The potential relationship between levels of perceived stress and subtypes of major depressive disorder (MDD)

OBJECTIVE: We wanted to explore whether major depressive disorder (MDD) subtypes (melancholic depression, atypical depression, double depression, and MDD with anger attacks) were related to levels of perceived stress, as measured by the Perceived Stress Scale (PSS). METHOD: Our sample [n = 298; female = 163 (55%); mean age 40.1 +/- 10.5 years] consisted of out-patients with MDD. The Structured Clinical Interview for DSM-III-R, the 17-item Hamilton Rating Scale for Depression, the Anger Attack Questionnaire, and the PSS were administered prior to initiating treatment. RESULTS: Depressed women had significantly higher levels of perceived stress (P = 0.02) than depressed men. Greater severity of depression at baseline was significantly related to higher levels of perceived stress (P < 0.0001). After adjusting for age, gender, and severity of depression at baseline, higher levels of perceived stress were significantly related to the presence of anger attacks (P < 0.0001; t = -4.103) as well as to atypical depression (P = 0.0013; t = 3.26). CONCLUSION: Out-patients with MDD who are more irritable and/or present with atypical features have higher levels of perceived stress, indicating a potential reactive component to their depression.     

An open pilot study of nefazodone in depression with anger attacks: relationship between clinical response and receptor binding

Nefazodone has been widely used as an antidepressant, but it has not been tested for depression with anger attacks. In an open study, we administered nefazodone (maximum 600 mg/day) for 12 weeks to 16 outpatients who had major depression with anger attacks. Assessment instruments comprised the Structured Clinical Interview for DSM-IV (SCID), Anger Attacks Questionnaire (AAQ), 17-item Hamilton Rating Scale for Depression (HAM-D-17), Clinician Global Impression Scale (CGI), Symptom Questionnaire (SQ), Modified Overt Aggression Scale (MOAS), and MOAS-Self-Rated. Three subjects underwent positron emission tomography (PET) with [18F]-setoperone for 5-HT2 binding potential (BP) and [11C]-SCH-23,390 for D1 BP, both at baseline and after 6 weeks of treatment. Eight subjects underwent PET with [18F]-setoperone and with [11C]-SCH-23,390 at baseline only. In an examination of whether D1 and 5HT2 (data available in six subjects) receptor BP predicted treatment response, we found significant decreases in the HAM-D-17, CGI-S, weighted MOAS, MOAS verbal scale, OAS Self-Rated verbal, SQ Depression and Anger/Hostility scales after nefazodone; 50% responded to nefazodone (defined as >or=50% decrease in HAM-D-17 score), and 44% reported disappearance of anger attacks. A statistically significant percentage decrease in 5HT2 BP was observed for the right mesial frontal and left parietal regions after 6 weeks of treatment. No significant change was observed in D1 BP in any region. Although CGI-I scores correlated significantly with D1 BP in the left thalamic region, the correlation was not significant after Bonferroni correction. The effectiveness of nefazodone for depression with anger attacks may be related to widespread changes in 5HT2 receptor BP.     

An open pilot study of nefazodone in depression with anger attacks: relationship between clinical response and receptor binding

Nefazodone has been widely used as an antidepressant, but it has not been tested for depression with anger attacks. In an open study, we administered nefazodone (maximum 600 mg/day) for 12 weeks to 16 outpatients who had major depression with anger attacks. Assessment instruments comprised the Structured Clinical Interview for DSM-IV (SCID), Anger Attacks Questionnaire (AAQ), 17-item Hamilton Rating Scale for Depression (HAM-D-17), Clinician Global Impression Scale (CGI), Symptom Questionnaire (SQ), Modified Overt Aggression Scale (MOAS), and MOAS-Self-Rated. Three subjects underwent positron emission tomography (PET) with [¹⁸F]-setoperone for 5-HT2 binding potential (BP) and [¹¹C]-SCH-23,390 for D1 BP, both at baseline and after 6 weeks of treatment. Eight subjects underwent PET with [¹⁸F]-setoperone and with [¹¹C]-SCH-23,390 at baseline only. In an examination of whether D1 and 5HT2 (data available in six subjects) receptor BP predicted treatment response, we found significant decreases in the HAM-D-17, CGI-S, weighted MOAS, MOAS verbal scale, OAS Self-Rated verbal, SQ Depression and Anger/Hostility scales after nefazodone; 50% responded to nefazodone (defined as ≥50% decrease in HAM-D-17 score), and 44% reported disappearance of anger attacks. A statistically significant percentage decrease in 5HT2 BP was observed for the right mesial frontal and left parietal regions after 6 weeks of treatment. No significant change was observed in D1 BP in any region. Although CGI-I scores correlated significantly with D1 BP in the left thalamic region, the correlation was not significant after Bonferroni correction. The effectiveness of nefazodone for depression with anger attacks may be related to widespread changes in 5HT2 receptor BP.     

Somatic symptoms as predictors of time to onset of response to fluoxetine in major depressive disorder

OBJECTIVE: In the present study we assessed the relationship between somatic symptoms and the time to onset of clinical response to fluoxetine in patients with major depressive disorder (MDD). METHOD: 87 outpatients (mean age = 41.4 +/- 10.2 years; 59.8% women) with DSM-III-R MDD who had sustained acute response to fluoxetine completed the Symptom Questionnaire (SQ) at baseline. Onset of response was defined as a 30% decrease in the total score for the 17-item Hamilton Rating Scale for Depression that led to a 50% decrease by week 8. With the use of 2 separate multiple regressions, controlling for the severity of depression at baseline, we then assessed the relationship between the number of somatic symptoms as assessed by the SQ subscale for somatic symptoms (SQ-SS) and both the time to onset of clinical response and the time to clinical response. The study was conducted between November 1992 and January 1999. RESULTS: A greater number of somatic symptoms at baseline predicted a greater amount of time to onset of clinical response to fluoxetine (p =.0233). The relationship between SQ-SS scores and time to response was not found to be statistically significant (p >.05). CONCLUSION: Somatic symptoms of depression were found to be associated with a delayed onset of antidepressant response to fluoxetine in MDD.     

Mental symptoms,hostility features and stressful life events in people with cancer

Hostility features, mental symptoms, and stressful life events were investigated in 100 patients (59 men and 41 women) suffering from cancer. Fifty-seven healthy men (n= 26) and women (n= 31) were used for comparison purposes. The assessment instruments were the Hostility and Direction of Hostility Questionnaire, the Delusions Symptoms States Inventory/states of anxiety and depression and a modified version of the Schedule of Life Experiences. Women patients reported lower scores than healthy women on total hostility, but men patients reported higher scores than healthy men. Introverted hostility was increased in both male and female patients, but due to different patterns: in women due to lower scores on extroverted hostility subscales, especially acting-out hostility, whereas in men due to higher scores on introverted hostility subscales, especially guilt. Female patients, compared with healthy women, reported significantly higher scores on the depressive and anxiety subscales, whereas in the man the differences were not statistically significant even though patients reported higher scores than normals. On the Schedule of Life Experiences, female patients reported statistically significant higher scores than healthy women.     

Depression following pegylated interferon-alpha: characteristics and vulnerability

OBJECTIVE: Interferon-alpha2 (IFN-alpha) injections may be capable of triggering depression in some individuals. The first objective was to further characterize this depression and, secondly, to examine whether pre-treatment temperament was correlated with subsequent vulnerability to IFN-alpha. METHODS: Twenty-three initially euthymic adults undergoing year-long PEG-IFN-alpha treatment for hepatitis C were evaluated at baseline and then prospectively monitored using both the Structured Clinical Interview for DSM-IV (SCID) and self-report questionnaires. RESULTS: A major depressive episode developed within 3 months in 39%. Principal component analysis of the change in self-report scores after 1 month of treatment demonstrated three orthogonal factors: (i) a specific increase in depression as manifested in the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS), (ii) an increase in hostility and anxiety, (iii) and a generalized combination of worse symptoms including somatic symptoms on the Symptom Check List (SCL-90). BDI at 1 month was predicted by baseline BDI (r=0.76, P=.004). Hostility at 1 month was predicted by low baseline agreeableness (r=0.75, P=.01). Controlling for baseline BDI scores, categorical major depression was predicted by combined high baseline neuroticism and low agreeableness (combined r=0.66, P=.03). CONCLUSION: These initial results (i) support the depressogenic nature of IFN-alpha treatment in a subset of vulnerable individuals, (ii) indicate that some individuals are also independently vulnerable to worsened hostility, and (iii) suggest that it may be possible to clinically predict these vulnerabilities in initially euthymic subjects.     

Personality disorders and perceived stress in major depressive disorder

The investigation of comorbidity between major depressive disorder (MDD) and personality disorders (PDs) has attracted considerable interest. Whereas some studies found that the presence of PDs has adverse effects on the course and treatment of MDD, others have failed to demonstrate this link. These inconsistent findings suggest that specific PD comorbidity might affect the course of MDD by modulating factors that increase the overall risk of depression, including an elevated tendency to perceive stress. To investigate whether the presence of a specific PD cluster was associated with elevated levels of stress appraisal, we administered the Perceived Stress Scale (PSS) before and after treatment to 227 MDD outpatients enrolled in an 8-week open-label treatment with fluoxetine. Following treatment, multiple linear regression analyses revealed that the presence of Cluster A, but not Cluster B or C, was associated with higher levels of perceived stress, even after adjusting for baseline depression severity and PSS scores, as well as various sociodemographic variables. The presence of Cluster A PD comorbidity was uniquely associated with elevated stress appraisal after antidepressant treatment, raising the possibility that stress exacerbation might be an important factor linked to poor treatment outcome in MDD subjects with Cluster A pathology.     

Psychophysiological ante-natal predictors of post-natal depressed mood

Forty-seven women were studied during the course of pregnancy in an attempt to predict which of them would later rate themselves as suffering from depressed mood post-natally.Psychometric and physiological measures were used in the three trimesters of pregnancy and six weeks after birth. The psychometric measures used ante-natally and post-natally comprised the Hostility and Direction of Hostility Questionnaire, the Locus of Control Scale, the DSSI/SAD sub-scale to measure anxiety, and the Zung Self-Rating Scale to measure depression. Psychophysiological measures used were heart-rate and blood pressure.Post-natal ratings of depression were associated with a high ante-natal score on overall hostility. Women with high anxiety and hostility ratings had a more pronounced response to the sound of a baby crying than to noise of similar frequency and intensity. This more pronounced heart response was also related to later post-natal depression ratings.However, by far the most useful predictive measure was the Hostility and Direction of Hostility Questionnaire: its predictive power in the first trimester of pregnancy was almost as good as in the third trimester.     

Hostility and recovery from melancholia

Twenty inpatients suffering from major depressive illness with melancholia were administered the hostility subscale of the Kellner Symptom Questionnaire and Paykel's Clinical Interview for Depression before and after treatment with amitriptyline. A matched control group of normal subjects had the same assessments at two points in time. Hostility decreased and friendliness increased in depressives after amitriptyline; upon recovery, there were no significant differences in hostility between depressed patients and control subjects, whereas such differences were striking during the illness. Patients who had reported losses before onset of illness rated themselves as more friendly than the other depressives; their hostility did not significantly decrease with recovery. The results suggest that hostility improves with the treatment of depression; life events appear to influence the degree of hostility in depressive illness as well as the response to treatment.     

Childhood trauma and hostility as an adult: relevance to suicidal behavior

The objective of this study is to look for a relationship between childhood trauma and hostility as an adult. Toward this end, 294 recently abstinent cocaine or opiate dependent patients were asked to complete two questionnaires: the Childhood Trauma Questionnaire (CTQ) and the Hostility and Direction of Hostility Questionnaire (HDHQ). It was found that there were significant correlations between the HDHQ total hostility score and scores on the CTQ for childhood emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Thus, these results suggest the possibility that childhood trauma may be a determinant of the personality dimension of hostility as an adult.     

碳酸锂合并米氮平或氟西汀治疗双相抑郁的对照研究

目的评价米氮平合并碳酸锂治疗双相抑郁的疗效和安全性。方法将126例双相抑郁患者分为两组,研究组61例,应用米氮平合并碳酸锂,对照组65例,应用氟西汀合并碳酸锂,治疗8周。分别于治疗后第2、4、6、8周末用汉密尔顿抑郁量表(HAMD)和不良反应量表(TESS)比较两组的疗效和安全性。结果治疗后第2、4、6、8周末两组HAMD总分比较,差异均有显著性(P<0.05),研究组疗效优于对照组(P<0.05),两组脱落率比较差异有显著性(P<0.05),两组治疗后各时期TESS总分比较差异均无显著性(P>0.05),但研究组在治疗早期的嗜睡、困倦发生率较高、失眠发生率较低、胃肠道反应较少、治疗末体重增加较多(P均<0.05)。结论米氮平合并碳酸锂治疗双相抑郁疗效肯定,不良反应较少,依从性好。     

Pattern analysis of antidepressant response to fluoxetine

Seventy patients with unipolar major depressive disorder were treated with fluoxetine or placebo in a 6-week double-blind trial and were evaluated by changes in scores on the Hamilton Rating Scale for Depression (HAM-D) and the global improvement measure of the Clinical Global Impressions (CGI) scale. High correlations were found between the changes in HAM-D scores from baseline to endpoint and the final CGI improvement ratings. In patients with moderate depression (baseline HAM-D score of 20 or more), the differences in endpoint analysis between active treatment and placebo groups were significant. A persistent pattern of improvement was noted in 27% of those receiving fluoxetine but in none of those receiving placebo. Physician and patient evaluations as determined by the improvement measure of the CGI were closely correlated.     

Personal and psychophysiological characteristics associated with puerperal mental state

An attempt was made to predict the occurrence of post-natal depression in a sample of women assessed in the third trimester of pregnancy.Psychometric measures used ante-natally comprised the Hostility and Direction of Hostility Questionaire, the Locus of Control Scale, and the DSSI/sAD sub-scales to measure anxiety and depression. Psychophysiological measures used were heart-rate and skin conductance. Depression was assessed by the Zung Self-Rating Scale at 6 weeks post partum.Post-natal depression was associated with high ante-natal scores on either overall hostility and extrapunitiveness or external locus of control ratings and intrapunitiveness.Women with high anxiety or hostility scores had a more pronounced ante-natal heart response to the sound of a baby crying than to noise of similar frequency and intensity. This more pronounced heart response was also related to later post-natal depression.     

Hostility, somatic symptoms and recovery with antidepressants.

Patients were treated with protriptyline or nortriptyline (double-blind). They were assessed on the Zung Depression Scale and on the Hostility and Direction of Hostility Questionnaire (HDHQ). A good response was heralded by low ratings on criticism of self and others,and on projected (paranoid) hostility. The outcome was better with initial low scores on depressive symptoms, particularly unworthiness, restlessness and constipation. As to reported side effects, initial loss of interest augured badly for drowsiness, lack of clear mind for blurred vision, loss of libido for constipation and ideas of suicide for dry mouth.     

Personality factors and pathological gambling

Pathological gambling is a disorder in which personality factors are thought to be important. Therefore, we compared 19 male pathological gamblers with 18 male normal controls for their scores on 3 personality questionnaires. Pathological gamblers were found to have significantly higher psychoticism and neuroticism scores on the Eysenck Personality Questionnaire than controls. Gamblers also had significantly higher total hostility scores on the Hostility and Direction of Hostility Questionnaire. The possible implications of these findings are discussed.     

Self-ratings of anger and hostility in borderline personality disorder

Forty-six patients with borderline personality disorder with and without major depression and 27 normal volunteers completed the Buss-Durkee Hostility Inventory, a self-rating scale of anger and hostility. The patients with borderline personality had significantly higher scores than the normal volunteers. The scores of the patients with borderline personality disorders were not related to gender, treatment or research setting, the degree of acute distress, or the presence of major depression. These findings suggest that a proneness to anger and hostility are enduring characteristics of borderline personality disorder and that anger and depression may represent independent clinical conditions with independent biological mechanisms regulating these two affective states.     

Depressive symptoms at baseline predict fewer negative symptoms at follow-up in patients with first-episode schizophrenia

There is uncertainty regarding the prognostic value of depressive symptoms in schizophrenia, having previously been associated with both favourable and poor outcome. This study investigated the relationship between baseline depressive symptoms and treatment outcome at 6, 12 and 24 weeks in 80 subjects with first-episode schizophrenia or schizophreniform disorder in terms of PANSS total and subscale score changes. No significant association was found between baseline PANSS depression factor scores and PANSS total and subscore changes. However, a significant inverse correlation between baseline depression scores and negative scores at 6, 12 and 24 weeks was found (p=0.044, 0.023 and 0.012, respectively). Multiple regression analysis indicated that this finding could not be explained on the basis of age, gender or duration of untreated psychosis. These findings support previous work suggesting that high baseline depressive scores predict favourable outcome.     

The relationship between blood pressure and personality in a large unselected adult sample

As part of a general health survey of a small New Zealand town, the Crow-Crisp Experiential Index, the State-Trait Anxiety Inventory, a shortened version of the Hostility and Direction of Hostility Questionnaire, and the Zung Self-rating Depression Scale were administered to 1173 subjects over the age of 15. Blood pressure was moderately correlated with age and Quetelet's Index, a measure of obesity. Low but significant correlations were found between Somatic Anxiety, Hysteria, and the Urge to Act-out Hostility scale. However, when effects of age were controlled for, in a series of multiple regression analyses, the correlations with psychometric test scores were no longer significant. This study confirms several previous reports that neuroticism, anxiety, depression, and hostility are of little significant in predicting levels of blood pressure in the general population.     

Timing of clinical improvement and symptom resolution in the treatment of major depressive disorder

The goal of the present work is to assess for the relationship between the timing of clinical improvement and the resolution of depressive symptoms in Major Depressive Disorder (MDD). 182 MDD outpatients (40.5+/-9.7 years; 53.8% female) who responded following an 8-week, 20 mg, open trial of fluoxetine were included in the analysis. The symptoms questionnaire (SQ) and Beck hopelessness scale (BHS) were also administered to 83 and 153 of these patients, respectively. Onset of clinical improvement was defined as a 30% decrease in 17-item Hamilton depression scale (HDRS-17) scores. Controlling for baseline symptom severity, we then assessed for the relationship between the timing of clinical improvement and depressive symptom at endpoint. Earlier clinical improvement in responders predicted lower HDRS-17, BHS, SQ-depression, SQ-anxiety, but not SQ-somatic symptom or SQ-anger/hostility scores at week 8. This was true regardless of whether improvement was defined as a continuous measure (30% decrease in symptom severity), as a dichotomous measure (clinical response occurring in the first two weeks of treatment). In conclusion, earlier clinical improvement with fluoxetine treatment is predictive of greater symptom resolution at endpoint. Further studies exploring the impact of various treatment modalities and placebo on the timing of clinical improvement and symptom resolution in MDD are warranted.     

Depressive symptoms in stable chronic schizophrenia: prevalence and relationship to psychopathology and treatment

The prevalence and correlates of the depressive syndrome were explored in a population of 120 patients with stable, chronic schizophrenia living in the community. The presence of clinically significant depressive symptoms was defined by a score of 17 or greater on the Beck Depression Inventory. Patients were examined to assess severity of schizophrenic symptoms and medication side-effects. Sixteen of the 120 patients (13.3%) had significant depressive symptoms. Depressive symptoms were significantly correlated with the hostility/suspiciousness (P<0.0001), the positive symptom (P=0.0009) factor of the BPRS and with scores on the Significant Others Scale, a measure of patients' perceived lack of social support (P=0.0004). The association between depression and akathisia approached significance (P=0.007). There was no correlation with demographic variables, alcohol intake, antipsychotic dosage or anticholinergic dosage. Using a scale that rates the subjective aspects of the depressive syndrome, we found no evidence of a relationship between depression and negative symptoms in this population. These results indicate that persistent depressive symptoms in stable patients in the community are related to the degree of persistent positive psychotic symptoms, patient perceptions of social support and, weakly, to the degree of akathisia but not other aspects of antipsychotic treatment.