Influence of personality on objective and subjective social support among patients with major depressive disorder: a prospective study.

Personality and social support (SS) influence risk for depression and modify its outcome through multiple pathways. The impact of personality dimensions neuroticism and extraversion on SS among patients with major depressive disorder (MDD) has been little studied. In the Vantaa Depression Study, we assessed neuroticism and extraversion with the Eysenck Personality Inventory, objective SS with the Interview Measure of Social Relationships, and subjective SS with the Perceived Social Support Scale-Revised at baseline, at 6 and 18 months among 193 major depressive disorder patients diagnosed according to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DMS-IV). At all time-points, low neuroticism and high extraversion associated significantly with between-subject differences in levels of objective and subjective SS. Lower neuroticism (beta = 0.213, p = 0.003) and higher extraversion (beta = 0.159, p = 0.038) predicted greater within-subject change of subjective, but not objective SS. Thus, neuroticism and extraversion associated with the size of objective and subjective SS and predicted change of subjective SS. Modification of subjective SS, particularly, may indirectly influence future vulnerability to depression.

The influence of major depressive disorder on objective and subjective social support: a prospective study.

The impact of persistent depression on social support (SS) is not well known. In the Vantaa Depression Study (VDS), 193 patients with DSM-IV MDD were interviewed at baseline, at 6 and 18 months. Objective SS was measured with the Interview Measure of Social Relationships (IMSR), and subjective SS with the Perceived Social Support Scale-Revised (PSSS-R); the influence of time spent in major depressive episodes (MDEs) on SS at 18 months was investigated. Low objective SS was independently predicted by low baseline objective SS, male gender, and longer time spent in MDEs; low subjective SS by longer time spent in MDEs and lower baseline subjective SS. Along with clinical improvement, subjective SS improved but objective SS did not. The persistence of MDD seems to weaken both objective and subjective SS. Whether this results in progressively weakening objective and subjective SS, and thereby lowers the threshold for future depressive episodes, should be further investigated.

Adequacy of, attitudes toward, and adherence to treatments by suicidal and nonsuicidal depressed patients.

We examined differences in treatments received, and attitudes and adherence to them between suicidal and nonsuicidal patients with major depressive disorder (MDD). Psychiatric MDD patients with no suicidal behavior (N = 92), suicidal ideation (N = 92), or attempts (N = 34) were compared during 6 months of follow-up in the Vantaa Depression Study (VDS). Patients with suicidal behavior received antidepressants or adequate antidepressant treatment significantly more often, had more frequent appointments with psychiatrists, more psychotherapeutic support, and more favorable attitudes toward antidepressant treatment than nonsuicidal patients. However, after adjusting for the confounding severity of depression, the significance of these differences was lost. Adherence to treatment was similar in the patient groups. Overall, among psychiatric patients with MDD, those known to be suicidal have higher suicide risk and should receive more intensive treatment. However, suicidal behavior per se does not seem to markedly influence treatments provided nor should it be associated with negative attitudes or poor adherence to treatments.

Determinants of functional disability and social adjustment in major depressive disorder: a prospective study.

We examined prospectively factors influencing social and occupational disability and social adjustment among patients with major depressive disorder. The Vantaa Depression Study comprises a cohort of psychiatric inpatients and outpatients with major depressive disorder in the city of Vantaa, Finland. We prospectively interviewed 193 of 269 (72%) patients both 6 and 18 months after baseline. Axis I and II diagnoses were assessed via semistructured WHO Schedules for Clinical Assessment in Neuropsychiatry 2.0 and SCID-II interviews. Global disability and social and work adjustment were assessed. Patients' functional disability and social adjustment were alleviated concurrently with recovery from depression during the follow-up. The current level of functioning and social adjustment of a patient with depression was predicted by severity of depression, recurrence before baseline and during follow-up, lack of full remission, and time spent depressed. Comorbid psychiatric disorders, personality traits (neuroticism), and perceived social support had significant influence.

Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness.

BACKGROUND: Suicidal ideation is likely to represent a phase preceding suicidal acts among most suicidal patients with major depressive disorder (MDD). Factors predicting reversal of the suicidal process are unknown. Our aim was to test the hypothesis that a decline in suicidal ideation is preceded by a decline in hopelessness among patients with MDD. METHOD: Of the 269 Vantaa Depression Study patients with DSM-IV MDD, 103 patients scored > or = 6 points at baseline on the Scale for Suicidal Ideation (SSI). Seventy of these patients were followed-up weekly either until they scored zero points on the SSI, or up to 26 weeks. RESULTS: The median duration for a decline of suicidal ideation to zero was 2.2 months after baseline. The level of baseline suicidal ideation, depressive symptoms, and the presence of any personality disorder predicted duration of suicidal ideation. A decline in both depression (BDI) and hopelessness (HS) independently predicted a decline in suicidal ideation. LIMITATIONS: Due to study design, we do not know if suicidal ideation relapsed after the first time the patient reached zero score in the SSI. CONCLUSIONS: Among patients with major depressive disorder having suicidal ideation, the decline in suicidal ideation is independently predicted by preceding declines in the levels of both depressive symptoms as well as hopelessness. The findings are consistent with possible causal roles of declines in depression and hopelessness in reversing the suicidal process.

The influence of adversity and perceived social support on the outcome of major depressive disorder in subjects with different levels of depressive symptoms.

BACKGROUND: Adverse life events and social support may influence the outcome of major depressive disorder (MDD). We hypothesized that outcome would depend on the level of depressive symptoms present at the outset, with those in partial remission being particularly vulnerable. METHOD: In the Vantaa Depression Study (VDS), patients with DSM-IV MDD were interviewed at baseline, and at 6 and 18 months. Life events were investigated with the Interview for Recent Life Events (IRLE) and social support with the Interview Measure of Social Relationships (IMSR) and the Perceived Social Support Scale - Revised (PSSS-R). The patients were divided into three subgroups at 6 months, those in full remission (n = 68), partial remission (n = 75) or major depressive episode (MDE) (n = 50). The influence of social support and negative life events during the next 12 months on the level of depressive symptoms, measured by the Hamilton Rating Scale for Depression (HAMD), was investigated at endpoint. RESULTS: The severity of life events and perceived social support influenced the outcome of depression overall, even after adjusting for baseline level of depression and neuroticism. In the full remission subgroup, both severity of life events and subjective social support significantly predicted outcome. However, in the partial remission group, only the severity of events, and in the MDE group, the level of social support were significant predictors. CONCLUSIONS: Adverse life events and/or poor perceived social support influence the medium-term outcome of all psychiatric patients with MDD. These factors appear to have the strongest predictive value in the subgroup of patients currently in full remission.

Prospective study of risk factors for attempted suicide among patients with DSM-IV major depressive disorder.

BACKGROUND: There are few prospective studies on risk factors for attempted suicide among psychiatric out- and in-patients with major depressive disorder. AIMS: To investigate risk factors for attempted suicide among psychiatric out- and in-patients with major depressive disorder in the city of Vantaa, Finland. METHOD: The Vantaa Depression Study included 269 patients with DSM-IV major depressive disorder diagnosed using semistructured interviews and followed up at 6- and 18-month interviews with a life chart. RESULTS: During the 18-month followup, 8% of the patients attempted suicide. The relative risk of an attempt was 2.50 during partial remission and 7.54 during a major depressive episode, compared with full remission (P 0.001). Numerous factors were associated with this risk, but lacking a partner, previous suicide attempts and total time spent in major depressive episodes were the most robust predictors. CONCLUSIONS: Suicide attempts among patients with major depressive disorder are strongly associated with the presence and severity of depressive symptoms and predicted by lack of partner, previous suicide attempts and time spent in depression. Reducing the time spent depressed is a credible preventive measure.

Continuity is the main challenge in treating major depressive disorder in psychiatric care.

OBJECTIVE: Several evidence-based treatment guidelines for major depressive disorder (MDD) have been published. However, little is known about how recommendations for treatment are adhered to by patients in current usual psychiatric practice. METHOD: The Vantaa Depression Study is a prospective, naturalistic cohort study of 269 psychiatric patients with a new episode of DSM-IV MDD who were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and Structured Clinical Interview for DSM-III-R Personality Disorders between February 1, 1997, and May 31, 1998, and again at 6 and 18 months. Treatments provided, as well as adherence to and attitudes toward both antidepressants and psychotherapeutic support/psychotherapy, were investigated among the 198 unipolar patients followed for 18 months. RESULTS: Most depression patients (88%) received antidepressants in the early acute phase, but about half (49%) terminated treatment prematurely. This premature termination was associated with worse outcome of major depressive episodes, and with negative attitudes, mainly explained by fear of dependence on or side effects of antidepressants. Nearly all patients (98%) received some psychosocial treatment in the acute phase; about one fifth (16%) had weekly psychotherapy during the follow-up. About a quarter of patients admitted nonadherence to ongoing treatments. CONCLUSION: Problems of psychiatric care seem most related to continuity of treatment. While adequate treatments are provided in the early acute phase, antidepressants are terminated too soon in about half of patients, often following their autonomous decisions. From a secondary and tertiary preventive point of view, improving continuity of treatment would appear a crucial task for improving the outcome of psychiatric patients with MDD.

Functional and work disability in major depressive disorder.

We examined factors related to social and occupational disability, social adjustment, and work disability among patients with major depressive disorder (MDD), the dominant mental disorder causing functional and work disability. The Vantaa Depression Study comprises a cohort of 269 psychiatric inpatients and outpatients with MDD in the city of Vantaa, Finland. Axis I and II diagnoses were assessed via semistructured WHO Schedules for Clinical Assessment in Neuropsychiatry Version 2.0 and Structured Clinical Interview for DSM-III-R personality disorders interviews. Global disability, social and work adjustment, and being at work or on sick leave were assessed. The most important factors associated with level of social, functional, and work disability were severity and recurrence of depression, but older age and current Axis I and II comorbidity also significantly contributed. Of those employed, almost half (43%) were on sick leave. The most pervasive factors explaining level of functional and work disability among patients with MDD were severity and recurrence of depression. However, older age and comorbidity also contributed.

Severity and comorbidity predict episode duration and recurrence of DSM-IV major depressive disorder.

BACKGROUND: Information on the naturalistic outcome of major depressive disorder (MDD) is important in developing rational clinical practices. The aim of this study was to determine the outcome of MDD in a modern secondary-level psychiatric setting and the influence of comorbidity plus psychosocial factors on the outcome of MDD. METHOD: The Vantaa Depression Study is a prospective, naturalistic cohort study of 269 secondary-level care psychiatric outpatients and inpatients diagnosed with a new episode of DSM-IV MDD. Patients were initially interviewed to determine the presence of MDD using the World Health Organization Schedule for Clinical Assessment in Neuropsychiatry and to assess Axis II diagnoses using the Structured Clinical Interview for DSM-III-R personality disorders between February 1, 1997, and May 31, 1998, and were interviewed again at 6 months and 18 months. The exact duration of the index episode and the timing of relapses/recurrences were examined using a life chart. RESULTS: The median length of time that patients met full criteria for a major depressive episode was 1.5 (95% CL = 1.3 to 1.7) months, and the median time to full remission was 8.1 (95% CL = 5.2 to 11.0) months after entry. During the follow-up, 38% of patients had a recurrence. Although numerous factors predict outcome of MDD to some extent, severity of depression and current comorbidity were the 2 most important predictors of longer episode duration and recurrence. CONCLUSION: The course of MDD in modern psychiatric settings remains unfavorable. Any estimates of duration of depressive episodes and rates of recurrence are likely to be dependent on the severity of depression and level of comorbidity. At least among a population of mostly outpatients with MDD in medium-term follow-up, severity of depression and comorbidity appear to be more useful predictors of recurrence than does the number of prior episodes. These factors should influence clinical decision-making regarding the need for maintenance therapy.

Life events, social support, and onset of major depressive episode in Finnish patients.

We investigated differences in life events and social support between subgroups of depressed patients and the distribution of life events in phases preceding or during depression. In the Vantaa Depression Study, 269 psychiatric patients with DSM-IV major depressive disorder were diagnosed with Schedule for Clinical Assessment in Neuropsychiatry, Version 2.0, and Structured Clinical Interview for DSM-III-R personality disorders (SCID-II). Life events during the 12 months preceding the interview were investigated with the Interview for Recent Life Events, and social support with the Interview Measure of Social Relationships and the Perceived Social Support Scale-Revised. Nearly all patients (91%) reported life events, on average 4.1 per preceding year. No major differences between sociodemographic or clinical subgroups were found; the frequency of events was somewhat greater among the younger subjects, whereas those with comorbid alcoholism or personality disorders perceived less social support. Although events were distributed evenly between the time preceding depression, the prodromal phase, and the index major depressive episode, two thirds of the patients attributed their depression to some event. Despite clinical and sociodemographic heterogeneity, patients with major depressive disorder are fairly homogeneous in terms of life events during the preceding year. Events do not cluster in any particular phase of the progression to an episode.

Co-morbidity and stability of melancholic features in DSM-IV major depressive disorder.

BACKGROUND: The descriptive validity of the melancholic features specifier of the DSM-IV major depressive disorder (MDD) is uncertain. Little is known about its relationship to psychiatric co-morbidity, stability across episodes, or strength in predicting course of illness. METHOD: The Vantaa Depression Study (VDS) is a prospective, naturalistic cohort study of 269 patients with a new episode of DSM-IV MDD who were interviewed with SCAN and SCID-II between 1 February 1997 and 31 May 1998, and again at 6 and 18 months. Ninety-seven (36%) MDD patients met DSM-IV criteria for the melancholic features specifier, and were contrasted with 172 (64 %) subjects with a non-melancholic MDD. The duration of the index episode was examined using a life chart. RESULTS: We found no difference in rates of any current co-morbid Axis I or II disorders between melancholic and non-melancholic depressed patients. Of those who had melancholic features at the index episode and subsequent episodes during the 18-month follow-up, only 22 % (5/23) presented melancholic features during the latter. The non-melancholic subtype switched to melancholic in 25 % (8/32) of cases. Differences in the course of melancholic and non-melancholic depression were very minor. CONCLUSIONS: The descriptive validity of the DSM-IV melancholic features specifier may be questionable in MDD. There appear to be no major differences in current co-morbidity, or course of depression between melancholic and non-melancholic patients. The consistency of DSM-IV melancholic features across episodes appears weak.

Suicidal ideation and attempts among psychiatric patients with major depressive disorder.

BACKGROUND: Few studies have investigated risk factors for suicidal ideation and attempts, or possible variations in them, among representative samples of psychiatric patients with major depressive disorder. METHOD: As part of the Vantaa Depression Study in Vantaa, Finland, 269 patients with DSM-IV major depressive disorder (MDD), diagnosed by interview using semistructured World Health Organization Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and Structured Clinical Interview for DSM-III-R Personality Disorders, were thoroughly investigated. Information was gathered on patients' levels of depression, anxiety, hopelessness, perceived social support, social and occupational functioning, and alcohol use. Suicidal behavior was assessed by interviews, including the Scale for Suicidal Ideation, and by information from psychiatric records. Data were gathered from Feb. 1, 1997, to May 31, 1998. RESULTS: During the current MDD episode, 58% of all patients had experienced suicidal ideation; among the 15% of the total who had attempted suicide, almost all (95%) had also had suicidal ideation. In nominal regression models predicting suicidal ideation, hopelessness, alcohol dependence or abuse, low level of social and occupational functioning, and poor perceived social support were found to be significant (p < .05) independent risk factors. High severity of depression and current alcohol dependence or abuse in particular, but also younger age and low level of social and occupational functioning, predicted suicide attempt. CONCLUSION: Suicidal ideation is prevalent and appears to be a precondition for suicide attempts among psychiatric patients with MDD. The risk factors for suicidal ideation and attempts locate in several clinical and psychosocial domains. While these risk factors largely overlap, the overall level of psychopathology of suicide attempters is higher compared with that in patients with ideation, and substance use disorders and severity of depression may be of particular importance in predicting suicide attempts.

Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study.

BACKGROUND: While numerous studies have documented the high comorbidity of major depressive disorder (MDD) with individual mental disorders, no published study has reported overall current comorbidity with all Axis I and II disorders among psychiatric patients with MDD, nor systematically investigated variations in current comorbidity by sociodemographic factors, inpatient versus outpatient status, and number of lifetime depressive episodes. METHOD: Psychiatric outpatients and inpatients in Vantaa, Finland, were prospectively screened for an episode of DSM-IV MDD, and 269 patients with a new episode of MDD were enrolled in the Vantaa Depression MDD Cohort Study. Axis I and II comorbidity was assessed via semistructured Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and Structured Clinical Interview for DSM-II-R personality disorders interviews. RESULTS: The great majority (79%) of patients with MDD suffered from 1 or more current comorbid mental disorders, including anxiety disorder (57%), alcohol use disorder (25%), and personality disorder (44%). Several anxiety disorders were associated with specific Axis II clusters, and panic disorder with agoraphobia was associated with inpatient status. The prevalence of personality disorders varied with inpatient versus outpatient status, number of lifetime depressive episodes, and type of residential area, and the prevalence of substance use disorders varied with gender and inpatient versus outpatient status. CONCLUSION: Most psychiatric patients with MDD have at least 1 current comorbid disorder. Comorbid disorders are associated not only with other comorbid disorders, but also with sociodemographic factors, inpatient versus outpatient status, and lifetime number of depressive episodes. The influence of these variations on current comorbidity patterns among MDD patients needs to be taken account of in treatment facilities.