Neuroendocrine responses in psychiatric and pain patients with major depression

Basal and postdexamethasone concentrations of cortisol and prolactin were studied in three groups of male patients: chronic pain patients with no psychiatric diagnosis (n = 12), chronic pain patients with coexisting major depression by Research Diagnostic Criteria (RDC) (n = 24), and pain-free psychiatric patients meeting RDC criteria for major depression (n = 28). Basal cortisol concentrations were significantly higher in pain-major depression and psychiatric-major depression patients compared to pain patients without psychiatric illness. The frequency of cortisol nonsuppression after dexamethasone was significantly greater in pain patients with major depression (41.7%) compared to pain patients without psychiatric disorder (8.3%), and was comparable to that of psychiatric patients (21.4%). Prolactin concentrations, but not cortisol levels, were significantly correlated with observer-rated severity of depression in pain patients. These findings suggest that cortisol and prolactin abnormalities in chronic pain may be related to psychiatric disorder rather than to pain per se, at least in male patients, and may indicate a role for cholinergic mechanisms in the interface of pain and depression.     

Depressogenic medication as an aetiological factor in major depression: an analysis in a clinical population of depressed elderly people.

OBJECTIVE: To study the role of depressogenic medication in the aetiology of major depression in the elderly. BACKGROUND: Depression can be caused, provoked or sustained by drugs prescribed for other reasons. The evidence for this statement is based on case-reports, not on investigations in relevant populations. METHOD: In the geriatric wards of three Dutch psychiatric hospitals, 195 patients with a DSM-III-R diagnosis of major depression (MDD) were studied. In the first week after admission the following data were recorded: age, gender, personal psychiatric history, family psychiatric history, Montgomery-Asberg Depression Rating Scale, Mini-Mental State Examination, history of stroke, use of medication and number of different medications used. Subjects using depressogenic medication were contrasted with subjects not using depressogenic medication on all variables. RESULTS: There was a significant negative relationship, adjusted for the other variables, between the use of depressogenic medication and a previous admission for depression. No other significant relationships between the use of depressogenic medication and aetiological variables were found. Patients with a first-time admission for MDD use depressogenic medication 2.44 times more often than patients with previous admissions for depression. CONCLUSION: The use of depressogenic medication is an independent and clinically relevant aetiological factor in MDD.     

Headache and major depression: is the association specific to migraine?

OBJECTIVE: To examine the relationship between migraine and major depression, by estimating the risk for first-onset major depression associated with prior migraine and the risk for first migraine associated with prior major depression. We also examined the extent to which comorbidity with major depression is specific to migraine or is observed in other severe headaches. METHODS: Representative samples of persons 25 to 55 years of age with migraine or other severe headaches (i.e., disabling headaches without migraine features) and controls with no history of severe headaches were identified by a telephone survey and later interviewed in person to ascertain history of common psychiatric disorders. RESULTS: Lifetime prevalence of major depression was approximately three times higher in persons with migraine and in persons with severe headaches compared with controls. Significant bidirectional relationships were observed between major depression and migraine, with migraine predicting first-onset depression and depression predicting first-onset migraine. In contrast, persons with severe headaches had a higher incidence of first-onset major depression (hazard ratio = 3.6), but major depression did not predict a significantly increased incidence of other severe headaches (hazard ratio = 1.6). CONCLUSIONS: The contrasting results regarding the relationship of major depression with migraine versus other severe headaches suggest that different causes may underlie the co-occurrence of major depression in persons with migraine compared with persons with other severe headaches.     

Multiple sclerosis,interferon beta-1b and depression A prospective investigation

The objectives were twofold: a) to explore a possible association between major depression and treatment with interferon beta-1b in patients with multiple sclerosis; and b) to investigate whether putative antecedent risk factors such as a previous psychiatric history and a family history of affective illness influence the prevalence of major depression post-treatment with interferon beta-1b. Forty-two patients with relapsing-remitting MS underwent neurological examination and were interviewed with the Structured Clinical Interview for Axis 1 DSM-IV Disorders prior to starting interferon beta-1b and thereafter at 3, 6 and 12 months. Ethical considerations dictated that patients diagnosed with major depression received anti-depressant medication. At index assessment, 21.4 % of the sample were diagnosed with a major depression, the figures falling to 17.5 %, 11.4 % and 6.3 % at 3, 6 and 12 months respectively. The majority of subjects with a major depression had a history of psychiatric illness prior to treatment with interferon beta-1b. A family history of affective disorder was not associated with a significantly increased rate of major depression either before or after treatment with interferon beta-1b. While the study's methodology did not address causality, the data demonstrate that major depression post-treatment with interferon beta-1b is linked to a history of psychiatric illness prior to starting treatment. The threefold decline in prevalence rates for major depression over the course of a year demonstrates a good response to anti-depressant medication and possible beneficial effects of interferon beta-1b on mood.     

Psychopathology and clinical features in an Italian sample of patients with myofascial and temporomandibular joint pain: preliminary data

OBJECTIVE: Aim of this study was to provide data on the relationships between psychopathological variables and temporomandibular disorders (TMD). Sixty-three TMD patients were investigated using clinical and anamnestical psychiatric informations and psychopathological measures. METHODS: Three groups of TMD patients were recruited according to the Research Diagnostic Criteria for TMD guidelines: a group of patients presenting myofascial pain alone (RDC/TMD axis I group I), a group with temporomandibular joint (TMJ) pain alone (RDC/TMD axis I group IIIa, IIIb), and a group presenting both myofascial and TMJ pain. Two secondary groups were identified on the basis of the presence/absence of myofascial pain. The study design provided a psychiatric interview and psychometric assessment including the Symptom Check List-90-Revised (SCL-90-R), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS). RESULTS: --Psychiatric evaluation: Myofascial pain patients had higher scores for personal psychiatric history and a history of more frequent psychotropic drug use. --HDRS and HARS: The sample presented scores indicating mild depressive symptoms and moderate anxiety symptoms. --SCL-90-R: The global sample showed acute levels of psychological distress as measured by the GSI score (Global Severity Index). Myofascial pain patients scored higher than TMJ pain patients in the GSI (p = .028), PAR (paranoia; p = .015), PSY (psychoticism; p = .032), and HOS (hostility; p = .034) subscales. CONCLUSIONS: TMD patients showed elevated levels of depression, somatization, and anxiety. These characteristics did not differ significantly between patients with myofascial or TMJ pain. Other specific psychopathological dimensions, detected with SCL-90-R, appeared to be closely associated to the myofascial component.     

Comparison of users and non-users of mental health services among depressed, older, urban African Americans.

OBJECTIVE: The authors sought to determine differences between depressed older black residents in an urban community who do and do not use formal mental health services. METHODS: The Treatment Group (TG) consisted of 106 black patients age >or=55 with a diagnosis of depression who were recruited from outpatient psychiatric programs in Brooklyn, NY. The Untreated Community Group (UCG) consisted of 101 cognitively intact black subjects age >or=55 from randomly selected block groups in Brooklyn who met symptom criteria for major or minor depression and had no previous history of psychiatric treatment. RESULTS: In logistic regression analysis, TG persons were significantly more likely than the UCG persons to be female, younger, born in the United States, to have impaired daily functioning, have a family history of mental illness, and believe that environmental factors and religious activities could influence mental illness. TG persons were significantly less likely to have social network members who provided advice, to use spiritualists or their products, to have vision or hearing impairments, and to have depressive symptoms. Although most UCG persons visited their doctor at least three times annually, only 11% reported using these physicians for help with mental health problems. CONCLUSIONS: A combination of demographic and attitudinal factors, family psychiatric history, social supports, and functional impairments were associated with the use of mental health services. Despite reluctance of persons in the UCG to use primary-care physicians for mental health reasons, the latter remain the most feasible intervention point within the existing service system.     

Pilot study on the use of psychotropic medication in persons with mental retardation

OBJECTIVE: To explore the status of the psychotropic medication in persons with mental retardation 6 years after their deinstitutionalization. METHOD: The authors compared the profiles of psychotropic medication of 60 persons with mental retardation deinstitutionalized (D-sample) from our local mental hospital 6 years ago, to their actual pharmacological profile. Later, we compared our results to the ones of persons with mental retardation on an in-patient (In-sample) unit where existed a concerted team effort to lower the medication when deemed appropriate. RESULTS: Six years post-deinstitutionalization, the authors observed that the same percentage of patients remained on antipsychotic and benzodiazepine medication in our D-sample, and a threefold increase of those using antidepressive medication. However, we observe a general decrease of all types of psychotropic medication in the In-sample with complete withdrawal in a substantial number of patients. CONCLUSIONS: The authors take these pilot data to mean that a concerted team effort at lowering medication in persons with mental retardation makes a significant difference. The possibility of other factors (age, sex, severity of mental retardation, psychiatric diagnosis) explaining the difference in the results is discussed.     

Markers of vulnerability to obsessive-compulsive disorder in an ultra-high risk sample of patients who developed psychosis

Aims: The study aims to identify markers of vulnerability to obsessive–compulsive disorder (OCD) in an ultra‐high risk sample of patients who developed psychosis. Methods: Three hundred and eleven patients at ultra‐high risk for psychosis were examined at baseline and after a mean of 7.4 years follow‐up. Patients who developed psychosis with OCD (PSY + OCD; n = 13) and psychosis without OCD (PSY − OCD; n = 45) were compared in terms of socio‐demographic and clinical features. Results: PSY + OCD patients displayed greater severity of depression before and after conversion to PSY + OCD, and increased rates of depressive disorders before exhibiting PSY + OCD. However, they only displayed greater severity of anxiety and increased rates of non‐OCD anxiety disorders after psychosis. Further, PSY + OCD patients were more likely to report a positive family history for anxiety disorders than PSY − OCD. Conclusion: Although depression and a family history of anxiety disorder may act as vulnerability markers for OCD in psychosis, the resulting anxiety may be a correlate or a consequence of PSY + OCD.     

Psychiatric disorders and diabetes--results from a community study

In the Upper Bavarian Field Study a total of 1536 persons (15 years and older) were interviewed by research psychiatrists. The prevalence of diabetes (ICD 250) identified by the interviewer and/or the primary care physician was 4.0%. Since the number of diabetics among the younger age groups was relatively low (n = 7) and in order to obtain a more homogeneous study group, only those over the age of 55 were considered in further analysis. Diabetics were compared with a control group of persons with another chronic medical condition of similar clinical severity and a control group without a somatic disorder. The sex- and age-adjusted prevalence of psychiatric disorders identified with the aid of the Clinical Interview Schedule was significantly higher among diabetics (43.1%) and persons with other chronic medical conditions (50.7%) in comparison to the healthy control group (26.2%). The difference was mainly due to mild psychiatric disorders and those suffering from depression. No statistically significant association was found between diabetes and moderate to severe mental disorders, the use of psychotropic drugs and previous psychiatric treatment.     

Medication use and nonadherence to psychoactive medication for mental health problems by community-living canadian seniors with depression

Objectives: To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada. Methods: Canadian Community Health Survey-Mental Health and Well-Being respondents aged 65 years and older (n = 7736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed. Results: In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence. Conclusion: All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low.     

Depression in rheumatoid arthritis patients: demographic, clinical, and psychological predictors

OBJECTIVE: To confirm the prevalence of depression in a sample of rheumatoid arthritis (RA) patients; to identify the most significant predictors of depression in RA and to explore patients attitudes to medication in relation to depression. METHODS: A cross-sectional survey was used to collect data from 134 RA patients (77% female, 23% male). Participants were divided into depressed and nondepressed groups based on their scores on the Center for Epidemiological Studies-Depression (CES-D) scale. Discriminant analysis was conducted to identify the predictors that would best categorise patients into those two groups. RESULTS: Twelve predictors correctly classified 80% of patients into depressed or nondepressed groups. The strongest predictors of depression were high tension and low self-esteem followed by the perceived impact of RA, fatigue, passive coping, pain, and physical disability. Other predictors included medication effectiveness and importance as well as perceived lack of control over pain. CONCLUSION: Both physical and psychological factors have an impact on depression in RA. The key predictors identified in this study need to be considered within the regular RA management as possible cues to depression development.     

A national study of the effect of chronic pain on the use of health care by depressed persons

OBJECTIVE: The objective of this study was to provide national estimates of the impact of common pain conditions such as back pain, chronic headache, self-reported arthritis, and unspecified chronic pain on the use of health services and quality of care among persons with depression. METHODS: This was a cross-sectional study of data from a U.S. national household survey conducted in 1997-1998. The participants were 1,486 community-dwelling adults who met criteria for major depression or dysthymia according to the Composite International Diagnostic Interview Short-Form. RESULTS: Depressed persons with comorbid pain (N=938) were older, had lower incomes, and reported more severe psychiatric distress than depressed persons who did not have pain. When sociodemographic characteristics and severity of psychological distress were adjusted for, comorbid pain was associated with about 20 percent more visits to medical providers by patients who made at least one visit during a year. However, the patients with comorbid pain were about 20 percent less likely to see a mental health specialist than patients without pain. Pain was also shown to be associated with greater use of complementary or alternative medicine but not with differences in the use of antidepressants. CONCLUSION: Comorbid pain among persons with depression is associated with more intensive use of general medical services but lower rates of use of mental health services.     

The implication of selection bias in clinical studies of late life depression: an empirical approach

OBJECTIVES: It is supposed that selection bias precludes the extrapolation of results of studies carried out in a clinical setting to the general population. There is little empirical evidence demonstrating the degree to which those depressed in the community are different from those treated in clinical settings. This study compared elderly patients with major depression admitted to a psychiatric hospital with those living in the community. METHODS: All elderly (55 years and older) patients admitted between 1990 and 1992 to a psychiatric hospital with DSM major depression as the primary diagnosis (n=104), were compared with all elderly patients with the same diagnosis (n=59) who were participating in a large community study (Longitudinal Aging Study, Amsterdam). Data were gathered from the clinical sample using chart-reviews while the community-based sample was interviewed. The two groups were compared with respect to differences in demographic variables, presenting symptoms, risk factors and treatment. RESULTS: The following characteristics were significantly more prevalent in the clinical sample: late onset of the depression, threat of suicide, conflicts with significant others and use of antidepressant medication. Chronic physical illness was the only characteristic that was more prevalent in the community sample. CONCLUSION: The results confirm that elderly patients treated in clinical psychiatry represent a group with more threatening and more disruptive depressive illness. Major depression in the community was more often associated with chronic physical illness, which may hamper the recognition and treatment of depression. As the two samples were similar in all other respects, selection bias, hampering comparison of results of studies carried out across treatment settings, appears to have a very limited effect.     

Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus.

The current study evaluated the association of glycemic control and major depression in 33 type 1 and 39 type 2 diabetes mellitus patients. Type 1 patients with a lifetime history of major depression showed significantly worse glycemic control than patients without a history of psychiatric illness (t = 2.09; df = 31, p < 0.05). Type 2 diabetes patients with a lifetime history of major depression did not have significantly worse control than those with no history of psychiatric illness. Findings from this study indicate different relationships between lifetime major depression and glycemic control for patients with type 1 and type 2 diabetes. Treatment implications for glycemic control in type 1 and type 2 diabetes patients are discussed.     

Clinical presentation and course of depression in youth: does onset in childhood differ from onset in adolescence?

OBJECTIVE: To simultaneously and prospectively compare the clinical presentation, course, and parental psychiatric history between children and adolescents with major depressive disorder. METHOD: A group of prepubertal children (n = 46) and postpubertal adolescents (n = 22) were assessed with structured interviews for psychopathology and parental psychiatric history and followed once every 2 years for approximately 5 years. RESULTS: With the exception of more depressive melancholic symptoms in the adolescents, both groups had similar depressive symptomatology, duration (average 17 months), severity of the index episode, rates of recovery (85%) and recurrence (40%), comorbid disorders, and parental psychiatric history. Female sex, increased guilt, prior episodes of depression, and parental psychopathology were associated with worse longitudinal course. CONCLUSIONS: In general, major depressive disorder is manifested similarly in children and adolescents, and both groups have a protracted clinical course and high family loading for psychiatric disorders.     

Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: a blind comparison of DSM-III diagnoses

OBJECTIVE: The major purpose of this study was to compare the frequency of the occurrence of DSM-III diagnoses in patients with primary fibromyalgia syndrome, patients with rheumatoid arthritis, and subjects without pain. METHOD: Thirty-five patients with primary fibromyalgia, 33 patients with rheumatoid arthritis, and 31 nonpatients without pain were blindly assessed for psychiatric diagnoses with the Psychiatric Diagnostic Interview. RESULTS: Data from this interview revealed no group differences in terms of lifetime history of any psychiatric disorders, including major depression, somatization disorder, or anxiety-based disorders. Analysis of the auxiliary symptoms of depression on the Psychiatric Diagnostic Interview revealed that the patients with fibromyalgia did not report a higher frequency of vegetative signs of depression. However, analysis of the somatization scale revealed an interaction between medical and psychiatric diagnoses: patients with primary fibromyalgia syndrome and a psychiatric history endorsed significantly more somatic symptoms than did patients with rheumatoid arthritis or subjects without pain, and fibromyalgia patients without a psychiatric history were no more likely to endorse somatic symptoms than were arthritis patients or subjects without pain. CONCLUSIONS: The Psychiatric Diagnostic Interview data failed to discriminate in any major way between primary fibromyalgia syndrome (a disorder with no known organic etiology) and rheumatoid arthritis (a disorder with a known organic etiology). Therefore, these data do not support a psychopathology model as a primary explanation of the symptoms of primary fibromyalgia syndrome.     

Major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder

Patients with panic disorder and/or agoraphobia appearing in psychiatric settings report rates for lifetime major depression between 24% and 91%. Between 40% and 90% of patients with panic disorder in psychiatric populations report concomitant agoraphobia. A recent study of panic disorder subjects appearing in an outpatient cardiology clinic confirmed the strong link between panic and depression but found only a weak association between panic disorder and agoraphobia. In order to test the reliability of these outpatient cardiology findings, the authors studied major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder. Twelve of the 32 (37.5%) panic disorder subjects reported a lifetime history of major depression (nine current, three past only). Only two of the 32 (six percent) reported any phobic avoidance. This study confirms the previous findings which suggest that major depression is common in cardiology populations with panic disorder and that phobic avoidance is uncommon in this group.     

Depression with atypical features in the National Comorbidity Survey: classification,description, and consequences

BACKGROUND: Atypical depression has been found to be distinct from other types of depression in terms of psychiatric symptom profile and treatment response. However, debate continues regarding its specific characteristics, impact, and diagnostic criteria. The current study was conducted to increase understanding of atypical depression diagnosed using only the reversed vegetative symptoms of hypersomnia and hyperphagia. METHODS: An atypical depression group (n = 304 [36.4% of the depressed sample; 39.0% when weighted to approximate the national population]) was identified within the US National Comorbidity Survey, which assessed psychiatric disorders among a nationally representative sample using the Composite International Diagnostic Interview. The atypical group was identified based on DSM-III-R criteria for a major depressive episode, in addition to atypical features of hypersomnia and hyperphagia. Comparison groups were those with nonatypical depression (n = 532) and individuals without a psychiatric disorder (n = 4071). RESULTS: Compared with nonatypical depression, atypical depression was associated with a greater percentage of women and an earlier age of onset. The atypical group also reported higher rates of most depressive symptoms, suicidal thoughts and attempts, psychiatric comorbidity (panic disorder, social phobia, and drug dependence), disability and restricted activity days, use of some health care services, paternal depression, and childhood neglect and sexual abuse (P<.05). Compared with people without psychiatric disorders, the atypical group reported higher rates of disability and restricted activity days, use of all mental health care services, parental depression, and childhood abuse (P<.001). CONCLUSIONS: This analysis of a nationally representative US sample suggests that overeating and oversleeping can be used to identify an atypical depression subgroup that is distinct from other depressed patients in terms of demographics, psychiatric comorbidities, and abuse history. Findings also suggest that atypical depression is associated with increased distress, suicidal ideation, and disability compared with nonatypical depression.