DST nonsuppressor status: relationship to specific aspects of the depressive syndrome

Using a conservative definition of suppressor status in hospitalized depressives, we found a relationship between abnormal endocrine function and certain kinds of depressive symptoms, i.e., melancholic symptoms, delusions, and memory deficit. Normal suppressor status is related to an early age of onset, absence of delusions, absence of memory deficit, absence of melancholia symptoms, and a presence of a diagnosis of secondary depression or a family history of alcoholism in depressives. The data suggest the distinction between neurotic-reactive depression and endogenous depression. It is equally important to note that these specific symptoms and characteristics possibly are associated with suppressor status independently of each other.     

Familial subtypes of unipolar depression: a prospective study of familial pure depressive disease compared to depression spectrum disease.

In a large multicenter effort, major depressives were systematically studied at index admission and prospectively followed up for 5 years. Primary unipolar depressives with a family history of alcoholism (depression spectrum disease) differ from depressives with a family history of depression only (familial pure depressive disease) in having more familial anxiety and somatization disorder, more divorce, more suicide attempts, more negative life events, and needed more time to recover from the index episode. In the 5-year follow-up they are more likely to develop alcoholism and drug abuse. Depressive spectrum disease patients are more likely to meet systematic criteria for neurotic depression. The data suggest that major depression is a syndrome that is heterogeneous, and may be a final common pathway of more than one familial illnesses.     

The relationship of anxiety and depression to symptoms of hyperthyroidism using operational criteria

Twenty-six females and seven males with newly diagnosed, untreated hyperthyroidism were administered a structured questionnaire designed to identify anxiety and depression using operational criteria. By DSM III criteria, 10 patients were found to have depression and 15 anxiety. The number of anxiety symptoms paralleled the number of hyperthyroid symptoms whereas depressive symptoms did not. Prior history of psychiatric disease and family history of psychiatric disease did not predict anxiety or depression in patients with hyperthyroidism. The number with depression and anxiety was felt to be artificially inflated by the concurrent presence of somatic thyroid symptoms. Psychiatric practitioners should be careful to exclude patients with hyperthyroidism before a primary psychiatric diagnosis is made.     

Testing the validity of the neurotic depression concept.

We applied an operational definition of neurotic depression to 185 hospitalized patients who met Feighner and DSM-III-R criteria for unipolar depression. Based on a systematic chart review, 37 patients met the criteria for neurotic depression. As a group, these patients differed from nonneurotics in symptoms, clinical course, outcome, and family history. The neurotic depressives were younger and more likely to identify precipitating factors. They were less likely to meet criteria for melancholia and to have delusions. They were more likely to be ill 3 years later and more likely to have familial alcoholism. These differences help to confirm the validity of the neurotic depression concept.     

Diagnosing major depressive disorder VII: family history as a diagnostic criterion

Eliciting information about a patient's family history is a component of a standard diagnostic evaluation. Since depression runs in families, a question arises as to whether family history information should be considered when diagnosing depression. The text of DSM-IV indicates that a family history of a mood disorder should sometimes be considered when trying to distinguish between major depressive disorder and other conditions such as catatonic schizophrenia. The questions posed herein are how well family history of depression performs as a diagnostic criterion, and how its performance compares with the DSM-IV symptom criteria. One thousand eight hundred psychiatric outpatients were evaluated with a semistructured diagnostic interview as part of a research assessment infrastructure that has been embedded in the Rhode Island Hospital Department of Psychiatry outpatient practice. Family history diagnoses were based on information provided by the patient. The interview followed the guide provided in the Family History Research Diagnostic Criteria. We constructed a continuum of family history morbidity based on the number of first-degree family members with a history of depression and whether the family member was treated for their depression. Thus, we determined the presence or absence of the family history diagnostic criterion in different ways. Family history information was collected on 9763 first-degree relatives of 1776 patients. The sensitivity of the family history criterion was lower than each of the symptoms. Based on the broadest definition of the family history variable, the specificity was also lower than all other symptoms. Based on the narrowest definition (two or more family members who were treated for depression), the specificity was higher than all of the symptom criteria though sensitivity dropped to 15%. Overall, as a diagnostic criterion, a family history of depression did not perform as well as the DSM-IV symptom criteria. Consistent with the familial nature of depression, the family history variable performed better as a diagnostic criterion when considering diagnosis from a lifetime, rather than a current, perspective. This has implications for the future consideration of genetic markers as diagnostic criteria.     

Medical illness, past depression, and present depression: a predictive triad for in-hospital mortality

OBJECTIVE: The authors' objectives were to determine 1) whether major depressive disorder diagnosed according to DSM-IV criteria modified for the medically ill predicted in-hospital mortality better than major depressive disorder diagnosed according to inclusive DSM-IV criteria and 2) whether a history of depression and current depression predicted mortality independent of severity of physical illness. METHOD: Of 392 consecutive medical inpatients, 241 were interviewed within the first 3 days of admission and 151 were excluded from the study. Chart review and a clinical interview that included the Schedule for Affective Disorders and Schizophrenia were used to determine demographic variables, past psychiatric history, psychiatric diagnoses, and illness measures. Diagnoses included major depressive disorder and minor depression diagnosed according to DSM-IV criteria that included all symptoms regardless of etiology and according to criteria modified for the medically ill (hopelessness, depression, or anhedonia were used as the qualifying affective symptoms; depressive symptoms were eliminated if easily explained by medical illness, treatments, or hospitalization). The Charlson combined age-comorbidity index was used to measure severity of illness. RESULTS: A diagnosis of major depressive disorder based on criteria modified for patients with medical illness better predicted mortality than a diagnosis based on inclusive criteria. A past history of depression and the Charlson combined age-comorbidity index predicted in-hospital mortality, but demographic variables, pain, discomfort, length of stay, medical diagnoses, and minor depression did not. In the final multivariate logistic regression model, the Charlson combined age-comorbidity index, a modified diagnosis of major depressive disorder, and a history of depression were independent predictors of in-hospital death. CONCLUSIONS: Severity of medical illness, a diagnosis of major depressive disorder based on modified criteria, and a past history of depression independently predicted in-hospital mortality in medical inpatients.     

Family history of depression and alcoholism in Alzheimer patients and age-matched controls

Depression and depressive symptoms are reported to occur frequently in patients with Alzheimer's disease; however, familial and psychobiological contributions associated with depression in Alzheimer patients are poorly understood. In this study, we compared family history of depression and alcoholism in 44 patients with probable Alzheimer's disease and 38 aged-matched cognitively intact controls. Results from comparison showed no overall difference between the occurrence of depression in first-degree relatives of Alzheimer patients compared to first-degree relatives of controls. There was, however, significantly lower incidence of alcoholism in relatives of Alzheimer patients, particularly male relatives (p<0.05). This finding suggests that family history and depression alone may not fully explain the high rate of depression in Alzheimer patients and that other factors including neurochemical changes in the brains of Alzheimer patients should be considered.     

Caffeine dependence in combination with a family history of alcoholism as a predictor of continued use of caffeine during pregnancy

OBJECTIVE: The purpose of the study was to examine whether caffeine dependence and a family history of alcoholism are associated with continued use of caffeine during pregnancy. METHOD: Forty-four women seeking obstetrical care in an office-based practice completed questionnaires and provided saliva samples at three prenatal visits occurring 2-3, 3-4, and 7 months postconception. On visit 1, the patients received the physician's instructions to stop using caffeine. Structured interviews were used to assign a diagnosis of caffeine dependence (lifetime) and to identify family history of alcoholism. Outcome measures included self-reported levels of caffeine use and saliva caffeine levels at the three prenatal visits. RESULTS: Although most women eliminated or substantially reduced their caffeine consumption between pregnancy awareness and prenatal visit 1, those with a lifetime diagnosis of caffeine dependence and a family history of alcoholism had higher levels of caffeine use and lower rates of abstinence throughout pregnancy. Saliva caffeine levels confirmed these effects. Withdrawal symptoms, functional impairment, and craving were cited as reasons they failed to eliminate or cut back on caffeine use. Fifty percent of the women with both a lifetime diagnosis of caffeine dependence and a family history of alcoholism continued to use caffeine in amounts (>300 mg/day) greater than those considered safe during pregnancy, compared to none of the women without caffeine dependence and a family history of alcoholism. Women with a lifetime diagnosis of caffeine dependence and a family history of alcoholism also reported higher rates of past cigarette smoking and problematic alcohol use. CONCLUSIONS: Caffeine-dependent women with a family history of alcoholism were not able to follow their physician's advice to reduce or eliminate caffeine consumption during pregnancy, despite their wanting to do so. This subgroup may require more intensive intervention to ensure caffeine abstinence and may be at greater risk for abuse of or dependence on other drugs.     

The depressed alcoholic. Clinical features and medical management.

A relationship between depression and alcoholism has long been postulated. A review of prior research studies reveals that though patients with depression do not appear to develop alcoholism to any great extent, recently detoxified alcoholics have a depressive syndrome about 20% of the time. This cannot be accounted for readily from data on family studies or genetic studies, which generally suggest that alcoholism and depression are two independent illnesses, albeit both quite common. Clinically, depressed alcoholics resemble alcoholics more than they resemble depressives. The clinical course of depression when it coexists with alcoholism is generally benign and self-limited, with most patients becoming euthymic over the course of 2-4 weeks without specific antidepressant treatment. In some depressed alcoholics, however, a more chronic depression persists, and may predict a worse outcome for the alcoholism. Treatment of depression in alcoholics should be initially conservative. Tricyclic and other antidepressants should be used with extreme care as they may potentiate toxic effects of alcohol.     

Children of alcoholics in Spain: from risk to pathology

OBJECTIVE: To identify the possible risk factors and negative outcomes associated with parental alcoholism. A secondary aim was to determine the influence of the family density of alcoholism on children of alcoholics' (COAs) psychological functioning. METHOD: A multisite epidemiological study was conducted in 8 Spanish cities, recruiting a total sample of 371 COAs (whose parents were in contact with alcohol treatment centers and accepted to participate in this study) and 147 controls (from schools in the same localities as COAs). Both groups were 6-17 years old and received a comprehensive evaluation of mental disorders (no symptoms, subclinical symptoms or clinical diagnosis for each disorder; according to DSM-IV criteria); alcohol and other substance use (none, occasional, regular and risky consumption); school achievement (low, middle and high) and other academic performance indicators (WISC-R Information and Arithmetic subtests, school support activities and failed subjects and courses). Lastly, several cognitive functions were measured by the WISC-R Similarities, Block Design and Digit Symbol subtests, the Toulouse-Piéron test and the Stroop test. Logistic regression methods were used to compare both groups and a linear regression model was used to determine the influence of the family density of alcoholism. The following confounding variables were controlled for: age, gender, socio-economic status and family cohesion. RESULTS: Children of alcoholics' were twice as likely as controls to present subclinical symptoms and four times more likely than controls to have a definite diagnosis of any mental disorder. More specifically, COAs had a significantly higher risk than controls of attention deficit disorder/hyperactivity, depression, phobias, enuresis and tics. COAs also tended to have more symptoms of generalized anxiety disorder. COAs had worse results on all the cognitive tests used and their risk of low school achievement was nine times higher than that of controls. Family density of alcoholism was significantly related to several psychiatric disorders and to low academic and cognitive performance in these children. CONCLUSION: Children of alcoholics' whose parents are in contact with treatment centers in Spain constitute a target group for selective prevention, as they have a higher risk of different negative outcomes, which mainly include attention disorders and other cognitive deficits, depression and anxiety.     

Family (genetic) studies in neurotic depression

Neurotic depression may be defined as a depression that occurs in the context of a long standing history of personality difficulties or neurotic symptoms. Two types of conditions fit this definition: (1) depressions secondary to personality disorder, neuroses or substance abuse; and (2) primary depressions with a family history of alcoholism. Depressions so defined show familial relationships with secondary depression, anxiety disorders, alcoholism, and depressions with personality disorders. The data suggest that these cluster in the same family and are related to the definition of neurotic depression given above. Whether these familial relationships are genetic awaits further research.     

Psychiatric comorbidity and suicidality among intravenous drug users.

BACKGROUND: Prevalence of lifetime psychiatric comorbidity and history of attempted suicide among intravenous drug users was investigated. METHOD: One thousand sixty-two relatives of hospitalized alcoholics, felons, and control subjects were administered a structured interview that gathered data on lifetime psychiatric symptoms and psychoactive drug use. Psychiatric diagnoses were based on interview information, medical records, and family history data. Comparisons were made between 411 subjects who used no illicit drugs, 329 cannabis users, 230 subjects who had used psychoactive drugs other than cannabis more than five times but had never injected drugs, and 92 intravenous drug users. RESULTS: Any history of injecting drugs increased the odds of being diagnosed with antisocial personality disorder by a factor of 21.01, alcoholism by 4.42, and unipolar depression by 3.02. A diagnosis of antisocial personality disorder increased the odds of having injected drugs by a factor of 27.19, while diagnoses of alcoholism or unipolar depression conveyed odds for injecting drugs of 4.62 and 3.70, respectively. Intravenous drug use was associated with an 8.27-fold increase in odds for a suicide attempt compared with no drug use. CONCLUSION: Rates of alcoholism, depression, and antisocial personality disorder, but not other psychiatric disorders (other than drug dependence), are significantly elevated in intravenous drug users. Moreover, among drug users, the decision to inject is differentially made by those with antisocial personality disorder. A history of suicide attempt is common among intravenous drug users, but injecting appears to convey little additional risk above substantial but non-intravenous drug use.     

Interinformant reliability of family history information on psychiatric disorders in relatives

Knowledge on the reliability of family history information is essential for every family study. However, systematic analyses of interinformant reliability of family history information on individual relatives have not yet been published. Consequently, family history information on 1306 first-degree relatives and spouses of patients and of control subjects was collected from at least two other family members using questionnaires. Interinformant reliability was acceptable for dementia [Kappa = 0.58, 95% confidence interval (CI) = 0.48–0.68], but less so for alcoholism (Kappa = 0.41, CI = 0.23–0.59), depression (Kappa = 0.26, CI = 0.14–0.38) and anxiety disorders (Kappa = 0.19, CI = 0.05–0.43). Demographic variables of subjects and informants and their familial relationship did not influence diagnostic agreement on the diagnosis of dementia. Diagnostic agreement on depression was significantly reduced when information from siblings of index subjects was compared with information from spouses of index subjects. The interinformant agreement for the diagnosis of depression was higher in younger than in older subjects (relative risk for disagreement 1.08/additional year, CI = 1.02–1.15). Siblings of index subjects seem to provide different, but not necessarily less relevant, family history information in comparison with other relatives. Researchers should be aware of the problem that depression in the elderly can be easily missed by family history. It seems more important for the diagnosis of depression than for a diagnosis of dementia to get information from multiple informants. Received: 20 May 1997 / Accepted: 12 December 1997     

On the neurobiology of depression: research based on heterogeneous diagnostic groups produces heterogeneous biological data

An improvement in the accuracy and specificity of the criteria for identifying people with major depressive disorder would be of great benefit not only in the diagnosis and treatment of patients with depression, but also in research concerning the biological substrates of the emotions. Unfortunately, attempts at developing a biological diagnostic test for depression based on the analysis of major depressive disorder patients identified on the basis of existing diagnostic criteria have not been successful. Undoubtedly, this is due in part to the complexity of the neurochemistry and neuroanatomy of the emotions. But more importantly, it is due to the broad global nature of the criteria used to identify depressed patients. This results in the biological study of patients who are similar in general terms but who differ in specific behavioral symptoms and underlying neurobiology. A detailed analysis of the behavior of depressed people might reveal subtle differences that could be used to separate patients with depression into more homogeneous subgroups for biological study. This would increase the probability of developing biological tests that would lead to further refinement in the diagnosis of depression and in the selection of the most appropriate therapeutic intervention for a particular patient.     

The relationships of historically defined subtypes of depression to ACTH and cortisol levels in depression: preliminary study

A family history of depression (but no alcoholism), a history of bipolarity, and a history of nonsuppressor status on the Dexamethasone Suppression Test (DST) have all been positively associated with each other in previous studies. We divided depressives into three mutually exclusive groups, using the three historical parameters described above. Group A included those who were nonsuppressors at index. Group B included normal suppressors at index who met one of the following three criteria: (1) past history of a nonsuppressing DST, (2) past history of a mania, and (3) family history of depression (but no alcoholism). The remaining suppressors at index made up Group C. We found that Groups A and B show a phase advance (an earlier nadir) in the predexamethasone circadian curve for cortisol. Adrenocorticotrophic hormone (ACTH) varies in part (but not solely) with cortisol and may separate the groups.     

Genetic approach to heterogeneity in psychoses: relationship of a family history of mania or depression to course in bipolar illness

A specific family history or genetic background may be used to distinguish valid subgroups in patients who show similar symptoms. Also, a familial background may predict differences in other characteristics, i.e. course of illness, response to treatment or biological characteristics. Two hundred and fifty-one bipolar patients were separated according to their family history, 20 with a family history of mania with or without depression, 86 with a family history of depression only, and 145 with a family history of neither mania nor depression. The group that had a family history of mania was notable in that it showed more episodes of affective illness and was more likely to be readmitted to hospital. This difference in course suggests a familial association with multiple episodes and mania. In other respects than in course of illness, the groups separated by family history were similar.     

Why do primary care doctors diagnose depression when diagnostic criteria are not met?

This study examines predictors of false positive depression diagnoses by primary care doctors in a sample of primary care attendees, taking the patients' diagnostic status from a self‐report measure (Depression Screening Questionnaire, DSQ) as a yardstick against which to measure doctors' correct and false positive recognition rates. In a nationwide study, primary care patients aged 15–99 in 633 doctors' offices completed a self‐report packet that included the DSQ, a questionnaire that assesses depression symptoms on a three‐point scale to provide diagnoses of depression according to the criteria of DSM‐IV and ICD‐10. Doctors completed an evaluation form for each patient seen, reporting the patient's depression status, clinical severity, and treatment choices. Predictor analyses are based on 16,909 patient‐doctor records. Covariates examined included depression symptoms, the total DSQ score, number and persistence of depression items endorsed, patient's prior treatment, history of depression, age and gender. According to the DSQ, 11.3% of patients received a diagnosis of ICD‐10 depression, 58.9% of which were correctly identified by the doctor as definite threshold, and 26.2% as definite subthreshold cases. However, an additional 11.7% of patients not meeting the minimum DSQ threshold were rated by their doctors as definitely having depression (the false positive rate). Specific DSQ depression items endorsed, a higher DSQ total score, more two‐week depression symptoms endorsed, female gender, higher age, and patient's prior treatment were all associated with an elevated rate of false positive diagnoses. The probability of false positive diagnoses was shown to be affected more by doctors ignoring the ‘duration of symptoms’ criterion than by doctors not following the ‘number of symptoms’ criterion for an ICD or DSM diagnosis of depression. A model selection procedure revealed that it is sufficient to regress the ‘false positive diagnoses’ on the DSQ‐total score, symptoms of depressed mood, loss of interest, and suicidal ideation; higher age; and patient's prior treatment. Further, the total DSQ score was less important in prediction if there was a prior treatment. The predictive value of this model was quite good, with area under the ROC‐curve = 0.86. When primary care doctors use depression screening instruments they are oversensitive to the diagnosis of depression. This is due to not strictly obeying the two weeks duration required by the diagnostic criteria of ICD‐10 and DSM‐IV. False positive rates are further increased in particular by the doctor's knowledge of a patient's prior treatment history as well as the presence of a few specific depression symptoms. Copyright © 2000 Whurr Publishers Ltd.     

The Iowa 500: familial and clinical findings favor two kinds of depressive illness

A clinical and blind family history evaluation was performed on 225 depressive patients. Early onset patients are more likely to have a family history of affective disorder. Early onset females are particularly likely to have a family history of alcoholism in the male parent. Suicides are more frequently seen in parents of early onset patients. Early onset depressive illness is associated with more frequent episodes of illness. This last is a new finding which could be a considerable help in finding homogeneous illnesses within the depressive syndrome. These data back up the concept of two types of depressive illness, depression spectrum disease and pure depressive disease.     

Diagnosing major depressive disorder V: applying the DSM-IV exclusion criteria in clinical practice

To be diagnosed with DSM-IV major depressive disorder (MDD), a patient must meet five out of nine symptom criteria, one of which is depressed mood or pervasive loss of interest or pleasure. Once a patient has reached this symptom threshold, there are several exclusionary criteria that need to be passed to receive the diagnosis. The symptoms must cause significant distress or impairment in functioning, the symptoms cannot be caused by substance use or a general medical condition, and the symptoms cannot be better accounted for by bereavement. Finally, the presence of psychotic symptoms not coincident with the depressive symptoms excludes the diagnosis. We are not aware of any studies of psychiatric patients that have examined the impact of all of these exclusionary rules on the diagnosis of MDD in clinical practice. It is important for clinicians to know how often each of these factors might exclude the diagnosis of MDD so that they can be more or less vigilant to their presence. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project was to examine the impact of the DSM-IV exclusion rules on the diagnosis of MDD. In total, 38 (3.0%) of the 947 patients meeting the DSM-IV symptom inclusion criteria were excluded from a diagnosis of MDD or bipolar depression. These results suggest that the DSM-IV exclusion criteria for MDD had only a modest impact on diagnosis in psychiatric outpatients. It is likely that the results of a study of the impact of the DSM-IV depression exclusion criteria will depend on where the study is conducted. The potential influence of different settings on diagnostic exclusion is discussed.     

Psychological disorders in survivors of torture: exhaustion, impairment and depression

Post-traumatic stress disorder (PTSD) has been described as the characteristic sequel to extreme events in life such as war and especially torture. This limitation to a single approach in regard to diagnosis and treatment has been criticised as being a too narrow concept to describe the effects following extreme events in life, especially as most studies so far were limited to PTSD and a small range of symptoms or disorders. The study presents data on psychiatric disorders in a group of exiled survivors of torture presenting to an out-patient department for psychiatry. A DSM-III-R-based psychiatric interview, including the general assessment of functioning scale (GAF), an open list of symptoms and the Vienna diagnostic criteria in regard to depression were used to evaluate a broader range of possible sequels. The most frequent present diagnosis in 44 patients seen over a period of 3 years was PTSD (n = 40), but criteria for a present diagnosis of other disorders were fulfilled in 34 patients, even years after torture, mainly major depression or dysthymia (n = 26). Criteria for functional psychosis were fulfilled in 4 patients. Many patients reported symptoms not assessed by DSM-III-R criteria, including feelings of shame and guilt, and ruminations on existential fears. The impairment as indicated by the GAF (mean 59.1) correlated best with the presence of the endogenomorphic-depressive axial syndrome, but not with duration of imprisonment, age or other factors. Research on sequels to extreme trauma should not be restricted to a simple diagnosis of PTSD, but should continue to look for a broader conceptualisation, including neglected categories like the axial syndrome, as PTSD is common, but might not be the only factor of importance for research and treatment. ICD-10 might offer a more adequate interpretation of sequels.