffected by SRD or severe life events. These findings refine the hypothesis that SRD may precipitate onset of affective episodes to be specific to manic onsets.     

Provoking agents, vulnerability factors and depression in an Italian setting: a replication of Brown and Harris's model.

The aetiological model of depression proposed by Brown and Harris in 1978 was examined in a sample of 120 women in Milan, using the same method for the assessment of life stresses. The role of provoking agents (severe events and major difficulties) was found to be similar to that of the earlier study. There was some evidence that lack of an intimate relationship with a husband or a boyfriend acted as a vulnerability factor, increasing the risk of depression in the face of provoking agents. The overall results support the Brown-Harris aetiological model in a quite different cultural setting.     

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.     

Stressful life events and depressive problems in early adolescent boys and girls: the influence of parental depression, temperament and family environment

BACKGROUND: Stressful life events increase the probability of depressive problems in early adolescence. Several genetic and environmental risk factors may change individual sensitivity to the depressogenic effect of these events. We examined modification by parental depression and gender, and mediation of the former by temperament and family environment. METHODS: Data were collected as part of a longitudinal cohort study of (pre)adolescents (n = 2127). During the first assessment wave at approximately age 11, we assessed parental depression, family functioning, perceived parenting behaviours, and temperamental frustration and fearfulness. At the second wave, about two and a half years later, stressful life events between the first and second assessment were assessed. Depressive problems were measured at both waves. RESULTS: Adolescents with parents who had a (lifetime) depressive episode were more sensitive to the depressogenic effect of stressful events than adolescents without depressed parents. Furthermore, girls are more sensitive to these effects than boys. The modifying effect of parental depression was not mediated by temperament, family functioning and perceived parenting. LIMITATIONS: Life events were assessed without consideration of contextual information. Depressive problems were measured by questionnaires that did not directly represent DSM-IV criteria. The measure of parental depression was unspecific regarding severity and timing of depressive episodes. CONCLUSION: The results suggest that gender and parental depression are associated with increased sensitivity to depression after experiencing stressful life events during adolescence.     

Functioning status of adult children of depressed parents: a 23-year follow-up

BACKGROUND: We compared adult offspring of depressed or control parents who were followed for 23 years. Comparisons were on depression symptoms, physical functioning and disability, social functioning, and utilization of help and coping. Also examined was whether the parent's course of depression (stably remitted, partially remitted, non-remitted) was associated with offspring functioning. METHOD: Depressed parents successfully followed at 23 years (n=248, 82%) identified 215 adult offspring; 67% returned questionnaires. Matched control parents successfully followed (n=235, 79%) identified 261 adult offspring; 68% completed questionnaires. RESULTS: Adult offspring of depressed parents were more impaired than adult offspring of controls (with gender and education controlled) in the domains of depression and disability, and obtained more help for mental health problems. They also reported more severe recent stressors and relied more on active cognitive coping and seeking alternative rewards to cope. Adult offspring of depressed and control parents were comparable in a number of domains: psychiatric and behavioral problems other than depression, physical functioning and pain, social functioning, and hospitalizations and medication use for depression. Adult offspring of parents with a non-remitted course of depression were the most likely to show impaired functioning compared with controls. CONCLUSIONS: Having a parent with depression is associated with more depression and disability in adulthood, but does not have debilitating effects in other life domains. Nonetheless, it may be important for offspring of depressed parents, particularly offspring of parents with a non-remitting depression course, to recognize their elevated risk of depression and potential need for help.     

Psychoendocrine antecedents of persistent first-episode major depression in adolescents: a community-based longitudinal enquiry

BACKGROUND: This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression. METHOD: Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression. RESULTS: Compared to the never depressed (N = 30) and remitted adolescents (N = 19), persistently depressed cases (N = 11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence. CONCLUSIONS: In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.     

Negative cognitive style as a predictor of negative life events in depression-prone individuals: a test of the stress generation hypothesis

BACKGROUND: Stress generation effects in depressed individuals have been well-documented. However, less is known about what personal attributes of depression-prone individuals may contribute to the stress generation effect. This study investigated the role of negative cognitive style in predicting the occurrence of negative life events. METHODS: Undergraduates identified as either high (n=76) or low (n=81) in negative cognitive style were assessed for lifetime history of depression followed by periodic assessment over the course of six months for the occurrence of negative life events and depressive episodes. RESULTS: Individuals with negative cognitive styles generated more negative life events (dependent events and interpersonal events, but not more independent or achievement-related events) than individuals with more positive cognitive styles. These results appear to be unique to women. LIMITATIONS: Utilizing participants specifically chosen to be high or low in negative cognitive style may limit generalizability to other individuals. CONCLUSIONS: Results suggest that an underlying negative cognitive style may account for the stress generation effect often found in depressed individuals, particularly for women. Adequately addressing cognitive patterns in treatment or prevention programs may not only effectively reduce depression, but may also reduce the likelihood of experiencing negative life events that often serve as precipitants for depression.     

Physical activity, exercise coping, and depression in a 10-year cohort study of depressed patients

BACKGROUND: Epidemiological research examining the relationship between physical activity and depression has been conducted almost exclusively with community samples. We examined associations between physical activity, exercise coping, and depression in a sample of initially depressed patients, using four waves of data spanning 10 years. METHODS: A cohort (n=424) of depressed adults completed measures of physical activity, exercise coping, depression, and other demographic and psychosocial constructs at baseline, 1-year, 4-years, and 10-years, with a 90% wave-to-wave retention rate. Multilevel modeling was used to analyze individual depression trajectories. RESULTS: More physical activity was associated with less concurrent depression, even after controlling for gender, age, medical problems, and negative life events. Physical activity counteracted the effects of medical conditions and negative life events on depression. However, physical activity was not associated with subsequent depression. The findings for exercise coping were comparable. LIMITATIONS: Measures of physical activity and exercise coping encompassed a limited set of activities and did not include information about duration or intensity. CONCLUSION: Our results suggest that more physical activity is associated with reduced concurrent depression. In addition, it appears that physical activity may be especially helpful in the context of medical problems and major life stressors. Clinically, encouraging depressed patients to engage in physical activity is likely to have potential benefits with few obvious risks.     

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.     

Factors associated with alexithymia in patients suffering from depression.

BACKGROUND: We studied the factors associated with alexithymia in 137 depressed outpatients. METHODS: Diagnosis of depression was confirmed by means of the Structured Clinical Interview for DSM-III-R. Alexithymia was screened using the 20-item version of the Toronto Alexithymia Scale. Severity of depression was assessed using the 21-item Beck Depression Inventory, and other psychiatric symptoms with the help of the Symptoms Checklist (SCL-90). Life satisfaction was also assessed with a structured scale. RESULTS: Almost half of the patients were considered alexithymic. They were significantly more often male, unmarried and had a lower education than the nonalexithymic patients. Alexithymic patients more often showed psychiatric symptoms (SCL-90) and were also more often severely depressed and dissatisfied with their life than were the other patients. Logistic regression analyses revealed that four factors were independently associated with alexithymia: male gender, a low level of education, low life satisfaction and severe depression. Sleep disturbances were independently associated with alexithymia in men and severe depression in women. CONCLUSIONS: Alexithymia is very common among patients with depressive disorder. An awareness of these risk factors would be useful in improving the efficacy of treatment.     

Do characteristics of patients with major depressive disorder differ between primary and psychiatric care?

BACKGROUND: Despite the need for rational allocation of resources and cooperation between different treatment settings, clinical differences in patients with major depressive disorder (MDD) between primary and psychiatric care remain obscure. We investigated these differences in representative patient populations from primary care versus secondary level psychiatric care in the city of Vantaa, Finland. METHOD: We compared MDD patients from primary care in the Vantaa Primary Care Depression Study (PC-VDS) (n=79) with psychiatric out-patients (n=223) and in-patients (n=46) in the Vantaa Depression Study (VDS). DSM-IV diagnoses were assigned by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I in PC-VDS) or Schedules for Clinical Assessment in Neuropsychiatry (SCAN in VDS), and SCID-II interviews. Comparable information was collected on depression severity, Axis I and II co-morbidity, suicidal behaviour, preceding clinical course, and attitudes towards and pathways to treatment. RESULTS: Prevalence of psychotic subtype and severity of depression were highest among in-patients, but otherwise few clinical differences between psychiatric and primary care patients were detected. Suicide attempts, alcohol dependence, and cluster A personality disorder were associated with treatment in psychiatric care, whereas cluster B personality disorder was associated with primary care treatment. Patients' choice of the initial point of contact for current depressive symptoms seemed to be independent of prior clinical history or attitude towards treatment. CONCLUSIONS: Severe, suicidal and psychotic depression cluster in psychiatric in-patient settings, as expected. However, MDD patients in primary care or psychiatric out-patient settings may not differ markedly in their clinical characteristics. This apparent blurring of boundaries between treatment settings calls for enhanced cooperation between settings, and clearer and more structured division of labour.     

Detection of depression in the stroke patient.

The literature suggests the hypothesis that nonpsychiatrists will underrecognize depression in evaluations of stroke patients. On a medical rehabilitation ward, 15 stroke patients were evaluated for depression by psychiatric interview and self-report. Charts were examined for detection of depression by the rehabilitation team. The hypothesis was supported: in contrast to psychiatric interview (68% depressed) and self-report (Beck Depression Inventory, 50% depressed), none of the patients were described as depressed in chart notes by the rehabilitation team (excluding the psychiatrists). Psychiatrists should develop ongoing interactions with primary care physicians to improve detection of poststroke depression and other depressions on medical wards.     

The influence of adversity and perceived social support on the outcome of major depressive disorder in subjects with different levels of depressive symptoms

BACKGROUND: Adverse life events and social support may influence the outcome of major depressive disorder (MDD). We hypothesized that outcome would depend on the level of depressive symptoms present at the outset, with those in partial remission being particularly vulnerable. METHOD: In the Vantaa Depression Study (VDS), patients with DSM-IV MDD were interviewed at baseline, and at 6 and 18 months. Life events were investigated with the Interview for Recent Life Events (IRLE) and social support with the Interview Measure of Social Relationships (IMSR) and the Perceived Social Support Scale - Revised (PSSS-R). The patients were divided into three subgroups at 6 months, those in full remission (n = 68), partial remission (n = 75) or major depressive episode (MDE) (n = 50). The influence of social support and negative life events during the next 12 months on the level of depressive symptoms, measured by the Hamilton Rating Scale for Depression (HAMD), was investigated at endpoint. RESULTS: The severity of life events and perceived social support influenced the outcome of depression overall, even after adjusting for baseline level of depression and neuroticism. In the full remission subgroup, both severity of life events and subjective social support significantly predicted outcome. However, in the partial remission group, only the severity of events, and in the MDE group, the level of social support were significant predictors. CONCLUSIONS: Adverse life events and/or poor perceived social support influence the medium-term outcome of all psychiatric patients with MDD. These factors appear to have the strongest predictive value in the subgroup of patients currently in full remission.     

抑郁症患者生活事件及社会支持特征的研究

目的：探讨抑郁症患者生活事件和社会支持的特点和规律。方法：对96例抑郁症患者分别在其入院时进行测评，测评工具包括自评抑郁量表、社会支持量表和生活事件量表。此外对99例正常对照亦进行上述测评。结果：抑郁症患者经历的应激性生活事件较多，得到较多的主观社会支持，但对社会支持的利用度却不如对照组高；男女患者之间的生活事件和社会支持得分无显著差异；低应激状态的患者得到的社会支持总分及主观社会支持均高于高应激状态组。结论：抑郁症患者经历的应激性生活事件较多；而社会支持在应激性生活事件与抑郁症发病之间起着缓冲作用。     

Significance of prior episodes of depression in two patient populations

Perhaps the single best predictor of current depression is a prior episode of depression. This study examined the significance of prior depressive episodes in a weighted sample of 425 primary medical care (PC) patients. It also compared the 53 PC patients with major depression with 93 depressed psychiatric patients with respect to percentage of recurrences versus 1st episodes. PC patients with prior depression were over 8 times more likely to be currently depressed than those without such a history. Having at least 1 prior episode of depression was modestly more sensitive, but less specific, than an elevated Center for Epidemiologic Studies--Depression Scale score in predicting current depression. Most currently depressed patients in both PC (85%) and psychiatry (78%) had prior episodes of depression. These findings highlight the importance of assessing history of depression in research and clinical practice.     

Cognitive functioning in a population-based sample of young adults with a history of non-psychotic unipolar depressive disorders without psychiatric comorbidity

BACKGROUND: There is evidence for cognitive dysfunction in unipolar depression among middle-aged and elderly patients, but cognitive functioning among depressed young adults has scarcely been systematically investigated. The aims of the present study were to examine cognitive functioning among depressed young adults identified from the general population and to determine whether cognitive deficits vary as a function of different disorder characteristics, such as severity and age at onset. METHODS: Performance in verbal and visual short-term memory, verbal long-term memory and learning, attention, processing speed, and executive functioning was compared between a population-based sample of 21-35-year-olds with a lifetime history of non-psychotic unipolar depressive disorders without psychiatric comorbidity (n=68) and healthy controls derived from the same population (n=70). RESULTS: Depressed young adults were not found to be impaired in any of the assessed cognitive functions, except for some suggestion of mildly compromised verbal learning. Nevertheless, younger age at depression onset was associated with more impaired executive functioning. LIMITATIONS: The results may slightly underestimate of the true association between depression and cognitive impairments in the young adult population due to possible dropout of participants. Additionally, the problem of multiple testing was not entirely corrected. CONCLUSION: The findings from this study indicate that a lifetime history of non-psychotic unipolar depressive disorders among young adults without psychiatric comorbidity may be associated only with minimal cognitive deficits, even when some residual depressive symptoms are prevalent. However, early-onset depression may represent a more severe form of the disorder, associated with more cognitive dysfunction.     

Do early adverse experiences establish a cognitive vulnerability to depression on exposure to mirroring life events in adulthood?

BACKGROUND: We pursue a 'lock and key' hypothesis which posits that early adverse events ('locks') create an increased vulnerability to depression in the face of mirroring life events ('keys') in adulthood. Here we examine whether any such vulnerability links are cognitively mediated. METHODS: We study a sample of 96 clinically depressed patients who reported an identifiable 'cognitive schema' being activated when depressed. We examine for significant associations between early adverse events and later precipitants to the patients' depression, and then assess the extent to which any identified links are cognitively mediated. RESULTS: Qualitative analyses suggested quite strong associations between early childhood experiences and identified schemas, while the quantitative analyses identified few links. LIMITATIONS: These contrasting results may present a challenge to the hypothesis or reflect methodological limitations, and we therefore detail some of the complexities involved in identifying cognitive schemas.     

Pituitary-adrenal function in adolescent psychiatric patients: impact of depressive symptoms

BACKGROUND: The aim of this study was to determine whether depressive symptoms affect pituitary-adrenal function in adolescents, as they do in adults. METHODS: Salivary cortisol was measured before and after physical exercise in 23 hospitalized adolescent psychiatric patients and 13 age- and sex-matched healthy controls in a placebo-controlled design. In patients, cortisol profiles were assessed from 08:00 to 20:00 h before and after administration of low doses of dexamethasone or the natural steroid hydrocortisone. Patients were classified according to DSM III-R criteria and assigned to either a depressed group (n=10) or a non-depressed group (n=13). Subjective depressive symptoms were rated with the 90-item symptom checklist. RESULTS: Physical exercise increased cortisol output significantly in all subjects, but there were no differences between groups. In patients, no differences in basal cortisol levels were found between the depressed and non-depressed groups. Dexamethasone, but not hydrocortisone, was able to suppress cortisol levels in both groups. Differences between groups were only found in total cortisol output over the 3 days when data were analyzed according to the patients 'subjective' feelings of depression, with the highest cortisol levels in the 'subjectively more depressed' patients. CONCLUSIONS: The results obtained only partially support the hypothesis that depressive symptoms in adolescent psychiatric patients determine pituitary-adrenal (mal)function, and appear to depend on the strategy used.