Psychosocial disability during the long-term course of unipolar major depressive disorder

BACKGROUND: The goal of this study was to investigate psychosocial disability in relation to depressive symptom severity during the long-term course of unipolar major depressive disorder (MDD). METHODS: Monthly ratings of impairment in major life functions and social relationships were obtained during an average of 10 years' systematic follow-up of 371 patients with unipolar MDD in the National Institute of Mental Health Collaborative Depression Study. Random regression models were used to examine variations in psychosocial functioning associated with 3 levels of depressive symptom severity and the asymptomatic status. RESULTS: A progressive gradient of psychosocial impairment was associated with a parallel gradient in the level of depressive symptom severity, which ranges from asymptomatic to subthreshold depressive symptoms to symptoms at the minor depression/dysthymia level to symptoms at the MDD level. Significant increases in disability occurred with each stepwise increment in depressive symptom severity. CONCLUSIONS: During the long-term course, disability is pervasive and chronic but disappears when patients become asymptomatic. Depressive symptoms at levels of subthreshold depressive symptoms, minor depression/ dysthymia, and MDD represent a continuum of depressive symptom severity in unipolar MDD, each level of which is associated with a significant stepwise increment in psychosocial disability.     

Psychosocial disability before, during, and after a major depressive episode: a 3-wave population-based study of state, scar, and trait effects

BACKGROUND: Psychosocial disability after remission from a unipolar major depressive episode (MDE) can be due to (1) residual symptoms (state effect), (2) the continuation of premorbid disability (trait effect), and/or (3) disability that developed during the MDE and persisted beyond recovery (scar effect). METHODS: Data came from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective Dutch psychiatric population-based survey. We obtained psychiatric data (Composite International Diagnostic Interview) and information on psychosocial functioning (work, housekeeping, spouse/partner, and leisure-time domains) from 4796 respondents in 1996 (T1), 1997 (T2), and 1999 (T3). We evaluated trait effects using between-subject comparisons, and state and scar effects using within-subject comparisons. RESULTS: In 216 and 118 respondents, a first and a recurrent MDE developed, respectively, after T1 that remitted before T3. Compared with never-MDE individuals, first-MDE subjects had higher disability scores long before their episode (effect size, 0.42-0.57 U). During the MDE, disability further increased in first- and recurrent-MDE subjects (effect size, 0.44-0.79 U), but returned to its premorbid level after MDE remission, except in subjects who experienced a severe recurrent episode. If the premorbid period (T1 to MDE onset) was longer than the postmorbid period (MDE remission to T3), disability at T3 was higher than at T1, misleadingly suggesting scar effects. The reverse occurred if the premorbid period was shorter than the postmorbid period. CONCLUSIONS: Postmorbid psychosocial disability reflects largely the continuation of premorbid psychosocial disability. Scarring does not occur routinely, but may occur in a severe recurrent episode. Within-subject premorbid-postmorbid comparisons are sensitive to state effects of prodromal and residual symptoms. These findings point at the following 2 independent processes: (1) the ongoing expression of trait vulnerability to depression in mild psychosocial dysfunctioning; and (2) synchrony of change between severity of depressive symptoms and psychosocial disability.     

Psychosocial disability in the course of bipolar I and II disorders: a prospective, comparative, longitudinal study

CONTEXT: Evidence of psychosocial disability in bipolar disorder is based primarily on bipolar I disorder (BP-I) and does not relate disability to affective symptom severity and polarity or to bipolar II disorder (BP-II). OBJECTIVE: To provide detailed data on psychosocial disability in relation to symptom status during the long-term course of BP-I and BP-II. DESIGN: A naturalistic study with 20 years of prospective, systematic follow-up. SETTING: Inpatient and outpatient treatment facilities at 5 US academic centers.Patients One hundred fifty-eight patients with BP-I and 133 patients with BP-II who were followed up for a mean (SD) of 15 (4.8) years in the National Institute of Mental Health Collaborative Depression Study. MAIN OUTCOME MEASURES: The relationship, by random regression, between Range of Impaired Functioning Tool psychosocial impairment scores and affective symptom status in 1-month periods during the long-term course of illness from 6-month and yearly Longitudinal Interval Follow-up Evaluation interviews. RESULTS: Psychosocial impairment increases significantly with each increment in depressive symptom severity for BP-I and BP-II and with most increments in manic symptom severity for BP-I. Subsyndromal hypomanic symptoms are not disabling in BP-II, and they may even enhance functioning. Depressive symptoms are at least as disabling as manic or hypomanic symptoms at corresponding severity levels and, in some cases, significantly more so. At each level of depressive symptom severity, BP-I and BP-II are equally impairing. When asymptomatic, patients with bipolar disorder have good psychosocial functioning, although it is not as good as that of well controls. CONCLUSIONS: Psychosocial disability fluctuates in parallel with changes in affective symptom severity in BP-I and BP-II. Important findings for clinical management are the following: (1) depressive episodes and symptoms, which dominate the course of BP-I and BP-II, are equal to or more disabling than corresponding levels of manic or hypomanic symptoms; (2) subsyndromal depressive symptoms, but not subsyndromal manic or hypomanic symptoms, are associated with significant impairment; and (3) subsyndromal hypomanic symptoms appear to enhance functioning in BP-II.     

Delineating the longitudinal structure of depressive illness: beyond clinical subtypes and duration thresholds

Through the use of polysomnographic, epidemiologic, and prospective clinical follow-up studies, the authors document that the course of major depressive disorder (MDD) is expressed by fluctuating symptoms in which depressive subtypes included in official diagnostic systems do not represent discrete disorders, but are stages along a dimensional continuum of symptomatic severity. Depressive symptoms at the major, minor, dysthymic or otherwise sub-threshold levels are all integral components of the longitudinal clinical structure of MDD with each symptom level representing a different phase of illness intensity, activity and severity. Detailed analyses indicate that patients are symptomatic 60 % of the time, much of it at the minor, dysthymic or subthreshold level. The symptomatic phases of illness activity are interspersed sporadically with inactive phases, when patients are asymptomatic. These findings are pertinent to both clinical cohorts and community-based epidemiologic samples. Each level of depressive symptom severity is associated with significant psychosocial impairment; such impairment increases progressively with each stepwise increment in symptom severity. When patients are asymptomatic their psychosocial functioning returns to good or very good levels. Residual subthreshold symptoms in the course of MDD are associated with high risk for early episode relapse and a significantly more chronic course of illness. Asymptomatic recovery from MDD is associated with significant delays in episode relapse and recurrence and a more benign course of illness. We submit that, as in the case of chronic medical conditions, the goal of treating unipolar depressive illness should optimally be to return the patient to as asymptomatic a level as is feasible by all available therapeutic means.     

The role of depression chronicity and recurrence on neurocognitive dysfunctions in HIV-infected adults

Research assessing whether major depressive disorders (MDD) impacts neurocognitive functions in HIV+ persons has yielded inconsistent results. However, none have considered the role of MDD remission, chronicity, and stability on treatment. Ninety-five HIV+ adults clinically stable on combined antiretroviral treatment completed a psychiatric interview, a depression scale, a neuropsychological, daily living, and cognitive complaints assessments at baseline and 18 months. Participants were screened for current (within 12 months of study entry) alcohol and/or substance use disorder. History of alcohol and/or substance abuse disorder prior to the 12 months entry screen and MDD treatments were recorded. Participants were grouped into two psychiatric nomenclatures: (1) lifetime: no MD episode (MDE), single MDE life-event treated and fully remitted, chronic MDD treated and stable, chronic MDD treated and unstable, and baseline untreated MDE; (2) recent: last 2 years MDE (yes or no). We found that lifetime and recent psychiatric history were more strongly associated with decreased in independence in daily living and cognitive complaints than with baseline neuropsychological performance. However, lack of full remission, instability on treatment in chronic MDD, and severity of symptoms in current MDE were factors in whether MDD impacted baseline neuropsychological performance. Depressive symptoms improved at follow-up in those with baseline moderate-severe symptoms, and MDD was not associated with neurocognitive change at 18 months. A history of alcohol and/or substance abuse disorder was significantly more frequent in those with treated and unstable chronic MDD but it was not associated with neuropsychological performance. MDD recurrence, chronicity profiles, and associated comorbidities are keys factors to understand any potential impact on neurocognitive abilities in HIV infection. More comprehensive consideration of these complex effects could serve at constructively updating the HAND diagnostic criteria.     

Are the vulnerability effects of personality and psychosocial functioning on depression accounted for by subthreshold symptoms?

Previous studies could not evaluate adequately the extent to which deviant levels of personality measures and psychosocial functioning found before and after a major depressive episode (MDE) should be attributed to subthreshold depressive symptoms. Our aim is to investigate whether pre- and post-MDE personality alterations and psychosocial disability truly reflect vulnerability, or whether they can be accounted for by the presence of subthreshold depressive symptoms. Data were derived from the Netherlands Mental Health and Incidence Study, a prospective general population study with three waves. Psychopathology was measured with the Composite International Diagnostic Interview (CIDI). Course of depressive symptoms was assessed with the Life Chart Instrument in a cohort of 195 respondents with a new or recurrent MDE between waves 2 and 3. Personality and psychosocial functioning were assessed with, respectively, four and two different measures. Alterations in measurements of personality and psychosocial functioning were present before onset and after remission of an MDE. Most pre- and postonset alterations occurred in the presence of subthreshold depressive symptoms. But even without these subthreshold symptoms, some alterations in measurements of personality and psychosocial functioning were found before and after an MDE. Depressive complaints between waves 2 and 3 were retrospectively assessed, and only a limited set of brief questionnaires was used to assess personality styles and psychosocial functioning. It is unlikely that the pre- and post-MDE alterations in personality and psychosocial functioning observed in earlier studies are entirely due to subthreshold depressive symptoms. This suggests that a depressive episode is interwoven in a long-standing and enduring pattern of mild personality deviance and limitations in psychosocial functioning.     

Melancholic outpatient depression in Bipolar-II vs. unipolar

BACKGROUND: DSM-IV melancholic major depressive episode (MDE) in bipolar II disorder (BP-II) is understudied. Study aim was to compare melancholic MDE in BP-II vs. unipolar major depressive disorder (MDD) on diagnostic validators and clinical features. METHODS: Consecutive 39 BP-II and 34 unipolar MDD outpatients in a private practice were interviewed (off psychopharmacotherapy) with the Structured Clinical Interview for DSM-IV, as modified by Benazzi and Akiskal [J. Affect. Disord. 73 (2003) 1], when presenting for treatment of MDE. DSM-IV criteria of melancholic features specifier were followed. Variables studied were index age, gender, age at onset of the first MDE, number of MDE recurrences, severity (measured by GAF, index MDE psychotic features, index MDE symptoms lasting more than 2 years, Axis I comorbidity), index MDE and melancholic symptoms, bipolar family history. Diagnostic validators were onset, family history, course of illness, and clinical picture. RESULTS: BP-II melancholic MDE, vs. MDD melancholic MDE, had significantly lower age at onset and more bipolar family history. Psychomotor agitation was significantly more common in BP-II melancholic MDE, but was present only in 43.5%. Psychomotor retardation was more common in MDD melancholic MDE at a trend level, but was present only in 20.5%. CONCLUSIONS: Psychomotor agitation was more common in BP-II melancholic MDE vs. unipolar MDD, while previous studies on bipolar I (BP-I) had usually found more retardation. The difference could be related to BP-I and BP-II being at least partly distinct disorders. The relatively low frequency of psychomotor change does not seem to support the view that this is the core feature of melancholia. Differences on diagnostic validators (most importantly family history) further support the distinction of melancholic MDE between BP-II and MDD, and support DSM-IV classification.     

Neurocognitive impairments and quality of life in unemployed patients with remitted major depressive disorder

Quality of life (QOL) has been reported to be impaired in patients with major depressive disorder (MDD), even after remission according to symptom rating scales. Although a relationship between QOL and neurocognitive dysfunction has been reported during depressive episodes, little is known about this relationship in remitted MDD patients. The aim of the present study was to investigate the relationship between QOL and neurocognitive dysfunction in patients with remitted MDD while controlling for confounding factors. Forty-three remitted MDD patients were assessed with neuropsychological tests and QOL, which was measured by a short-form 36-item health survey. The neurocognitive performances of the patients were compared with those of 43 healthy controls. We next evaluated the relationships between neurocognitive impairments, clinical factors, and QOL. Remitted MDD patients had poorer neurocognitive performances than healthy controls for psychomotor speed, attention, and verbal memory. Residual depressive symptoms were strongly associated with QOL. Delayed verbal recall was associated with general health perceptions, which are part of the QOL assessment, even after the effects of the residual depressive symptoms were considered. The results may indicate that clinicians should try to detect neurocognitive dysfunctions that may interfere with QOL using neurocognitive assessments in their daily practice.     

Depression in bipolar disorder versus major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

Moreno C, Hasin DS, Arango C, Oquendo MA, Vieta E, Liu S, Grant BF, Blanco C. Depression in bipolar disorder versus major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Bipolar Disord 2012: 14: 271–282. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: To compare the clinical features and course of major depressive episodes (MDEs) occurring in subjects with bipolar I disorder (BD‐I), bipolar II disorder (BD‐II), and major depressive disorder (MDD). Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (2001–2002), a nationally representative face‐to‐face survey of more than 43000 adults in the USA, including 5695 subjects with lifetime MDD, 935 with BD‐I and lifetime MDE, and 494 with BD‐II and lifetime MDE. Differences on sociodemographic characteristics and clinical features, course, and treatment patterns of MDE were analyzed. Results: Most depressive symptoms, family psychiatric history, anxiety disorders, alcohol and drug use disorders, and personality disorders were more frequent—and number of depressive symptoms per MDE was higher—among subjects with BD‐I, followed by BD‐II, and MDD. BD‐I individuals experienced a higher number of lifetime MDEs, had a poorer quality of life, and received significantly more treatment for MDE than BD‐II and MDD subjects. Individuals with BD‐I and BD‐II experienced their first mood episode about ten years earlier than those with MDD (21.2, 20.5, and 30.4 years, respectively). Conclusions: Our results support the existence of a spectrum of severity of MDE, with highest severity for BD‐I, followed by BD‐II and MDD, suggesting the utility of dimensional assessments in current categorical classifications.     

Psychological correlates of functional status in chronic fatigue syndrome

Background: The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry. Methods: We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry. Results: The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS. Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups. In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning, and both illness worry and depressive symptoms were associated with worse psychosocial functioning. Conclusions: Our findings support the role of depression and illness cognitions in disability in CFS sufferers. Different cognitive factors account for physical and psychosocial disability in CFS and MS. The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.     

Factors associated with health-related quality of life among outpatients with major depressive disorder: a STAR*D report

OBJECTIVE: Major depressive disorder (MDD) is often chronic and is often associated with significant morbidity and mortality. The importance of assessing disability and health-related quality of life (HRQOL) in patients with MDD has only recently been recognized. The aim of this study was to examine sociodemographic and clinical correlates of HRQOL in a large cohort of outpatients with MDD. METHOD: Baseline assessments were completed for 1500 consecutive patients enrolled in the Sequenced Treatment Alternatives to Relieve Depression trial, including sociodemographic characteristics and measures of depressive symptom severity, clinical features, and HRQOL. Multiple domains of HRQOL were assessed with the 12-item Short Form Health Survey, the Work and Social Adjustment Scale, and the Quality of Life Enjoyment and Satisfaction Questionnaire. The current analyses were conducted on HRQOL data available for 1397 of the 1500 subjects. RESULTS: Greater symptom severity was associated with reduced HRQOL by all measures. Even after age and symptom severity were controlled for, a number of clinical features and sociodemographic characteristics were independently associated with HRQOL in multiple domains, including age at onset of MDD, ethnicity, marital status, employment status, education level, insurance status, and monthly household income. CONCLUSION: Results strongly suggest the need to assess HRQOL in addition to symptoms in order to gauge the true severity of MDD. This study also highlights the necessity of measuring HRQOL in multiple domains. These results have implications for the assessment of remission and functional recovery in the treatment of MDD.     

Understanding the relationship between co-occurring PTSD and MDD: symptom severity and affect

How to best understand theoretically the nature of the relationship between co-occurring PTSD and MDD (PTSD + MDD) is unclear. In a sample of 173 individuals with chronic PTSD, we examined whether the data were more consistent with current co-occurring MDD as a separate construct or as a marker of posttraumatic stress severity, and whether the relationship between PTSD and MDD is a function of shared symptom clusters and affect components. Results showed that the more severe depressive symptoms found in PTSD + MDD as compared to PTSD remained after controlling for PTSD symptom severity. Additionally, depressive symptom severity significantly predicted co-occurring MDD even when controlling for PTSD severity. In comparison to PTSD, PTSD + MDD had elevated dysphoria and re-experiencing – but not avoidance and hyperarousal – PTSD symptom cluster scores, higher levels of negative affect, and lower levels of positive affect. These findings provide support for PTSD and MDD as two distinct constructs with overlapping distress components.     

Discordance between self-reported symptom severity and psychosocial functioning ratings in depressed outpatients: implications for how remission from depression should be defined

The diagnosis of depression is based on the presence of symptoms along with functional impairment. One might therefore expect the definition of remission of depressive disorder to be based on the resolution of both symptoms and functional impairments. This, however, is not how the field has been defining remission. Rather, in treatment studies of depression, remission has been defined in symptom terms only. Clinical experience suggests that there is sometimes discordance between patients' symptom severity and functioning. No studies, however, have examined the frequency of this discordance. We examined the concordance of ratings of depression symptom severity and psychosocial functioning in a sample of 503 outpatients receiving treatment for major depressive disorder. The majority of patients were concordant in these ratings (i.e. no symptoms and no functional impairment, or ongoing symptoms and impairment), though one quarter of the patients were discordant. Specifically, approximately one quarter of the patients with depressive symptoms denied concurrent psychosocial impairment. In contrast, it was rare for patients without symptoms to report functional impairment. Almost all patients without both symptoms and functional impairment considered themselves to be in remission, and almost all patients with both symptoms and functional impairment did not consider themselves to be in remission. Half of the patients who reported normal functioning despite ongoing depressive symptoms considered themselves to be in remission from their depression. This suggests that current symptom-based definitions of remission might be too narrow.     

Challenging the unipolar–bipolar division: Does mixed depression bridge the gap?

BACKGROUND: Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the categorical splitting of mood disorders in bipolar disorders and unipolar depressive disorders, and may support a continuum between these disorders. Study aim was to find if there were a continuum between hypomania (defining BP-II) and depression (defining MDD), by testing mixed depression as a 'bridge' linking these two disorders. A correlation between intradepressive hypomanic symptoms and depressive symptoms could support such a continuum, but other explanations of a correlation are possible. METHODS: Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed, cross-sectionally, with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive hypomanic symptoms) and the Family History Screen, by a mood disorders specialist psychiatrist in a private practice. Patients presented voluntarily for treatment of depression when interviewed drug-free and had many subsequent follow-ups after treatment start. Mixed depression (depressive mixed state) was defined as the combination of MDE (depression) and three or more DSM-IV intradepressive hypomanic symptoms (elevated mood and increased self-esteem were always absent by definition), a definition validated by Akiskal and Benazzi. RESULTS: BP-II, versus MDD, had significantly lower age at onset, more recurrences, atypical and mixed depressions, bipolar family history, MDE symptoms and intradepressive hypomanic symptoms. Mixed depression was present in 64.5% of BP-II and in 32.1% of MDD (p=0.000). There was a significant correlation between number of MDE symptoms and number of intradepressive hypomanic symptoms. A dose-response relationship between frequency of mixed depression and number of MDE symptoms was also found. CONCLUSIONS: Differences on classic diagnostic validators could support a division between BP-II and MDD. Presence of intradepressive hypomanic symptoms by itself, and correlation between intradepressive hypomanic symptoms and depressive symptoms could instead support a continuum. Other explanations of such a correlation are possible. Depending on the method used, a BP-II-MDD continuum could be supported or not.     

Family history validation of a definition of mixed depression

PURPOSE: The study aim was to test different definitions of mixed depression, defined as a depression with concurrent hypomanic symptoms. METHODS: Consecutive 245 non-tertiary care outpatients with bipolar II disorder (BP-II) and 189 non-tertiary care outpatients with major depressive disorder (MDD) were interviewed (off psychoactive drugs) using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders-Clinician Version, Hypomania Interview Guide (HIG), and Family History Screen when presenting for major depressive episode (MDE) treatment. Intra-MDE hypomanic symptoms were systematically assessed. Mixed depression was defined as an MDE with concurrent hypomanic symptoms. Receiver operating characteristic (ROC) analysis and multivariate analysis were used to test different definitions of mixed depression (dimensional and categorical ones). Factor analysis was also used. Bipolar family history was the validator. FINDINGS: Bipolar II disorder, vs MDD, had significantly more intra-MDE hypomanic symptoms (racing/crowded thoughts, irritable mood, psychomotor agitation, more talkativeness, and increased goal-directed and risky activities). Major depressive episode plus 3 or more hypomanic symptoms was present in 68.7% of BP-II and 42.3% of MDD. A "motor activation" factor, including psychomotor agitation and talkativeness, and a "mental activation" factor including racing/crowded thoughts were found. Different definitions (dimensional and categorical ones) of mixed depression were tested vs bipolar family history as validator (ie, MDE plus more than 1, 2, 3, and 4 concurrent hypomanic symptoms, MDE plus psychomotor agitation, MDE plus racing thoughts). Major depressive episode plus more than 1 hypomanic symptom had the highest sensitivity but the lowest specificity. Instead, MDE plus more than 4 hypomanic symptoms had the lowest sensitivity and the highest specificity. The better-balanced combination of sensitivity and specificity was shown by MDE plus more than 2 hypomanic symptoms. The same definition also showed the highest ROC area value. Multivariate regression of bipolar family history vs different mixed depression definitions found that the only strong and significant predictor was MDE plus more than 2 hypomanic symptoms. A dose-response relationship was found between the number of hypomanic symptoms during MDE and the bipolar family history loading. CONCLUSIONS: Mixed depression (MDE plus 3 or more hypomanic symptoms) was common in BP-II and MDD. A dimensional definition based on 3 or more hypomanic symptoms during depression was the most supported by using bipolar family history as validator. The study of mixed depression may be important for its possible impact on treatment (antidepressants could increase hypomanic symptoms, and mood stabilizers and antipsychotics could control hypomanic symptoms during antidepressant treatment).     

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression,bipolar depression,and borderline personality disorder

Background

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

Methods

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

Results

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

Conclusions

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.     

Sleep disturbances: Core symptoms of major depressive disorder rather than associated or comorbid disorders

Depression is increasingly prevalent in Western countries. It has severe consequences and is associated with increased rates of disability, morbidity, and mortality. Despite numerous therapeutic options, a great number of depressed patients do not achieve full remission. In addition, despite good short-term outcomes, long-term therapeutic results remain disappointing and associated with a poor prognosis, raising significant concern in terms of public health. Impaired sleep – especially insomnia – may be at least partly responsible for this problem. Very close relationships between major depressive disorder (MDD) and sleep disorders have been observed. In particular, residual symptoms of sleep disturbance in a remitted patient may predict a relapse of the disease. However, most currently available antidepressants do not always take into consideration the sleep disturbances of depressed patients; some agents long used in clinical practice even appear to worsen them by their sleep-inhibiting properties. But some other new medications were shown to relieve early sleep disturbance in addition to alleviating other depression-related symptoms. This positive impact should promote compliance with medication and psychological treatments, and increase daytime performance and overall functioning. Complete remission of MDD appears therefore to depend on the relief of sleep disturbances, a core symptom of MDD that should be taken into consideration and treated early in depressed patients.     

Stability of DSM-IV criterion symptoms for major depressive disorder

Given the chronic and recurrent nature of major depressive disorder (MDD), it is important to understand whether specific symptoms are stable over time or vary over the course of the disorder. This is the first longitudinal investigation examining the stability of the nine criterion symptoms of depression, as specified in the DSM-IV, among diagnosed depressed adults who were not recovered at follow-up. In this study, participants were assessed twice, ten months apart, with the structured clinical interview for DSM-IV, and stability of the nine criterion symptoms of MDD was examined. Findings indicate strong stability in individuals' symptom profiles. Among individuals who were clinically depressed at both assessments, there were no statistically significant fluctuations in specific symptoms endorsed. Changes in symptom endorsement among individuals who no longer met diagnostic criteria for MDD at Time 2 were attributable to reduced severity (i.e., number of symptoms) rather than to inconsistency of symptom endorsement. These results indicate that depressed individuals experience essentially the same pattern of specific symptoms over the course of a year. Variation in clinical course is likely to be attributable more to fluctuations in overall severity than to changes in specific symptoms of depression.     

Bipolar II disorder and major depressive disorder: continuity or discontinuity?

AIM: To find if bipolar II disorder (BPII) and major depressive disorder (MDD) were distinct categories or overlapping syndromes. METHODS: 308 BPII and 236 MDD outpatients, presenting for major depressive episode (MDE) treatment, were interviewed with the Structured Clinical Interview for DSM-IV. History of mania and hypomania, and hypomanic symptoms present during MDE, were systematically investigated. Presence of zones of rarity between BPII and MDD depressive syndromes was assessed. Atypical and hypomanic symptoms were chosen because atypical features and depressive mixed state (ie, MDE plus more than 2 concurrent hypomanic symptoms, according to Akiskal and Benazzi 2003) were often reported to distinguish BPII from MDD depressive syndromes (more common in BPII). If BPII were a distinct category, distributions of these symptoms should show zones of rarity between BPII and MDD depressive syndromes. Histograms and Kernel density estimate were used to study distributions of these symptoms. RESULTS: BPII had significantly more atypical features and depressive mixed state than MDD. Histograms and Kernel density estimate curves of distributions of atypical and hypomanic symptoms in the entire sample did not show zones of rarity. CONCLUSIONS: Finding no zones of rarity supports a continuity between BPII and MDD (meaning partly overlapping disorders without clear boundaries).     

The effects of neuroticism, extraversion, and positive and negative life events on a one-year course of depressive symptoms in euthymic previously depressed patients versus healthy controls

We investigated a) the concurrent impact of positive and negative life events on the course of depressive symptoms in persons remitted from depression and healthy controls, b) whether the impact of life events on symptom course is moderated by the history of depression and the personality traits of neuroticism and extraversion, and c) whether life events mediate possible relationships of history of depression and personality traits with symptom course. Using data from the Netherlands Study of Depression and Anxiety, we examined 239 euthymic participants with a previous depressive disorder based on DSM-IV and 450 healthy controls who completed a) baseline assessments of personality dimensions (NEO Five-Factor Inventory) and depression severity (Inventory of Depressive Symptoms [IDS]) and b) 1-year follow-up assessments of depression severity and the occurrence of positive and negative life events during the follow-up period (List of Threatening Events Questionnaire). Remitted persons reported higher IDS scores at 1-year follow-up than did the controls. Extraversion and positive and negative life events independently predicted the course of depressive symptoms. The impact of life events on symptom course was not moderated by history of depression or personality traits. The effect of extraversion on symptom course was partly caused by differential engagement in positive life events.