Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults

OBJECTIVE: The primary purpose was to identify factors related to the recurrence of major depressive disorder during young adulthood (19-23 years of age) in a community sample of formerly depressed adolescents. METHOD: A total of 274 participants with adolescent-onset major depressive disorder were assessed twice during adolescence and again after their 24th birthday. Lifetime psychiatric information was obtained from their first-degree relatives. Adolescent predictor variables included demographic characteristics, psychosocial variables, characteristics of adolescent major depressive disorder, comorbidity, family history of major depressive disorder and nonmood disorder, and antisocial and borderline personality disorder symptoms. RESULTS: Low levels of excessive emotional reliance, a single episode of major depressive disorder in adolescence, low proportion of family members with recurrent major depressive disorder, low levels of antisocial and borderline personality disorder symptoms, and a positive attributional style (males only) independently predicted which formerly depressed adolescents would remain free of future psychopathology. Female gender, multiple major depressive disorder episodes in adolescence, higher proportion of family members with recurrent major depressive disorder, elevated borderline personality disorder symptoms, and conflict with parents (females only) independently predicted recurrent major depressive disorder. Comorbid anxiety and substance use disorders in adolescence and elevated antisocial personality disorder symptoms independently distinguished adolescents who developed recurrent major depressive disorder comorbid with nonmood disorder from those who developed pure major depressive disorder. CONCLUSIONS: Formerly depressed adolescents with the risk factors identified in this study are at elevated risk for recurrence of major depressive disorder during young adulthood and therefore warrant continued monitoring and preventive or prophylactic treatment.     

The validity of the dexamethasone suppression test as a marker for endogenous depression

The validity of the dexamethasone suppression test (DST) as an indicator of endogenous depression has been most frequently tested by examining its relationship to operational criteria of endogenous depression. However, these criteria sets themselves have not been empirically validated. We examined the DST in terms of a series of hypotheses and predictions that are consistent with the theoretical construct of endogenous depression. In a consecutively admitted sample of 187 primary unipolar depressed inpatients, the DST nonsuppressors were older, had less premobid personality disorder, better social support, less frequent marital separations or divorces, fewer nonindependent stressful life events during the year prior to admission, made fewer nonserious suicide attempts during the index episode, had fewer dysfunctional attitudes, and had a lower rate of treated alcoholism and antisocial personality in their first-degree relatives. The only clearly negative finding was the lack of association between DST results and family history of depression. Our results strongly support the construct validity of the DST as a marker of endogenous depression.     

Psychiatric disorders in relatives of probands with opiate addiction

Previous research has documented high rates of major depression and antisocial personality in opiate addicts. This study was designed to investigate the relationship of dual diagnosis in opiate-addicted probands to family history of psychiatric disorders and substance use disorders in biological relatives. Psychiatric disorders and substance use disorders were evaluated using direct interview and family history in a sample of 877 first-degree relatives of 201 opiate addicts and 360 relatives of 82 normal controls. Results indicate that (1) compared with relatives of normal subjects, opiate addicts' relatives had substantially higher rates of alcoholism, drug abuse, depression, and antisocial personality; (2) relatives of depressed opiate-addicted probands had elevated rates of major depression and anxiety disorders but not of other disorders, suggesting the validity of subtyping opiate addicts by the presence or absence of major depression; and (3) in contrast, relatives of antisocial opiate addicts had rates of disorders that were not significantly different from those of relatives of opiate addicts without antisocial personality. Implications of these findings for the classification and treatment of substance abuse are discussed.     

Affective disturbance in eating disorders

Thirty-three bulimic and 14 restrictive anorexics were compared on DSM-III diagnoses of affective and anxiety disorders, observer-rated and self-rated measures of depression and anxiety, and family history. A subgroup of 18 eating disorder subjects was administered the dexamethasone suppression test. The same 18 subjects were compared to 13 subjects with affective disorder on the Schedule for Affective Disorders and Schizophrenia. It was found that a large group with bulimia and restrictive anorexia nervosa was subject to a depressive disorder. Thirty-eight percent of the sample fulfilled criteria for a major depressive episode. The dysphoric experience seemed as intense in the bulimic and restricter group. There was a high incidence of dexamethasone nonsuppression (55%), which was found to be related to various measures of depression. Bulimics and restricters differed in their family history of affective disorder. While 61% of bulimics had a positive history of depression, this was found in only 23% of restricters (p less than .03).     

Psychiatric disorders in the first-degree relatives of probands with bulimia nervosa

Data from a family study of psychiatric disorders showed higher rates of major affective disorders, eating disorders, and alcoholism in first-degree relatives of 40 bulimic probands than in first-degree relatives of 24 control subjects. More importantly, the data showed higher rates of major affective disorders in relatives of bulimic probands who themselves had no history of major affective disorders than in relatives of control subjects. This significant finding indicates a familial relationship between bulimia nervosa and major affective disorders, which suggests the possibility of a common diathesis.     

Diagnostic subgroups of antisocial alcoholics: outcome at 1 year

Of 233 alcoholics initially evaluated and subdivided into groups with an additional diagnosis of antisocial personality disorder (ASP) only (N = 38), ASP plus drug abuse (N = 30), ASP plus major depressive disorder (N = 18), and those with no additional diagnosis (N = 147), 205 were followed up 1 year later. The ASP plus drug group, although younger and having fewer years of alcoholism, did worse in the 1-year follow-up on many indicators of alcoholism severity compared with the other antisocial groups and the alcoholism only group. The ASP plus depressed group demonstrated marked improvement on measures of psychopathology and alcoholism severity over the course of 1 year such that they were comparable on these measures at 1-year follow-up to the other antisocial groups. These findings may indicate that the ASP/drug alcoholic has a poor long-term prognosis compared with the ASP only alcoholic, while the ASP/depressed patient has a disorder comparable in prognosis to the ASP only alcoholic.     

Dexamethasone suppression test in hospitalized depressed patients with borderline personality disorder

There is considerable disagreement about the relationship between borderline personality disorder and the affective disorders. The authors report the results of a study of the relationship between dexamethasone suppression and depressive subtype in hospitalized depressed borderline patients. Twenty-three patients met research criteria for unipolar major depressive episode without psychosis of at least moderate severity. Thirteen patients also met criteria for borderline personality disorder. Dexamethasone suppression test (DST) results showed no significant correlation with either melancholia or borderline personality disorder alone. However, of the 13 borderlines, eight failed to suppress and six of those eight were not melancholic. The authors conclude that abnormal response to dexamethasone in nonmelancholic borderlines casts some doubt on the specificity of the DST for melancholia.     

The dexamethasone suppression test in bulimia before and after successful treatment with desipramine

Recent reports have suggested that normal-weight bulimic patients without clinical evidence of major depressive disorder will have an abnormal response to dexamethasone. Of 23 normal-weight bulimic patients without clinical evidence of major depressive disorder, 11 had abnormal results on their dexamethasone suppression tests (DSTs). This finding closely matches those of other reports. After successful treatment with desipramine, repeat DSTs showed conversion to normal suppression in 6 of the 7 patients tested. Pretreatment DST results failed to predict the response to medication. The striking similarity of these findings to those reported in patients with major depression suggests that bulimia may be a consequence or an equivalent of major affective disorder.     

Affective Disorders in Alcoholism

The author examined affeotive disorders and other related symptoms (atypical chronic depressive state, suicide and self-destructive behavior) in 141 male alcoholics to evaluate the relationship between alcoholism and affective disorders. The results were: five cases (3.5%) with primary affective disorder (2 with circular type, 1 with depressed type and 2 with involutional melancholia), nine with atypical chronic depression (4 with depressive neurosis and 5 with depressive paranoid reaction), one with successful suicide and three with prominent self-destructive behavior on excessive drinking. The incidence of primary affective disorder in alcoholism approximates to 2 to 4 percent in Japan, and is a little lower than that of U.S.A or of Europe. A characteristic of the clinic for alcoholism was the frequent presentation of atypical or chronic depression. This was usually diagnosed as depressive neurosis or depressive personality disorder, and some developed to a transient paranoid state with excessive drinking. The rate of suicide in alcoholism seems to be lower in Japan than in Western countries: approximately a few percent in a few years in this country and 7 to 8 percent in Western countries. Those cases with prominent self-destructive behavior were young alcoholics. They had underlying personality disorders and complicated life histories.     

The caregiving environments provided to children by depressed mothers with or without an antisocial history

OBJECTIVE: Many depressed women have a history of antisocial behavior, but research into maternal depression has not ascertained if this has implications for children of depressed mothers. This study compared the developmental outcomes in and caregiving environments provided to children by depressed mothers with or without an antisocial history. METHOD: In the Environmental Risk Longitudinal Twin Study, a nationally representative study of 1,106 families, mothers were administered the Diagnostic Interview Schedule for Major Depressive Disorder and interviewed about their lifetime history of antisocial personality disorder symptoms. Mothers and teachers provided information regarding the children's behavior problems at 5 and 7 years of age. The authors assessed the quality of the caregiving environment through maternal reports and interviewer observations. RESULTS: Compared with children of mothers with depression only, the children of depressed and antisocial mothers had significantly higher levels of antisocial behavior and rates of DSM-IV conduct disorder, even after the authors controlled for numbers of symptoms and chronicity of maternal major depressive disorder. The children of depressed and antisocial mothers were at an elevated risk of experiencing multiple caregiving abuses, including physical maltreatment, high levels of maternal hostility, and exposure to domestic violence. CONCLUSIONS: If one ignores the common co-occurrence of an antisocial history in depressed mothers, it may obscure the significantly elevated risks in children's development. Clinicians treating women's depression should be aware that children of depressed and antisocial mothers constitute a group at extremely high risk for early-onset psychopathology.     

Suicidal behavior in bipolar manic-depressive patients and their families

There is a high risk of suicidal behavior in patients with primary affective disorder. An extensive investigation in patients with primary affective disorder reported attempted suicide in 26% of bipolar patients and 21% of unipolar patients, the highest rate occurring in female bipolar patients.¹ Woodruff et al.²⁰ found attempted suicide in 14% of unipolar patients as against 32% of bipolar patients with the highest rate in male bipolar patients. Winokur¹⁸ in a study of bipolar manic depressive patients found that 25% of patients had made at least one suicidal attempt and 70% had made threats of suicide at least some time in their lives. Venkabo Rao¹⁶ reported that suicidal ideas occurred in 75% of patients with recurrent affective disorder.Family studies have also reported a high incidence of suicide in the relatives of patients with affective disorder.⁸Mendlewicz et al.⁷ studying a matched group of bipolar probands with and without a family history of manic depressive illness, found high rates of suicide in first and second degree relatives but there was no significant difference in relation to sex or family history. The diagnosis of the relative that suicided was not stated. A study of relatives of patients with primary affective disorder¹⁰ reported that 79% of the suicides in first degree relatives were associated with a diagnosis of probable affective disorder and 10% by a diagnosis of probable alcoholism in the relative. Fathers in index cases were more likely to have committed suicide than mothers. A family history of suicide is considered a major risk factor in assessment of potentially suicidal patients,¹³ however, the relationship between attempted suicide in patients and suicide or attempted suicide in relatives has received little attention and the nature and predictability of this association is uncertain.The following report concerns an analysis of suicidal behavior in a population of bipolar manic-depressive patients and the relationship of this attempt to suicide or attempted suicide in their first and second degree relatives.     

The dexamethasone suppression and thyrotropin-releasing hormone tests in depressed borderline patients

Borderline patients can be both a diagnostic and a therapeutic enigma. We investigated a group of 24 depressed women with borderline personality disorder or strong borderline features by DSM III criteria for the presence of either an abnormal dexamethasone suppression test (DST) or a blunted TSH response to TRH, abnormalities which have been reported in major depression. Thirteen of the 24 borderlines failed to suppress on the DST, compared with one of 14 normal women (p < 0.01). Nine of the 24 borderlines had a blunted TSH response to TRH, compared with one of 11 normal women. Neuroendocrine abnormalities were found in a total of 75% of the borderline women, independent of whether or not they met DSM III criteria for major depressive disorder. The results of this study support the notion that many borderline patients with depression have a genuine affective component to their illness, perhaps biologically similar to major depression in non-borderlines.     

Psychiatric diagnoses of treatment-seeking cocaine abusers

In a sample of 298 cocaine abusers seeking inpatient (n = 149) or outpatient (n = 149) treatment, rates of psychiatric disorders were determined by means of the Schedule for Affective Disorders and Research Diagnostic Criteria. Overall, 55.7% met current and 73.5% met lifetime criteria for a psychiatric disorder other than a substance use disorder. In common with previous reports from clinical samples of cocaine abusers, these overall rates were largely accounted for by major depression, minor bipolar conditions (eg, hypomania, cyclothymic personality), anxiety disorders, antisocial personality, and history of childhood attention deficit disorder. Affective disorders and alcoholism usually followed the onset of drug abuse, while anxiety disorders, antisocial personality, and attention deficit disorder typically preceded drug abuse.     

Monoamine metabolites in cerebrospinal fluid of depressive subgroups

Lumbar punctures were performed on 69 patients who met Research Diagnostic Criteria (RDC) for major affective disorder, while they were drug-free and depressed. None of the patients met RDC for alcoholism. Cerebrospinal fluid 5-hydroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) were measured by fluorometry and 3-methoxy-4-hydroxyphenylglycol (MHPG) by gas chromatography. Family histories were ascertained by systematic interviews of patients and their relatives, and diagnoses were made by family history diagnostic criteria (Andreasen et al., 1977). Depressed patients with alcoholism in a first degree relative had significantly lower levels of 5-HIAA and MHPG than patients without a family history of alcoholism (p < 0.05). No difference in HVA levels was found. The metabolite differences remained significant when the influence of sex ratio was considered. These results are in agreement with previous work linking alcoholism to abnormal serotonin metabolism. They provide further biochemical evidence of distinct genetic subtypes of affective disorder along lines suggested by Winokur (1979a, 1979b), and illustrate the usefulness of the family history method in defining patient subgroups.     

The clinical implications of primary diagnostic groups among alcoholics

Interviews with patients and two resource persons were used to determine primary psychiatric diagnoses in 577 consecutive men entering an alcohol treatment program (ATP) at a veterans hospital. Twelve months later, about 95% of the sample were successfully followed up with a patient and resource person interview to establish the clinical course over the year for the four most populous diagnostic subgroups. At intake into the treatment program, the 432 group 1 primary alcoholic men were older, had a later age at onset of alcoholism, demonstrated a lower intensity of drinking, had fewer antisocial problems, and used fewer categories of drugs than the 60 men in group 2 with primary drug abuse and the 40 men in group 3 with primary antisocial personality disorder. During the follow-up, men in groups 2 and 3 had a greater likelihood of drug use, more police and social problems, and demonstrated higher (more adverse) outcomes on a clinical outcome scale. The nine group 4 men with primary affective disorder at intake demonstrated an increased risk for past suicide attempts and psychiatric care and had a higher rate of affective disorder in first-degree family members. These findings underscore the importance of distinguishing between symptoms (eg, sadness or antisocial problems) and diagnoses and the need to establish primary and secondary labels in substance abusers.     

The relationship between risk factors for affective disorder and poststroke depression in hospitalised stroke patients.

The influence of psychiatric risk factors on the development of depression following stroke was examined in 88 patients undergoing inpatient rehabilitation. In this sample, 34 patients (38%) had a diagnosis of major or minor depression. Older age and a personal or family history of affective or anxiety disorder were associated significantly with major depression. Minor depression was more common among males and those patients with greater physical disability. Severity of depressive symptoms was associated with a personal or family history of affective or anxiety disorder and higher pre-stroke personality neuroticism. We conclude that certain psychiatric risk factors for affective disorder are strongly associated with poststroke depression. The implications of these findings for anticipating and managing poststroke depression are discussed.     

Dexamethasone suppression in depressed elderly outpatients

The dexamethasone suppression test (DST) was performed as part of the preliminary workup in 85 previously untreated outpatients with major affective disorder, unipolar depressive type, who were over age 60. All patients were given a systematic structured interview (NIMH-DIS), and all had scores over 20 on the 21-item Hamilton Depression Rating Scale (HAM-D). Only 12 patients (14%) had positive DSTs; more of the non-melancholic (6 of 25; 24%) than melancholic (6 of 60; 10%) patients failed to suppress serum cortisol following standard dexamethasone challenge (p less than .10). DST results did not correlate with patients' HAM-D or Zung depression scores, gender, response to treatment, or any other variable studied. These findings suggest that, in comparison to previous reports, a positive DST may be 1) less common in major depressive disorders, 2) no more common in more severely depressed patients, and 3) less relevant to indications for specific treatment.     

A controlled family history study of prepubertal major depressive disorder

First-degree (N = 195) and second-degree (N = 785) adult relatives of prepubertal children with major depression (N = 48), children with nonaffective psychiatric disorders (N = 20), and normal children (N = 27) were assessed by the Family History-Research Diagnostic Criteria method (FH-RDC), except for the adult informant (usually the mother), who was directly interviewed. Compared with normal controls, prepubertal children with major depressive disorder (MDD) had significantly higher familial rates of psychiatric disorders in both first- and second-degree relatives, especially MDD, alcoholism, and "other" (mostly anxiety) diagnoses. Relatives of children in the nonaffective psychiatric control (PC) group had low rates of alcoholism, high rates of other (anxiety) disorder diagnoses, and intermediate rates of MDD (accounted for by those children with separation anxiety). This suggests that prepubertal onset of major depression may be especially likely in families with a high aggregation of affective disorders when these families also have a high prevalence of alcoholism, and that a proportion of children without affective disorder but with separation anxiety disorder in this study were at high risk for the development of affective illness later in life. These results support the validity of prepubertal-onset depressive illness as a diagnostic category, and are consistent with high familial rates of MDD and other psychiatric disorders found in family studies of adolescent and early-onset adult probands with major affective disorders, and with studies of the offspring of parents with major affective disorders. Within the child MDD group substantial heterogeneity was found. Low familial rates of MDD were associated with suicidality and comorbid conduct disorder in the child probands. The highest familial rates of MDD, approximately threefold those in the normal controls, and all the bipolar relatives, were found in the families of prepubertal probands with MDD who never had a concrete suicidal plan or act and who were without comorbid conduct disorder. A useful nosological continuum in which to classify prepubertal MDD may be to place at one end those patients with comorbid conduct disorder and at the other end those patients with manifestations related to bipolarity, including hypomania, mania, and psychotic subtype.     

Depressive disorders in children and adolescents

Depressive disorders in children and adolescents are valid clinical entities which can be identified using adult diagnostic criteria. Recent research has resulted in significant progress in the areas of diagnosis, epidemiology, family pathology, pharmacokinetics and psychopharmacology. Many rating instruments have been developed to screen, diagnose and measure changes of depression in children and adolescents. The prevalence of depressive disorders in prepubertal children is about 2% and in adolescents about 5%. Depressive episodes are usually of long duration, with high rates of relapse. These relapses are usually associated with school, family and social failure. Follow-up studies of depressed adolescents indicated that about half of the patients continue to suffer from mood disturbances and psycho-social adaptational problems. In North America suicidal behaviour in adolescents has increased 300% in the past 30 years. However, its relationship to depression is more complex than in adults. There is a significant excess of affective illness and alcoholism in the families of depressed adolescents. Similarly, there is a high rate of impairment among children of parents with affective disorders. During depressive episodes, prepubertal children show abnormalities of growth hormone and cortisol secretion. However, DST findings are contradictory. Polysomnographic findings in childhood depression appear unremarkable. In adolescent depression these findings are similar to those in depressed adults. Biological manifestations of depressive disorders may be significantly affected by developmental and hormonal changes. Antidepressants have been effective in the therapy of several disorders in childhood. These include enuresis, school phobias, attention deficit, conduct disorders and obsessive-compulsive disorders. Open drug studies suggest that antidepressants are useful in depressed children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Personality disorder in the families of depressed, schizophrenic, and never-ill probands

In a blind family study of 176 probands with nonpsychotic major depression, psychotic major depression, schizophrenia, or no history of DSM-III disorders, only the relatives of depressed probands with mood-incongruent psychotic features had a risk for personality disorders higher than that for the relatives of never-ill probands. The authors did not find a high rate of borderline personality in relatives of depressed probands or of schizotypal personality disorder in relatives of probands with schizophrenia or any psychosis. However, depressed probands with normal dexamethasone test results had a significantly higher familial loading for the DSM-III cluster of histrionic, antisocial, borderline, and narcissistic personality disorders.