Gender differences in depression severity and symptoms across depressive sub-types.

BACKGROUND: Lifetime rates of depression are distinctly higher in women reflecting both real and artefactual influences. Most prevalence studies quantifying a female preponderance have examined severity-based diagnostic groups such as major depression or dysthymia. We examined gender differences across three depressive sub-type conditions using four differing measures to determine whether any gender differences emerge more from severity or symptom prevalence, reflect nuances of the particular measure, or whether depressive sub-type is influential. METHODS: A large clinical sample was recruited. Patients completed two severity-weighted depression measures: the Depression in the Medically Ill 10 (DMI-10) and Quick Inventory of Depressive Symptoms-Self-Report (QIDS-SR) and two measures weighting symptoms and illness correlates of melancholic and non-melancholic depressive disorders - the Severity of Depressive Symptoms (SDS) and Sydney Melancholia Prototype Index (SMPI). Analyses were undertaken of three diagnostic groups comprising those with unipolar melancholic, unipolar non-melancholic and bipolar depressive conditions. RESULTS: Women in the two unipolar groups scored only marginally (and non-significantly) higher than men on the depression severity measures. Women in the bipolar depression group, did however, score significantly higher than men on depression severity. On measures weighted to assessing melancholic and non-melancholic symptoms, there were relatively few gender differences identified in the melancholic and non-melancholic sub-sets, while more gender differences were quantified in the bipolar sub-set. The symptoms most commonly and consistently differentiating by gender were those assessing appetite/weight change and psychomotor disturbance. CONCLUSION: Our analyses of several measures and the minimal differentiation of depressive symptoms and symptom severity argues against any female preponderance in unipolar depression being contributed to distinctly by these depression rating measures. Our analyses indicated that gender had minimal if any impact on depression severity estimates. Gender differences in depressive symptoms and severity were more distinctive in bipolar patients, a finding seemingly not previously identified or reported. LIMITATIONS: The study had considerable power reflecting large sample sizes and thus risks assigning significant differences where none truly exist, although we repeated analyses after controlling for the type I error rate.

Refining a complex diagnostic construct: subtyping Dysthymia with the Shedler-Westen Assessment Procedure-II.

OBJECTIVE: We sought to determine whether meaningful subtypes of Dysthymic patients could be identified when grouping them by similar personality profiles. METHOD: A random, national sample of psychiatrists and clinical psychologists (n=1201) described a randomly selected current patient with personality pathology using the descriptors in the Shedler-Westen Assessment Procedure-II (SWAP-II), completed assessments of patients' adaptive functioning, and provided DSM-IV Axis I and II diagnoses. RESULTS: We applied Q-factor cluster analyses to those patients diagnosed with Dysthymic Disorder. Four clusters were identified-High Functioning, Anxious/Dysphoric, Emotionally Dysregulated, and Narcissistic. These factor scores corresponded with a priori hypotheses regarding diagnostic comorbidity and level of adaptive functioning. We compared these groups to diagnostic constructs described and empirically identified in the past literature. CONCLUSIONS: The results converge with past and current ideas about the ways in which chronic depression and personality are related and offer an enhanced means by which to understand a heterogeneous diagnostic category that is empirically grounded and clinically useful.

An examination of generalized anxiety disorder and dysthymic disorder by latent class analysis.

BACKGROUND: The nosological status of generalized anxiety disorder (GAD) versus dysthymic disorder (DD) has been questioned. The aim of this study was to examine qualitative differences within (co-morbid) GAD and DD symptomatology. METHOD: Latent class analysis was applied to anxious and depressive symptomatology of respondents from three population-based studies (2007 Australian National Survey of Mental Health and Wellbeing; National Comorbidity Survey Replication; and Netherlands Mental Health Survey and Incidence Study-2; together known as the Triple study) and respondents from a multi-site naturalistic cohort [Netherlands Study of Depression and Anxiety (NESDA)]. Sociodemographics and clinical characteristics of each class were examined. RESULTS: A three-class (Triple study) and two-class (NESDA) model best fitted the data, reflecting mainly different levels of severity of symptoms. In the Triple study, no division into a predominantly GAD or DD co-morbidity subtype emerged. Likewise, in spite of the presence of pure GAD and DD cases in the NESDA sample, latent class analysis did not identify specific anxiety or depressive profiles in the NESDA study. Next, sociodemographics and clinical characteristics of each class were examined. Classes only differed in levels of severity. CONCLUSIONS: The absence of qualitative differences in anxious or depressive symptomatology in empirically derived classes questions the differentiation between GAD and DD.

A nosological review of depressive disorders based on observations in clinical practice, Part 2: a working typology for clinicians.

OBJECTIVE: The purpose of this paper is to examine the essential nosological differentiation between melancholic and non-melancholic forms of depression with a view to promoting a meaningful, working typology for clinicians. The paper primarily comprises observations and reflections drawn from clinical practice. CONCLUSIONS: The most specific symptoms of melancholic depression are described, as are the main varieties of non-melancholic 'depression', including demoralisation, grief, loneliness, existential depression and depressive personality.

Mood disorders in epilepsy - diagnostic and methodological considerations.

BACKGROUND: Mood disorders are common in people with epilepsy (PWE) with prevalence rates ranging from 11% to 62%. The variation in epidemiological data results probably from the diversity of methodologies employed and selection of the populations across the studies. Moreover, the symptomathology of mood disorders in epilepsy is often atypical, intermittent and pleomorphic and fails to meet DSM-IV-TR categories. Several studies suggested the existence of distinct interictal dysphoric disorder (IDD) in patients with epilepsy. The majority of research studies in mood disorders in epilepsy were based on screening instruments in the diagnosis of mood disorders in PWE. However, the results in validity and reliability in detecting major depression in epilepsy using self-report inventories of mood symptoms is vague. The aim of this study was to review studies on mood disorders in epilepsy with particular focus on diagnostic methods. SUBJECTS AND METHODS: The focus of this Review was on patient studies on mood disorders in epilepsy (2000-2012). We searched PubMed using the following search terms (effective date: 20th May 2012): (epilepsy (Title/Abstract) OR seizure (Title/Abstract)) AND depression (Title/Abstract) OR Dysthymia OR mania OR bipolar disorder OR affective disorder OR Interictal Dysphoric Disorder OR AND (humans (MeSH Terms) AND English (lang) AND (2000/01/01(PDAT): 2012/04/31(PDAT)). RESULTS: Depression is the most frequent comorbid psychiatric disorder in epilepsy. Recent studies pointed out that bipolar disorders are not rare in epilepsy. Most of the research in PWE did not rely on standardized psychiatric measures and only about 18% of studies were based on diagnostic psychiatric interviews (mainly MINI and SCID-I). Mood disorders in epilepsy excluding the ictal or periictal symptoms can be categorized using standardized measures. CONCLUSIONS: Common self-report depression measures may be used to screen for depression in clinical settings. The use of screening instruments in epilepsy must be followed by structured psychiatric interviews designed to establish a DSM-IV-TR diagnoses. Standardized psychiatric interview procedures based on DSM criteria like SCID-I or MINI provide a comprehensive way to diagnose mood disorders in patients with epilepsy.

Are there meaningful differences between major depressive disorder, dysthymic disorder, and their subthreshold variants?

A number of researchers have proposed adding an increasing number of subthreshold variants of major depressive disorder (MDD) as new mood disorder. However, this research has suffered from a number of theoretical and methodological flaws that the current investigation has attempted to address. Individuals with MDD (n = 470) were compared with individuals with subthreshold MDD (n = 57). Individuals with MDD reported consistently more severe symptoms, albeit of small magnitude, as well as differences in comorbidity with only two disorders. Results also indicated that diagnosis did not significantly predict rate of symptom change when MDD was compared with its subthreshold variant. Taken together, the aforementioned evidence suggests that small differences exist between MDD and its subthreshold variant. In addition, the extent to which the latter serves as useful analogs for the former may depend upon the variables under study.

I can see what you feel, but I can't deal with it: Impaired theory of mind in depression.

BACKGROUND: Even though unipolar depression is associated with considerably impaired social functioning, only a few studies so far have investigated Theory of Mind (ToM) abilities of unipolar depressed patients. Therefore, the main goal of this study is to examine whether depressed patients are impaired in their ToM as compared to healthy controls. Thereby, both aspects of ToM, i.e. decoding and reasoning, are examined separately. METHODS: Acutely depressed patients with unipolar affective disorder (n=24) and healthy controls (n=20) were examined with the 'Reading the Mind in the Eyes Test' (RMET) and the 'Movie for the Assessment of Social Cognition' (MASC) to address the two aspects of ToM. RESULTS: Patients compared to controls did not show impaired decoding ability in the RMET, but did show deficits in integrating contextual information about other people (reasoning) in the MASC. This impairment is independent of the mental state modality that had to be judged (emotional vs. cognitive). LIMITATIONS: Possible differences between the diagnostic subgroups of depression, which play an important role in clarifying the opposing results concerning the association between ToM abilities and depression in the existing literature, have not been examined. CONCLUSIONS: It is possible that the low level of social functioning associated with depression can be ascribed partially to a ToM deficit and should be addressed in the treatment of depression.

(Post-traumatic) embitterment disorder: critical evaluation of its stressor criterion and a proposed revised classification.

BACKGROUND: In 2003, the German psychiatrist Michael Linden proposed the new mental disorder concept of "post-traumatic embitterment disorder (PTED)". PTED is defined as the mental reaction to a critical event that is normal, but not everyday, such as conflict at work. The patient sees this event as unjust and as a violation of basic beliefs. The principal aspect of the reaction pattern is a prolonged feeling of embitterment. AIM: In the present paper, the concept of PTED is systematically evaluated. Moreover, future developments in terms of diagnostic systems of mental disorders (ICD-11, DSM-V) are addressed. RESULTS: The evaluation of critical points concerning PTED revealed that the question of whether PTED is a mental disorder of the post-traumatic type cannot be finally answered. It is not possible to specify an empirical criterion by means of which traumatic and non-traumatic life events can be differentiated. An empirical criterion for determining the traumatic nature of a given event depends on whether this event has already been classified as traumatic (i.e. circular argument). CONCLUSIONS: For the purpose of a clear classification of embitterment disorders, the new concept of adjustment disorders of Andreas Maercker and co-workers is introduced. Based on the criteria and their findings, the best and most viable possibility to classify embitterment disorders in accordance with the current adjustment disorder and post-traumatic stress disorder definitions of ICD and DSM is by regarding embitterment disorders as a subtype of adjustment disorders.

Emotional disorders: cluster 4 of the proposed meta-structure for DSM-V and ICD-11.

BACKGROUND: The extant major psychiatric classifications DSM-IV, and ICD-10, are atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis would be greatly enhanced by an understanding of risk factors and clinical manifestations. In an effort to group mental disorders on the basis of aetiology, five clusters have been proposed. This paper considers the validity of the fourth cluster, emotional disorders, within that proposal. METHOD: We reviewed the literature in relation to 11 validating criteria proposed by a Study Group of the DSM-V Task Force, as applied to the cluster of emotional disorders. RESULTS: An emotional cluster of disorders identified using the 11 validators is feasible. Negative affectivity is the defining feature of the emotional cluster. Although there are differences between disorders in the remaining validating criteria, there are similarities that support the feasibility of an emotional cluster. Strong intra-cluster co-morbidity may reflect the action of common risk factors and also shared higher-order symptom dimensions in these emotional disorders. CONCLUSION: Emotional disorders meet many of the salient criteria proposed by the Study Group of the DSM-V Task Force to suggest a classification cluster.

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management.

BACKGROUND: Major depressive disorder (MDD) is one of the most burdensome illnesses in Canada. The purpose of this introductory section of the 2009 revised CANMAT guidelines is to provide definitions of the depressive disorders (with an emphasis on MDD), summarize Canadian data concerning their epidemiology and describe overarching principles of managing these conditions. This section on "Classification, Burden and Principles of Management" is one of 5 guideline articles in the 2009 CANMAT guidelines. METHODS: The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to the Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support. RESULTS: Epidemiologic data indicate that MDD afflicts 11% of Canadians at some time in their lives, and approximately 4% during any given year. MDD has a detrimental impact on overall health, role functioning and quality of life. Detection of MDD, accurate diagnosis and provision of evidence-based treatment are challenging tasks for both clinicians and for the health systems in which they work. LIMITATIONS: Epidemiologic and clinical data cannot be seamlessly linked due to heterogeneity of syndromes within the population. CONCLUSIONS: In the eight years since the last CANMAT Guidelines for Treatment of Depressive Disorders were published, progress has been made in understanding the epidemiology and treatment of these disorders. Evidence supporting specific therapeutic interventions is summarized and evaluated in subsequent sections.

Chronic depression: update on classification and treatment.

A significant proportion of patients with depressive disorders suffer from chronic conditions. The DSM-IV recognizes several forms of chronic depression. Chronic depressions differ from nonchronic major depressive disorder (MDD) on many clinical, psychosocial, and familial variables. However, less support exists for current distinctions between the various forms of chronic depression. Antidepressant medications and at least some forms of psychotherapy are efficacious in treating chronic depression, and the combination of pharmacotherapy and psychotherapy appears to be superior to either monotherapy alone. Still, chronic depression is often inadequately treated, and many patients fail to respond or continue to experience residual symptoms after treatment. An important direction for future research is to elucidate the multiple pathways to chronic depression and to tailor treatments to specific etiopathogenetic subgroups.

A study of the incidence of bipolar spectrum disorders in a private psychiatric practice.

An audit of the diagnosis of 300 consecutive new cases presenting in a private practice over the period of the last four years (from January 2003 to December 2006) is presented. The main observation is the high percentage of patients who fall within the bipolar spectrum who are diagnosed and reported. In particular, there is a large proportion of patients who suffer from Bipolar II illness. The consequences of this in the diagnosis and management of patients is discussed.

Depressive subtypes and efficacy of antidepressive pharmacotherapy.

Efficacy studies suggest that all kinds of treatment have similar efficacy. For instance, according to a meta-analysis from 102 randomised controlled trials in major depression, there is no overall difference in efficacy between SSRIs and TCAs. Taking into consideration the pathophysiological heterogeneity of affective disorders involving a number of neurotransmitters, the different pharmacodynamic profiles of the antidepressant compounds, and the large variety of presentations of depressive illness, it is very simplistic to suppose that all classes of antidepressants are equally effective. Meanwhile, the development of antidepressants with different mechanisms of action provides the opportunity to evaluate whether certain relevant subtypes of depressed patients, based on specific patterns of symptoms, respond preferentially to one class of antidepressants compared with another. The aim of this paper is to review the relationship between the depressive subtypes included in the DSM-IV (melancholic depression, atypical depression, bipolar depression, psychotic bipolar and dysthymia) and the efficacy of antidepressant treatment.

Borderline personality disorder in clinical practice.

OBJECTIVE: Most studies of borderline personality disorder have drawn patients from among hospital inpatients or outpatients. The aims of this study were to examine the nature of borderline personality disorder patients in everyday clinical practice and to use data from a sample of borderline personality disorder patients seen in the community to refine the borderline construct. METHOD: A random national sample of 117 experienced psychiatrists and psychologists from the membership registers of the American Psychiatric Association and American Psychological Association provided data on a randomly selected patient with borderline personality disorder (N=90) or dysthymic disorder (N=27) from their practice. The clinicians provided data on axis I comorbidity, axis II comorbidity, and adaptive functioning, as well as a personality description of the patient using the Shedler-Westen Assessment Procedure-200 (SWAP-200) Q-sort, an instrument designed for assessment and taxonomic purposes. Analyses compared borderline personality disorder and dysthymic disorder groups on variables of interest and aggregated SWAP-200 items across all borderline personality disorder patients to create a composite portrait of borderline personality disorder as seen in the community. RESULTS: The borderline personality disorder sample strongly resembled previously studied borderline personality disorder samples with regard to comorbidity and adaptive functioning. However, the SWAP-200 painted a portrait of borderline personality disorder patients as having more distress and emotion dysregulation, compared to the DSM-IV description. CONCLUSIONS: Borderline personality disorder patients in research samples are highly similar to those seen in a cross-section of clinical practice. However, several studies have now replicated a portrait of borderline personality disorder symptoms that places greater weight than the DSM-IV description on the intense psychological pain of these patients and suggests candidate diagnostic criteria for DSM-V.

¿Es la distimia tardía un trastorno diferente a la distimia precoz? / Is late-onset dysthymia a different disorder than early-onset dysthymia?

La distimia es un tipo de depresión crónica, de al menos dos años de duración, a menudo acompañada de episodios sobreañadidos de depresión mayor. Los pacientes con distimia parecen formar un grupo heterogéneo. Este artículo revisa lo que se sabe de las características de la distimia en los pacientes geriátricos. La mayoría de los pacientes distímicos ancianos no son simplemente pacientes jóvenes que han envejecido. La distimia en los ancianos se relaciona menos con trastornos comórbidos en el eje I y en el eje II, pero está más asociada a las enfermedades somáticas y a los acontecimientos vitales estresantes (AU)

Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2.

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.

[Neurotic depression--a disease without a diagnosis or a diagnosis without a glossary? ]. / Die neurotische Depression--Eine Krankheit ohne Diagnose oder eine Diagnose ohne Glossar?

With the transition from ICD-9 to ICD-10 the diagnosis of neurotic depression was omitted. Freyberger showed that this diagnosis in the ICD-10 was replaced mainly by the diagnoses of dysthymia, recurrent depression and depressive episode (with this ranking of frequency). A renowned German psychiatrist criticized this change as replacing an unsubstantiated dichotomic with an unsubstantiated dimensional model. The same was the case with the change from DSM-II to DSM-III: Torgersen criticized here that the heterogeneous diagnosis of neurotic depression was basically replaced by the similarly heterogeneous diagnosis of major depression. The underlying rationale behind the omission of the traditional diagnosis of neurotic depression in the new glossaries must be seen in the critical contributions of such renowned researchers as Winokur, Klerman and Akiskal during the 60's and 70's of the last century. The present work compares these exclusively phenomenological approaches to classification with a psychodynamic approach, and the author defends the possibility of operationalizing such an attempt as validly as a mere descriptive one. This view is supported by the successful work of a group of German scientists in promoting the OPD (operationalized psychodynamic diagnostics) system. Operationalizable elements are not only to be found in the critics' own contributions, but in recent empirical studies on dysthymia and the other subsequent diagnoses as well. An operationalized and verifiable diagnosis of neurotic depression would have to go far beyond the two main criteria of the ICD-9 (psychoreactive genesis, exclusion of psychosis) and include new insights and perspectives; this, however, is considered feasible. It must be recognized that there is no place in the prevailing diagnostic scene for such a diagnostic construct. Perhaps with time diagnostic modes will change, as has often been the case in the past.

Dysthymia and chronic depression: introduction, classification, risk factors, and course.

Chronic forms of depression are more common and impairing than is generally recognized. This article introduces an In Session issue devoted to dysthymic disorder and chronic depression, and it reviews current knowledge about these disorders. First, we discuss nosological issues, followed by a summary of potential risk factors. Finally, the naturalistic course of chronic depression is described and implications for clinical practice are discussed.

Psychomotor changes in melancholic and atypical depression: unipolar and bipolar-II subtypes.

Psychomotor changes are reported to be 'nearly always present' in the melancholic subtype of major depressive episode (MDE) in DSM-IV-TR, and are believed by some researchers to be markers of melancholia. The aim of this study was to compare melancholic and atypical forms of MDE and to determine whether psychomotor changes are core features of melancholic MDE. The Structured Clinical Interview of DSM-IV was used to consecutively assess 107 unipolar and 164 bipolar-II MDE outpatients. The criteria used to define melancholic and atypical MDE followed DSM-IV-TR. Melancholic MDE was present in 17.7% of patients; atypical MDE, in 35.0%. The group of patients with melancholic MDE had the following differences from the atypical group: higher age, higher age at onset, fewer females, more unipolar cases, fewer bipolar-II cases, lower Global Assessment of Functioning scores, more MDE symptoms, and more psychotic features. Percentages of observable and marked psychomotor changes (agitation and retardation combined) did not differ significantly between the two groups, though the melancholic group tended to have more symptoms. Retardation was significantly more common in melancholic MDE, but its frequency was very low in both melancholic and atypical cases (12.5 vs. 0.0%). Logistic regression controlling for age, gender and illness duration had little effect on the findings, which suggests that psychomotor changes are not core features of melancholic MDE.