Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses

BACKGROUND: The purpose of this study was to investigate the prevalence and comorbidity of affective disorders, especially current major depressive episode and bipolar disorder among suicide attempters in Hungary. METHODS: Using a structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 100 consecutive suicide attempters, aged 18-65. RESULTS: Eighty-eight percent of the attempters had one or more current diagnoses on Axis I. In 69% it was major depressive episode and 60% of them were suffering their first episode. Thirty-five percent of the patients with current major depressive episode had had hypomanic (n=19) or manic (n=5) episodes in the past. Seventy percent of the individuals received two or more current diagnoses on Axis I. Eighty-six percent of all current Axis I disorders (except major depressive episode) were diagnosed together with a current major depressive episode. The diagnosis of current major depressive episode and the number of current psychiatric disorders was significantly and positively related to the number of suicide attempts, but the diagnosis of past major depressive episode was not. LIMITATIONS: This study included suicide attempters who had presented selfpoisoning, but not individuals with very high risk of fatality. CONCLUSIONS: In suicide attempters there is a very high prevalence of affective disorders, especially major depression, first episode of major depression and bipolar II disorder. This study underlines the importance of early detection and treatment of psychiatric disorders for the prevention of suicidal behavior.     

The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention

BACKGROUND: Previous reports have shown a significant relationship between suicide ideation and mixed depression. The aim of this study was to explore the prevalence and clinical characteristics of mixed depression among non-violent suicide attempters. METHODS: Using a structured interview (modified Mini International Neuropsychiatric Interview) and assessing all the symptoms of 16 psychiatric diagnoses, the authors examined 100 consecutive nonviolent suicide attempters (aged 18-65) within 24 h after their attempts. Mixed depression was defined as a major depressive episode (MDE)/dysthymic disorder plus 3 or more co-occurring hypomanic symptoms, according to the definition validated by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2003a. Delineating depressive mixed states: Their therapeutic significance. Clin. Approaches Bipolar Disord. 2, 41-47, Akiskal, H.S., Benazzi, F., 2003b. Family history validation of the bipolar nature of depressive mixed states. J. Affect. Disord. 73, 113-122.]. RESULTS: Current mixed depression was present in 63.0% in the total sample, and in 70.8% among the 89 depressive suicide attempters. Irritability, distractibility and psychomotor agitation were present in more than 90% of the subjects with mixed depression. The rate of mixed depression was significantly higher among bipolar than non-bipolar depressive suicide attempters (90% vs. 62%). Patients with mixed depression had the following concurrent disorders: bipolar disorders 41.0%, panic disorder 30.0%, generalized anxiety disorder 89.0%, alcohol abuse/dependence 56.0%, and substance abuse 27.0%. Mixed depression versus non-mixed depression had the following significant associations (odds ratio=OR): females 2.4, bipolar II disorder 9.3, generalized anxiety disorder 41.3, irritability 101.6 and psychomotor agitation 61.1. LIMITATIONS: The study didn't include suicide attempters with very high risk of fatality. CONCLUSIONS: The important new finding of this study is the very high prevalence of mixed depression among depressed suicide attempters. The rates of mixed depression among bipolar and non-bipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt. From a public health standpoint, our data highlight the necessity of detecting and treating mixed (bipolar) depression in the prevention of suicidal behaviour.     

The DSM IV diagnoses of melancholic and atypical depression in pregnancy

Atypical and melancholic subtypes of depression based on the Diagnostic and Statistical Manual (DSM) IV are important concepts, especially for biological psychiatry. The aim of this study was to determine whether the symptoms used for the diagnoses of atypical and melancholic depression can distinguish these subtypes during pregnancy. A modified version of the Structured Clinical Interview for DSM IV (SCID interview) was used that allowed assessment of all DSM IV symptoms of melancholic and atypical depression with depressed and non-depressed women in pregnancy. A Swiss cohort of 449 women was interviewed. Four diagnostic groups were compared: women with melancholic, atypical or non specified depression, and those without depression. Seventeen per cent of the cohort met SCID criteria for a depressive episode of depression at least once in pregnancy, with melancholic depression 2.4%, atypical depression 4.4% and non specified depression 10.2%. Many of the symptoms used to distinguish atypical and melancholic depression did not discriminate between these groups during pregnancy. However some, such as mood reactivity, distinct quality of mood and sleep pattern, did discriminate. Differential diagnosis between melancholic and atypical depression in pregnancy needs to be based on pregnancy specific definitions. The possible therapeutic consequences and the neurobiological basis for these findings warrant further research.     

An examination of DSM-IV depressive symptoms and risk for suicide completion in major depressive disorder: a psychological autopsy study

BACKGROUND: It is unclear whether certain DSM-IV depressive symptoms are more prevalent among individuals who die in the context of a major depressive episode and those who do not, whether this is associated with proximal or distal suicide risk, and whether depressive symptoms cluster to indicate suicide risk. METHOD: A psychological autopsy method with best informants was used to investigate DSM-IV depressive symptoms among 156 suicides who died in the context of a major depressive episode and 81 major depressive controls. RESULTS: Suicides' depressive symptoms were more likely to include weight or appetite loss, insomnia, feelings of worthlessness or inappropriate guilt as well as recurrent thoughts of death or suicidal ideation. Fatigue and difficulties concentrating or indecisiveness were less prevalent among depressed suicides. These associations were independent of concomitant axis I and II psychopathology. The concomitant presence of (a) fatigue as well as impaired concentration or indecisiveness and (b) weight or appetite gain and hypersomnia was associated with decreased suicide risk. Inter-episode symptom concordance suggests that insomnia is an immediate indicator of suicide risk, while weight or appetite loss and feelings of worthlessness or guilt are not. LIMITATIONS: This study employed proxy-based interviews. CONCLUSIONS: We found that discrete DSM-IV depressive symptoms and clusters of depressive symptoms help differentiate depressed individuals who die by suicide and those who do not. Moreover, some DSM-IV depressive symptoms are associated with an immediate risk for suicide, while others may result from an etiology of depression common to suicide without directly increasing suicide risk.     

Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening

The study was designed to validate the Patient Health Questionnaire (PHQ-9) for depression risk identification among pregnant women. Pregnant women were routinely administered the Prenatal Risk Overview, a comprehensive psychosocial screening interview, which included the PHQ-9, at their prenatal intake appointment at three community clinics. Study participants completed the Structured Clinical Interview for DSM-IV (SCID) at a later appointment. PHQ-9 risk classifications were cross-tabulated with SCID diagnostic categories to examine concordance, sensitivity, specificity, and positive and negative predictive values. The study sample included 745 women. Prevalence of a current major depressive episode was 3.6?%; an additional 7.0?% were classified as meeting subdiagnostic criteria of three or more depressive symptoms. A PHQ-9 score cutoff of 10 yielded sensitivity and specificity rates of 85 and 84?%, respectively, for a depression diagnosis and 75 and 88?% for a subdiagnosis, respectively. Positive predictive value was higher for the expanded group (43?%) than that of the diagnosis-only group (17?%). The PHQ-9, embedded within a multidimensional risk screening interview, effectively identified pregnant women who met criteria for current depression. The moderate risk score cutoff also identified women with subdiagnostic symptom levels who may benefit from interventions to alleviate their distress and improve pregnancy outcomes.     

北京地区40家综合医院住院病人自杀意念和自杀未遂的调查

目的:了解北京地区综合医院住院病人自杀意念、自杀未遂的出现率及其危险因素。方法:采用自制抑郁筛选量表在随机抽取的北京40家各级综合医院中调查了2914例年龄>15岁的住院病人,了解他们自杀意念、自杀未遂发生情况及相关因素,并通过多因素logistic模型发现其危险因素。结果:2914例患者中,187人(6·42%;95%CI为5·58%~7·64%)有过自杀意念,其危险因素排列为:近一年感到绝望的频率高(OR=9·2,95%CI为6·5~12·9)、亲属有过自杀行为(4·3,2·3~8·3)、调查当时有重性抑郁发作(2·7,1·7~4·3)、熟人有过自杀行为(2·0,1·3~2·9)、年龄<55岁(1·7,1·2~2·3)、女性(1·5,1·1~2·1)。2914例患者中,25人(0·86%;95%CI为0·56%~1·26%)有过自杀未遂,其危险因素排列为:目前有重性抑郁发作(OR=5·6,95%CI为2·1~15·1)、亲属有过自杀行为(5·1,1·4~18·9)、近一年感到绝望频率高(4·7,1·9~11·9)、年龄<55岁(3·6,1·4~9·3)、女性(3·6,1·4~9·3)。结论:伴有抑郁症状的综合医院住院病人应视为自杀高危人群,需投入更多的关注。根据其自杀意念、自杀未遂的危险因素,应在综合医院制定和执行有针对性的自杀预防计划。     

青少年抑郁症患者的健康相关危险行为

目的:探讨青少年抑郁症患者的健康相关危险行为特点。方法:纳入符合ICD-10抑郁发作和复发性抑郁障碍诊断标准的青少年抑郁症患者78例,以及性别和年龄相匹配的正常对照143例。青少年健康相关危险行为问卷(AHRBI)评定健康相关危险行为,同时抑郁症组被试家长完成AHRBI父母版(AHRBI-P)评定。结果:抑郁症组的AHRBI总分、破坏纪律和自杀自伤行为因子分均高于对照组(均P<0.05)。抑郁症组AHRBI总分、攻击暴力、破坏纪律和自杀自伤行为因子分均高于AHRBI-P相应评分(均P<0.05)。AHRBI自杀自伤行为因子分女性高于男性,AHRBI-P攻击暴力和破坏纪律行为因子分女性均低于男性(均P<0.05)。结论:青少年抑郁症患者的健康相关危险行为多于正常青少年,并存在性别差异。父母可能低估青少年抑郁症患者的健康相关危险行为。     

Prevalence, course, and comorbidity of insomnia and depression in young adults

STUDY OBJECTIVES: (1) To describe the prevalence and prospective course of insomnia in a representative young-adult sample and (2) to describe the cross-sectional and longitudinal associations between insomnia and depression. DESIGN: Longitudinal cohort study. SETTING: Community of Zurich, Switzerland. PARTICIPANTS: Representative stratified population sample. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The Zurich Study prospectively assessed psychiatric, physical, and sleep symptoms in a community sample of young adults (n=591) with 6 interviews spanning 20 years. We distinguished 4 duration-based subtypes of insomnia: 1-month insomnia associated with significant distress, 2- to 3-week insomnia, recurrent brief insomnia, and occasional brief insomnia. The annual prevalence of 1-month insomnia increased gradually over time, with a cumulative prevalence rate of 20% and a greater than 2-fold risk among women. In 40% of subjects, insomnia developed into more chronic forms over time. Insomnia either with or without comorbid depression was highly stable over time. Insomnia lasting 2 weeks or longer predicted major depressive episodes and major depressive disorder at subsequent interviews; 17% to 50% of subjects with insomnia lasting 2 weeks or longer developed a major depressive episode in a later interview. "Pure" insomnia and "pure" depression were not longitudinally related to each other, whereas insomnia comorbid with depression was longitudinally related to both. CONCLUSIONS: This longitudinal study confirms the persistent nature of insomnia and the increased risk of subsequent depression among individuals with insomnia. The data support a spectrum of insomnia (defined by duration and frequency) comorbid with, rather than secondary to, depression.     

Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk

BACKGROUND: The present naturalistic study aimed to distinguish between suicide attempts (SAs) of bipolar and unipolar patients, and among SAs characterized by different lethality risk. METHODS: The records of 2395 consecutive admissions to our psychiatric intensive care unit (PICU) were assessed for presence of suicide attempt (SA). Cases of SA were rated for symptom severity with the brief psychiatric rating scale (BPRS), the scale for the assessment of positive symptoms (SAPS), the scale for the assessment of negative symptoms (SANS), the mini mental state examination (MMSE), the global assessment of functioning scale (GAF) and the clinical global impression (CGI). An original questionnaire was administered to explore clinical aspects related with suicidal behavior. RESULTS: Among 2395 admissions, 80 (3.3%) had attempted suicide. Fifty-three cases (66.2%) suffered from a mood episode, including 22 (27.5%) with unipolar depression and 31 (38.7%) with bipolar depression (types I and II combined) or mixed state, while 27 (33.8%) cases received other diagnoses. Forty-eight (60%) cases had attempted suicide prior to the index episode. Ten cases (12.5%) had a relative who attempted or committed suicide. Thirty-nine cases (48.7%) described their SA as impulsive. Twenty cases (25.0%) reported alcohol ingestion before SA. In comparison with women, men used more violent methods. Cases characterized by a non-lethal risk SA had higher BPRS psychotic cluster and SAPS scores than cases with either low or high lethal risk SA. Bipolar cases were over-represented in the high lethality risk group. BPRS anxiety-depressive cluster score was higher in unipolar than in bipolar cases. LIMITATIONS: The sample may not be representative of all patients with SA. The questionnaire has not been standardized for use in psychiatric populations. CONCLUSIONS: The higher proportion of high lethal risk SA in bipolar cases suggests that the risk of completed suicide is higher in bipolar disorder than in unipolar depression. The risk of lethality in SA was not associated with the intensity of symptoms of anxiety and depression.     

Depression and folate status in the US Population

BACKGROUND: Folate deficiency and low folate status have been linked in clinic studies to depression, persistent depressive symptoms, and poor antidepressant response. These relationships have not been demonstrated in general populations. This study examined associations between depression and folate status indicators in an ethnically diverse general US population sample aged 15-39 years. METHODS: Healthy subjects whose red blood cell (RBC) folate concentrations had been measured were determined to have no depression (n = 2,526), major depression (n = 301), or dysthymia (n = 121) using a diagnostic interview schedule. Serum concentrations of folate and total homocysteine (tHcy) were also measured. RESULTS: After adjustment for sociodemographic factors, serum vitamin B(12) concentration, alcohol consumption over the past year and current status as to overweight and use of vitamin/mineral supplements, cigarettes and illegal drugs, subjects who met criteria for a lifetime diagnosis of major depression had folate concentrations in serum and RBCs that were lower than those of subjects who had never been depressed. Subjects who met criteria for dysthymia alone had lower RBC folate concentrations than never-depressed subjects, but the serum folate concentrations of the two groups were comparable. Serum tHcy concentration was not related to lifetime depression diagnoses. Low folate status was found to be most characteristic of recently recovered subjects, and a large proportion of such subjects were folate deficient. CONCLUSIONS: Low folate status was detectable in depressed members of the general US population. Folate supplementation may be indicated during the year following a depressive episode.     

The long-term course of depressive disorders in the Lundby Study

BACKGROUND: The Lundby Study is a longitudinal cohort study on a geographically defined population consisting of 3563 subjects. Information about episodes of different disorders was collected during field investigations in 1947, 1957, 1972 and in 1997. Interviews were carried out about current health and past episodes since the last investigation; for all subjects information was also collected from registers, case-notes and key informants. This paper describes the course and outcome of 344 subjects who had their first onset of depression during the follow-up. METHOD: In this study individuals who had experienced their first episode of depression were followed up. Their course was studied with regard to recurrence of depression related to duration of follow-up, transition to other psychiatric disorders including alcohol disorders, as well as incidence and risk factors of suicide. RESULTS: Median age at first onset of depression was around 35 years for individuals followed up for 30-49 years. The recurrence rate was about 40% and varied from 17% to 76% depending on length of follow-up. Transition to diagnoses other than depression was registered in 21% of the total sample, alcohol disorders in 7% and bipolar disorder in 2%. Five per cent committed suicide; male gender and severity of depression were significant risk factors. CONCLUSION: The low rates of recurrence and suicide suggest a better prognosis for community samples than for in- and out-patient samples.     

Lone mothers,social exclusion and depression

BACKGROUND: In this paper, data from the British National Survey of Psychiatric Morbidity are used to assess depressive disorders and markers of social disadvantage in women bringing up children on their own. METHOD: The household component of the British National Surveys of Psychiatric Morbidity was based on a stratified random sample of > 10000 subjects. This paper reports on 5281 women interviewed in person. Psychiatric symptoms and ICD-10 diagnoses were established by lay interviewers using the CIS-R. Results are presented in terms of depressive episode and mixed anxiety/depressive disorder. Housing tenure and access to a car were used as proxy measures of material status. The life event rate in the 6 months before interview was used to indicate overall exposure to stress, and subjects were asked in detail about perceived social support. Information was collected about various other sociodemographic attributes. Lone mothers were compared with supported mothers and with women not involved in care of children under 16. RESULTS: Lone mothers had prevalence rates of depressive episode of 7%, about three times higher than any other group. The milder condition, mixed anxiety/depression, was also increased in frequency. These increased rates of depressive conditions were no longer apparent after controlling for measures of social disadvantage, stress and isolation. CONCLUSIONS: Lone mothers are increasing in numbers as marital stability declines. Their high rates of material disadvantage and of depressive disorder may have considerable implications for psychiatric and social policy.     

Prevalence of depression and anxiety in older users of formal Dutch intellectual disability services

BackgroundLittle is known about the prevalence of depression and anxiety among older people with intellectual disabilities (ID). Therefore, the aim of this study was to study the prevalence of depression and anxiety in this population.MethodThis study is a cross-sectional epidemiologic multicentre study which was part of the “Healthy Ageing and Intellectual Disabilities” study. The study population consisted of 990 participants aged ≥50 years with borderline to profound ID which were screened with self-report and informant-report instruments; 290 of them were assessed with a standardized diagnostic interview.ResultsDepressive symptoms were prevalent in 16.8% (95% CI: 14.4–19.1) and significantly associated with higher age. Anxiety symptoms were prevalent in 16.3% (95% CI: 14.0–18.6) and significantly associated with female gender and borderline to mild ID. Major depressive disorder was prevalent in 7.6% (95% CI: 5.2–11.0), anxiety disorders in 4.4% (95% CI: 2.6–7.0) and both in 0.7% (95% CI: 0.2–1.6). There was no relationship with gender, age or level of ID.LimitationsFor most participants, informant-report instruments have been used instead of self-report to overcome communication difficulties or inabilities. Also, a standardized psychiatric diagnostic interview has been used instead of psychiatric diagnoses made by an experienced psychiatrist.ConclusionPrevalence of major depressive disorder is higher and of anxiety disorders lower than in the Dutch general older community-dwelling population.     

Serum lipid profiles in major depression with clinical subtypes, suicide attempts and episodes

BACKGROUND: We tried to report the data between serum lipid profiles and major depression with different clinical subtypes, with or without suicide attempts, and with single episode or recurrent episodes. METHOD: During a 2-year period, a total of 168 participants (109 patients with major depression and 59 subjects in a healthy control group) were recruited in this study. Blood samples for serum lipid profiles in all participants were collected. Data analysis was performed by using an analysis of covariance (ANCOVA) with body mass index (BMI) adjustment. RESULTS: The data showed that there were no significant differences of any kind in serum lipid profiles between depressive patients with melancholic feature or atypical feature, with or without suicide attempts nor between depressive patients with single episode or recurrent episodes. CONCLUSION: The results suggested there were no serum lipid profiles used as biological markers to distinguish the clinical subtypes, suicide attempts and episodes in patients with major depression.     

成都地区55周岁及以上人群中抑郁症患病率调查

目的了解成都地区55周岁及以上人群中抑郁症患病率及其影响因素。方法本文采用分层随机整群抽样方法,从成都市所辖地区抽取10个区市县。按农业人口和非农业人口所占比例确定应查城乡55周岁及以上人口数。调查由两阶段组成,先用流调用抑郁自评量表(CES-D)筛查,然后用DSM-Ⅲ-R定式临床检查(SCID-P)进行诊断复查。应查5587人,实查5385人,其中5350人完成了CES-D检查,35人因耳聋(且不识字),失语无法完成CES-D,改用SCID-P询问家属或其他知情者。外出171人,拒查31人,漏查率3.6%。结果发现CES-D评分≥16分者168人,为被调查人口的3.14%。诊断复查发现各类抑郁症的患病率分别为适应性障碍0.85%。心境恶劣障碍0.76%,躯体疾病所致抑郁心境0.52%,重型抑郁症0.45%。各类抑郁症总患病率为2.62%,其中男性1.60%,女性3.54%,女性患病率显著高于男性。多元逐步回归分析表明日常生活能力受损、女性以及认知功能下降老人有抑郁症状者较多。结论本文结果表明我国抑郁症患病率较低。适应性障碍,心境恶劣障碍和躯体疾病引起的抑郁是主要的抑郁类型。     

Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters

OBJECTIVE: Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors. METHODS: Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n = 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time. RESULTS: Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity. LIMITATIONS: The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied. CONCLUSIONS: Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts.     

The detection of depression in medical setting: a study with PRIME-MD

BACKGROUND: Studies investigating the performance of instruments to detect major depressive disorder (MDD) have reported inconsistent results. Subsyndromal depression (SD) has also been associated to increased morbidity, and little is known about its detection in primary care setting. This study aimed to investigate the performance of the Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect MDD and any depression (threshold at SD) in an outpatient unit of a teaching general hospital. METHODS: Nineteen primary care physicians using the PRIME-MD evaluated 577 patients, 240 of them (75% female; mean age, 40.0 +/- 14.4), including all with MDD and a randomly subset of those without MDD, were evaluated by 11 psychiatrists using the Structured Clinical Interview Axis I Disorders, Patient Version (SCIDI/P) for DSM-IV as the standard instrument. RESULTS: The kappa between the PRIME-MD and the SCID was 0.42 for the diagnosis of any depression and 0.32 for MDD. The distribution of the number of depressive symptoms per patient suggested the existence of a continuum between SD and MDD, and a high frequency of subjects with 4-6 symptoms (close to the cutoff for the diagnosis of MDD). LIMITATIONS: The sample has a modest size and is a subset of an original one. CONCLUSION: A continuum between SD and MDD may in part explain the relatively low agreement for the diagnosis of MDD in our sample and possibly in other studies. Studies investigating the performance of screening instruments to detect MDD, should consider the relevance of identifying SD, and the influence of the distribution of the number of depressive symptoms in their results.     

Bipolar depression: relationship between episode length and antidepressant treatment

BACKGROUND: The role of antidepressant medications in bipolar depression remains controversial, mainly due to a lack of research in this area. In this study the authors examined the episode length in bipolar depression and the relationship between antidepressant therapy and episode length. METHOD: A retrospective chart review of 165 subjects identified 50 (30%) with bipolar illness who experienced a major depressive episode between 1 January 1998 and 15 December 2000. Data gathered utilized a structured instrument completed by the clinician at each visit. This instrument includes modified SCID mood modules as well as continuous ratings for each associated symptom of depression and mood elevation. Survival analysis was employed to calculate the median length of the depressive episodes for the entire group. Further survival analysis compared the episode length for subjects treated with antidepressants during the depression (N = 33) with those who did not receive antidepressants (N = 17). The rate of switch into elevated mood states was compared for the two groups. RESULTS: The survival analysis for the entire sample demonstrated 25%, 50% and 75% probability of recovery at 33 (S.E. 8.7), 66 (S.E. 17.9) and 215 (S.E. 109.9) days, respectively. Comparing those who received (N = 33) and those who did not receive (N = 17) antidepressants during the episode did not reveal any difference in the length of the depressive episode. Switch rates were not significantly different between those receiving antidepressants and those not taking these medications (15.2% v. 17.6%, respectively). CONCLUSIONS: Over the past 20 years little progress has been made in reducing the length of depressive episodes in those with bipolar illness. This is despite increasing pharmacological options available for treating depression. Clinicians treating bipolar depression should discuss with their patients the likelihood that the episode will last between 2-3 months. Our results also suggest that antidepressant treatment may not reduce the length of depressive episodes, neither did it appear to contribute to affective switch in our sample.     

DSM-III Melancholia: Do the criteria accurately and reliably distinguish endogenous pattern depression?

The Structured Clinical Interview for DSM-III (SCID), Newcastle Endogenous/Reactive Index, Feinberg-Caroll Discriminant Index, and Hamilton Depression Scale were used to assess 70 depressed patients in order to determine similarities and differences in symptom structure and severity in those patients with and without endogenous/melancholic depression. All patients with melacholia according to DSM-III had definite endogenous major depression by the Research Diagnostic Criteria (RDC), but only 20 out of 35 patients with RDC definite endogenous depression were DSM-III melancholic. There was a greater difference in symptom pattern between those patients with definite endogenous depression and those with probable or non-endogenous depression than there was between the melancholic and non-melancholic definite endogenous depressives.

A prerequisite for the valid delineation of a nosological category is the establishment of good reliability for diagnostic criteria. Using SCID ratings of audiotaped interviews of 9 patients (5 with major depression), the 8 raters in this study achieved a kappa coefficient of 0.79, suggesting that the use of a structured interview can improve the reliability of DSM-III diagnoses. Interrater reliabilities for most of the individual DSM-III major depressive episode and melacholia items were reasonable, but some were low. The low reliabilities could be improved by redefinition of the items to reduce ambiguity and by development of a SCID glossary.     

Residual symptoms at remission from depression: impact on long-term outcome

Background: Although residual symptoms after remission from depression are common and predict early relapse, little is known about the impact of residual symptoms on longer-term clinical course of depression or social functioning. Methods: Sixty severe recurrent depressives, who remitted from an index episode of depression with residual symptoms or below residual symptomatology, were followed-up at 8–10 years. Subjects underwent detailed longitudinal interviewing on course of depression, treatment and socioecomonic functioning over follow-up. Results: Long-term follow-up data was obtained on all living subjects and 55 (95%) were interviewed. The residual symptoms group spent more time with depressive symptoms over follow-up but not at full criteria for major depression and showed greater impairment in longitudinal and follow-up social adjustment. No significant differences were found between the two groups in percentage recurring long-term, mean number of recurrences, readmissions, chronic episodes or clinical global outcome criteria. Limitations: Long-term clinical and social outcomes were assessed by a single retrospective longitudinal interview. Conclusions: Patients who remit from depression with residual symptomatology continue to have more depressive symptoms and impaired social functioning long-term and may need more aggressive treatment.