Depression in neurological disorders: an update

PURPOSE OF REVIEW: Depressions are a heterogeneous group of conditions that contribute significantly to impairments in quality of life, independent of the severity of neurological illness. Depression may predate neurological signs and symptoms in the evolution of neurodegenerative disorders, and there is some evidence that depressive illness itself may be a risk factor in the aetiology of some dementias. This review aims to summarize the relevant current literature on diagnosis, aetiology and treatment of depression in neurology. RECENT FINDINGS: Diagnosing depression in neurological conditions can be particularly difficult because of communication difficulties and changes in emotional expression as a result of the underlying neurological disease. Rating scales loaded towards somatic symptoms can show poor validity for screening or rating of severity in this setting. The evidence for the treatment of depression in neurological disease is scant, and often the treatment advice is based on consensus views of clinicians. Nevertheless, there have been some clinical trials, which are reported. SUMMARY: Depression is common in neurology. It is underrecognized and undertreated. Recent research has allowed us to define depression more clearly in this setting. Trials of treatment are urgently needed, especially as depression is a significant factor in quality of life and may affect prognosis.     

Some recommendations to assess depression in Chinese people in Australasia

OBJECTIVE: To provide some general recommendations for psychiatric assessment of depression among Chinese patients within a predominately Western society. METHOD: A literature review is provided with interpretive comments. RESULTS: The prevalence of depression reported in community studies undertaken in Chinese communities is very low. To what extent Chinese people experience and seek help for depression, and how they report depressive symptoms have long been topics of some importance. The impact of acculturation as well as concepts and interpretations of illness in traditional Chinese medicine are discussed. Awareness of sensitive issues and practices within the Chinese culture will facilitate communication between medical professionals and patients, resulting in more accurate identification and diagnosis of depressive disorders. CONCLUSION: Direct but culturally sensitive and empathic questioning of psychological symptoms is needed to unveil patients' explanatory models, as most Chinese initially nominate only somatic symptoms to health practitioners. Successfully treated patients can promote earlier and wider utilization of mental health services to other Chinese people.     

Do the Chinese somatize depression? A cross-cultural study

Background: A large literature argues for the Chinese – whether in mainland China or elsewhere – being highly likely to express depression somatically, leading to predictable detection and diagnostic difficulties. If true, detection might be assisted if a set of somatic proxies of depression were identified, and this was the principal initial objective in mounting this study. Methods: We studied two sets of depressed outpatients, one of Malaysian Chinese and the other of Australian Caucasians, matched by age and sex. We identified the prime symptom nominated by them when they first sought assistance, and required them to complete an inventory of both somatic and cognitive symptoms, and rank the three items they judged as most capturing their distress. Results: The Chinese were distinctly more likely to nominate a somatic symptom as their presenting complaint (60 % vs 13 %), while the Australian subjects were more likely to nominate depressed mood, cognitive and anxiety items. Responses to the inventory established that the Chinese did score somewhat higher on a somatic set of items, but differed far more distinctly in being less likely to affirm cognitive items of depression, resulting in significantly lower total inventory scores. Variation across the contrast samples in acknowledging the presence of symptoms did not relate simply to the prevalences of those symptoms. Conclusions: Our failure to identify a culture-specific somatic factor as a proxy of depression, together with establishing a high rate of somatic and related items (e. g. insomnia) in both samples, may largely reflect the phenomenon of ‘corporization’, whereby depressed patients irrespective of culture are more likely to experience and report in response to a ‘somatosensory amplification’ influence. Accepted: 25 January 2001     

The psychiatric significance of the personal self

Drawing upon literature reviews in psychiatry, the social sciences, and philosophy, this article defines the concept of the "personal self" and briefly describes its importance to the following areas of psychiatry: (1) mental illness, (2) psychiatric ethics, (3) diagnosis, (4) the clinician, (5) clinical research, (6) psychiatric pluralism, and (7) the goals of psychiatric treatment. The personal self is a Western common-sense concept which is characterized by five aspects: agency, identity, trajectory, history, and perspective. Because of the intimate and often ambiguous relationship between the personal self and mental illness, the personal self has considerable psychiatric significance in moral, professional, research, and existential realms.     

Psychological factors in severe chronic asthma.

OBJECTIVE: Levels of psychological distress, social support factors, and emotional adjustment to illness were measured in a sample of patients with severe asthma. These were then examined in terms of their interrelationships and their ability to predict self-management knowledge. METHOD: A sample of 80 patients was recruited from a hospital-based asthma clinic designed for patients with severe asthma. Thirty-four percent of consecutive attenders approached took part. Morbidity and asthma management were recorded from case records. Anxiety, depression, social support, emotional adjustment to asthma and asthma knowledge were measured using self-report instruments selected for their acceptability and ease of administration. RESULTS: Twenty-five percent of the sample had possible or definite caseness for anxiety; 10.3% had possible or definite caseness for depression. Twenty-five percent had inadequate social support in some way. Three independent attitudinal factors were found: emotional maladjustment to asthma, the doctor-patient relationship, and asthma-related stigma. Level of asthma knowledge was very low. None of the measures of psychosocial function chosen were predictive of asthma knowledge. CONCLUSIONS: Levels of asthma knowledge were dangerously low, despite apparently adequate educational initiatives. In addition, patients with severe asthma have high levels of distress, particularly of anxiety, even between attacks. Their attitudes to their illness are multifactorial, and are significantly correlated with emotional distress, morbidity indices and some demographic factors. While this may point the way to interventions designed to relieve patients' distress, the hypothesis that this might in turn relate to practical asthma knowledge was not confirmed.     

Differential diagnosis and classification of apathy

This paper discusses the definition of apathy, reviews its differential diagnosis, and proposes a classification for the conditions that may produce it. Apathy is defined as diminished motivation not attributable to diminished level of consciousness, cognitive impairment, or emotional distress. In its differential diagnosis, abulia, akinesia and akinetic mutism, depression, dementia, delirium, despair, and demoralization must be ruled out. Classification of apathy is organized in terms of its adaptive and functional consequences, its relationship to personality or to sociocultural or environmental events, and its association with psychiatric, neurological, and medical disorders. An approach to assessment and treatment is proposed.     

Evidence for a possibly X-linked trait related to affective illness

OBJECTIVE: The present report attempts to replicate on the probands' brothers, a previously reported (1992) negative relationship between maternal grandfather longevity (MGFL) and affective illness in grandsons. Hitherto this finding had not been replicated. To provide further evidence that the association may be recessive and X-linked, we also examined the association between MGFL and affective illness in the probands' mothers. Finally, in order to examine why MGFL might be a predictor of affective illness, the report examines the association of the probands' affective illness and their own mortality. METHOD: A 60-year prospective study of men selected in 1940 and followed until the present day provided good information on depressive illness in relatives and longevity of ancestors. To overcome the uncertainty of depressive diagnoses, we assessed affective illness in the probands categorically, dimensionally, operationally and with the Lazare Personality Inventory. RESULTS: Presence of affective illness in brothers was negatively associated with MGFL (p = 0.003) but maternal affective illness was independent of MGFL. Test items suggesting emotional lability in the probands were significantly and negatively associated with MGFL. Consistent with the association of increased MGFL with low affective distress in the probands, the 70 probands showing the least evidence of affective distress before age 50 had twofold (p < 0.001) lower mortality at 80 than the rest of the sample. The 31 probands manifesting the greatest affective distress manifested twofold higher mortality before age 65 (p < 0.001) than the rest of the sample. CONCLUSION: The strong negative association of proband affective distress -- and equally important -- the positive association of proband mental health with MGFL and the lack of association of maternal longevity and depression with MGFL points to the possibility of a recessive X-gene or genes playing a role in depressive illness.     

The emotional toll of spousal morbidity and mortality.

OBJECTIVE: Spouse caregivers have an increased risk of mental and physical illness during caregiving and widowhood. The authors sought to evaluate whether partners of an ill spouse have a higher likelihood of developing mental health or substance abuse (MHSA) disorders than partners who have healthy spouses, accounting for both spousal illness and death. METHODS: The authors used Medicare claims from 1993-2001 for 474,228 married couples. The authors used Cox models to determine the effect of spouse illness on partner MHSA diagnosis, controlling for demographic and clinical characteristics. RESULTS: A wife's hospitalization increased the husband's risk of MHSA diagnosis by 1.29 (95% confidence interval [CI]: 1.28-1.29) and his risk of depression by 1.49 (95% CI: 1.48-1.51). A husband's hospitalization increased the risk of a wife's MHSA diagnosis by 1.33 (95% CI: 1.32-1.33) and her risk of depression by 1.41 (95% CI: 1.39-1.42). A wife's death increased the risk of the husband's MHSA diagnosis by 1.12 (95% CI: 1.11-1.13) and increased his risk of depression by 1.49 (95% CI: 1.46-1.51). A husband's death increased the risk of the wife's MHSA diagnosis by 1.14 (95% CI: 1.14-1.15) and increased her risk of depression by 1.41 (95% CI: 1.39-1.42). CONCLUSION: Spouse hospitalizations and spouse death independently increase the risk for partner MHSA and depression diagnoses. These findings can identify which individuals are at greatest risk for emotional distress and should be targeted for interventions to relieve caregiver burden that can arise separately and additively from both spousal illness and death.     

Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study

OBJECTIVE: Somatization has often been viewed as a defense against awareness of emotional distress or as a masked version of depression. This report examines whether community residents with high levels of functional somatic symptoms also report overt psychological distress and whether somatization is associated with any specific psychiatric disorder. METHOD: Analyses used data from the community sample of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study, a population-based survey of psychiatric morbidity among more than 18,000 residents of five U.S. communities. RESULTS: Increasing number of somatization symptoms was strongly associated with overt expression of psychological distress and psychiatric symptoms. Among ECA respondents with five or more current functional somatic symptoms, 63% reported current psychological symptoms and 50% met criteria for a current psychiatric diagnosis (compared to 7% and 6%, respectively, among those with no current somatization symptoms). Somatization symptoms showed strongest associations with anxiety and depressive symptoms, intermediate association with symptoms of psychotic disorders, and weakest associations with symptoms of substance abuse and antisocial personality. CONCLUSIONS: ECA study respondents with high levels of somatization symptoms typically reported overt psychological distress, especially anxiety and depression. Patterns of response do not support a dissociation between physical and emotional symptoms. Functional somatic symptoms appear to be common expressions of distress instead of defenses against awareness.     

Unipolar mania: a distinct clinical entity?

Of the 241 lithium clinic patients at the New York State Psychiatric Institute with bipolar I affective disorder, 38 (15.7%) had never been hospitalized or somatically treated for depression. These "unipolar manic" patients had a significantly lower incidence of rapid cycling and suicide attempts than other bipolar I patients. No differences were found, however, in risk of illness in first-degree relatives. Lithium was an effective prophylactic agent in these patients. Some patients originally classified as "unipolar manic" were found to have depressive episodes with additional information and clinical observation. "Unipolar mania" appears to be a subgroup of bipolar I illness, but there are no data to support the hypothesis that it is a separate entity.     

Emotional reactions to the diagnosis and treatment of early breast cancer

Forty-four patients with early breast cancer were interviewed before mastectomy and on three occasions during the following year about psychiatric symptomatology, and their emotional reactions to various aspects of the illness and its treatment. Eight patients developed symptoms of depressive illness. Thirty-five patients expressed emotional distress related to the diagnosis or the loss of the breast or both. All ten who had adjuvant chemotherapy considered this the most unpleasant aspect of treatment. Post-operative distress could often be predicted by a high score on the General Health Questionnaire, or a high level of expressed concern before the operation.     

Social learning, affective state and passive coping in irritable bowel syndrome and inflammatory bowel disease

The association between the use of passive coping strategies to deal with pain and reported levels of anxiety, depression, and parental reinforcement of illness behavior was examined in individuals with Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD). Individuals with IBS and IBD recruited primarily from outpatient clinics completed questionnaire measures of pain-coping (the Vanderbilt Pain Management Inventory, VPMI) as well as measures of anxiety and depression, parental reinforcement of illness behavior and physical symptoms. Factor analysis of the passive coping sub-scale of the VPMI indicated that it was comprised of two components corresponding to emotional and behavioral facets of passive coping. Higher levels of behavioral passive coping were associated with higher levels of parental reinforcement of illness behavior and higher levels of depression, but only amongst individuals with IBS. In contrast emotional passive coping was associated in both groups with higher levels of anxiety and depression (but not illness-related social learning). Different factors predict the use of emotional and behavioral passive coping strategies in IBS and IBD. It is suggested that illness-related social learning occurring during childhood influences the development of habitual illness behaviors and that, because of the more benign nature of symptoms in IBS, individuals with IBS may be more likely than individuals with IBD to revert to such habitual behaviors to cope with symptoms. The degree to which the emotional component of passive coping, associated with psychological distress in both groups, can be considered in terms of 'coping strategies', rather than markers of illness-related distress, is discussed.     

Frontal and occipital perfusion changes in dissociative identity disorder

There is some evidence that emotional reactivity to daily life stress is related to a genetic or familial liability to develop schizophrenia. However, it is unclear whether the emotional distress is elevated in schizophrenia patients with positive compared to negative family history. The aim of the study was to test the hypothesis that a persistent higher level of emotional distress in schizophrenia subjects is associated with a positive family history of schizophrenia. This study used the Talbieh Brief Distress Inventory (TBDI), the Positive and Negative Syndrome Scale (PANSS; including dysphoric mood, positive and negative subscales), Montgomery-Asberg Depression Rating Scale (MADRS), and the Distress Scale for Adverse Symptoms (DSAS) to investigate the difference in the magnitude of emotional distress scores between schizophrenia subjects with and without a positive family history of schizophrenia over time. Data were recorded for 69 multiplex family and 79 singleton patients at admission and about 16 months thereafter. No between-group differences were obtained in PANSS and DSAS scores. With regard to the TBDI: (a) both group of patients had no significant differences in emotional distress scores at admission; (b) patients with negative family history reported improvement in distress severity and depression severity (MADRS) 16 months after admission, while those with positive family history experienced persistent elevated emotional distress, mainly, on obsessiveness, and depression subscales; and (c) both groups of patients are characterized by elevated emotional distress at follow-up examination compared to healthy subjects. Thus, it appears that there is a strong association between positive family history and persistent elevated emotional distress. Because patients with positive and negative family history are likely to differ in genetic risk, our results suggest that long-term elevated levels of emotional distress may be related to a familial (environmental)/genetic vulnerability to schizophrenia.     

A systematic review of the epidemiology of somatisation disorder and hypochondriasis

BACKGROUND: This paper reviews current knowledge regarding the prevalence and associated features of somatisation disorder and hypochondriasis in population-based and primary care samples. METHOD: A systematic review of the literature, which used a standardised definition of somatisation disorder or hypochondriasis and which examined the characteristics and associated features of these disorders in population-based samples or primary care settings. RESULTS: In population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. In studies using abridged criteria, a clear female predominance was not found in either disorder; there was a consistent relationship with few years of education. There was a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies. No studies showed that these symptom clusters fulfil the criteria of characteristic onset, course and prognosis required to merit the status of discrete psychiatric disorders. CONCLUSIONS: On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.     

Complementary and alternative medicine in the treatment of anxiety and depression

PURPOSE OF REVIEW: There is well documented evidence for the increasing widespread use of complementary and alternative medicine in the treatment of physical and psychiatric symptoms and disorders within Western populations. Here we provide a review of the recent literature on evidence for using such interventions in the treatment of anxiety and depression. RECENT FINDINGS: With regard to herbal treatments, kava is effective in reducing anxiety symptoms and St John's wort in treating mild to moderate depression. The association of kava with hepatotoxicity, however, is a significant concern. Promising data continue to emerge for the use of omega-3 fatty acids in managing depression. Evidence for the use of acupuncture in treating anxiety disorders is becoming stronger, although there is currently minimal empirical evidence for the use of aromatherapy or mindfulness-based meditation. SUMMARY: The evidence base for the efficacy of the majority of complementary and alternative interventions used to treat anxiety and depression remains poor. Recent systematic reviews all point to a significant lack of methodologically rigorous studies within the field. This lack of evidence does not diminish the popularity of such interventions within the general Western population.     

Human immunodeficiency virus and depression in primary care: a clinical review

Background: Human immunodeficiency virus (HIV)-infected individuals are at increased risk of developing depression. Depressive syndromes in these patients pose a challenge both diagnostically and therapeutically. These syndromes reflect both the presence of preexisting mood disorders and the development of depressive syndromes subsequent to HIV infection. Data Sources: A search of the literature to 2005 was performed using the PubMed and Ovid search engines. English- and Portuguese-language articles were identified using the following keywords: HIV or AIDS and depression, mental illness, suicide, fatigue, psychiatry, and drug interactions. Additional references were identified through bibliography reviews of relevant articles. Data Synthesis: The clinical presentation and differential diagnosis of depressive symptoms in HIV illness and the role of HIV in the development of these conditions are reviewed. Management issues including suicide assessment and treatment options are then discussed, and potentially important pharmacokinetic interactions are reviewed. Conclusions: Individuals with HIV show higher rates of depression. This phenomenon may be due to a preexisting psychiatric disorder or to the HIV infection. Untreated depression symptoms may lead to non-compliance with drug regimens or increased high-risk behaviors. Given the adverse sequelae of untreated depressions in HIV illness, identification and management of depression are integral components of comprehensive HIV care.     

Depression in pediatric illness.

Depression is a major complication of medical illness in adults and is increasingly being recognized as a complication of pediatric illness. The author reviews issues in the assessment and diagnosis of depression in pediatric illness and reviews recent studies on the prevalence of and risk factors for depression in different illnesses. Pediatric illness may be a major stressor that precipitates depression in children vulnerable because of life events, family dysfunction, or predisposition to affective illness.     

Impact of the WHO depression guideline on patient care by psychiatrists: A randomized controlled trial

BACKGROUND: Scientific literature reviews aim to summarize the state of knowledge and published empirical evidence. In contrast, medical guidelines are intervention tools that aim to improve physician behaviour and patient outcome. They can have positive effects, but they can also have negative effects. Their effects must be tested by research. METHODS: In a randomized controlled trial, 103 psychiatrists in private practice were either provided with the WHO depression guideline only (information group), or provided with the WHO depression guideline and trained for one day in this guideline (intervention group), or left uninformed (control group). They then treated a total of 497 patients according to individual clinical considerations and the needs of the patients. Observation of routine treatment lasted 12weeks. Physicians and patients documented the course of illness and treatment, including the patient-physician interaction. RESULTS: Psychiatrists in the intervention group saw more psychosocial stressors in their patients, prescribed higher dosages of medication, had fewer drop-outs, and rated treatment outcome as better. The ratings of patient-physician interactions indicated more strain in their relationships. CONCLUSIONS: The results show both positive and negative effects of guideline exposure, but only in the training group and not in the information group. Guidelines should be empirically tested before being called "evidence based". Every guideline should also explain how it can or must be implemented in order to become effective.     

Postdisaster emotional distress,depression and event-related variables: findings across child and adolescent developmental stages

OBJECTIVE: Developmental approaches have not been widely used in child and adolescent posttraumatic stress disorder research, and little is known about developmental differences in response to postdisaster trauma. Our objective was to investigate postdisaster depression and emotional distress psychopathology across a broad child and adolescent developmental range. METHOD: Six months following a bushfire disaster, 2379 grade 4-12 school students -completed an extensive self-report battery, which included the Impact of Event Scale and the Birleson Depression Inventory. Generalized linear models were constructed to model the effects of multiple covariates on continuous outcome measures of depression and emotional distress. RESULTS: Significant independent predictors of persisting depressive symptoms were increased symptoms of emotional distress; increased symptoms of anxiety; evacuation experience; and school grade. Significant independent predictors of emotional distress were persisting depressive symptoms; perception of threat to self or to parents; evacuation experience; and school grade. Gender was not a significant predictor in either the depression or emotional distress multivariate models. Complex, non-linear relationships between depression, emotional distress and school grade were found. CONCLUSION: This study suggests that important developmental differences in postdisaster psychological responses exist across a broad spectrum of developmental stages in children.