The nosological status of neurotic depression: a prospective three- to four-year follow-up examination in light of the primary-secondary and unipolar-bipolar dichotomies.

One hundred patients with "mild" depressive states, variously referred to as "situational," "reactive," or "neurotic," were studied. During a three- to four-year prospective follow-up, 4% had developed bipolar I, 14% bipolar II, and 22% unipolar disorders with predominantly favorable social outcome. Most of the remainder were suffering from nonaffective disorders; in this group, intermittent depressive symptomatology followed a protacted course (paralleling the underlying disorder) with generally unfavorable outcome. Irrespective of diagnostic subtype, a "characterological" component occurring in 24% of the total sample appeared to predict unfavorable prognosis, including three suicides. The diagnostic usage of the concept of neurotic depression may no longer be clinically meaningful, since it lacks sufficient phenomenological characterization and refers to a heterogeneous group of disorders. The data suggest the merits of a biaxial approach to the nosology of depressive disorders whereby phenomenologically based affective diagnoses are qualified as to the presence or absence of character disorder.

Differentiation of primary affective illness from situational, symptomatic, and secondary depressions.

Analysis of family history and antidepressant drug response variables of 100 "neurotic" depressives followed up prospectively over three to four years disclosed that primary depressions (unipolar and bipolar) could be distinguished from nonprimary cases by (1) the early occurrence of "pharmacological-hypomania;" (2) family history of bipolar illness; (3) family history for affective disorder in two or three consecutive generations, especially when "loaded." Although each of these variables alone occurred in only one fifth to one third of the primary group, they individually displayed better than 95% specificity for it. Thus, the confidence with which the diagnosis of primary affective illness could be made in the presence of any of these variables ranged from 88% to 100%. These findings argue for considering such nonsymptomatological variables for their potential in strengthening the phenomenologic diagnostic criteria for depressive illness.

Borderline: an adjective in search of a noun.

Outpatients diagnosed as borderline (N = 100) were prospectively followed for 6-36 months and examined from phenomenologic developmental, and family history perspectives. At index evaluation, 66 met criteria for recurrent depressive, dysthymic, cyclothymic, or bipolar II disorders, and 16 for those of schizotypal personality. Other subgroups included sociopathic, somatization, panic-agoraphobic, attention deficit, epileptic, and identify disorders. Compared with nonborderline personality controls, borderlines had a significantly elevated risk for major affective but not for schizophrenic breakdowns during follow-up. Prominent substance abuse history, tempestuous biographies, and unstable early home environment were common to all diagnostic subgroups. In family history, borderlines were most like bipolar controls, and differed significantly from schizophrenic, unipolar, and personality controls. It is concluded that, despite considerable overlap with subaffective disorders, the current adjectival use of this rubric does not identify a specific psychopathologic syndrome.

Bipolar outcome in the course of depressive illness. Phenomenologic, familial, and pharmacologic predictors.

Twenty percent of a cohort of 206 outpatient depressives with no past bipolar history switched during prospective observation. These 41 probands developed manic periods on the average of 6.4 years (median 4, range 1-25) after their first depressive episode. The change in polarity occurred throughout the life span, but was most common in adolescence and early adulthood. The following variables were found useful in predicting this outcome: onset less than or equal to 25 years, bipolar family history, loaded pedigrees, precipitation by childbirth, hypersomnic-retarded phenomenology, and pharmacologically-mobilized hypomania. Although the respective sensitivities of these findings were relatively low (32-71%), their specificities ranged from 69% to 100% for bipolar outcome; the diagnostic specificity of any 3 of these variables when combined was 98%. When compared with nonbipolar depression, bipolar disorder was seldom chronologically secondary to nonaffective psychiatric disorders. These findings suggest that many young depressives with lethargy and oversleeping are not manifesting a "neurotic" disorder, but rather a precursor of primary bipolar affective disorder. Finally, a psychotically depressed adolescent or young adult with positive bipolar family history should be observed for eventual bipolar outcome, especially when the clinical presentation is that of stupor.

TEMPS-I: delineating the most discriminant traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population.

BACKGROUND: Although most personality constructs have been standardized in population studies, cyclothymic, depressive, irritable and hyperthymic temperaments putatively linked to mood disorders have been classically derived from clinical observations. METHODS: We therefore administered the semi-structured affective temperament schedule of Memphis, Pisa, Paris and San Diego, Interview version (TEMPS-I) -- in its original University of Tennessee operationalization -- to 1010 Italian students aged between 14 and 26. The interview, administered in a randomized format, took 20 min per subject. RESULTS: The semi-structured interview was easy to administer and well accepted by subjects, with no refusals. Principal component analysis with varimax rotation confirmed the hypothesized four-dimensional factor structure of the interview, with good to excellent internal consistency. Furthermore, discriminant analysis and multiple regression provided suggestions for identifying the traits that are most useful in defining a weighted cut-off for each of the temperaments (and which, with minor exceptions, are in agreement with those previously proposed on clinical grounds). In an additional exploratory factorial analysis, a depressive type which loads negatively on hyperthymia was distinguished from cyclothymia; the irritable temperament did not appear to have significant loading on either factor. LIMITATION: All the present analyses were internal to the scale itself, but ongoing studies are comparing them with other systems of temperament as well as testing their clinical cogency for affectively ill populations. CONCLUSION: While more work needs to be done on better operationalization of the irritable temperament, our findings overall support the existence -- in a relatively young nonpatient population -- of cyclothymic, depressive and hyperthymic types according to the classic descriptions of Kraepelin, Kretschmer and Schneider, in their TEMPS-I operationalization. CLINICAL IMPLICATIONS: Coupled with a previous report identifying 10% of the same 14-26-year-old nonpatient population meeting an empirically defined statistical cut-off for these temperaments, the present data define the putative 'fundamental states' that Kraepelin considered to be the personal predisposing anlagé of major affective disorders.