Psychiatric diagnoses of treatment-seeking cocaine abusers.

In a sample of 298 cocaine abusers seeking inpatient (n = 149) or outpatient (n = 149) treatment, rates of psychiatric disorders were determined by means of the Schedule for Affective Disorders and Research Diagnostic Criteria. Overall, 55.7% met current and 73.5% met lifetime criteria for a psychiatric disorder other than a substance use disorder. In common with previous reports from clinical samples of cocaine abusers, these overall rates were largely accounted for by major depression, minor bipolar conditions (eg, hypomania, cyclothymic personality), anxiety disorders, antisocial personality, and history of childhood attention deficit disorder. Affective disorders and alcoholism usually followed the onset of drug abuse, while anxiety disorders, antisocial personality, and attention deficit disorder typically preceded drug abuse.

Inverse relationship between defensiveness and lifetime prevalence of psychiatric disorder.

Defensiveness (the tendency not to report unfavorable information about oneself), as measured by the Marlowe-Crowne Social Desirability Scale, has been shown to be inversely correlated with self-reported symptoms. In this family study of depression, direct interviews with 380 subjects combined with relatives' reports revealed a similar inverse relationship between defensiveness and lifetime prevalence of any psychiatric disorder, especially when diagnostic status was most certain and among those at greater risk for psychopathology. The authors conclude that the Marlowe-Crowne scale measures a factor or trait associated with the relative absence of psychiatric disorder, not the underreporting or denial of disorder.

Delusional depression and bipolar spectrum: evidence for a possible association from a family study of children.

Recent pedigree studies demonstrating a possible linkage of bipolar disorder to markers on different chromosomes have included family members with major depression and cyclothymia as affected. There is general agreement that cyclothymia is related to bipolar disorder and that major depression is heterogenous. It is unclear which subtype of major depression is related to bipolar disorder. Data suggesting a relationship between delusional subtype of major depression and bipolar spectrum are presented. The data derive from a direct-interview study of 220 offspring (ages 6 to 23 years) of probands with either delusional or nondelusional major depression and normal controls. The children of delusional as contrasted with nondelusional probands had nearly a threefold increase in cyclothymia, were more often described by health professionals as hyperactive, and had increased school and social impairments. These findings in children replicate earlier findings in adults on the possible relationship between delusional depression and bipolar disorder and its spectrum. The findings must be considered tentative, however, because of the small sample of children in the subgroups of interest.

Parental concordance for affective disorders: psychopathology in offspring.

This paper examines the effects of parental concordance for affective disorders and psychopathology among the 219 offspring of probands with major depression and normal controls. The lifetime prevalence of psychiatric disorders was significantly higher among the spouses of depressed probands as compared to those of normal controls. The spouses of 37% of the normals and 69% of the depressed probands met criteria for a diagnosis of major depression, an anxiety disorder, or alcoholism. Parental concordance for diagnoses, particularly for anxiety disorders, substantially increased the risk of major depression and anxiety disorders in their children. Moreover, the marital relationship, some aspects of family adjustment and severity of current symptoms were significantly worse among the couples who exhibited diagnostic concordance for anxiety, alcoholism and/or depression. The major implication of these findings is that the diagnostic status of both parents should be considered in the design and analysis of studies of children. The findings of the present study also underscore the importance of assessment of comorbid disorders in parents and offspring. Although the original study design focused on the risk of depression in children of parents in treatment for major depression, stronger transmissibility was found for anxiety disorders plus depression than for major depression alone. However, the exclusion criteria of a lifetime history of mania or hypomania led to an extremely low proportion of probands with pure major depression without concomitant anxiety disorders. These findings confirm the results of previous studies which have demonstrated a strong degree of overlap between affective and anxiety syndromes. The increased risk of anxiety disorders in the offspring of parents who had sought treatment for non-bipolar major depression suggests that anxiety may constitute an early form of expression of affective disorders. Confirmation of the finding of age-dependent expression of anxiety and depression in prospective longitudinal studies of children is indicated.

Early-onset major depression in parents and their children.

In a study of 6-23-year-old offspring of depressed and of normal parents, an inverse relationship between the rates of major depression among the children and the age of onset of major depression in their proband parents was found. The children of parents who had an onset of major depression that was younger than age 20 years overall had the highest risk of major depression. There was specificity in the findings in that these higher rates were nearly all accounted for by prepubertal onsets of major depression in their children. There was a 14-fold increased risk of onset of depression before age 13 in the children of probands who had onset less than age 20. These results were not confounded by the current age of the proband or the children, by interview status (children were interviewed), by comorbidity in the parents or by assortative mating. Future family genetic studies should examine the rates and patterns of illness of the biological relatives of probands with prepubertal-onset major depression.

Parental representations of depressed outpatients from a U.S.A. sample.

A case-control study of adult depressed outpatients derived from a U.S. sample confirmed previous Australian reports of a significantly greater likelihood for depressives to report an earlier lack of parental care as well as parental overprotection. Only 32% of the patients, as against 62% of the non-psychiatric controls, reported 'optimal bonding', as defined by the Parental Bonding Instrument (PBI), from one or both parents. By contrast 62% of the depressives and 27% of the controls reported exposure to PBI-defined 'affectionless control' from one or both parents. As in previous studies, a raw PBI care score of less than 10 was highly discriminating, being reported by 32% of the depressives and only 3% of the controls.

Assortative mating and affective disorders: psychopathology in offspring.

Familial aggregation has been frequently observed among probands with depression, anxiety disorders, and alcoholism (Gershon et al. 1976; Goodwin et al. 1973; Crowe et al. 1983). Because of the familial nature of these disorders, offspring of such probands have been identified to be at high risk for developing these illnesses themselves (Tarter 1983). Information regarding such risk has come from several sources: retrospective studies of patients with psychiatric disorders; studies of children whose parents are being treated for these disorders; and longitudinal follow-up studies of children with symptoms of the disorder.

Lifetime prevalence and age of onset of psychiatric disorders: recall 4 years later.

The blind test-retest reliability of lifetime prevalence and age of onset of psychiatric diagnoses, based on the SADS-L interview and RDC over a three-to-five year period, was examined in 143 probands and their relatives. Reliability of lifetime prevalence of major depression was excellent; reliability of antisocial personality, panic disorder, drug abuse, GAD, depressive personality, and alcoholism was good; reliability of obsessive-compulsive disorder and phobia was acceptable but lower. The reliability of hyperthymia or cyclothymia was not acceptable. Reliability for major depression did not vary substantially by age or sex of the informant, but recall of major depression was significantly higher in the probands than in their relatives. The test-retest reliability for the age of onset of major depression and panic disorder was excellent, and for phobia, GAD and alcoholism, was acceptable. Both probands and relatives recalled the age of onset of their depression fairly accurately. However, there was a reduction in agreement over time. Recall after 3-4 yr was better than 5-6 yr. There was a tendency for older respondents to systematically increase the age of onset of their depression across the two interviews, although the increase was only a few years. Recall of age of onset did not differ significantly by sex of respondent or whether the respondent was a proband or relative. These findings are discussed in light of several available studies of reliability of lifetime prevalence of psychiatric diagnoses.

Parent and child reports of depressive symptoms in children at low and high risk of depression.

The K-SADS-E psychiatric interview was administered to children and parents (N = 220) from families containing proband parents who had previously been depressed or who were normal. Agreement between parents and their children about depressive symptoms in the children was significant but low. Boy's reports agreed more highly with their parents' reports about them than did girls' reports. Overall, the children reported more depressive symptoms than their parents reported about them and the overall pattern suggests that parents are relatively insensitive to their children's depressive symptomatology, but their reports show high specificity. The implications of these findings for research and clinical work are discussed.

Children of depressed parents. Increased psychopathology and early onset of major depression.

Data on the psychiatric diagnosis, overall functioning, and treatment of 220 6- to 23-year-old subjects who were at high or low risk for major depression are presented. The subjects' diagnoses were made by a child psychiatrist based on best-estimate evaluation of diagnostic information derived from structured interviews (Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Epidemiologic Version) with the subjects and separately with their mothers about their children. The major findings were an increased overall prevalence of major depression and substance abuse, psychiatric treatment, poor social functioning, and school problems in the children of depressed proband parents compared with children of normal proband parents. Overall prepubertal depression was uncommon and the sex ratios were equal. After 12 years of age, there was an increasing preponderance of female subjects in the group with major depression. The mean age at onset of major depression was similar for male and female subjects. However, it was significantly earlier in the children of depressed probands (mean age at onset, 12 to 13 years) compared with the children of normal probands (mean age at onset, 16 to 17 years). Symptom profiles and additional types of diagnoses in the depressed children from either proband parent group did not differ. These children are being followed up longitudinally to determine the prognostic significance, persistence, recurrence, and recall of their symptoms. Several research and clinical strategies are suggested by these data.

Assessing psychiatric disorders in children. Discrepancies between mothers' and children's reports.

Results were compared from independent interviews using the Schedule for Affective Disorders and Schizophrenia for School-aged Children-Epidemiologic Version and DSM-III with 220 subjects (ages 6 to 23 years) and their parent informants. In agreement with results from studies using a variety of structured diagnostic interviews or symptom scales, considerable discrepancies were found between parents' and children's reports on the degree and nature of the child's psychopathology. The children reported more illness about themselves than their parents reported about them. The parents' reports were primarily a subset of the children's reports. Various factors that might affect agreement, including demography, parental clinical status, severity of illness, and treatment, were also explored. The findings that parents under-report psychiatric disorders in their children are comparable with those reported in studies of adults when family informants are used to obtain diagnostic information. Until these parent-child discrepancies can be resolved by longitudinal, family, and other research, diagnostic assessment of children should include direct interviews with them. An independent assessment of the child's diagnosis based on information from multiple informants, including the child, may be the best estimate.

The relationship of patient difficulty to therapist performance in interpersonal psychotherapy of depression.

The efficacy of Interpersonal Psychotherapy (IPT) in the treatment of ambulatory major depression was demonstrated in the recently completed NIMH Treatment of Depression Collaborative Research Program (Elkin et al. 1986). Factors which enhance or impede the administration of the treatment delimit effective patient care and should therefore be understood. This report examines the relationship of pretreatment patient attitudes and in-treatment patient difficulty to the ability of therapists to competently conduct IPT, using data from a training program in IPT. The hypothesis was that the patient's ability and willingness to establish a relationship and undertake the task demands of therapy would influence the therapist's ability to administer treatment. Patient difficulty was found to be strongly related to both therapists' and supervisors' judgements of therapist performance during IPT sessions: when patients were more difficult, therapists were judged to have performed more poorly. Patients' preexisting negative expectations about the potential outcome of treatment were associated with patient difficulty and poorer therapist performance, while the level of presenting symptomatology was not. Thus, it appears that the patient's ability to engage in a productive therapeutic relationship rather than the severity of his presenting problems influenced the therapist's ability to competently perform IPT. The findings regarding the relationship of patient difficulty to ratings of therapist performance suggest that patient difficulty should be taken into account in assessing therapist competence, whether for studies of therapeutic efficacy or for clinical supervision and training in general.

Family-genetic studies of psychiatric disorders. Developing technologies.

During the past decade new concepts and technologies have improved the conduct of family-genetic studies in psychiatry. We compiled and critically evaluated these advances, including study design, pedigree collection, diagnostic procedures in adults and children, and epidemiologic and genetic approaches to data analysis. These approaches have improved the collection of accurate information on the nature and patterns of psychiatric illness in families. The data generated from well-designed and well-conducted family studies are useful for the identification of homogeneous subgroups of psychiatric disorders, for understanding the spectrum of psychiatric disorders, for examining the associations between psychiatric disorders, and for studying the continuity between adult and childhood manifestations of psychiatric disorders. Findings from these studies also may enhance our capacity to identify the mode of transmission of the psychiatric disorders and to select potentially informative families for future genetic linkage studies using the new recombinant DNA techniques. The adaptation of these methods to routine clinical practice and new directions in the application of family-genetic studies employing more refined assessments and analytic methods are also discussed.

Validation of criteria for major depression through controlled family study.

As compared with depressed relatives of normals, depressed relatives of affective patients are more likely to have severe impairment or incapacitation in their major life role when depressed, and more likely to suffer multiple episodes. These findings suggest that among major depressions, these clinical criteria may usefully identify cases with a familial, possibly genetic, vulnerability.

Depressed parents and their children. General health, social, and psychiatric problems.

Two hundred twenty children (aged 6 to 23 years) from families with either depressed or normal (nonpsychiatrically ill) parents of comparable sociodemographic backgrounds were studied. The children from families in which at least one parent had experienced a major depression were reported to have had more adverse perinatal events; were later in achieving some developmental landmarks; had more convulsions, head injuries, operations, and psychiatric disorders (particularly major depression); and made more suicide attempts. Overall, there were no significant differences in IQ between children in both groups. Mothers in families with a depressed parent reported more medical problems during pregnancy and labor, and the children were reported to have experienced more distress at birth. Since major depression is a highly prevalent disorder in women of childbearing ages, these findings have direct clinical implications for pediatricians. Their specificity for major depression, as contrasted with other psychiatric disorders or chronic illnesses in the parents, requires further study.

Understanding the clinical heterogeneity of major depression using family data.

For major depression, putative subgroups have been defined by age at onset, clinical severity, symptom patterns, or the presence of other disorders (comorbidity), yet the high degree of overlap in clinical presentation makes it difficult to determine which combination of criteria for defining subgroups best predicts familial aggregation. In dealing with this overlap, we found that only early age at onset, or major depression with an anxiety disorder or secondary alcoholism, were independently related to increased risk of major depression in relatives. Once the effects of these proband factors had been taken into account, endogenous, delusional, melancholic, or autonomous symptom patterns, recurrent depression, history of hospitalization, and suicidal ideation or attempts in probands were not associated with increased risk of major depression in relatives.

The use of survival time models with nonproportional hazard functions to investigate age of onset in family studies.

The use of survival time models with non-proportional hazard functions is introduced as a method of studying age of onset effects in family studies. Statistical methods for investigating non-proportionality of the hazard function are described, and the application of these methods is illustrated using data from a family study of depression to investigate transmission of age of onset between probands and their first degree relatives. The method is broadly applicable and useful for many chronic diseases where transmission of a disorder in families varies by age of onset of the disorder. It may also be used to investigate the effect of other proband factors such as sex on the age of onset of disease in relatives.