Common mental disorder diagnosis and need for treatment are not the same: findings from a population-based longitudinal survey.

BACKGROUND: Controversy exists regarding whether people in the community who meet criteria for a non-psychotic mental disorder diagnosis are necessarily in need of treatment. Some have argued that these individuals require treatment and that policy makers need to develop outreach programs for them, whereas others have argued that the current epidemiologic studies may be diagnosing symptoms of distress that in many cases are self-limiting and likely to remit without treatment. All prior studies that have addressed this issue have been cross-sectional. We examined the longitudinal outcomes of individuals with depressive, anxiety and substance use (DAS) disorder(s) who had not previously received any treatment. Method Data came from a nationally representative US sample. A total of 34 653 non-institutionalized adults (age ≥20 years) were interviewed at two time points, 3 years apart. DAS disorders, mental health service use and quality of life (QoL) were assessed at both time points. RESULTS: Individuals with a DAS disorder who had not previously received any treatment were significantly more likely than those who had been previously treated to have remission of their index disorder(s) without subsequent treatment, to be free of co-morbid disorder(s) and not to have attempted suicide during the 3-year follow-up period (50.7% v. 33.0% respectively, p < 0.05). At wave 2, multiple linear regression demonstrated that people with a remission of their baseline DAS disorder(s) had levels of functioning similar to those without a DAS disorder. CONCLUSIONS: Individuals with an untreated DAS disorder at baseline have a substantial likelihood of remission without any subsequent intervention.

Subsyndromal depression in the United States: prevalence, course, and risk for incident psychiatric outcomes.

BACKGROUND: Subsyndromal depression (SD) may increase risk for incident major depressive and other disorders, as well as suicidality. However, little is known about the prevalence, course, and correlates of SD in the US general adult population. Method Structured diagnostic interviews were conducted to assess DSM-IV Axis I and II disorders in a nationally representative sample of 34 653 US adults who were interviewed at two time-points 3 years apart. RESULTS: A total of 11.6% of US adults met study criteria for lifetime SD at Wave 1. The majority (9.3%) had <5 total symptoms required for a diagnosis of major depression; the remainder (2.3%) reported ⩾5 symptoms required for a diagnosis of major depression, but denied clinically significant distress or functional impairment. SD at Wave 1 was associated with increased likelihood of developing incident major depression [odds ratios (ORs) 1.72-2.05], as well as dysthymia, social phobia, and generalized anxiety disorder (GAD) at Wave 2 (ORs 1.41-2.92). Among respondents with SD at Wave 1, Cluster A and B personality disorders, and worse mental health status were associated with increased likelihood of developing incident major depression at Wave 2. CONCLUSIONS: SD is prevalent in the US population, and associated with elevated rates of Axis I and II psychopathology, increased psychosocial disability, and risk for incident major depression, dysthymia, social phobia, and GAD. These results underscore the importance of a dimensional conceptualization of depressive symptoms, as SD may serve as an early prognostic indicator of incident major depression and related disorders, and could help identify individuals who may benefit from preventive interventions.

Persistent pro-inflammatory cytokines following the initiation of pegylated IFN therapy in hepatitis C infection is associated with treatment-induced depression.

Pegylated interferon (IFN), the basis for chronic hepatitis C virus (HCV) treatment, causes depression in 30-40% of patients. The potential for cytokine mRNA patterns from baseline into early treatment to associate with the onset of treatment-induced depression (TID) was examined. Depression was measured by the Beck Depression Inventory at baseline and weeks 2, 4, 8 and 12 of treatment (n = 38). At baseline and weeks 2 and 4, peripheral blood mononuclear cell (PMBC, n = 28), isolated ex vivo, were examined for tumour neurosis factor (TNF)-alpha, interleukin (IL)-1beta and IL-10 mRNA expression. In patients that developed treatment-induced depression, pro-inflammatory TNF-alpha mRNA levels from baseline into week 4 of therapy remained constant (1.1-fold increase); whereas IL-1beta transcripts decreased 3.5 fold. However, corresponding TNF-alpha (3-fold, P < 0.05) and IL-1beta (7.5-fold) transcript expression diminished to a greater extent in the absence of TID. Changes in TNF-alpha mRNA values correlated to the average change in BDI scores over the 12 weeks (r = 0.56, P < 0.05). Concomitantly, anti-inflammatory IL-10 transcript levels decreased in (TID), relative to increased expression in the absence of TID (P < 0.05). The potential influence of IL-10 was observed upon calculation of individual pro- verses anti-inflammatory mRNA ratios. Stable in the presence of depression, TNF-alpha/IL-10 and IL-1beta/IL-10 mRNA ratios declined significantly over time in its absence (P < 0.05). This study suggests that in chronic HCV infection, upon pegylated IFN administration persistent pro-inflammatory cytokine MRNA expression associates with TID. In contrast, therapeutic activation of mechanisms that decrease pro-inflammatory immunity may protect against depression during therapy.

Parental bonding and adult psychopathology: results from the US National Comorbidity Survey.

BACKGROUND: Research using the parental bonding instrument (PBI) has suggested that lack of parental care and/or overprotection may be important risk factors for adult mental disorders. Much of this research, however, has relied on clinical populations with one or two disorders, or has used highly select community samples. METHOD: The association between parenting experiences and the occurrence of 13 common mental disorders in adulthood was evaluated in the US National Comorbidity Survey (N = 5877). The effect of sociodemographic variables (age, education, income) was statistically controlled and the effects of six parenting variables (maternal and paternal care, overprotection and authoritarianism) were examined simultaneously. The effects in men and women were examined separately. RESULTS: Lack of care was the parenting variable most consistently associated with adult psychopathology. Parenting experiences with one's mother were more consistently associated with adult mental disorders. In general the impact of parenting was diagnostically non-specific. However, there appeared to be some unique effects for externalizing disorders (substance use disorders and antisocial personality disorder) in males; paternal overprotection and authoritarianism conferred a reduced risk of externalizing disorders in adult males. The overall impact of parenting as assessed by the PBI was modest, accounting for about 1 to 5 % of the variance in the occurrence of adult mental disorders. CONCLUSION: Parenting experiences, particularly lack of care, are potentially causally related in a non-specific manner to a wide variety of forms of adult psychopathology in both men and women. The overall magnitude of the effect is small but statistically significant in a nationally representative US sample.

Anxiety sensitivity and major depression: examination of affective state dependence.

An emerging body of research suggests that anxiety sensitivity (AS), and particularly a facet of AS labelled fear of cognitive dyscontrol, is elevated in depressed individuals and is associated with severity of depressed mood. The current prospective study extended previous work by investigating the extent of affective state dependency in the AS-depression relationship in 51 patients who had major depressive episode (MDE) at baseline assessment (Time 1) and did not have MDE 1 year later at follow-up (Time 2). Despite considerable reduction in severity of depressed mood, scores on the Anxiety Sensitivity Index (M=27) remained elevated. Hierarchical regression analysis indicated that, after controlling for both Time 1 and Time 2 depression severity, Time 1 AS continued to predict residual Time 2 AS and increased prediction of variance from approximately 25% to 50%. Time 1 fear of cognitive dyscontrol AS continued to significantly predict Time 2 fear of cognitive dyscontrol AS when Time 2 fear of physical symptoms AS was statistically controlled. A subsample of recovered patients who displayed only minimal depression symptoms was compared to a matched sample of community controls. While the two groups did not significantly differ on level of depressed mood, the formerly depressed patients had significantly higher levels of AS. Implications for a proposed "depression sensitivity" are discussed.

Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation.

OBJECTIVES: The personality of medical students may have an important impact on both their academic performance and emotional adjustment during medical school. There has been little systematic study of the impact of perfectionism on medical students. The present study sought to compare the perfectionism profile of medical students with that of a general arts student group and to examine the relationship among perfectionism, distress symptoms and academic expectations and satisfaction. DESIGN: Medical students (n=96) and arts students (n=289) completed a baseline assessment including two multidimensional perfectionism scales. The medical students also completed measures of distress symptoms, personality (neuroticism, conscientiousness) and questions about their perceptions of their academic performance. Of the medical students, 58 completed a second set of questionnaires 6 months later (time 2). SUBJECTS: First-, second- and third year medical students and first-year arts students. RESULTS: In comparison with arts students, the perfectionism profile of medical students showed higher personal standards, lower doubts about actions and lower maladaptive perfectionism scores. In the medical students adaptive perfectionism (achievement striving) was significantly correlated with baseline academic performance expectations and conscientiousness and was predictive of dissatisfaction with academic performance at time 2. Maladaptive perfectionism (excessive evaluative concerns) was significantly correlated with baseline distress symptoms and neuroticism and was predictive of symptoms of depression and hopelessness at time 2. CONCLUSIONS: Perfectionism in medical students differs systematically from perfectionism in general arts students. Distinguishing adaptive and maladaptive aspects of perfectionism is important in understanding the cross-sectional and longitudinal implications of perfectionism for medical students.

Correlates of analogue and clinical depression: a further test of the phenomenological continuity hypothesis.

BACKGROUND: The use of college students with high scores on a depression rating scale as analogues for depression by psychological researchers has generated controversy. Critics of analogue research argue that depression is qualitatively different in analogue and clinical samples. OBJECTIVE: To conduct a further comparison of the phenomenology of clinical and analogue depression to determine if the differences between these groups are best understood as quantitative (consistent with the continuity hypothesis) or whether these forms of depression are qualitatively distinct. METHOD: This study compared 161 outpatients with major depressive disorder to 148 "analogue" subjects (college students with a Beck Depression Inventory score > or =9) and 141 non-distressed controls. Study measures included several proposed personality vulnerability factors for depression, a measure of developmental experiences that may confer vulnerability to adult depression, and family history of emotional disorders. RESULTS: Most comparisons of personality vulnerability factors, developmental experiences and family history information followed a pattern of greatest risk in the clinical group, intermediate risk in the analogue group and lowest risk in the non-distressed group. Noteworthy exceptions included several aspects of perfectionism and a number of childhood experiences reflecting parental over-control, which appeared to be more strongly associated with analogue depression than clinical depression. IMPLICATIONS: Several personality and developmental variables could represent important areas of discontinuity between clinical and analogue depression. However, the overall results were consistent with a growing body of literature suggesting continuity between subthreshold depression symptoms and syndromal depression.

Clinical guidelines for the treatment of depressive disorders. VII. Comorbidity.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, on Axis I, Axis II, and Axis III comorbidity, is 1 of 7 articles that were drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Comorbid depression on Axis I is particularly prevalent in patients with anxiety disorders, substance use disorders, and eating disorders, but it also occurs in patients with schizophrenia, attention-deficit hyperactivity disorder (ADHD), and dementia. Depressive comorbidity has implications for assessment, management, and outcome. The relation between depression and personality disorders is complex. Patient with this comorbidity often require longer, more intense, and multimodal therapies. Depression is also prevalent in medical illnesses, requires careful diagnosis, and responds to standard antidepressant treatments. CONCLUSIONS: Comorbidity can influence the course and outcome of both associated conditions. Depression-specific psychotherapy and/or pharmacotherapy should be considered when comorbid depression is diagnosed.

The continuity of depression symptoms: use of cluster analysis for profile identification in patient and student samples.

BACKGROUND: Findings from several sources suggest that depression lies on a continuum whereby mild and severe variants are thought to differ in severity (i.e., quantitatively), but not in kind (i.e., qualitatively). The current study used cluster analysis to extend this work to examination of depression symptom profiles obtained in distressed student 'analogue' samples and clinically depressed samples. METHOD: Patients with major depressive disorder (n = 101) provided seed points for the depressed cluster, and 176 non-distressed university students (Beck Depression Inventory score < or = 8) provided seed points for the non-depressed cluster. The symptom profiles of three levels of analogue depressed samples were then evaluated (BDI > or = 9, BDI > or = 16, and BDI > or = 21). RESULTS: Only 35.4% of BDI > or = 9 analogue respondents were empirically sorted to the depression cluster and the majority were assigned to the non-depressed cluster. The proportion assigned to the depression cluster increased to 70.5% and to 86.2% when higher BDI cutoffs of 16 and 21 were examined, respectively. The DSM-IV depression symptom profile of the BDI > or = 21 group was very similar to the profile defined by clinical patients. LIMITATIONS: The study relied solely on self-report to assess symptom severity. CONCLUSIONS: It is recommended that higher BDI cutoffs be utilized in analogue depression research than is currently common. On quantitative grounds, analogue subjects who were sorted to the clinically defined depression cluster seem to best represent the idea of depression continuity.

Psychological vulnerabilities in patients with major depression vs panic disorder.

The tripartite model (Clark & Watson, 1991: Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316-336) posits that anxiety and depression share nonspecific features of neuroticism but that somatic arousal appears unique to anxiety, and low positive affect appears unique to depression. The present study controlled for these higher-order effects and evaluated the relative contributions of four, specific lower-order vulnerabilities (anxiety sensitivity, rumination, self-criticism, self-oriented perfectionism). Participants were 38 depressed patients and 38 patients with panic disorder matched as closely as possible for age and gender, and all were diagnosed using the same structured interview by an experienced clinician. Results from hierarchical logistic regression analysis were consistent with predictions from the tripartite model in that only the unique features of arousal and positive affectivity differentiated the two diagnostic groups. At a lower-order level, only anxiety sensitivity (and its facet of fear of physical symptoms) and a ruminative response style demonstrated incremental predictive ability. The discussion focuses on the relationships among these higher-order and lower-order variables, and their potential importance for understanding specific manifestations of psychopathology.

The Parental Bonding Instrument: confirmatory evidence for a three-factor model in a psychiatric clinical sample and in the National Comorbidity Survey.

BACKGROUND: Study of the contribution of retrospective perceptions of dysfunctional parenting in relation to adult psychopathology has been greatly facilitated by the development of the 25-item Parental Bonding Instrument (PBI; Parker et al. 1979). METHOD: The present study employed confirmatory factor analytic techniques to evaluate competing models of the basic dimensions underlying different versions of the PBI, in a psychiatric sample from a mood disorders program and with a new modification of the PBI employed in the US National Comorbidity Survey. RESULTS: The results indicated that a three-factor model originally identified in a 16-item version of the PBI modified for epidemiological research (Kendler 1996) showed the best fit to the data. The three dimensions of care, overprotection, and authoritarianism also explained the underlying structure of the NCS-modified, eight-item PBI that is now part of the NCS public use dataset available to psychopathology researchers. CONCLUSIONS: The replicability of findings across gender, age, and clinical versus community samples attests to the robustness of this three-factor structure of parenting styles.

Problem and probable pathological gambling: considerations from a community survey.

OBJECTIVE: To investigate the nature and extent of gambling problems in a region of Canada in which legalized gambling activities were expanded during the 1990s. METHOD: A standardized telephone interview was conducted with a random sample of 738 community-dwelling adults (response rate 74%) in Winnipeg, Manitoba. RESULTS: According to traditional classification criteria, the lifetime prevalence of "probable pathological gambling" was 2.6%. A further 3.0% of the sample met criteria for traditionally defined "problem gambling," and evidence suggests that both types of gamblers share several characteristics. Social or recreational gamblers significantly differed on several variables from individuals who reported gambling problems. CONCLUSIONS: The 2.6% prevalence figure is the highest yet reported in a Canadian epidemiological survey and was obtained in a region that developed a more liberal attitude toward gambling in the 1990s. Further, a continuum of severity was demonstrated by scores on the South Oaks Gambling Screen (SOGS), and a clear and consistent distinction between problem and probable pathological gambling was not apparent. Frequenting casinos and using video poker and slot machines, rather than buying lottery tickets, distinguishes problem or pathological gamblers from recreational gamblers.

Discrepancies between self and observer ratings of depression. The relationship to demographic, clinical and personality variables.

BACKGROUND: The observer-rated Hamilton depression scale (HamD) and the self-report Beck Depression Inventory (BDI) are among the most commonly used rating scales for depression, and both have well demonstrated reliability and validity. However, many depressed subjects have discrepant scores on these two assessment methods. The present study evaluated the ability of demographic, clinical and personality factors to account for the discrepancies observed between BDI and HamD ratings. METHOD: The study group consisted of 94 SCID-diagnosed outpatients with a current major depressive disorder. Subjects were rated with the 21-item HamD and completed the BDI and the NEO-Five Factor Inventory. RESULTS: Younger age, higher educational attainment, and depressive subtype (atypical, non-melancholic) were predictive of higher BDI scores relative to HamD observer ratings. In addition, high neuroticism, low extraversion and low agreeableness were associated with higher endorsement of depressive symptoms on the BDI relative to the HamD. In general, these predictive variables showed a greater ability to explain discrepancies between self and observer ratings of psychological symptoms of depression compared to somatic symptoms of depression. LIMITATIONS: The study does not determine which aspects of neuroticism and extraversion contribute to the observed BDI/HamD discrepancies. CONCLUSIONS: Depression ratings obtained with the BDI and HamD are frequently discordant and a number of patient characteristics robustly predict the discrepancy between these two rating methods. The value of multi-modal assessment in the conduct of research on depressive disorders is re-affirmed.

Perceptions of parental bonding and symptom severity in adults with depression: mediation by personality dimensions.

OBJECTIVE: An association between anomalous parental bonding experiences (lack of parental care, overprotection, or both) and depression during adulthood has been observed in several studies. The objective of the present study was to evaluate several different personality dimensions as possible mediators of the relationship between perceptions of parental bonding and depressive symptoms in adulthood. METHODS: Outpatients with depression (n = 138) completed the Parental Bonding Instrument (PBI), the Beck Depression Inventory (BDI), and several measures of proposed personality vulnerabilities to depression. The conceptual and methodological criteria of Baron and Kenny (1986) were used to assess possible mediating effects of personality variables. RESULTS: In men, overprotection by their fathers was significantly associated with depression; neuroticism, socially prescribed perfectionism, and concern over mistakes acted as mediators of this relationship. In women, lack of care by their mothers was significantly associated with depression; self-criticism, socially prescribed perfectionism, and concern over mistakes mediated this relationship. CONCLUSIONS: The present study provides evidence that personality factors may mediate the observed relationship between parental rearing style and depression. These potential causal mechanisms warrant longitudinal evaluation.

The impact of clinically diagnosed personality disorders on acute and one-year outcomes of electroconvulsive therapy.

Clinical experience suggests that patients with depression and a comorbid personality disorder (PD) may have a poorer response to electroconvulsive therapy (ECT). Only a few published studies have examined the relationship between comorbid personality disorders and response of major depression to ECT. These studies have used relatively small numbers of patients. The present study is a retrospective review of 107 inpatients with a major depressive episode referred for ECT. Patients with a clinically diagnosed PD, especially a cluster B PD, had a significantly poorer acute response to ECT than those without a PD. During the first year after treatment, ECT responders with a comorbid PD had a higher rate of relapse of depression. The retrospective study design limits the strength of conclusions that can be drawn. Nevertheless, it appears that clinically diagnosed PDs may be predictive of poor outcome in patients receiving ECT for depression. Further prospective study of the relationship between both clinically diagnosed PDs and structured interview based PD diagnoses and ECT treatment response is warranted.

Impact of adult attachment styles on pain and disability associated with arthritis in a nationally representative sample.

OBJECTIVE: The objective of this study was to evaluate Mikail et al.'s hypothesis that adult attachment styles are associated with important pain-related variables such as pain and disability levels. DESIGN: A cross-sectional design was used to examine the relation between measures of adult attachment styles and both pain and disability. SETTING: The data used were obtained from the National Comorbidity Survey, a large and nationally representative sample of community-dwelling individuals aged 15 to 54 years. In the present study, individuals (n = 381) in the National Comorbidity Survey with arthritis or related conditions were included. OUTCOME MEASURES: Ratings regarding three adult attachment styles (secure, anxious, and avoidant) were obtained by administering Hazan and Shaver's attachment self-report in an interview format. Pain and disability were assessed in a similar manner using four-point rating scales. RESULTS: Ratings of insecure attachment were positively and significantly correlated with both pain and disability. A multiple regression analysis revealed that pain severity and the rating of anxious attachment could account for 20.3% of the variance in disability. CONCLUSIONS: The attachment theory holds promise for understanding reactions to pain conditions, and Mikail et al.'s model warrants further investigation.