Adjunctive yoga v. health education for persistent major depression: a randomized controlled trial.

BACKGROUND: The objective of this study was to determine whether hatha yoga is an efficacious adjunctive intervention for individuals with continued depressive symptoms despite antidepressant treatment. METHOD: We conducted a randomized controlled trial of weekly yoga classes (n = 63) v. health education classes (Healthy Living Workshop; HLW; n = 59) in individuals with elevated depression symptoms and antidepressant medication use. HLW served as an attention-control group. The intervention period was 10 weeks, with follow-up assessments 3 and 6 months afterwards. The primary outcome was depression symptom severity assessed by blind rater at 10 weeks. Secondary outcomes included depression symptoms over the entire intervention and follow-up periods, social and role functioning, general health perceptions, pain, and physical functioning. RESULTS: At 10 weeks, we did not find a statistically significant difference between groups in depression symptoms (b = -0.82, s.e. = 0.88, p = 0.36). However, over the entire intervention and follow-up period, when controlling for baseline, yoga participants showed lower levels of depression than HLW participants (b = -1.38, s.e. = 0.57, p = 0.02). At 6-month follow-up, 51% of yoga participants demonstrated a response (⩾50% reduction in depression symptoms) compared with 31% of HLW participants (odds ratio = 2.31; p = 0.04). Yoga participants showed significantly better social and role functioning and general health perceptions over time. CONCLUSIONS: Although we did not see a difference in depression symptoms at the end of the intervention period, yoga participants showed fewer depression symptoms over the entire follow-up period. Benefits of yoga may accumulate over time.

Family functioning and major depression: an overview.

The authors review the evidence supporting the idea that the family plays a major role in the development and course of major depression. They find that the family pathology evident during an acute depressive episode continues after the patient's remission; that the course of depressive illness, relapse rates, and suicidal behavior are all affected by family functioning; and that children of depressed parents are at high risk for psychopathology. The authors explore unresolved issues regarding our understanding of the factors mediating the interaction between major depression and family functioning, concluding that there is evidence to support family and marital interventions, particularly in the treatment of depressed women.

Psychosocial characteristics of "double depression".

Thirty-nine patients with "double depression" (major depression and dysthymia) were compared to 38 patients with recurrent major depression without dysthymia on a number of severity of illness, psychosocial, and biological variables. No significant differences were found on any psychosocial or biological measure.

Cognitive-behavioral treatment of depressed inpatients: six- and twelve-month follow-up.

The authors report 6- and 12-month follow-up data for 45 depressed inpatients who were randomly assigned to either standard treatment (hospital milieu therapy, pharmacotherapy, clinical management sessions), cognitive therapy plus standard treatment, or social skills training plus standard treatment. All treatments began in the hospital and continued for 4 months after discharge on an outpatient basis. Significantly higher proportions of the patients who received additional cognitive-behavioral treatment (cognitive therapy or social skills) had responded by the end of the formal treatment period and did not relapse for the remainder of the 1-year follow-up period.

12-month outcome of patients with major depression and comorbid psychiatric or medical illness (compound depression).

OBJECTIVE: Inpatients with major depressive illness often have coexistent nonaffective psychiatric and/or medical conditions. The authors' objective is to address the following questions: 1) What is the effect of comorbid illness on the severity of major depression and associated psychosocial factors? 2) How does the course of depression differ for patients with and without concurrent illness? 3) Do patients with compound depression differ in rate of recovery and time to recovery from patients with pure depression? METHOD: The subjects were 78 patients with a DSM-III diagnosis of major depression who were consecutively admitted to an acute care university-affiliated psychiatric hospital; 37 of these patients had major depression only and 41 had major depression compounded by a coexisting axis I, II, or III condition. The patients were studied while hospitalized and for 12 months after hospital discharge. Instruments used included the Modified Hamilton Rating Scale for Depression, the Global Assessment Scale, and the Social Readjustment Rating Scale. RESULTS: Patients with compound depression reported significantly poorer functioning over the 12-month follow-up period and had lower recovery rates than the patients with pure depression. There were no differences in recovery rates between men and women with compound depression, but significantly more men than women with pure depression recovered. CONCLUSIONS: Compound depression is a common clinical occurrence, the course of illness is more difficult for patients with compound depression than for patients with pure depression, and the recovery rate of patients with compound depression is lower than that of patients with pure depression.

Recovery and major depression: factors associated with twelve-month outcome.

OBJECTIVE: In spite of the prevalence and chronicity of major depression, there is no consensus regarding which clinical and psychosocial variables are associated with recovery. The authors examined the probability of recovery from a major depressive episode 12 months after hospital discharge, the factors most closely associated with recovery, and the patterns of improvement distinguishing patients who recovered from those who did not. METHOD: Seventy-eight inpatients with a DSM-III diagnosis of major depression were assessed at hospitalization and at monthly intervals for 12 months after discharge on a variety of clinical and psychosocial factors. Recovery status at 12-month follow-up was then used as a basis for comparing acute-phase patient characteristics and change in symptoms over time. RESULTS: By the 12th month of follow-up, 34 (48.6%) of 70 patients met criteria for recovery. The five most important factors related to recovery were shorter length of hospital stay, older age at onset of depression, better family functioning, fewer than two previous hospitalizations, and absence of comorbid illness. The majority of patients who had recovered by 12 months had done so within 6 months of discharge; the average length of time to recovery was 4.9 months. CONCLUSIONS: Patients hospitalized for major depression have less than a 50-50 chance of recovering by 1 year. Some variables associated with nonrecovery (e.g., comorbid illness, poor family functioning) are amenable to clinical intervention; however, findings also suggest that there may be two distinct types of depressive illness with respect to recovery, one that remits quickly and the other with a more prolonged course of illness.

Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention.

OBJECTIVE: This study investigated whether a preventive intervention based on the principles of interpersonal psychotherapy administered to pregnant women would reduce the risk of postpartum major depression. METHOD: Thirty-seven pregnant women receiving public assistance who had at least one risk factor for postpartum depression were randomly assigned to a four-session group intervention or to a treatment-as-usual condition. Thirty-five of the women completed the study. Structured diagnostic interviews were administered to assess for postpartum major depression. RESULTS: Within 3 months after they gave birth, six (33%) of the 18 women in the treatment-as-usual condition had developed postpartum major depression, compared with none of the 17 women in the intervention condition. CONCLUSIONS: A four-session interpersonal-therapy-oriented group intervention was successful in preventing the occurrence of major depression during a postpartum period of 3 months in a group of financially disadvantaged women.

Role of the family in recovery and major depression.

OBJECTIVE: Major depression is significantly influenced by the family environment of the depressed patient. In order to explore how family functioning relates to this illness, the authors examined changes in family functioning over a 1-year course of major depression. METHOD: Subjective (Family Assessment Device) and objective (McMaster Clinical Rating Scale) assessments of family functioning were collected at hospitalization and 6 and 12 months after discharge for 45 inpatients diagnosed with major depression and their family members. Patterns of family functioning were examined by subjective and objective perspectives, initial levels of functioning, and reports of patients and other family members. RESULTS: Approximately 50% of families with a depressed member perceived their own family functioning as unhealthy; clinicians rated 70% of the families as unhealthy. While family functioning improved significantly from hospitalization through 12 months after discharge, the improvement was not uniform across all areas of functioning. Further, patients with good family functioning at hospitalization generally maintained their healthy functioning and were more likely to recover by 12 months than patients with poor family functioning. Although steady improvement in family functioning characterized the subjective ratings, objective assessments of family functioning suggested initial improvement followed by a decline from month 6 to month 12. CONCLUSIONS: Results show a clear association between family functioning and recovery from major depression. Different aspects of family life respond differently to the depressive illness; no one family dimension was uniquely related to outcome.

Course of illness and maintenance treatments for patients with bipolar disorder.

BACKGROUND: Both naturalistic studies and treatment research on bipolar disorder are reviewed to describe its clinical course, the need for maintenance therapy, the efficacy of current pharmacologic prophylaxis, and the empirical basis for more comprehensive approaches to treatment. METHOD: Articles were identified through computerized literature searches and from bibliographies of published studies, review articles, and textbooks. RESULTS: Bipolar disorder is marked by multiple relapses and recurrences, as well as significant interepisode psychopathology. Within 1 year of recovery from a mood episode, half of all patients will have suffered a second episode. Various clinical and demographic variables have been investigated as risk factors for recurrence. Although lithium represents the single greatest advance in the treatment of this disease, it is clear that a substantial number of patients fail lithium prophylaxis, including those with a high frequency of prior episodes, mixed (dysphoric) mania, comorbid personality disturbance, and rapid cycling. The foremost pharmacologic alternatives to lithium are the anticonvulsants carbamazepine and valproate. Increased recognition of the psychosocial sequelae of bipolar disorder and the limitations of pharmacotherapy alone have led to the investigation of psychosocial interventions. These preliminary studies are small in number and of poor quality for the most part, but have nevertheless yielded positive findings. CONCLUSION: Although lithium often fails to meet the clearly established need for prophylactic treatment, there is little evidence from rigorous clinical trials to support the wide-spread use of anticonvulsants in maintenance therapy. Treatment research should further examine these medications and the use of psychosocial treatments as adjuvants to pharmacotherapy.

A pilot study of lithium carbonate plus divalproex sodium for the continuation and maintenance treatment of patients with bipolar I disorder.

BACKGROUND: This pilot study compared the efficacy of lithium plus divalproex sodium with the efficacy of lithium alone for the continuation and maintenance treatment of patients with bipolar I disorder. METHOD: Twelve patients with bipolar I disorder as defined by the DSM-III-R were recruited and followed prospectively for up to 1 year. Each subject received lithium at serum levels of 0.8 to 1.0 mmol/L and a management/education session weekly or every 2 weeks. By random assignment, subjects received either divalproex sodium or placebo in conjunction with lithium. Divalproex sodium was adjusted to achieve a serum concentration of 50 to 125 micrograms/mL. Adjunctive medications were used on an as needed basis to treat psychosis, depression, and anxiety. The course of illness was monitored through use of the Longitudinal Interval Follow-up Examination. RESULTS: Subjects treated with the combination of lithium and divalproex were significantly less likely to suffer a relapse or recurrence (p = .014), but were significantly more likely to suffer at least one moderate or severe adverse side effect (p = .041). There was no significant difference between groups in the use of adjunctive medication. CONCLUSION: These results provide preliminary evidence of the risks and benefits of combining lithium with divalproex sodium for the continuation and maintenance treatment of bipolar I disorder.

Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine.

BACKGROUND: The literature on predictors of response to treatment of nonchronic major depression has identified shorter duration of illness, acute onset, and less severity of illness as positive predictors. Unfortunately, there are almost no data on predictors of response to treatment for chronic depression. This study examined predictors of response to pharmacotherapy (sertraline or imipramine) in the treatment of outpatients who had DSM-III-R-defined chronic major or double depression. METHOD: The acute phase of the Chronic Major Depression and Double Depression Study is a double-blind, randomized, parallel-group 12-week comparison of sertraline and imipramine. Analyses are based on 623 patients who comprised the intent-to-treat sample, of whom 299 were nonresponders and 324 were responders, defined by a priori criteria as either remission or satisfactory therapeutic response. A stepwise logistic multiple regression analysis was performed on candidate clinical, psychosocial, and demographic variables previously identified as statistically significant in an attempt to develop a predictive model of positive antidepressant response. RESULTS: The sociodemographic variables that were predictive of positive response included living with spouse or partner or being at least a high school graduate. With regard to symptomatology and clinical history, responders had significantly lower baseline depression severity scores. In general, comorbid anxiety, substance abuse, and personality disorders did not influence rates of response. However, the presence of depressive personality traits was associated with a higher nonresponse rate. Among psychosocial variables, longer duration of personal relationships as well as higher baseline quality of life were associated with positive response. A stepwise logistic multiple regression identified 5 variables-living with spouse or partner, higher educational level, passive-aggressive personality, lower introverted-tense personality traits, and higher quality of life--that significantly and independently contributed to the predictive model. This model correctly classified 67% of patients. CONCLUSION: A higher baseline quality of life, living with spouse or partner, and having more education were the strongest predictors of response to acute pharmacotherapy among chronically depressed patients. Clinical variables and comorbidity were not identified as independent predictors, although personality traits did appear to influence treatment response. Overall, the predictive value of these baseline measures was modest, and therefore of limited clinical utility.

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine.

BACKGROUND: Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported. METHOD: We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples. RESULTS: Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples. CONCLUSION: These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Cognitive therapy with depressed inpatients: specific effects on dysfunctional cognitions.

Specificity of cognitive change following cognitive therapy for depression was assessed in 39 depressed inpatients who completed either a standard inpatient treatment (pharmacotherapy and milieu management) or the standard treatment plus cognitive therapy. Following treatment, patients in both groups endorsed fewer dysfunctional cognitions on 2 of 4 measures of cognitive distortion. Compared with patients receiving only the standard treatment, patients also receiving cognitive therapy reported less hopelessness and fewer cognitive biases at posttreatment and 6- and 12-month follow-up assessments and fewer dysfunctional attitudes at the 6-month follow-up. Treatment effects for dysfunctional cognitions were found even though the treatment groups did not differ in depression severity, suggesting that results did not reflect state-dependent differences between treatments secondary to difference in depression.

Cognitive-behavioral treatment for depression in alcoholism.

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.

Cognitive-behavioral treatment for depression in smoking cessation.

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Personality and family functioning in families of depressed patients.

In this cross-sectional study, the authors attempted to identify correlates of family functioning in 86 couples with a depressed member during the acute phase of the patient's depression. Demographic variables, psychiatric status, and personality traits of both the patient and spouse were investigated as potential predictors of family functioning. Regression analyses indicated that lower levels of personality pathology in the patient, higher levels of patient conscientiousness, and less psychological distress in the spouse were associated with healthier family functioning. Future research implications and clinical importance of these findings are discussed.

Depressed patients with dysfunctional families: description and course of illness.

Sixty-eight depressed patients were subdivided according to their family's level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels of neuroticism. A 12-month follow-up of these patients indicated that depressed patients with dysfunctional families had a significantly poorer course of illness, as manifested by higher levels of depression, lower levels of overall adjustment, and a lower proportion of recovered patients. Thus, impaired family functioning appears to be an important prognostic factor in major depression.

Combined medication and psychotherapy in the treatment of chronic mood disorders.

This article discusses the use of combined treatments for patients with chronic mood disorders. Although very little research concerning the efficacy of combined treatments for patients with chronic depression exists, clinical experience and limited available research suggest that combined treatment may be the most effective treatment option available for this population. The use of combination treatment involving pharmacotherapy, individual psychotherapy, and marital/family therapy is recommended to address the complex biopsychosocial issues involved in chronic mood disorders. Other theoretical and pragmatic issues concerning the delivery of combined treatment also are discussed.

Psychosocial factors and the long-term course of major depression.

Fifty-nine subjects participated in a telephone follow-up interview 6 years after being hospitalized with a severe major depressive episode and 5 years after completing a 12 month follow-up study. Patient information was used to provide a rating of symptom-free (n = 19), episodic (n = 30), or chronic (n = 10) that described each patient's long-term course of illness. Few variables from the acute stage were related to long-term course of illness; however, early patterns of global and family functioning, number of life events, and rapid reduction in depressive symptomatology were found to be of prognostic significance. For patients whose depression is severe enough to warrant hospitalization, the pattern of functioning in the first few months after discharge from hospital is a strong indicator of the future long-term course.

MMPI, personality dysfunction and the dexamethasone suppression test in major depression.

In this study we examined the relationship of psychopathology and personality dysfunction to neuroendocrine functioning. MMPI profiles were examined for 30 psychiatric inpatients with major depression who were suppressors (60%) and nonsuppressors (40%) on the dexamethasone suppression test. There were no differences between suppressors and nonsuppressors on any of the MMPI scales or on DSM-III Axis-II diagnosis. When subdivided according to T-score elevations above 70 on MMPI scales 4 and 6, or 4 and 9, 30% of the sample, however, met criteria for personality dysfunction. Furthermore, a significantly higher proportion of suppressors (50%) evidenced personality dysfunction than did the nonsuppressors (8%). This suggests that certain MMPI scales are able to identify a subgroup of depressed patients with personality disturbances who also have a hypothalamic-pituitary-adrenal dysfunction.