The dual factor structure of self-rated MDQ hypomania: energized-activity versus irritable-thought racing

BACKGROUND: Bipolar II is diagnosed in a clinically depressed patient by documenting history of hypomania. Therefore, it is of great significance for both clinical and research purposes to characterize the factor structure of hypomania. METHODS: Among consecutive depressive outpatients-126 major depressives and 187 bipolar II-diagnosed by the Structured Clinical Interview for DSM-IV (Clinician Version), 181 who had clinically recovered from depression were administered the Mood Disorder Questionnaire (MDQ of. Am. J. Psychiatry 157, 1873). The MDQ is a newly developed, psychometrically validated self-report screening instrument for bipolar spectrum disorders. It screens for lifetime history of manic/hypomanic symptoms by including yes/no items covering all DSM-IV symptoms of mania/hypomania. The MDQ symptom interrelationships were studied by principal component analysis with varimax rotation. RESULTS: Hypomanic symptoms occurring in >50% were racing thoughts, increased energy and social activity, and irritability. Factor analysis revealed two factors: 'Energized-Activity' (eigenvalue=3.1) and 'Irritability-Racing Thoughts' (eigenvalue=1.5). LIMITATIONS: Cross-sectional assessment. CONCLUSIONS: Self-assessment of past hypomanic symptoms by patients, during clinical remission from depression, revealed two independent hypomanic factors, neither of which comprised euphoria. Hypomanic behavior appears to be more fundamental for the diagnosis of hypomania than elated mood accorded priority in DSM-IV; of hypomanic moods, irritability had greater significance than elation. It would appear that self-report of euphoria is less likely when hypomanias are brief (>or=2 vs. >or=4 days). The main implication for busy clinical practice is that energized activity and irritable mood associated with racing thoughts represent the modal experiences of hypomania among bipolar II outpatients; euphoria is neither sensitive, nor pathognomonic, in the diagnosis of these patients. These conclusions accord with recommendations made many years ago for the diagnosis of hypomania among cyclothymic patients [. Am. J. Psychiatry 134, 1227].     

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

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

BPRS Syndrome scales during the course of an episode of psychiatric illness

This report examines changes in symptom levels on the four major syndrome scales from the Brief Psychiatric Rating Scale (BPRS): thought disturbance, paranoid disturbance, anxiety/depression, and emotional withdrawal/motor retardation. Baseline BPRS ratings were obtained during the first week of hospitalization for an acute episode of psychiatric illness, in 120 patients with schizophrenia, schizoaffective disorder, and depression. BPRS ratings were carried out in the week prior to discharge. Findings indicated that patients with schizoaffective disorder showed a greater magnitude of general clinical improvement than schizophrenics, although both groups had comparable improvement on thought disorder from admission to discharge. Paranoid symptoms did not recover as completely among schizophrenics compared to schizoaffective disorder patients. As expected, anxiety and depression symptoms remitted most prominently among the depressed inpatients. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53 : 455–458, 1997.     

Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy

BACKGROUND: The nosologic status of agitated depression is unresolved. Are they unipolar (UP) or bipolar (BP)? Are they mixed states? Even more controversial is the notion that antidepressants might play some role in the suicidality of such patients (Akiskal and Mallya, 1987) [Akiskal, H.S., Mallya, G., 1987. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol Bull. 23, 68-73]. METHODS: After excluding all patients with history of hypomanic episodes occurring outside the frame of a major depressive episode (MDE), even those with a shorter duration of hypomanic symptoms than stipulated in DSM-IV, the remaining consecutive 254 unipolar major depressive disorder (MDD) private adult (> 21 years old) outpatients were interviewed (off psychoactive drugs for 2 weeks) with the Structured Clinical Interview for DSM-IV (SCID-CV), the Hypomania Interview Guide (HIGH-C), and the Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed, with > or = 3 such symptoms required for a diagnosis of depressive mixed state (DMX). Agitated depression was defined as an MDE with HIGH-C psychomotor agitation score > or = 2. Logistic regression was used to study associations and control for confounding variables. RESULTS: In this strictly defined unipolar sample, agitated depression was present in 19.7%. Compared with its non-agitated counterpart, it had significantly fewer recurrences, less chronicity, higher rate of family history for bipolar disorder, and DMX; and, among the intra-depressive non-euphoric hypomanic symptoms (in decreasing order of frequency), distractibility, racing/crowded thoughts, irritable mood, talkativeness, and risky behavior. The most striking finding was the robust association between agitated depression and DMX (OR = 36.9). Furthermore, patients with psychomotor agitation had significantly higher rate of weight loss and suicidal ideation. Of DMX symptoms, we found an association between suicidal ideation, psychomotor activation, and racing thoughts. Agitated depression was tested by forward stepwise logistic regression versus all variables significantly different in the pairwise comparisons, yielding DMX, talkativeness, and suicidal ideation as the independent significant positive predictors. LIMITATIONS: No suicidal ideation scale was used. CONCLUSIONS: Agitated depression emerges as a distinct affective syndrome with weight loss, pressure of speech, racing thoughts and suicidal ideation. Psychomotor activation and racing thoughts during MDD independently predicted suicidal ideation. In this "unipolar" MDD sample, agitated depression had a strong clustering of intra-episode non-euphoric hypomanic symptoms (i.e. DMX) which, coupled with its association with bipolar family history, support its link with the bipolar spectrum. Agitated depression is therefore best regarded as "pseudo-unipolar." These findings overall accord with classical German concepts of agitated depression as a mixed state. Given that these patients are typically activated along the lines of risk-taking behavior, Kraepelin's rubric of "excited (mixed) depression" appears to us the preferred terminology over "agitated depression". CLINICAL IMPLICATIONS: The data reported herein, placed in the setting of the literature reviewed in the discussion suggest that the reports of increased risk of suicidal ideation and/or behavior in some depressed patients treated by antidepressant monotherapy or combinations thereof might be attributed to baseline psychomotor activation/agitation as part of an unrecognized bipolar mixed state. Whether antidepressants induce de novo suicidality in MDD cannot be answered without adequately powered prospective double-blind studies, unlikely to be conducted because of ethical constraints. Nonetheless, we submit that agitated, activated, or otherwise excited depressions (which we consider as depressive mixed states) overlap considerably with the so-called antidepressant "activation syndrome." Furthermore, the rare occurrence of suicidality on antidepressants should not obscure the fact that the advent of the new antidepressants is associated with worldwide decline in suicide rates. We finally wish to point out that our formal nosology (i.e. DSM-IV and ICD-10), in its failure to recognize the bipolar nature of depressive mixed states, thereby fails to shield pseudo-unipolar patients from antidepressant monotherapy, which is inappropriate for such patients.     

Atypical depression with hypomanic symptoms

BACKGROUND: Depressive mixed states (major depressive episodes with some hypomanic symptoms) (DMS) are not classified in DSM-IV and are understudied. The aims of this study were to find the prevalence and clinical features of DMS in atypical depression. METHODS: A total of 87 bipolar II and unipolar depressed outpatients were interviewed within the DSM-IV Structured Clinical Interview. RESULTS: More than two hypomanic symptoms were present in 50.0% of the atypical and 20.3% of the non-atypical depression cases (P=0.006). DMS mainly included irritable mood, distractibility, racing thoughts, and increased talking. LIMITATIONS: There was a single interviewer, and it was a non-blind, cross-sectional assessment, with bipolar II reliability. CONCLUSIONS: Findings have treatment implications, as antidepressants may worsen DMS, and mood stabilizers may improve it.     

Recognizing increased risk of depressive comorbidity after myocardial infarction: looking for 4 symptoms of anxiety-depression

BACKGROUND: Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression. METHODS: One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD(4)) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness). RESULTS: Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD(4), alpha = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD(4)>or=3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6-12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0-42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0-27.6, p < 0.0001). CONCLUSIONS: Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD(4) represents an easy way to recognize the increased risk of post-MI depression.     

Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression

STUDY OBJECTIVES: To examine sleep disturbance (insomnia and hypersomnia) and associated clinical profiles among depressed children and adolescents in terms of illness history, depressive severity, depressive phenomenology, and psychiatric comorbid disorders. DESIGN: Clinical profiles from standardized clinical evaluations were compared. SETTING: Twenty-three mental health facilities in Hungary between April 2000 and December 2004. PATIENTS AND MEASUREMENTS: Five hundred fifty-three children with a current episode of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder: 55% were boys, mean age was 11.7 years (SD = 2.0, range = 7.3-14.9), and 94% were Caucasian. Sleep and depressive symptoms were assessed with the Interview Schedule for Children and Adolescents-Diagnostic Version. INTERVENTIONS: N/A. RESULTS: Of the total sample, 72.7% had sleep disturbance: 53.5% had insomnia alone, 9.0% had hypersomnia alone, and 10.1% had both disturbances. Depressed girls were more likely to have sleep disturbance than boys (77.0% vs 69.2%, p < .05), but age had no significant effects. Compared with children without sleep disturbance, sleep-disturbed children were more severely depressed and had more depressive symptoms and comorbid anxiety disorders. Across sleep-disturbed children, those with both insomnia and hypersomnia had a longer history of illness, were more severely depressed, and were more likely to have anhedonia, weight loss, psychomotor retardation, and fatigue than were those with either insomnia or hypersomnia. CONCLUSION: Clinical profiles differ between depressed children without and with sleep disturbance, with those presenting insomnia plus hypersomnia being most severely depressed. Differentiating depressed children with different sleep disturbances may have important implications for research efforts on the etiology and therapeutics of child depression.     

Is there a continuity between bipolar and depressive disorders?

BACKGROUND: Recent studies questioned the current categorical split of mood disorders into bipolar disorders (BP) and depressive disorders (MDD). METHODS: Medline database search of papers from the last 10 years on the categorical-dimensional classification of mood disorders. Various combinations of the following key words were used: mood disorders, bipolar, unipolar, major depressive disorder, spectrum, category/categorical, classification, continuity. Only English language clinical papers were included, review papers were excluded, similar papers selected by quality. The number of papers found was 1,141. The number of papers selected was 109. RESULTS: The continuity/spectrum between BP (mainly BP-II) and MDD was supported by the following findings:(1) high frequency of mixed states (mixed mania, mixed hypomania, mixed depression, i.e. co-occurring depression and noneuphoric manic/hypomanic symptoms) because opposite polarity symptoms in the same episode do not support a hypomania/mania-depression splitting; (2) MDD was the most common mood disorder in BP probands' relatives; (3) no bimodal distribution of distinguishing symptoms between BP and MDD; (4) bipolar signs not uncommon in MDD; (5) many MDD shifting to BP; (6) many lifetime manic/hypomanic symptoms in MDD; (7) correlation between lifetime manic/hypomanic symptoms and MDD symptoms; (8) hypomania factors in MDD; (9) MDD often recurrent; (10) similar cognitive style.The categorical distinction between BP (mainly BP-I) and MDD was supported by the following findings: (1) BP more common in BP probands' relatives; (2) lower age at BP onset; (3) females as common as males in BP-I, more common than males in MDD; (4) BP-I depression more atypical and retarded, MDD depression more sleepless and agitated; (5) BP more recurrent. CONCLUSIONS: Focusing on mood spectrum's extremes (BP-I vs. MDD), a categorical distinction seems supported. Focusing on midway disorders (BP-II and MDD plus bipolar signs), a continuity/spectrum seems supported. Results seem to support both a categorical and a dimensional view of mood disorders.     

Immunity and depression: Insomnia,Retardation, and reduction of natural killer cell activity

Depressed patients show a reduction of natural killer (NK) cell activity which may be associated with specific depressive symptoms. The present study demonstrated that sleep disturbance and retardation, but not other depressive symptoms, were negatively correlated with NK activity in 38 depressed patients. Specific behavioral changes in depression such as sleep disturbance and retardation were found to predict 16% of the variance of cytotoxicity levels in depression.     

Self-reported data from patients with bipolar disorder: frequency of brief depression

OBJECTIVE: Patients with bipolar disorder often report depressive symptoms that do not meet the DSM-IV criteria for an episode. Using daily self-reported mood ratings, we studied how changing the length requirement to that typical of recurrent brief depression (2-4 days) would impact the number of depressed episodes. METHOD: 203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software on a home computer (30,348 total days; mean 150 days). Episodes of depression and days of depression outside of episodes were determined. Symptom intensity (mild versus moderate or severe) was investigated within and outside of depressive episodes. RESULTS: Decreasing the minimum duration criterion for an episode of depression to 2 days increased the number of patients with a depressed episode two and a half times (52 to 131), and quadrupled both the number of depressed episodes per patient (0.62 to 2.88) and the number of depressed episodes for all patients (125 to 584). With a 2-day episode length, 34% of days of depression remained outside an episode. The ratio of days with severe symptoms within episodes remained consistent (about 25%) in spite of decreasing the episode length to 2 days. Considering only days with severe symptoms, about 25% remained outside of episodes even with a 2-day length. None of the results distinguished bipolar I from bipolar II disorder. LIMITATIONS: Self-reported data, computer access required, relatively short study length, no control group. CONCLUSION: Brief depressive episodes and single days of depression outside of episodes occur frequently in both bipolar I and bipolar II disorder. Moderate or severe symptoms occur during brief episodes at a ratio similar to that for episodes that meet the DSM-IV criteria.     

Emotional Awareness: A Transdiagnostic Predictor of Depression and Anxiety for Children and Adolescents

Research increasingly suggests that low emotional awareness may be associated with symptoms of depression and anxiety among children and adolescents. However, because most studies have been cross-sectional, it has remained unclear whether low emotional awareness predicts subsequent internalizing symptoms. The current study used longitudinal data to examine the role of emotional awareness as a transdiagnostic predictor of subsequent symptoms of depression and anxiety. Participants were 204 youth (86 boys and 118 girls) ages 7–16 who completed self-report measures of emotional awareness, depressive symptoms, and anxiety symptoms at baseline, as well as measures of depression and anxiety symptoms every 3 months for a year. Results from hierarchical mixed effects modeling indicated that low baseline emotional awareness predicted both depressive and anxiety symptoms across a 1-year period. These findings suggest that emotional awareness may constitute a transdiagnostic factor, predicting symptoms of both depression and anxiety, and that emotional awareness training may be a beneficial component of treatment and prevention programs for youth depression and anxiety.     

Clinical characterization of depressive mixed state in bipolar-I patients: Pisa-San Diego collaboration

BACKGROUND: Although mixed states were classically described as various concomitant admixtures of depression and mania, the official current definitions in both DSM-IV and ICD-10 tend to restrict the concept to manic patients with full syndromal depression. Recent research has actually shown that mania with few depressive symptoms constitutes the most prevalent clinical presentation of mixed or dysphoric mania. Major depressive patients with few concomitant manic symptoms are not officially recognized within the current nosology. In this paper we attempt to delineate the clinical profile of such depressive mixed states in the context of bipolar I disorder. METHODS: In the Pisa day center, we studied 195 bipolar I patients who either met Pisa criteria for bipolar mixed state (n=159) or DSM-III-R criteria for major depressive episode (bipolar major depression or B-MD, n=36). Of the 159 patients identified by Pisa criteria as mixed state, 86 also met the criteria of the DSM-III-R for mixed episode (core mixed state or MS group), while 32 met the DSM III-R criteria for major depressive episode (provisionally defined as depressive mixed states, D-MS); the remaining patients (n=41, 25.7%) with predominatly manic picture were not included in the present comparisons. RESULTS: The three groups (B-MD, MS and D-MS) had close similarities in clinical and sociodemographic characteristics such as age, sex distribution, marital status, schooling, residence, age at onset, age of first treatment, age of first hospitalization, degree of chronicity of the index episode, stressor within the 6 months before the index episode, lifetime suicide attempts and premorbid temperament. First degree family history for bipolar illness and that for other mental disorders was also similar, except for major depression that was more common among the relatives of D-MS. MS and D-MS were further distinguished from B-MD by the fact that the latter followed a more 'cyclic' course with shorter yet greater number of episodes, and which began with a pure depressive episode; by contrast, MS and D-MS had fewer episodes of longer duration, less interepisodic remission, and tended to begin with a mixed episode. Incongruous psychotic features were more common in the two mixed groups compared to B-MD, and the most common features of the D-MS group were agitation, psychotic depression with irritable mood, pressured speech and/or flight of ideas. LIMITATION: It was not feasible to collect information blind to clinical status in patients with severe psychotic mood states. CONCLUSION: These data confirm the existence of psychotic agitated depressive mixed states with flight of ideas, distinct from cyclic retarded pure bipolar depressive states. The recognition of these affective states is clinically important to protect patients from the potentially harmful indiscriminate use of antidepressants and to provide them with the benefits of an anticonvulsant, a short-term neuroleptic, or ECT.     

Psychological status at the menopausal transition: an Italian epidemiological study

OBJECTIVES: To provide epidemiological data about psychological symptoms derived from a large Italian non-clinical sample, and to investigate the correlation with psychosocial factors. METHODS: The study design was a cross-sectional postal survey of a sample of menopausal women recruited from the General Registry Office in Ferrara's province. Four thousands and seventy-three women were sent a questionnaire designed on the basis of the Women Health Questionnaire (WHQ). Together with the WHQ, women were asked to fill out a personal file to define social status, cultural level, family's characteristics, recent menstrual cycles, gynaecological history and operations, drug's assumption, life events in the last year and lifetime depression. RESULTS: Factor analysis resulted in eight clusters of symptoms. Among psychiatric symptoms, three different clusters were identified: depressive symptoms, depressed mood with anxiety symptoms, and anxiety. The cluster "depressive symptoms" was more evident in the postmenopausal period with respect to the premenopausal one. CONCLUSION: The cluster "depressive symptoms" is significantly different in the premenopausal group with respect to the postmenopausal group, with greater levels of symptomatology in the postmenopausal group. On the contrary, the factor "depressed mood with anxiety symptoms" is present to the same extent in the pre-, peri- and postmenopausal groups. Prior depression is the most predictive variable of subsequent depression in postmenopausal women. Factors related to more pronounced depressive symptoms are number of life events, postmenopausal status, place of residence in rural areas and lower cultural level.     

Delineating bipolar II mixed states in the Ravenna-San Diego collaborative study: the relative prevalence and diagnostic significance of hypomanic features during major depressive episodes

BACKGROUND: Depressive mixed state (DMX), defined by hypomanic features during a major depressive episode (MDE) is under-researched. Accordingly, study aims were to find DMX prevalence in unipolar major depressive disorder (MDD) and bipolar II depressive phase, to delineate the most common hypomanic signs and symptoms during DMX, and to assess their sensitivity and specificity for the diagnosis of DMX and bipolar II. METHODS: 161 unipolar and bipolar II MDE psychotropic drug- and substance-free consecutive outpatients were interviewed during an MDE with the Structured Clinical Interview for DSM-IV. DMX was defined at two threshold levels as an MDE with two or more (DMX2), and with three or more (DMX3) simultaneous intra-episode hypomanic signs and symptoms. RESULTS: DMX2 was present in 73.1% of bipolar II, and in 42.1% of unipolar MDD (P<0.000); DMX3 was present in 46.3% of bipolar II, and in 7.8% of unipolar MDD (P<0.000). The most common hypomanic manifestations during MDE were irritability, distractibility, and racing thoughts. Irritability had the best combination of sensitivity and specificity for the diagnosis of DMX2 and DMX3. Various combinations of irritability, distractibility, and racing thoughts correctly classified the highest number of DMX2 and DMX3, and had the strongest predictive power. DMX2 had high sensitivity and low specificity for bipolar II, whereas DMX3 had low sensitivity (46.3%) and high specificity (92.1%). LIMITATIONS: Single interviewer, cross-sectional assessment, and interviewing clinician not blind to patients' unipolar vs. bipolar status. CONCLUSIONS: When conservatively defined (>or = 3 intra-episode hypomanic signs and symptoms during MDE), DMX is prevalent in the natural history of bipolar II but uncommon in unipolar MDD. These findings have treatment implications, because of growing concerns that antidepressants may worsen DMX, which in turn may respond better to mood stabilizers. These data also have methodological implications for diagnostic practice: rather than solely depending on the vagaries of the patient's memory for past hypomanic episodes, the search for hypomanic features--ostensibly elation would not be one of those--during an index depressive episode could enhance the detection of bipolar II in otherwise pseudo-unipolar patients. Strict adherence to current clinical diagnostic interview instruments (e.g. the SCID) would make such detection difficult, if not impossible.     

Anxiety and depression in a community sample: the influence of comorbidity on social functioning

The main aim of the present study was to examine whether the well-established association between depression and social dysfunction still remains when effects of a coexistent anxiety disorder are eliminated from the data. As these effects strongly depend on the proportion of depressed subjects suffering simultaneously from an anxiety disorder, we first examined the frequency of mixed and pure depressive disorders and that of pure anxiety disorders (control subjects) in a community sample (n = 483). Using DIS/DSM-III criteria (reference period 6 months), pure anxiety disorders were most frequent (6%), followed by pure depressive disorders (3%) and the coexistence of anxiety and depression (2%). Cases suffering from both disorders were most severely afflicted in terms of psychopathology (persistence of symptoms, comorbidity regarding other mental disorders). At the diagnostic level, the association between depression and social dysfunction was only slightly influenced by effects resulting from comorbidity; at the level of actual symptoms, however, we found that cases suffering simultaneously from severe depression and severe anxiety were significantly more handicapped in their social lives than depressive subjects with only mild anxiety symptoms.     

Is there evidence for a male depressive syndrome in inpatients with major depression?

BACKGROUND: The question is investigated whether atypical depressive symptoms such as irritability, anger attacks, aggressiveness or abusive behavior, which are hypothesized to indicate a hypothetical male depressive syndrome are more prevalent in male than in female inpatients with unipolar major depression. METHODS: Data were obtained from 2411 patients who had been consecutively admitted to the Department of Psychiatry of the Ludwig-Maximilians-University of Munich. Psychopathological symptoms had been assessed by a standardized documentation system (AMDP). RESULTS: Neither frequency nor mean scores of most of the symptoms describing a male depressive syndrome differed between males and females. There were no gender differences in symptoms with respect to severity of depression, first hospitalization and duration of illness. However, gender differences emerged when regarding symptom patterns by factor analysis. Limitations: Only inpatients were studied, and comorbidity was not considered. CONCLUSIONS: The hypothesis of a male depressive syndrome needs further research, focusing on the gradual development of (masked) depression by men in mainly non-clinical samples.     

Depression and anxiety as predictors of heart rate variability after myocardial infarction

BACKGROUND: Reduced heart rate variability (HRV) is a prognostic factor for cardiac mortality. Both depression and anxiety have been associated with increased risk for mortality in cardiac patients. Low HRV may act as an intermediary in this association. The present study examined to what extent depression and anxiety differently predict 24-h HRV indices recorded post-myocardial infarction (MI). METHOD: Ninety-three patients were recruited during hospitalization for MI and assessed on self-reported symptoms of depression and anxiety. Two months post-MI, patients were assessed on clinical diagnoses of lifetime depressive and anxiety disorder. Adequate 24-h ambulatory electrocardiography data were obtained from 82 patients on average 78 days post-MI. RESULTS: In unadjusted analyses, lifetime diagnoses of major depressive disorder was predictive of lower SDNN [standard deviation of all normal-to-normal (NN) intervals; beta=-0.26, p=0.022] and SDANN (standard deviation of all 5-min mean NN intervals; beta=0.25, p=0.023), and lifetime anxiety disorder of lower RMSSD (root mean square of successive differences; beta=-0.23, p=0.039). Depression and anxiety symptoms did not significantly predict HRV. After adjustment for age, sex, cardiac history and multi-vessel disease, lifetime depressive disorder was no longer predictive of HRV. Lifetime anxiety disorder predicted reduced high-frequency spectral power (beta=-0.22, p=0.039) and RMSSD (beta=-0.25, p=0.019), even after additional adjustment of anxiety symptoms. CONCLUSIONS: Clinical anxiety, but not depression, negatively influenced parasympathetic modulation of heart rate in post-MI patients. These findings elucidate the physiological mechanisms underlying anxiety as a risk factor for adverse outcomes, but also raise questions about the potential role of HRV as an intermediary between depression and post-MI prognosis.     

Are there any differences between bipolar and unipolar melancholia?

Although it is now more than 30 years since Leohard originally proposed the distinction between bipolar and monopolar (unipolar) forms of affective disorder, there have been relatively few studies which have investigated clinical features which may differentiate the depressed phase of bipolar disorder from unipolar depression. In this study we examined the value of a new scale for rating depressive mental state signs (the 'core' score system), and a large series of symptoms and risk factors, in distinguishing between 27 age and sex-matched pairs of bipolar and unipolar patients diagnosed as melancholic on several diagnostic criteria. In general, we found a marked similarity between the groups on clinical features of the depressive episode when allowance was made for multiple tests. Bipolar patients, however, had shorter episodes of depression and were less likely to demonstrate 'slowed movements' than unipolar subjects. There were also consistent trends on other items for psychomotor retardation to be less common and agitation to be more likely in the bipolar patients. At the least, these findings suggest that the widely-held belief that bipolar depressed patients typically have psychomotor retardation is not as clear-cut as has been previously described.     

Blunted neural response to rewards prospectively predicts depression in adolescent girls

The prevalence of depression increases substantially during adolescence. Several predictors of major depressive disorder have been established, but their predictive power is limited. In the current study, the feedback negativity (FN), an event‐related potential component elicited by feedback indicating monetary gain versus loss, was recorded in 68 never‐depressed adolescent girls. Over the following 2 years, 24% of participants developed a major depressive episode (MDE); illness onset was predicted by blunted FN at initial evaluation. Lower FN amplitude predicted more depressive symptoms during the follow‐up period, even after controlling for neuroticism and depressive symptoms at baseline. This is the first prospective study to demonstrate a link between a neural measure of reward sensitivity and the first onset of an MDE. The current results suggest that low reward sensitivity may be an important factor in the development of depression.     

The Brief-HAPPI: a questionnaire to assess cognitions that distinguish between individuals with a diagnosis of bipolar disorder and non-clinical controls

BACKGROUND: Despite developments in cognitive behavioural therapy for bipolar disorder, little is known about the specific dysfunctional beliefs that may predispose individuals to mania. Therefore a measure was specifically designed for this purpose based on a cognitive approach. The measure is called the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI). METHOD: Fifty-six individuals with a diagnosis of bipolar disorder and 39 matched healthy controls completed a brief version of the HAPPI (Brief-HAPPI), the Internal State Scale, and the Hypomanic Interpretations Questionnaire (HIQ). RESULTS: The bipolar group scored higher on the overall Brief-HAPPI scale, higher on the forward items of the Brief-HAPPI, lower on the reverse items and no different on the filler items. The group differences in overall score remained when controlling for current self-reported symptoms of mania and depression, and recent history of hypomanic symptoms, yet within the bipolar group, Brief-HAPPI score was positively correlated with the level of symptoms. The Brief-HAPPI showed a sizeable correlation with the HIQ, yet each scale showed a significant and independent association with bipolar disorder. CONCLUSION: The Brief-HAPPI assesses dysfunctional beliefs that are associated with a diagnosis of bipolar disorder.