Journal of Affective Disorders

Editorial Board

2010-03-01

Phenomenology of racing and crowded thoughts in mood disorders: A theoretical reappraisal

2010-03-01

Abstract: Background: Racing thoughts is a frequent symptom in mood disorders, particularly mixed depressive states. This paper aims to summarize our current knowledge about its phenomenology and frequency in the spectrum of mood disorders, and to offer a new theoretical framework.Methods: We made a selective review of original and review papers in Medline and PsychInfo database using the keywords “racing thoughts”, “crowded thoughts” and “depressive mixed state” in conjunction with “mood disorders”.Results: In the context of a hypomanic state, “racing thoughts” may appear as a result from an excessive production of thoughts, moving quickly from one to the other, and generating a sense of fluidity and pleasantness. In the context of depression, “racing thoughts” are phenomenologically different and better described as “crowded thoughts”: they are not only characterized by too many thoughts occurring at the same time in the field of consciousness, but perceived as unpleasant and induce the feeling that ideas are difficult to catch.Discussion and clinical relevance: We suggest that crowded thoughts might result from the mixture of a hypomanic component, with an accelerated production of new thoughts (constituting the main source of this symptom in hypomania), and a depressive component, with a deficit of inhibition of previous thoughts (hence making thoughts crowded rather than truly racing). This distinction could help better identify crowded thoughts, and consequently depressive mixed states, which has important implications for therapeutic management. It might also help to further disentangle the psychobiological processes which contribute to the complexity of mood disorders.

Cyclothymic temperament and major depressive disorder: A study on Italian patients

Giuseppe Maina, Virginio Salvi, Gianluca Rosso, Filippo Bogetto — 2010-03-01

Abstract: Background: Classical authors had hypothesized that affective temperaments represent the subclinical manifestations of mood disorders: in particular, cyclothymic and hyperthymic temperaments have been considered as a subthreshold variant of bipolar disorder. The aim of our study is to test the presence of affective temperaments in a group of Italian patients with major depressive disorder (MDD), and to test the association between cyclothymic temperament and well-established validators of bipolar disorder diagnosis such as age at onset and family history of bipolar disorder.Methods: Patients with diagnosis of major depressive disorder (DSM-IV-TR) were included in the study. Affective temperaments have been evaluated through the Italian semistructured interview version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-I). In order to improve the accuracy of family history and age at onset reports, close family members of the patients were also interviewed.Results: 104 of patients included in the study have completed the temperament interview. 25.5% were diagnosed with a dominant affective temperament. Cyclothymic affective temperament was the most represented in the sample of MDD patients (12.3%); depressive, hyperthymic and irritable temperaments have been detected respectively in 7.5%, 2.8% and 2.8% of patients. Patients with CT showed a significantly lower age at onset of MDD than “pure” MDD patients (31.9 vs. 40.9 years; p=0.049) and higher rates of family history of bipolar disorder in first degree relatives (15.4% vs. 0%; p=0.001).Limitations: The major limitation of this study was the lack of a group of bipolar depressives, which would have been useful in order to confirm the similarities of age at onset and bipolar family history with cyclothymic MDD.Conclusions: Our data confirm previous reports in a sample of accurately screened patients with unipolar major depression: we found that patients with a cyclothymic temperament had an earlier age at onset and a higher family history for bipolar disorder than patients without any dominant affective temperament. Further research is needed to ascertain whether patients with “unipolar” cyclothymic MDD respond to mood stabilizers.

A prospective study of outcome and predictors of subclinical and clinical depression in an older biracial sample of psychiatric outpatients

Carl I. Cohen, Kah Hong Goh, Mario Gustave — 2010-03-01

Abstract: Objectives: There continues to be a debate about the long-term prognosis of psychiatric treatment of depression in later life. There have been no long-term naturalistic studies of psychiatric outpatient treatment of older adults in the United States. This study examines outcome and predictors of various levels of depression among a biracial sample of geropsychiatric outpatients in Brooklyn, NY.Methods: We conducted a naturalistic study (median: 33 months) of 143 persons aged 55 and over with diagnoses of depression drawn from 15 psychiatry outpatient clinics and 2 geriatric day programs. Their mean age was 68 years, 87% were female, and 43% were white and 57% were black, among whom 37% were African Caribbeans. Using George's Social Antecedent Model of Depression, we examined the impact of 15 predictor variables on two outcome measures: presence of any either subclinical or clinical depression (CES-D score ≥8) and presence of clinical depression (CES-D score ≥16).Results: On follow-up, 84% and 90% of subclinically and clinically depressed persons at baseline, respectively, were depressed (CES-D ≥8); 62% of those in remission at baseline were depressed. In logistic regression, 3 variables were significant predictors of any level of depression on follow-up: baseline depression, baseline anxiety, greater increase in anxiety symptoms during the follow-up period. These 3 variables along with financial strain were significant predictors of clinical depression on follow-up. There were no inter- or intra-racial differences in outcome.Conclusions: The bleak outcome findings among older psychiatric outpatients in Brooklyn were consistent with unfavorable results reported in European studies. Because there were only a few predictors of outcome, strategies that target high risk persons – e.g., such as those with subclinical depression, anxiety, or in more economic distress – may prevent transition to severe and persistent depressive states.

Validation of the Center for Epidemiologic Studies Depression Scale in screening for major depressive disorder among retired firefighters exposed to the World Trade Center disaster

2010-03-01

Abstract: Background: We evaluated the performance of a modified Center of Epidemiologic Studies Depression Scale (CES-D-m), which captured symptoms in the past month, in comparison to the Diagnostic Interview Schedule (DIS) in identification of major depressive disorder (MDD) in World Trade Center (WTC)-exposed retired Fire Department, City of New York (FDNY) firefighters.Methods: From 12/2005 to 7/2007, FDNY enrolled retired firefighters in its Medical Monitoring and Treatment Program. All participants completed the CES-D-m and the DIS on the same day. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and Youden's index were used to assess properties of the CES-D-m. Multivariate logistic regression analyses were also used.Results: 7% of 1915 retired male firefighters were diagnosed with MDD using the DIS. Using the most common CES-D cutoff score of 16, the prevalence of elevated risk was 36%, which declined to 23% using a cutoff score of 22, as determined by Youden's index. At 22, CES-D-m sensitivity was 0.84, specificity was 0.82, and the area under the ROC curve was 0.89 relative to DIS MDD diagnosis.Limitations: Participants were more likely than non-participants to live in the New York City area.Conclusions: This is the first study of WTC rescue/recovery workers to assess the performance of a one-month version of the CES-D. The CES-D-m performed well in identifying those at elevated risk. Since diagnostic follow-up is time consuming and costly, it is important to correctly distinguish those at elevated risk using a screening tool that has been validated in the population under study.

Increased neural resources recruitment in the intrinsic organization in major depression

2010-03-01

Abstract: Objective: To investigate the functional connectivity (FC) pattern within an intrinsic functional organization, including both task-positive (TPN) and task-negative (TNN) networks, in major depressive disorder (MDD), and to examine relationships between the involved FCs and clinical variables.Methods: Resting-state FC analyses were used to identify the component brain regions of the intrinsic organization and to investigate the FCs of the individual component regions in 18 first-episode, medication-naïve MDD and 20 healthy control subjects.Results: We found that the intrinsic organization of the depressed group recruited more extensive regions than the control group. All of the altered FCs associated with the component regions increased in MDD. Specifically, in the TPN the increased FCs were primarily located in the bilateral lateral prefrontal cortices and the inferior parietal lobes, which have been implicated in attention and adaptive control. In the TNN, the increased FCs were primarily located in the posterior cingulate cortex and the medial orbitofrontal cortex, which are involved in episodic memory, self-reflection and emotional regulation. We also found increased anti-correlations between the two networks. Additionally, the strengths of the FCs associated with the lateral prefrontal cortices were found to be correlated with the duration of the depressive episode and the HDRS scores in the depressed patients.Limitations: Clinical correlates of these abnormal FCs should be cautiously interpreted due to the small sample size in this study.Conclusions: Abnormalities in the intrinsic organization may be an underlying basis for the pronounced and prolonged negative bias in processing emotional information observed in MDD.

Volumetric MRI study of the insular cortex in individuals with current and past major depression

2010-03-01

Abstract: Background: Functional neuroimaging studies have implicated the insular cortex in emotional processing, including the evaluation of one's own emotion, as well as in the neurobiology of major depressive disorder (MDD). Nevertheless, it remains largely unknown whether MDD patients exhibit morphologic changes of the insular cortex, and whether such changes reflect state or trait markers of the disorder.Methods: We delineated the anterior and posterior insular cortices using magnetic resonance imaging in 29 currently depressed patients (mean age=32.5 years, 7 males), 27 remitted depressed patients (mean age=35.1 years, 9 males), and 33 age- and gender-matched healthy control subjects (mean age=34.0 years, 12 males).Results: Both current and remitted MDD patients showed significant volume reduction of the left anterior insular cortex as compared with healthy controls, but there was no group difference in the posterior insular cortex volume. Insular volumes did not correlate with the severity of depressive symptoms. Furthermore, the presence of melancholia and co-morbidity with anxiety disorders did not affect insular cortex volumes.Limitations: Although there was no difference in the insular cortex volume between medicated and unmedicated patients, a comprehensive investigation of medication effects was not possible, as complete data (e.g., dose, duration) were not available.Conclusions: These findings suggest that the morphologic abnormality of the anterior insular cortex, which plays a major role in introspection and emotional control, may be a trait-related marker of vulnerability to major depression, supporting the notion that MDD involves pathological alterations of limbic and related cortical structures.

Antidepressants, social adversity and outcome of depression in general practice

2010-03-01

Abstract: Background: The role of current social risk factors in moderating the impact of antidepressant medication has not previously been explored.Method: In a RCT of SSRIs of general practice patients with mild to moderate depression (HDRS 12–19) two social indices of aversive experience were developed on the basis of prior research. First, the Life Events and Difficulties Schedule (LEDS) was used twice to document: i) recent stressful experience prior to baseline, and ii) after baseline and before follow up at 12 weeks both stressful and positive experiences, taking account of ‘fresh start’ and ‘difficulty-reduction’ events. Second, an index of unemployment-entrapment at baseline was developed for the current project. The HDRS was used to measure outcome as a continuous score and as a cut-point representing improvement below score 8.Results: Each social index (LEDS and Unemployment-entrapment) was associated with a lower chance of remission at 12 weeks and each was required to model remission along with treatment arm. However there was no interaction: the degree of increased remission for those randomised to SSRIs plus supportive care compared to that for those with supportive care alone was the same regardless of social context.Limitations: Dating of remission was not as thorough as in previous work with the LEDS. Detailed examination of positive experiences suggested the large majority were not the result of remitting symptoms, but it is impossible to rule this out altogether.Conclusions: Remission rates among patients in aversive social contexts are consistently much lower irrespective of treatment. There is thus a need to evaluate the efficacy of alternative more socially focussed interventions for depressive conditions likely to take a chronic course in general practice.

Six year follow-up of a clinical sample of self-harm patients

Julia M.A. Sinclair, Keith Hawton, Alastair Gray — 2010-03-01

Abstract: Background: Mortality from suicide and other causes is significantly increased in patients who engage in self-harm, but their long-term morbidity and quality of life are poorly defined. As the majority of self-harm patients are under the age of 35 years, understanding their longer term health outcomes is important if we are to adequately manage their care. The aim of this study was to investigate the long-term mortality, morbidity and quality of life of such patients.Method: A representative cohort of patients who had presented to hospital following an episode of self-harm was traced after 6 years. Mortality and repetition of self-harm were primary outcome measures. Psychiatric morbidity and indices of quality of life, and social functioning were also obtained.Results: 143/150 (95.3%) patients were traced after a mean of 6.2 years. Eight (5.6%) had died during follow-up, significantly more than general population estimates (p≤0.001), four of these (2.8%) by probable suicide. Further self-harm occurred in 58/101 (57.4%) participants; 70/97 (72.2%) fulfilled criteria for at least one psychiatric disorder, and 51.3% screened positive for harmful use of alcohol. Measures of health status (EQ-5D and SF36-II) were significantly lower (p<0.001) than in the general population.Limitations: Due to the nature of this population group the attrition rate at 6 years is high; although this is the most complete such study to date.Conclusion: Despite positive outcomes in some patients, overall levels of mortality, morbidity, and harmful use of alcohol are high, whilst quality of life is reported as low. This has significant implications for the long-term management of this group.

Bipolar disorder as a risk factor for repeat DUI behavior

Mark J. Albanese, Sarah E. Nelson, Allyson J. Peller, Howard J. Shaffer — 2010-03-01

Abstract: Background: Bipolar disorder (BD) is more prevalent among people with substance use disorders (SUD) than the general population. SUD among recidivist driving under the influence (DUI) populations are extremely prevalent; not surprisingly, recent evidence suggests that rates of BD also are elevated among DUI offenders. Studies of BD patients with SUD have found high prevalence of other psychiatric disorders and relatively low rate of treatment engagement. This study examines both the prevalence of other mental disorders and treatment status among a cohort of DUI offenders with BD and SUD.Methods: A consecutively selected cohort (N=729) of repeat DUI offenders attending a two-week inpatient treatment program completed a standardized diagnostic interview (the Composite International Diagnostic Interview: CIDI). The CIDI generated DSM-IV diagnoses.Results: This study yielded three main results for this repeat DUI offender sample: (1) BD is associated with significantly higher lifetime prevalence of alcohol, drug, and non-substance psychiatric disorders (e.g., PTSD); (2) approximately one quarter of BD participants have not discussed their mania with a professional; and (3) only half of the BD participants in this cohort have had mania treatment they consider effective and even fewer have had any treatment during the past twelve months.Limitations: Participants were predominantly Caucasian males attending treatment as a sentencing option in a single Massachusetts DUI program.Conclusion: These findings suggest that clinicians in DUI treatment settings should consider both evaluating for BD and initiating therapy.

Cognitive training in affective disorders improves memory: A preliminary study using the NEAR approach

2010-03-01

Abstract: Background: Neuropsychological deficits in depression include difficulties with psychomotor speed, executive functions and memory. Some of these changes persist despite antidepressant treatment. While research in other areas of psychiatry has shown cognitive training techniques to be effective, only one study has evaluated this approach in depression.Methods: Sixteen patients (mean age=33.5years) with a lifetime diagnosis of major depressive disorder were administered a standardised battery of neuropsychological tests and allocated to treatment (n=8) or waitlist control (n=8) conditions. The treatment consisted of 10-weeks of twice weekly cognitive training using the Neuropsychological Educational Approach to Remediation. All participants were re-assessed after 10-weeks by interviewers blinded to group allocation.Results: Participants in the treatment condition demonstrated greater improvements on tests of memory encoding and memory retention than the waitlist control group. There were no observable benefits in terms of psychomotor speed or executive functions or in self-reported levels of disability. Affective symptoms also remained stable.Limitations: This study included a small sample of participants and treatment allocation was not randomised.Conclusions: Cognitive training in affective disorders improves memory performance. It may be an effective non-pharmacological treatment option for improving cognitive functions, which in turn, may improve psychosocial functioning and reduce disability. This study supports theories suggesting cognitive training may promote neuroplasticity.

Mental health scales and psychiatric diagnoses: Responses to GHQ-12, K-10 and CIDI across the lifespan

Daniel W. O'Connor, Ruth A. Parslow — 2010-03-01

Abstract: Background: Surveys based on complex interviews like CIDI report very low rates of affective disorder in older people, perhaps because the lengthy, convoluted questions present a special challenge to aged respondents. By contrast, mental health scales like the GHQ-12 and K-10 show much less change in score with age. Before concluding that scales present a fairer picture of aged mental health, it is important to check if scores are inflated by items that might reflect normal involutional changes in cognition, energy and social role.Methods: Secondary analysis of an Australian national survey of 10,641 adults.Results: GHQ-12 and K-10 scores declined with age to a relatively minor degree. When scores were bisected, the proportion of respondents scoring above the cutpoints fell with age but to a lesser degree than with ICD-10 diagnoses. Scores on GHQ-12 and K-10 items relating to cognition, energy and social role rose with age but, on factor analysis, these items loaded similarly in a two-factor model.Conclusion: No evidence emerged of age-related bias in either GHQ-12 or K-10. Items concerning cognition, energy and social role were associated with affect in older people, just as they were in younger ones. It seems unlikely therefore that the different trajectories over the lifespan of CIDI diagnoses and scores on GHQ-12 and K-10 are due to limitations within the scales. The possibility that CIDI minimizes affective disorder in older age-groups cannot be discounted.Limitations: Residents of aged care facilities and those with low cognitive scores were excluded.

Self- and clinician-rated Montgomery–Åsberg Depression Rating Scale: Evaluation in clinical practice

2010-03-01

Abstract: Background: Time- and cost-effective self-rating scales of depressive symptoms are particularly valuable for frequent use in large-scale effectiveness trials. The aim of the present study was to examine the psychometric properties of the French version of the self-rated Montgomery–Åsberg Depression Rating Scale (MADRS-S) and determine whether it might complement the MADRS in monitoring depression severity and change over time in routine clinical practice.Methods: Sixty-three adult outpatients with a current depressive episode completed the MADRS-S and were interviewed with the MADRS on two occasions, within a 1-month interval.Results: All patients readily accepted the MADRS-S. It showed good to excellent internal consistency (Cronbach's alpha 0.85 at Time 1; 0.94 at Time 2). Its factor structure revealed that a single component explained a large proportion of variability (47.0% at Time 1; 68.8% at Time 2). Concurrent validity of the self- and clinician-rated versions was good (Pearson's correlation coefficients for total scores 0.81 at Time 1; 0.91 at Time 2). The MADRS-S was sensitive to change over the 4-week observation period (correlation of 0.71 between change scores on self- and clinician-rated instruments).Limitations: Generalizability is restricted to outpatients with moderate to severe depression, and the MADRS-S ability to measure treatment effects needs to be examined.Conclusions: The present study indicates that the MADRS-S displays favourable psychometric properties and suggests that it might be a valid complement to the MADRS, both in research settings and clinical practice.

Genetic variation in apolipoprotein E alters regional gray matter volumes in remitted late-onset depression

Yonggui Yuan, Zhijun Zhang, Feng Bai, Jiayong You, Hui Yu, Yongmei Shi, Wen Liu — 2010-03-01

Abstract: Background: The apolipoprotein E (ApoE) gene has been confirmed as the major genetic risk factor for late-onset Alzheimer's disease (AD). The effect of ApoE polymorphism on brain morphology still remains unclear in remitted late-onset depression (RLOD).Methods: A total of 37 patients with remitted geriatric depression were investigated with optimized voxel-based morphometry. We tested for differences in gray matter volume between ApoE ε4 allele noncarriers (n=25) and ApoE ε4 allele carriers (n=12) in RLOD patients.Results: The volumes of right medial frontal gyrus, left middle frontal gyrus and left inferior occipital gyrus were significantly smaller in RLOD patients with ApoE ε4 allele carriers as compared to ApoE ε4 allele noncarriers. There was a significant positive correlation between gray matter volume of right medial frontal gyrus and Digit Span Test score in RLOD patients with ApoE ε4 allele carriers.Limitations: This study is cross-sectional, therefore it cannot determine whether abnormal gray matter volume is a state marker or trait marker of RLOD with ApoE ε4 allele carriers.Conclusion: Our findings support the hypothesis that the ApoE genotype might be associated with structural changes in RLOD.

Thyroid function and postpartum mood disturbances in Greek women

2010-03-01

Abstract: Background: Postpartum mood disturbances are very common with postpartum blues being as high as 44.5% among Greek women. This study aimed to investigate whether thyroid function within the normal range affects the incidence of postpartum mood disturbances.Methods: In a cross-sectional study in the maternity ward of Aretaieion Hospital, 57 Greek women were evaluated for postpartum mood swings by the Maternity Blues Questionnaire and the Edinburgh Postnatal Depression Scale on the first and sixth week postpartum. Serum Free T4, Free T3 and TSH concentrations as well as thyroglobulin and thyroid peroxidase antibodies were measured on admission for delivery and daily until the fourth postpartum day. We examined the association between hormone and antibody levels, and scores in the two scales evaluating postpartum mood disturbances.Results: Prepartum serum FT3 and FT4 correlated negatively with blues scores in the first week postpartum (blues on day 4: with FT3, rho=−0.44, p≤0.01; with FT4 rho=−0.36, p≤0.01). Women with lower FT3 and FT4 levels belonged to the high scoring group (high scoring group: FT3=1.22 pg/ml, FT4=0.66 ng/dl; low scoring group: FT3=1.64 pg/ml, FT4=0.73 ng/dl). Serum FT3 showed a negative independent correlation with postpartum blues scores in the first postpartum days. No association was found between thyroid antibody levels and mood scores.Conclusion: Our findings indicate an association between the occurrence of postpartum mood disorders and antenatal thyroid function. Within normal limits, lower levels of serum FT3 and FT4 are associated with increased incidence of mood disturbances in the first postpartum week.