Predictors of remission from chronic depression: a prospective study in a nationally representative sample.

PURPOSE: The aims of this study were to identify predictors of remission from chronic depression in a prospective longitudinal general population survey; second, to determine the relative level functioning and well-being of those in remission. METHODS: The sample included respondents who met the criteria for major depressive disorder from Wave 1 (2001-2002) and through Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). RESULTS: Panic Disorder, Generalized Anxiety Disorder, Cluster B personality disorders and a history of Physical Abuse were correlated with reduced likelihood of chronic depression remission. The functioning and well-being of the remitted group was below the norm. CONCLUSIONS: These prognostic factors are similar to those found in clinical samples. Despite remission from chronic depression, a significant proportion have impairments in functioning.

Predictors of alcohol dependence relapse during recurrence of major depression.

This study sought to determine clinical predictors of alcohol relapse during recurrence of major depression. The total sample included 2,820 adults with a history of alcohol dependence who had a comorbid current episode of major depression. Twenty-six percent had a relapse of alcohol dependence. Relapsers were more likely to be male, single, less educated, and younger than non-relapsers. Early onset alcohol dependence and past year drug use disorder significantly increased the likelihood of relapse. Early onset substance use dependence is a more powerful predictor of alcohol relapse than early onset major depression.

A randomized double-blind, placebo-controlled trial of venlafaxine-extended release for co-occurring cannabis dependence and depressive disorders.

AIM: To evaluate whether venlafaxine-extended release (VEN-XR) is an effective treatment for cannabis dependence with concurrent depressive disorders. DESIGN: This was a randomized, 12-week, double-blind, placebo-controlled trial of out-patients (n = 103) with DSM-IV cannabis dependence and major depressive disorder or dysthymia. Participants received up to 375 mg VEN-XR on a fixed-flexible schedule or placebo. All patients received weekly individual cognitive-behavioral psychotherapy that primarily targeted marijuana use. SETTINGS: The trial was conducted at two university research centers in the United States. PARTICIPANTS: One hundred and three cannabis-dependent adults participated in the trial. MEASUREMENTS: The primary outcome measures were (i) abstinence from marijuana defined as at least two consecutive urine-confirmed abstinent weeks and (ii) improvement in depressive symptoms based on the Hamilton Depression Rating Scale. FINDINGS: The proportion of patients achieving a clinically significant mood improvement (50% decrease in Hamilton Depression score from baseline) was high and did not differ between groups receiving VEN-XR (63%) and placebo (69%) (χ1 (2) = 0.48, P = 0.49). The proportion of patients achieving abstinence was low overall, but was significantly worse on VEN-XR (11.8%) compared to placebo (36.5%) (χ1 (2) = 7.46, P < 0.01; odds ratio = 4.51, 95% confidence interval: 1.53, 13.3). Mood improvement was associated with reduction in marijuana use in the placebo group (F1,179 = 30.49, P < 0.01), but not the VEN-XR group (F1,186 = 0.02, P = 0.89). CONCLUSIONS: For depressed, cannabis-dependent patients, venlafaxine-extended release does not appear to be effective at reducing depression and may lead to an increase in cannabis use.

Do manualized psychosocial interventions help reduce relapse among alcohol-dependent adults treated with naltrexone or placebo? A meta-analysis.

BACKGROUND: During the past decade, several novel medication treatments and psychosocial interventions have been tested. Overall, their impact on reducing alcohol use and preventing relapse has been modest. These outcomes have spurred researchers to investigate whether the addition of manualized psychosocial therapies with demonstrated efficacy to pharmacotherpy would have a synergistic effect. OBJECTIVES: We conducted a meta-analysis to test the hypothesis that the addition of manualized psychosocial therapies would reduce the frequency of relapse. RESULTS: This review analyzed data from six studies. Among studies that used random assignment to manually guided psychosocial interventions, the rates of relapse between the naltrexone plus a psychosocial intervention and naltrexone without a psychosocial intervention were very similar. Among patients allocated to placebo, similar rates of relapse were also found between Cognitive Behavioral Therapy (CBT) and non-CBT. In studies which used manualized psychotherapies as a platform, relapse rates were similar between naltrexone and placebo. In contrast, studies using Treatment As Usual psychotherapy as a platform demonstrated lower rates of relapse in the naltrexone group, compared to placebo group. CONCLUSIONS: We conclude that CBT does not appear to offer benefits beyond those derived from study medications. SCIENTIFIC SIGNIFICANCE: The benefit of the addition of CBT to medication in preventing relapse may be limited.

Does Attention Deficit Hyperactivity Disorder increase the risk of suicide attempts?

OBJECTIVE: To determine if Attention Deficit Hyperactivity Disorder (ADHD) is a risk factor for suicide attempts. METHODS: Data were drawn from the National Comorbidity Replication Survey (NCS-R), a nationally representative sample of adults (N=8098). RESULTS: Of the 365 adults with current ADHD, 16% attempted suicide. After controlling for the presence of comorbid disorders, logistic regression analyses revealed that the ADHD was not a not a strong predictor of suicide attempts; having one or more comorbid disorders was associated with fourfold to twelvefold elevated risk. LIMITATIONS: The small sample size of respondents with ADHD who attempted suicide significantly reduced the probability of determining which specific comorbid disorders were correlated with parasuicide. CONCLUSIONS: Early treatment of ADHD and comorbidity may reduce the risk of suicide attempts and improve its prognosis.

Impairment in psychosocial functioning associated with dysthymic disorder in the NESARC study.

BACKGROUND: Chronic depression is associated with impaired functioning. The National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) is a representative sample (N=43,093) of the United States non-institutionalized population aged 18years and older. We hypothesized that individuals with chronic low-grade depression, dysthymic disorder, would have more impaired functioning than individuals with acute major depression or the general population. METHOD: Diagnoses were generated by the NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The dysthymic disorder (DD) sample (N=328) consisted of DD diagnosis without current MDD. The dysthymic group was not chosen on the basis of alcohol use or abuse. Individuals with MDD with duration ≦24months, without lifetime DD constituted the acute depression (AD) sample (N=712). All other respondents were classified as general population (GP) (N=42,052). Past year functioning was assessed by Supplemental Social Security Income (SSI), employment, and Medicaid statuses. Past month functioning was assessed by Short-form 12-Item Health Survey (SF-12), with scores for social functioning, role emotional functioning, and mental health, using odds ratios. RESULTS: Over the past year, compared to AD, persons with DD were less likely to work full-time (36.2% vs. 44%; OR=0.70, CI=.54,.92) and more often received SSI (13.9% vs. 4.5%; OR=3.4, CI=2.0,5.9) and Medicaid (20.2% vs. 13%; OR=1.7 , CI=1.1,2.6). Dysthymics reported accomplishing less over the past month due to emotional problems, and that emotional or physical problems interfered with social activities. Relative to GP, respondents with DD were more likely to receive SSI (13.9% vs. 2.9%; OR=4.6, CI 3.4,6.2) and Medicaid (20.2% vs. 5.9%; OR=2.9, CI 2.0,4.1). Compared to GP, dysthymics reported accomplishing less due to emotional problems, and that emotional or physical problems interfered with social activities and work functioning. CONCLUSIONS: DD-associated psychosocial impairment in the community setting comprises a significant public health burden.

Does personality disorder decrease the likelihood of remission in early-onset chronic depression?

BACKGROUND: The impact of personality disorders (PD) on the course of depression has been gaining interest among clinical researchers over the past decade. Recent observational studies have found that PD was associated with impaired social functioning and reduced likelihood of depression recovery. Elevated rates of PD have been noted in early-onset and chronic forms subtypes of depression. However, scant data exist regarding the link between PD and outcome for this depression subtype. METHODS: The National Epidemiological Survey on Alcohol and Related Conditions database was analyzed. This survey included 43 093 respondents, 18 years and older, conducted in 2001 through 2002. Logistic regression was used to identify demographic and clinical predictors of remission in early-onset chronic depression. RESULTS: The absence of PD, having more years of education, and being married considerably improved the likelihood of remission. Paranoid personality disorder and obsessive-compulsive disorder were the only specific PD found to be associated with a reduced probability of remission. LIMITATIONS: Depression remission status may have biased the recollection of PD symptoms. Borderline personality disorder, narcissistic personality disorder, and schizotypal personality disorder were not assessed. CONCLUSIONS: This study suggests that PD are significant predictors of remission in early-onset chronic depression.

Does remission from alcohol and drug use disorders increase the likelihood of smoking cessation among nicotine dependent young adults?

BACKGROUND: This article tests the hypothesis that remission from substance use disorders is associated with smoking cessation in nicotine dependent young adults. DESIGN AND METHODS: The sample was composed of 976 young adults with lifetime substance use disorders and nicotine dependence who were subjects in the national epidemiologic survey on alcohol abuse and related conditions (NESARC). The Associated Disabilities Interview Schedule-DSM-IV Version was used to assess lifetime and past year psychiatric disorders. RESULTS: Past year nicotine cessation was obtained by self-report. Remission from substance use disorders was defined as the past year absence of DSM-IV substance use disorders. This study found that remission from substance use disorders increased the likelihood of smoking abstinence (OR=1.7). CONCLUSIONS: Our study found that remission from substance use disorders increased the likelihood of smoking abstinence in early adulthood. This finding is congruent with results from longitudinal studies.

Hypomania with and without Dysphoria: comparison of comorbidity and clinical characteristics of respondents from a national community sample.

OBJECTIVE: To compare rates of comorbidity, treatment utilization, the course of illness, and past year social functioning of Hypomania with and without Dysphoria Hypomania (mixed state). METHOD: The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) was a nationally representative face-to-face survey of 43,093 respondents, aged 18 years and older, conducted in 2001 through 2002. The target population of the survey is the civilian, noninstitutionalized population residing in the United States. RESULTS: Dysphoric Hypomania was associated with an increased lifetime risk for major depression, dysthymic disorder, anxiety disorders and personality disorders compared to Non-Dysphoric Hypomania. The former group had an earlier onset age of major depression, more episodes major depression and hypomania, and had a higher rate of treatment contact than the later group. Past year personal income and the frequency of full-time employment were lower in the Dysphoric Hypomania compared to Non-Dysphoric Hypomania. CONCLUSIONS: Dysphoric Hypomania is a more severe and persistent mood disorder compared to Non-Dysphoric Hypomania.

Efficacy and safety of antidepressant monotherapy in the treatment of bipolar-II depression.

Sparse data exist regarding the risks and benefits of treating bipolar-II depression with antidepressants alone. On the basis of studies of bipolar-I patients, treatment guidelines suggest antidepressants should be augmented with mood stabilizers. Whether these recommendations apply to bipolar-II is unclear. A post-hoc analysis of a double-blind study, which compared the relative efficacy of placebo, imipramine and phenelzine in depressed outpatients. Patients rated 1 ('very much improved') or 2 ('much improved') on the Clinical Global Inventory Scale were considered responders. In an intent to treat analysis, no significant differences between bipolar patients (N=62) and unipolar patients (N=248) in response rates to placebo, imipramine and phenelzine were seen. No patient developed manic symptoms that required medication discontinuation or mood stabilizer augmentation. Antidepressant monotherapy was found to be a safe and effective treatment for bipolar-II depression.

Predictors of cannabis dependence recovery among epidemiological survey respondents in the United States.

Cannabis Dependence remains a highly prevalent disorder in the United States. Though longitudinal studies have accumulated data regarding risk factors and psychosocial correlates of habitual cannabis use, the field lacks knowledge regarding predictors of recovery in community samples. Thus we conducted a secondary data analysis of The National Epidemiological Survey on Alcohol and Related Conditions to address this issue. Recovery was defined as the absence of Cannabis Dependence and Cannabis Abuse during the past year. Logistic Regression analysis revealed that older age, marriage, and non-daily cannabis use were positively associated with recovery.

One-year follow-up study of suicide attempters treated for drug dependence.

A large proportion of patients treated for substance dependencies have attempted suicide. Scarce empirical evidence exists regarding their prognosis. Data from the Drug Abuse Treatment Outcome Survey were analyzed to determine the course of depression and substance dependence of 416 suicide attempters one year after discharge. The likelihood of recovery from drug dependence did not differ between patients who did or did not attempt suicide. Among suicide attempters who recovered from substance dependence, the frequency of Major Depression Disorder was significantly lower compared to admission, but its prevalence was nearly three times higher than that found in the general community.

The effects of alcohol and drug dependence on the course of depression.

There is a paucity of epidemiological data regarding the effects of substance use dependence (SUD) on the course of depression. This study analyzed data from the National Comorbidity Survey (NCS). Among respondents with lifetime SUD and unipolar depression, current SUD increased the risk (OR = 2.9) of past year depression and anxiety disorders (OR = 2.2).

Predictors of treatment contact among individuals with cannabis dependence.

Epidemiological studies have repeatedly shown that cannabis is the most commonly used illegal drug in the United States. Furthermore, individuals with cannabis dependence have high rates of comorbid substance use disorders and depression. A significant proportion of individuals with addictive disorders develop withdrawal symptoms, cannot control their drug use despite substantial adverse psychosocial consequences, and frequently have a coexisting psychiatric disorder. Nevertheless, only a minority of persons with cannabis dependence ever seek treatment. We were unable to locate epidemiological reports regarding treatment seeking behavior among persons with cannabis dependence. Epidemiological studies of populations with substance disorders have observed that employment, higher educational level, previous use of treatment, major depression, and a co-occurring substance dependency increased the probability of seeking treatment for alcohol dependence. Thus we hypothesized that the same variables would predict service use among persons with cannabis dependence. The main findings of this study were that persons with cannabis dependence were more likely to contact a professional during the past year if they previously sought treatment and had alcohol dependence with major depression. Prospective, longitudinal studies of adolescents would increase our understanding of the processes by which individuals identify themselves as having problems related to their habitual use of marijuana, and why some seek help while others do not.

Rates of psychiatric comorbidity among U.S. residents with lifetime cannabis dependence.

Cannabis is the most widely used illegal drug in the U.S. population. Surveys have estimated that the lifetime prevalence rate for cannabis dependence is approximately 4%. Though the presence of a psychiatric disorder increases the likelihood of developing substance dependence, the field lacks data regarding the association between mental disorders and cannabis dependence. The aim of this study is to describe the prevalence of psychiatric disorders among individuals with cannabis dependence. The National Comorbidity Survey was used to obtain these data. We found that 90% of respondents with cannabis dependence had a lifetime mental disorder, compared to 55% without cannabis dependence. Alcohol dependence, antisocial personality disorder, and conduct disorder had the strongest associations with cannabis dependence, followed by anxiety and mood disorders. A large proportion of respondents with internalizing disorders developed mood or anxiety disorders prior to onset of their first cannabis dependence symptom. Data regarding the prevalence of comorbid mental disorders underscore the importance of thorough and systematic evaluation of patients seeking treatment for cannabis dependence. The failure to identify comorbidity may lead to inadequate treatment, and a poorer prognosis.

Comparison of the effects of fluoxetine, imipramine and placebo on personality in atypical depression.

BACKGROUND: Atypical depression is associated with elevated rates of personality disorders. Studies have confirmed the efficacy of a several antidepressants in the treatment of atypical depression. Whether their pathological dimensions of personality diminish after benefitting from effective medication treatment is unclear. AIMS: To determine the extent that pathological dimensions of character improved among patients who benefitted from treatment. METHOD: One-hundred and fifty-four outpatients with DSM-IV Major Depression who met Columbia criteria for atypical depression were randomized to receive fluoxetine, imipramine or placebo for a 10-week double-blind clinical trial. The Temperament and Character Inventory (TCI) was administered at the initiation of treatment and 8 weeks later. Low scores on either of two Character dimensions (Self-Directiveness or Cooperativeness) indicate psychopathology. RESULTS: Responders had a substantial reduction in Harm Avoidance, but post-treatment scores remained significantly higher than the normal control group (NCG). Fluoxetine and Imipramine did not produce different changes on personality, except for Self-Transcendence. LIMITATIONS: High proportion of missing data, inadequate sample size, post-hoc analysis. CONCLUSIONS: Among responders, Self-Directiveness improved and normalized; Harm Avoidance also improved but did not normalize. These data suggests that effective treatments reduce some pathological personality traits as well as improving mood.