"Barriers to Cognitive Behavioral Therapy Homework Completion Scale- Depression Version": Development and Psychometric Evaluation.

We conducted a two-phase study to develop and evaluate the psychometric properties of an instrument to identify barriers to Cognitive Behavioral Therapy (CBT) homework completion in a depressed sample. In Phase I, we developed an item pool by interviewing 20 depressed patients and 20 CBT therapists. In Phase II, we created and administered a draft instrument to 56 people with depression. Exploratory Factor Analysis revealed a 2-factor oblique solution of "Patient Factors" and "Therapy/Task Factors." Internal consistency coefficients ranged from .80 to .95. Temporal stability was demonstrated through Pearson correlations of .72 (for the therapist/task subscale) to .95 (for the patient subscale) over periods of time that ranged from 2 days to 3 weeks. The patient subscale was able to satisfactorily classify patients (75 to 79 %) with low and high adherence at both sessions. Specificity was .66 at both time points. Sensitivity was .80 at sessions B and .77 at session C. There were no consistent predictors of assignment compliance when measured by the Assignment Compliance Rating Scale (Primakoff, Epstein, & Covi, 1986). The Rating Scale and subscale scores did, however, correlate significantly with assignment non-compliance (.32 to .46).

Heart rate variability in depressed elderly.

OBJECTIVE: The present study examines a measure of cardiac autonomic function, the heart rate variability (HRV), in a group of depressed elderly. Cardiac autonomic abnormalities have been implicated as a potential mediator of cardiovascular events and sudden death in depression. Because aging is associated with decreased cardiac vagal activity, it is possible that autonomic abnormalities are even more pronounced in the older depressed patients. DESIGN: Cross-sectional comparison between those with or without depression. The groups were compared using the Wilcoxon matched-pair sign-rank test. SETTING: Advanced Center for Interventions and Services Research for Late-Life Mood Disorders at University of Pittsburgh Medical Center. PARTICIPANTS: Fifty-three patients with major depression (mean age: 73.3; SD: 7.4; range: 60-93) and an equal number of age and gender-matched subjects as a comparison group. INTERVENTION: None. MEASUREMENTS: Time domain and frequency domain measures of HRV. RESULTS: The groups did not differ in any of the time domain or frequency domain measures of HRV. As expected, subjects without depression displayed decreasing cardiac vagal function with aging (Spearman correlation coefficient r(s) = -0.33, p = 0.02). However, there was no significant change in vagal function with age in the depressed (r = 0.12, p= 0.38). Post-hoc analysis using Fisher's z(r) transformation revealed that the relationship between age and cardiac vagal function was significantly different between the groups (z = 2.32, p = 0.02). CONCLUSIONS: Our findings suggest that age has differential influence on vagal function in individuals with and without depression, a difference with implications for cardiovascular disease risk in depression. Prospective studies of cardiac vagal activity in depressed patients with or without preexisting cardiac disease in different age groups are needed to replicate and extend these findings.

Clinical features and functioning of patients with minor depression.

BACKGROUND: The two essential features of minor depression are that it has fewer symptoms than major depression and that it is less chronic than dysthymia. This study describes the clinical features and functioning of outpatients with minor depression. METHODS: Subjects with minor depression (with and without a prior history of major depression) were recruited through clinical referrals and community advertising. Assessments included the Structured Clinical Interview for DSM-IV (SCID), the 17-item Hamilton Rating Scale for Depression (HAM-D), the Inventory of Depressive Symptomatology-Self Report (IDS-SR) and Clinician Rated (IDS-C) scales, the Global Assessment of Functioning (GAF) scale, the Medical Outcomes Study 36-item Short-Form scale (MOS), and the Clinical Global Impressions Severity Scale (CGI). Data from previously published studies of major depression, minor depression, and normal controls were compared to our data set. RESULTS: Minor depression is characterized primarily by mood and cognitive symptoms rather than vegetative symptoms; the functional impairment associated with minor depression is as severe as for major depression in several areas; minor depression occurs either independently of major depression or as a stage of illness during the long-term course of major depression, and minor depression patients with and without a history of major depression have similar levels of depressive severity and functional impairment. CONCLUSIONS: These findings support the notion that minor depression is an important clinical entity that fits within the larger spectrum of depressive disorders.

Effects of tranylcypromine on the sleep of patients with anergic bipolar depression.

A significant proportion of patients with bipolar disorder are hypersomnolent. It is not clear if this affects response to treatment because few studies have systematically examined treatment effects on sleep in patients with bipolar depression. Reported herein are the results of what we believe to be the first study of the effects of the monoamine oxidase inhibitor tranylcypromine (average dose=37 mg/day) on the sleep of patients with bipolar depression.Twenty-three patients with anergic bipolar depression completed sleep studies before and after pharmacotherapy. Changes in polysomnographic variables were examined using paired t tests. The patients experienced a 40% reduction in rapid eye movement (REM) sleep time, as well as significant decreases in REM percentage,REM activity, number of REM periods, and REM intensity.REM latency was prolonged by nearly 3-fold. The decrease in REM sleep was accompanied by a modest (8%) reduction in total sleep time and increased "light" sleep. There was no change in sleep continuity indices or slow wave sleep. Correlational analyses suggested that antidepressant response was only weakly associated with changes in REM sleep. These findings indicate that tranylcypromine's effects on REM sleep greatly surpass effects on sleep architecture or sleep maintenance. Moreover, effective treatment of bipolar depression did not "normalize" the hypersomnolence associated with bipolar depression.

Effects of sertraline on sleep architecture in patients with depression.

Previous studies indicate that selective serotonin reuptake inhibitors (SSRIs), including fluoxetine, fluvoxamine, citalopram and paroxetine, suppress rapid eye movement sleep, and increased nocturnal arousals. There has been no published report of the impact of sertraline on the sleep of depressed patients. This study examines such effects. Forty-seven patients with major depressive disorder, randomized to double-blind treatment with sertraline or placebo, completed sleep studies before and after 12 weeks of pharmacotherapy. Groups were compared using multivariate analyses of covariance and/or analyses of covariance to examine 4 empirically defined sets of sleep measures. Compared to the placebo-treated group, patients who received sertraline experienced an increase in delta wave sleep in the first sleep cycle and prolonged rapid eye movement (REM) sleep latency. Although, sertraline therapy decreased the average number of REM periods (from 3.86 to 2.40), the activity of both REM period 1 and REM period 2 was significantly increased. Aside from an increase in sleep latency, sertraline therapy was not associated with a worsening of measures of sleep continuity. There was also no significant difference between the groups on a measure of subjective sleepiness. These findings are both similar and different from those observed in previous studies of other SSRIs. The increase in delta sleep ratio and consolidation of REM sleep may have some other clinical implications. However, the generalizability of these findings is limited because of a number of reasons. Further studies are needed to examine the effects of SSRIs in acute treatment of depressed patients with severe insomnia, and the relationship of acute changes and relapse prevention of recurrent depression.

Electroencephalographic sleep profiles in single-episode and recurrent unipolar forms of major depression: II. Comparison during remission.

BACKGROUND: Previous studies indicate that recurrent forms of depression are associated with greater biological disturbances as compared to single-episode cases. This study examines whether the observed differences in the sleep patterns during recurrent and single-episode depression persist into remission following nonpharmacologic treatment. METHODS: Two groups of patients (27 single episode [SE] and 53 recurrent unipolar [RU]) with major depression underwent sleep studies before and after nonpharmacologic treatment. Groups were equated for age, severity, and proportion of men and women. Groups were compared using multivariate analyses of covariance and/or analyses of covariance to examine six sets of sleep measures. RESULTS: The differences observed between the SE and RU groups during the index episode persisted into early remission. The findings of greater disturbances of sleep continuity, rapid eye movement sleep and diminished slow wave sleep in the RU group supports the hypothesis that recurrent depression is associated with a more severe neurophysiological substrate than clinically comparable SE cases. CONCLUSIONS: Although these observations are consistent with an illness progression model, the possibility that recurrent affective illness is associated with a more virulent, stable phenotype cannot be ruled out. Resolution of this issue requires longitudinal and family studies.

Spousally Bereaved Elders With Subsyndromal Depression: A Descriptive Analysis and Comparison With Major Depression.

The authors compared the frequency and severity of symptoms in subsyndromal and major depression after spousal bereavement in later life, as well as measures of social support, functional status, and grief intensity. Subsyndromal subjects (n = 25, mean age = 68.1) experienced fewer and less severe depressive symptoms and less functional impairment and anxiety than subjects with major depression (n = 25, mean age = 68.5). In a multivariate discriminant-function analysis (taking into account both symptom frequency and severity), mood, anxiety, early morning awakening, and weight loss correctly identified 92% of subsyndromal subjects and 92% of those with major depression. Further longitudinal study is under way to document the relationship of the current differences in symptomatology and clinical status to clinical outcome.

Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?

The authors determined differential clinical correlates of active suicidal ideation vs. passive death wish in elderly patients with recurrent major depression. Measures of lifetime suicidal behavior and ratings of suicidal ideation, hopelessness, and depression determined "ideator" status. Active and Passive Ideators as well as Non-Ideators were then compared. Sixty percent of Active Ideators endorsed disgust or self-hatred items on the Beck Depression Inventory, compared with only 25% of Passive Ideators and 20% of Non-Ideators. However, these data challenge the clinical utility of distinguishing active and passive suicidal ideation among such patients because the two groups overall appear to be more alike than different, and ideator status (passive vs. active) may change during an episode. Clinicians should therefore not be less clinically vigilant if such patients' suicidal ideation is "only" passive.

The Symptom Profile and Two-Year Course of Subsyndromal Depression in Spousally Bereaved Elders.

The authors describe the symptom presentation and clinical course of subsyndromal depression in 20 bereaved elderly persons (mean age = 68.0 years) over a period of 2 years from spousal loss. Clinical ratings on measures of general functioning, depressive symptoms, sleep disturbance, medical burden, social support, and social rhythm stability were contrasted for bereaved subjects with subsyndromal depression, nondepressed bereaved subjects, and control subjects who were neither bereaved nor depressed. Subsyndromally depressed subjects had greater impairment in work and pleasure and more pronounced anxiety. Over follow-up, they showed persistently higher bereavement intensity and were more impaired than nondepressed, bereaved subjects on measures of general functioning, sleep quality, and social support, suggesting that subsyndromally depressed, bereaved persons experience greater functional impairment, worse sleep quality, less perceived interpersonal support, and more intense grieving than non-depressed, bereaved subjects up to 2 years after spousal loss.

Two-Year Survival in Patients With Mixed Symptoms of Depression and Cognitive Impairment: Comparison With Major Depression and Primary Degenerative Dementia.

The authors compared the 2-year survival rates of patients with 1) mixed clinical presentations (n=58), 2) major depression without cognitive impairment (n = 51), and 3) primary degenerative dementia without depression (n = 34). Two-year survival rates were 100% in healthy controls, 91% in patients with major depression, and 76.1% and 78.3%, respectively, in patients with primary degenerative dementia and mixed symptoms. Patients with cognitive impairment (either primary degenerative dementia or mixed symptoms) were 2.55 times more likely to die within the 2-year follow-up than patients with major depression. These data are consistent with previous observations that survival rates of elderly patients with organic mental syndromes are lower than those of elderly patients with "functional" or "psychogenic" disorders.