A comparison of insomnia and depression as predictors of disability pension: the HUNT Study.

STUDY OBJECTIVES: Depression and insomnia are common and frequently comorbid. Unlike the priority now accorded to depression, insomnia is comparatively ignored as a reason for impaired occupational functioning. The objective of this study was to compare their relative impact upon medically certified disability pension award. DESIGN: Historical cohort study SETTING: Data from a population-based health survey in Nord-Trøndelag County in Norway (HUNT-2) was linked with a comprehensive national social security database. PARTICIPANTS: Participants within working age (20-66 years of age) not claiming disability pension (N = 37,302). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We compared complaints of insomnia and depression as predictors of disability pension award 18-48 months after a health survey. Insomnia complaints and depression each were similarly associated with disability pension award after adjustment for multiple health and sociodemographic factors, with similar odds ratios (1.66 [1.37-2.01] and 1.56 [1.24-1.96] respectively). Comorbidity did not contribute to disability beyond that expected from each condition. Taking the higher prevalence of insomnia complaints into account, insomnia complaints contributed as much or even more than depression to work-related disability. CONCLUSIONS: Depression is regarded as a major contributor to work disability and is increasingly the primary diagnosis in disability pension award. Our results suggest that although rarely reported in official registries of disability pension causes, insomnia has an equally important and independent role, particularly among the younger group. This suggests that this potentially treatable factor has considerable economic impact and should receive more attention in clinical and public health management.

Monthly variation in prevalence rates of comorbid depression and anxiety in the general population at 63-65 degrees North: the HUNT study.

BACKGROUND: To investigate monthly variation in depression, anxiety and their comorbidity (COM) in an epidemiologic study and their association to monthly variation in suicide rates. METHODS: 60,995 participants of the Health Study of Nord-Trøndelag County in 1995-97 rated themselves on the Hospital Anxiety and Depression Scale (HADS) in all months except July. All 10,670 male and 3833 female suicides in Norway from 1969 through 1996 were included. RESULTS: The prevalence of comorbid anxiety and depression was highest in spring (April, May) and in October (p<0.01). There was a correlation between the monthly variation in the national suicide rate and monthly variation in comorbid anxiety and depression (r=0.72, df=11, p=0.01) and for male alone (r=0.67, df=11, p=0.03). There was also a significant monthly variation in the prevalence of depression (p<0.001) and no monthly variation in the prevalence of anxiety. LIMITATIONS: Limited information about the third of the population who did not take part in the HUNT-2 Study. HADS based depression and anxiety cover psychological symptoms, not somatic and social ones. In relation to DSM-IV and ICD-10 defined anxiety disorders and depressions, the sensitivity and specificity of HADS caseness, give a considerable number of false-positive cases. CONCLUSIONS: Increased prevalence of comorbid depression and anxiety in males during spring, and its association with suicidality should have clinical importance, as identification and treatment could influence suicide rates.

Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the Type A behaviour speed and impatience subscale.

BACKGROUND: Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders. METHODS: The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya;s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour. RESULTS: Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n=30) and without an affective temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7 vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was still significant (p=0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder (n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions (n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p=0.043). LIMITATIONS: The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status. CONCLUSIONS: Dissociative symptoms measured with the Dissociative Experience Scale are associated with bipolar features, using formal DSM-IV criteria, cyclothymic temperament and the speed and impatience subscale of the JAS.

Chronic insomnia as a risk factor for developing anxiety and depression.

STUDY OBJECTIVE: To study prospectively the relations of insomnia to the development of anxiety disorders and depression in a population-based sample. DESIGN: Cohort study based on data from 2 general health surveys of the adult population. SETTING: Two general health surveys in the adult population in Nord-Trøndelag County of Norway, HUNT-1 performed in 1984-6 and HUNT-2 in 1995-7 PARTICIPANTS: Participants without significant anxiety and depression in HUNT-1 were categorized according to the presence and absence of insomnia in the 2 surveys (N=25,130). MEASUREMENTS AND RESULTS: Anxiety disorders and depression in HUNT-2 were assessed by the Hospital Anxiety and Depression Scale and analyzed using multivariate logistic regression analysis adjusted for age, gender, education, comorbid depression/anxiety, and history of insomnia. Anxiety disorders in HUNT-2 were significantly associated with the group with insomnia in HUNT-1 only (OR 1.6; 95% CI, 1.1-2.3), the group with insomnia in HUNT-2 only (OR 3.4; 95% CI, 3.1-3.8), as well as with the group with insomnia in both surveys (OR 4.9; 95% CI, 3.8-6.4). Depression in HUNT-2 was significantly associated with the group with insomnia in HUNT-2 only (OR 1.8; 95% CI, 1.6-2.0), but not with the groups with insomnia in HUNT-1 only or with insomnia in both surveys. CONCLUSIONS: Only a state-like association between insomnia and depression was found. In addition to being a state marker, insomnia may be a trait marker for individuals at risk for developing anxiety disorders. Results are consistent with insomnia being a risk factor for the development of anxiety disorders.

Type A behaviour differentiates bipolar II from unipolar depressed patients.

BACKGROUND: A relation between the type A behaviour pattern (TABP) and coronary heart disease has been found in many studies and the existence of a psychiatric coronary-prone mood profile has been suggested. TABP consist of fairly stable character traits such as time urgency, impatience, irritability and competitiveness, which in patients with affective disorders could be bipolar traits. The aim of this study was to compare TABP in depressed unipolar and bipolar II patients, and explore the relation between TABP, affective temperaments and migraine headaches, another disorder associated with bipolar II disorder. METHODS: The Jenkins Activity Survey (JAS) (Form C), a self-report multiple-choice questionnaire designed to measure TABP, was given to 99 patients diagnosed with a DSM-IV major affective disorder. Affective temperaments were diagnosed according to Akiskal's criteria and migraine diagnosed according to the criteria of the International Headache Society. The JAS was scored in the traditional manner, yielding scores for TABP and three factorially independent components, speed and impatiens (factor S), job involvement (factor J) and hard-driving and competitive (factor H). RESULTS: 65 patients diagnosed with a unipolar (n = 42) or bipolar II (n = 23) disorder had valid scores on the JAS. Patients with bipolar II diagnosis had significantly higher JAS scores than the unipolar patients (Wilks' lambda = 0.851, F = 2.62, df = 4, 60, p < 0.05). Type A behaviour differed (total JAS score: mean square 509.3, df = 1, F = 9.4, p < 0.005), mainly due to a divergence in factor S (mean square 465.5, df = 1, F = 6.0, p < 0.02). Higher JAS scores were significantly associated with having a cyclothymic temperament (Wilks' lambda = 0.728, F = 4.30, df = 4, p = 0.005) and lower JAS scores with having a depressive temperament (Wilks' lambda = 0.747, F = 3.13, df = 4, p = 0.026). TABP was not associated with migraine. LIMITATIONS: Non-blind, cross-sectional assessment of affective disorders and migraine headaches and questionnaire-based type A behaviour assessment. CONCLUSIONS: These results indicate that a well-established questionnaire designed to recognize the type A behaviour pattern, distinguishes depressed unipolar from depressed bipolar II patients as well.

The validity of the Hospital Anxiety and Depression Scale. An updated literature review.

OBJECTIVE: To review the literature of the validity of the Hospital Anxiety and Depression Scale (HADS). METHOD: A review of the 747 identified papers that used HADS was performed to address the following questions: (I) How are the factor structure, discriminant validity and the internal consistency of HADS? (II) How does HADS perform as a case finder for anxiety disorders and depression? (III) How does HADS agree with other self-rating instruments used to rate anxiety and depression? RESULTS: Most factor analyses demonstrated a two-factor solution in good accordance with the HADS subscales for Anxiety (HADS-A) and Depression (HADS-D), respectively. The correlations between the two subscales varied from.40 to.74 (mean.56). Cronbach's alpha for HADS-A varied from.68 to.93 (mean.83) and for HADS-D from.67 to.90 (mean.82). In most studies an optimal balance between sensitivity and specificity was achieved when caseness was defined by a score of 8 or above on both HADS-A and HADS-D. The sensitivity and specificity for both HADS-A and HADS-D of approximately 0.80 were very similar to the sensitivity and specificity achieved by the General Health Questionnaire (GHQ). Correlations between HADS and other commonly used questionnaires were in the range.49 to.83. CONCLUSIONS: HADS was found to perform well in assessing the symptom severity and caseness of anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population.

Mr morphometry analysis of grey matter volume reduction in schizophrenia: association with hallucinations.

The authors used voxel-based morphometry (VBM) to study GM volume differences in the whole brain volume between a group of patients with schizophrenia and a healthy control group. There were 12 patients and 12 control subjects. The subjects were scanned in a 1.5 T MR scanner. The patients had all been evaluated by a senior psychiatrist on the brief psychiatric rating scale (BPRS). The VBM data was correlated with reports of rate and frequency of hallucinations based on their scores on the BPRS hallucination item. There were significant grey matter volume reductions in the schizophrenia patient group in the left superior (transverse) temporal gyrus, the left middle frontal gyrus, and in the right cuneus. Areas of grey matter volume reduction that correlated negatively with hallucinations were found in the left superior (transverse) temporal gyrus, left thalamus, and left and right cerebellum. This article proposes that significant reductions in grey matter volume may be instrumental in generating spontaneous neuronal activity that is associated with speech perception experiences in the absence of an external acoustic stimulus that may cause hallucinations.

The long-term effect of insomnia on work disability: the HUNT-2 historical cohort study.

Chronic insomnia is common in the general population. Its effect on functioning and disability is usually attributed to an underlying condition, so the diagnosis of insomnia does not qualify for award of a disability pension in the United States or Europe. The aim of this study was to investigate whether insomnia, defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, contributed to long-term work disability. Using a historical cohort design, the authors gathered baseline data from a population-based Norwegian health study of 37,308 working-age people not claiming a disability pension through 1995-1997. The outcome was subsequent award of a disability pension (18-48 months after the health screening) as registered by the National Insurance Administration. Insomnia was a strong predictor of subsequent permanent work disability (adjusted odds ratio=3.90, 95% confidence interval: 3.20, 4.76). Sociodemographic and shift-work characteristics had little confounding effect (adjusted odds ratio=3.69, 95% confidence interval: 3.00, 4.53), and this association remained significant after adjustment for psychiatric and physical morbidity and for health-related behaviors (adjusted odds ratio=1.75, 95% confidence interval: 1.40, 2.20). This study suggests that insomnia should receive increased attention as a robust predictor of subsequent work disability.

Migraine aura without headache compared to migraine with aura in patients with affective disorders.

The characteristics of psychiatric comorbidity in migraine have been studied in migraine with aura (MA) and migraine without aura (MO). Little information is available concerning patients with migraine aura without headache. In a study of 201 patients with major affective disorders (DSM-IV) we have described the clinical characteristics of patients with these three sub-types of migraine (IHS criteria) and compared the MA and migraine aura without headache groups. Compared to patients having MA (n=57), the group with migraine aura without headache (n=18) had a higher age of onset of migraine (28.5 vs. 19.2, p=0.001), significantly lower prevalences of affective temperaments (28% vs. 56%, p=0.036), suicide attempts (17% vs. 53%, p=0.013) and Raynaud's syndrome (0% vs. 25%, p=0.017). These results indicate that there seem to be differences in the clinical characteristics found in patients with migraine with aura when compared to those having the migraine subtype without a headache phase. This may convey new information concerning the comorbid expression of migraine and affective disorders or concerning the processes that differentiates the migraine types with and without a subsequent pain attack.

Efficacy of repetitive transcranial magnetic stimulation in depression: a review of the evidence.

Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment in psychiatry. We reviewed all published evidence on the efficacy of this treatment option in depressive disorders. An extensive electronic and manual search for eligible research reports identified only 12 studies that met the predetermined criteria for inclusion. rTMS was administered differently in most studies, and patient characteristics varied widely. A formal meta-analysis of the studies was thus not possible. Instead, we conducted a qualitative evaluation of the included studies. The antidepressive efficacy was not consistent, and where efficacy was demonstrated, it was modest in most studies. Some patients had good but transient responses to rTMS. Treatment gains were not maintained beyond the treatment period. Comparisons with electroconvulsive therapy (ECT) indicated the superiority of ECT. More, larger and more carefully designed studies are needed to demonstrate convincingly a clinically relevant effect of rTMS. We conclude that there is insufficient evidence for rTMS as a valid treatment for depression at present.

Las experiencias disociativas diferencian a pacientes con trastorno bipolar de los deprimidos unipolares: papel mediador de la ciclotimia y la subescala de urgencia e impaciencia para la conducta de tipo A / Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the type A behaviour speed and impatience subscale

FUNDAMENTO: En pacientes con trastornos delhumor, con frecuencia se observan síntomasdisociativos, pero apenas se dispone de informaciónsobre la posible asociación con los subgrupos ycaracterísticas temperamentales de estos trastornos.MÉTODO: Se aplicó la escala de experienciadisociativa (Dissociative Experience Scale [DES]) a 85pacientes con trastorno depresivo mayor (TDM) otrastorno bipolar II (BP-II) según los criterios delDSM-IV. Se evaluaron tanto la disociación de amplioespectro (puntuación total DES) como las formasclaramente patológicas de disociación (DES-taxón).El temperamento se evaluó utilizando los criterios deAkiskal y Mallya de los temperamentos afectivos y elcuestionario de actividad de Jenkins (Jenkins ActivitySurvey [JAS]) para la conducta de tipo A.RESULTADOS: Proporcionaron respuestas válidaspara la DES 65 pacientes. Utilizando análisis deregresión logística univariable, las puntuacionesmedias DES y DES-T fueron más altas en pacientes elBP-II (16,8 y 12,7, respectivamente) comparado conTDM (9 y 5,7), con odds ratio (OR) = 1,58 (intervalode confianza [IC] del 95%, 1,15-2,18) y OR = 1,6 (ICdel 95%, 1,14-2,25), respectivamente. No se identificóuna diferencia significativa de la puntuación DES enpacientes con (n = 30) y sin temperamento afectivo (n= 35): media (IC del 95%), 13,5 comparado con 10,5(–7,8 a 1,9), p = 0,224. Sin embargo, en el subgrupocon temperamento ciclotímico (n = 18) se obtuvieronmayores puntuaciones DES: media (IC del 95%),17,8 comparado con 9,7 (2,9-13,3), p = 0,003,comparado con pacientes sin dicho temperamento.No se observó una diferencia significativa en laspuntuaciones DES para pacientes con (n = 35) o sin (n= 28) un patrón de conducta de tipo A (JAS > 0):media (IC del 95%), 12,7 comparado con 10,9 (–6,8 a3,3), p = 0,491, pero una puntuación positiva delfactor S en el cuestionario de JAS (subescala deurgencia e impaciencia) se asoció con puntuacionesDES significativamente más altas que una puntuaciónnegativa: media (IC del 95%), 14,9 comparado con 9(1,1-10,7), p = 0,017, y esto siguió siendo significativo(p = 0,005) utilizando una regresión lineal múltiple delas puntuaciones DES comparado con puntuacionesde la subescala JAS. (...)

BACKGROUND: Dissociative symptoms are often seenin patients with mood disorders, but there is littleinformation on possible association with subgroupsand temperamental features of these disorders.METHOD: The Dissociative Experience Scale wasadministered to 85 patients with a DSM-IV MajorDepressive Disorder (MDD) or Bipolar-II Disorder(BP-II). Both broad-spectrum dissociation (DES totalscore) and clearly pathological forms of dissociation(DES-Taxon) were assessed. Temperament wasassessed using Akiskal and Mallya’s criteria ofAffective Temperaments and the Jenkins ActivitySurvey (JAS) for Type A Behaviour.RESULTS: Sixty-five patients gave valid answers toDES. The mean DES and DES-T scores were higherin BP-II (16.8 and 12.7 respectively) compared toMDD (9.0 and 5.7); DES odds ratio (OR) = 1.58(95% CI, 1.15-2.18) and DES-T OR = 1.60 (95% CI,1.14-2.25) using univariate logistic regressionanalyses. There was no significant difference in DESscore in patients with (n = 30) and without anaffective temperament (n = 35): mean (95% CI), 13.5vs. 10.5 (–7.8 to 1.9), p = 0.224. However thesubgroup with a cyclothymic temperament (n = 18)had higher DES scores: mean (95% CI): 17.8 vs. 9.7(2.9-13.3), p = 0.003, compared to patients withoutsuch a temperament. There was no significantdifference in DES scores for patients with (n = 35) orwithout (n = 28) a Type A behaviour pattern (JAS >0): mean (95% CI) 12. 7 vs. 10.9 (–6.8 to 3.3), p =0.491, but a positive JAS factor S score (speed andimpatience subscale) was associated withsignificantly higher DES scores than a negative Sscore:mean (95% CI) 14.9 vs. 9 (1.1-10.7), p =0.017), and this was still significant (p = 0.005) usingmultiple linear regression of DES scores vs. the JASsubscale scores. DES-T scores were significantlyhigher in patients with OCD (n = 9): mean (95% CI)18.4 vs. 6.6 (6-17.7), p < 0.001; eating disorder (n =13): 14 vs. 6.8 (1.8-12.6), p = 0.009, psychoticsymptoms during depressions (n = 9): 16.6 vs. 6.9(3.7-15.8), p = 0.002, and in those with a history ofsuicide attempt (n = 28): 11.9 vs. 5.4 (2.2-10.8, p =0.003, but only OCD was an independent predictorafter multiple linear regression of DES-T scores vs.all co-morbid disorders (p = 0.043). (...)