Prediction of recurrence in recurrent depression and the influence of consecutive episodes on vulnerability for depression: a 2-year prospective study.

OBJECTIVE: Depression is a recurring disease. Identifying risk factors for recurrence is essential. The purpose of this study was to identify factors predictive of recurrence and to examine whether previous depressive episodes influence vulnerability for subsequent depression in a sample of remitted recurrently depressed patients. METHOD: Recurrence was examined prospectively using the Structured Clinical Interview for DSM-IV Axis I Disorders in 172 euthymic patients with recurrent depression (DSM-IV) recruited from February 2000 through September 2000. Illness-related characteristics, coping, and stress (life events and daily hassles) were examined as predictors. RESULTS: Risk factors for recurrence were a high number of previous episodes, more residual depressive symptomatology and psychopathology, and more daily hassles. Factors with both an increasing and decreasing pathogenic effect with increasing episode number were detected. CONCLUSION: We found some support for dynamic vulnerability models that posit a change of vulnerability with consecutive episodes. Preventive interventions should be considered in patients with multiple recurrences, focusing on residual symptomatology and specific coping styles.

Preventing relapse/recurrence in recurrent depression with cognitive therapy: a randomized controlled trial.

This article reports on the outcome of a randomized controlled trial of cognitive group therapy (CT) to prevent relapse/recurrence in a group of high-risk patients diagnosed with recurrent depression. Recurrently depressed patients (N = 187) currently in remission following various types of treatment were randomized to treatment as usual, including continuation of pharmacotherapy, or to treatment as usual augmented with brief CT. Relapse/recurrence to major depression was assessed over 2 years. Augmenting treatment as usual with CT resulted in a significant protective effect, which intensified with the number of previous depressive episodes experienced. For patients with 5 or more previous episodes (41% of the sample), CT reduced relapse/recurrence from 72% to 46%. Our findings extend the accumulating evidence that cognitive interventions following remission can be useful in preventing relapse/recurrence in patients with recurrent depression.

Psychiatric disorders in a representative sample of incarcerated boys in the Netherlands.

OBJECTIVE: To determine the prevalence of psychiatric disorders among incarcerated male adolescents and to investigate the influence of psychopathology on allocation to either plain detention or detention with compulsory treatment. METHOD: A cross-sectional study of a representative sample (N = 204) of incarcerated boys aged 12 to 18, using the Diagnostic Interview Schedule for Children (DISC). Data were collected from December 1998 to December 1999. RESULTS: Of the eligible subjects, 79% agreed to participate. Ninety percent reported at least one psychiatric disorder: disruptive behavior disorder 75% (95% confidence interval [CI]: 68-81%), substance use disorder 55% (95% CI: 48-63%), psychotic symptoms 34% (95% CI: 27-41%), ADHD 8% (95% CI: 5-13%), anxiety disorder 9% (95% CI: 6-15%), and affective disorder 6% (95% CI: 3-10%). After controlling for a broad range of sociodemographic characteristics and former treatment parameters, the presence of a psychiatric disorder was not associated with allocation to compulsory treatment. CONCLUSIONS: Compared with North American studies, relatively low rates of anxiety and affective disorders were found, probably due to the better availability of mental health services to disadvantaged youths with internalizing problems in the Netherlands. It should be examined whether standardized psychiatric assessments can improve the efficiency of allocation to detention programs with or without psychiatric treatment options.

Psychotic symptoms among male adolescent detainees in The Netherlands.

This study investigated the prevalence of psychotic symptoms among incarcerated boys as well as the relationship between these symptoms and violent offending and criminal recidivism. The presence of psychotic symptoms was assessed in a representative sample of 204 incarcerated boys aged 12-18 using the Diagnostic Interview Schedule for Children (DISC-2.3). Seventy-two percent of the study participants had committed a violent index offense and 30 percent were criminal recidivists. Thirty-four percent (95% confidence interval [CI]: 27-41%) were DISC-2.3 psychosis screen positive: 25% (95% CI: 19-31%) reported at least one pathognomonic of schizophrenia symptom and 9% (95% CI: 6-14%) reported at least three non-pathognomonic psychotic symptoms. In addition, 33 percent (95% CI: 26-40%) reported one or two isolated, atypical psychotic symptoms. The presence of psychotic symptoms was not associated with violent offending or criminal recidivism. The high prevalence rate of psychotic symptoms among incarcerated boys calls for increased attention to diagnosis and treatment of psychosis. To obtain conclusive answers regarding the relationship between psychosis and violent offending, additional studies are needed in general population samples.

Sustained medically unexplained physical symptoms in euthymic patients with recurrent depression: predictive value for recurrence and associations with omega 3- and 6 fatty acids and 5-HTTLPR?

BACKGROUND: Identification of potentially modifiable risk factors for recurrence in recurrent depression could provide opportunities to improve preventive interventions. In this study we aimed to examine the predictive value of medically unexplained physical symptoms (MUPS) on time to recurrence in recurrent depression. Additionally, to elucidate pathophysiological mechanisms that could explain the relations between MUPS and depression, we investigate the association between a sustained high level of MUPS, and (I) omega (ω)-3 and -6 fatty acid (FA)-status and (II) functional polymorphisms in the promoter region of the serotonin transporter gene (5-HTTLPR). METHODS: Based on three Physical Symptom Checklist (PCS) scores over 12 months, we defined two groups of remitted recurrently depressed patients: 41 patients with a sustained high number of MUPS and 34 patients with a sustained low number or no MUPS. Patients were followed-up for 3.5 years while recurrence of their depression was monitored. In addition, we analyzed patients' erythrocyte's FA-profiles and triallelically genotyped their 5-HTTLPR. RESULTS: A sustained high level of MUPS predicted consecutive depression recurrence over 3.5 years (adjusted relative risk 2.8). FA-status and distribution of 5-HTTLPR variant frequencies did not differ between patients with sustained high compared to low/absent MUPS-levels. LIMITATIONS: Our sample was relatively small. CONCLUSION: Remitted recurrently depressed patients with sustained MUPS have a considerably increased risk of recurrence. Having sustained MUPS is not associated with either erythrocyte ω-3 or -6 FA-levels or 5-HTTLPR polymorphism. Recognition and reducing MUPS in an early state could prevent a (depressive) relapse.

Long-term effects of preventive cognitive therapy in recurrent depression: a 5.5-year follow-up study.

OBJECTIVE: Major depressive disorder (MDD) was projected to rank second on a list of 15 major diseases in terms of burden in 2030. A crucial part of the treatment of depression is the prevention of relapse/recurrence in high-risk groups, ie, recurrently depressed patients. The long-term preventive effects of group cognitive therapy (CT) in preventing relapse/recurrence in recurrent depression are not known. This article reports on the long-term (5.5-year) outcome of a randomized controlled trial to prevent relapse/recurrence in patients with recurrent depression. We specifically evaluated the long-term effects of CT in relation to the number of previous episodes experienced. METHOD: From February through September 2000, patients with recurrent depression (DSM-IV-diagnosed) who were in remission (N = 172) were recruited from primary and specialty care facilities. They were randomly assigned to treatment as usual (TAU) versus TAU augmented with brief group CT. The primary outcome measure was time to relapse/recurrence, which was assessed over 5.5 years. RESULTS: Over 5.5 years, augmenting TAU with CT resulted in a significant protective effect (P = .003), which intensified with the number of previous depressive episodes experienced. For patients with 4 or more previous episodes (52% of the sample), CT significantly reduced cumulative relapse/recurrence from 95% to 75% (medium effect size). CONCLUSIONS: Our findings indicate that brief CT, started after remission from a depressive episode on diverse types of treatment in patients with multiple prior episodes, has long-term preventive effects for at least 5.5 years. Implementation of brief relapse prevention CT should be considered in the continued care of patients with recurrent depression. TRIAL REGISTRATION: ccmo-online.nl Identifier: NTR454.

Differential predictors of response to preventive cognitive therapy in recurrent depression: a 2-year prospective study.

BACKGROUND: Major depressive disorder is a recurrent disease. Brief cognitive therapy (CT), added to either regular care or medication, is helpful in preventing relapse/recurrence. Little is known which type of persons benefit from preventive CT, the so called 'aptitude treatment interaction' effect. METHOD: The present cohort included exclusively patients with at least two previous episodes remitted on various types of treatments (n = 172). They were assessed within a clinical trial comparing treatment as usual (TAU) with preventive CT added to TAU. Differential demographic, illness-related, psychological and biological risk factors in postponing recurrence by preventive CT were examined. RESULTS: Significant aptitude-treatment-interaction effects were found for the number of previous episodes, daily hassles and life events, avoidant coping, gender, and morning cortisol levels. Preventive CT seemed ineffective in patients with life events (as more frequently reported by women in our study) and in patients with high episode number characterized by higher levels of avoidant coping. Generic predictors indicate that in CT, as in TAU, patients with more residual depressive symptomatology and higher levels of dysfunctional attitudes profit less from preventive CT. CONCLUSION: The finding that preventive CT protects against the influence of a consistently found risk factor of relapse/recurrence, i.e. the number of depressive episodes, underlines the potential of psychological preventive interventions. Preventive CT seemed to be especially effective in reducing presumably internally provoked, relapse/recurrence but may be quite ineffective in reducing externally provoked relapse/recurrence. CT possibly prevents either stress generation or disrupts kindling effects. Kindling effects probably cannot be disrupted in patients with higher levels of avoidant coping who experienced a high number of episodes, and patients who experienced life events.

Substance use, substance use disorders, and comorbidity patterns in a representative sample of incarcerated male Dutch adolescents.

The aim of this study was to investigate the prevalence of substance use and substance use disorders (SUDs) among incarcerated boys, and comorbidity patterns and the relationship between SUDs and violent offending and criminal recidivism. The presence of SUDs and other psychiatric disorders was assessed in a representative sample of 204 incarcerated boys aged 12 to 18 years using the Diagnostic Interview Schedule for Children (DISC). Ninety-two percent had used alcohol, 86% had used cannabis, and 33% had used other substances. The 6-month prevalence of SUDs was 55%, and 22% reported polysubstance abuse or dependence. SUDs were positively associated with comorbid externalizing and psychotic disorders. Substance dependence was negatively associated with violent offending but not with criminal recidivism. These high prevalence rates call for more attention to diagnosis and management of SUDs among incarcerated male adolescents. The negative association between substance dependence and the violent nature of the index offense needs further investigation.