Pregnancy, delivery and postpartum in women with schizophrenia or schizoaffective disorder in Finland: a national register-based comparative study.

As part of anational Finnish study on reproductive health of women with severe mental disorders, we compared pregnancy- and delivery-, and postpartum-related outcomes between women with schizophrenia (n = 3444) and those with schizoaffective disorder (n = 985), focusing on their singleton pregnancies after illness onset (n = 708 and n = 242, respectively). For comparison, data also included 22,101 controls with 3668 pregnancies. The Finnish Medical Birth Register, the Register of Congenital Malformations and the Child Welfare Register were used. Despite known differences between the two disorders, we found no robust differences between these patient groups.

Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries.

BACKGROUND: Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care. METHODS: The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions. RESULTS: We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures. CONCLUSIONS: We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Risk factors for suicide in depression in Finland: first-hospitalized patients followed up to 24 years.

OBJECTIVE: To examine longitudinally risk factors for suicide in depression, and gender differences in risk factors and suicide methods. METHOD: We linked data from (i) The Finnish Hospital Discharge Register, (ii) the Census Register of Statistics Finland, and (iii) Statistics Finland's register on causes of deaths. All 56 826 first-hospitalized patients (25 188 men, 31 638 women) in Finland in 1991-2011 with a principal diagnosis of depressive disorder were followed up until death (2587 suicides) or end of the year 2014 (maximum 24 years). RESULTS: Clinical characteristics (severe depression adjusted hazard ratio [AHR] 1.19 [95% CI 1.08-1.30]; psychotic depression AHR 1.45 [1.30-1.62]; and comorbid alcohol dependence AHR 1.26 [1.13-1.41]), male gender (AHR 2.07 [1.91-2.24]), higher socioeconomic status and living alone at first hospitalization were long-term predictors of suicide deaths. Highest risk was associated with previous suicide attempts (cumulative probability 15.4% [13.7-17.3%] in men, 8.5% [7.3-9.7%] in women). Gender differences in risk factors were modest, but in lethal methods prominent. CONCLUSION: Sociodemographic and clinical characteristics at first hospitalization predict suicide in the long term. Inpatients with previous suicide attempts constitute a high-risk group. Despite some gender differences in risk factors, those in lethal methods may better explain gender disparity in risk.

Self-reported psychosis-like experiences in patients with mood disorders.

BACKGROUND: Self-reported psychosis-like experiences (PEs) may be common in patients with mood disorders, but their clinical correlates are not well known. We investigated their prevalence and relationships with self-reported symptoms of depression, mania, anxiety, borderline (BPD) and schizotypal (SPD) personality disorders among psychiatric patients with mood disorders. METHODS: The Community Assessment of Psychic Experiences (CAPE-42), Mood Disorder Questionnaire (MDQ), McLean Screening Instrument (MSI), The Beck Depressive Inventory (BDI), Overall Anxiety Severity and Impairment Scale (OASIS) and Schizotypal Personality Questionnaire-Brief form (SPQ-B) were filled in by patients with mood disorders (n=282) from specialized care. Correlation coefficients between total scores and individual items of CAPE-42 and BDI, SPQ-B, MSI and MDQ were estimated. Hierarchical multivariate regression analysis was conducted to examine factors influencing the frequency of self-reported PE. RESULTS: PEs are common in patients with mood disorders. The "frequency of positive symptoms" score of CAPE-42 correlated strongly with total score of SPQ-B (rho=0.63; P<0.001) and moderately with total scores of BDI, MDQ, OASIS and MSI (rho varied from 0.37 to 0.56; P<0.001). Individual items of CAPE-42 correlated moderately with specific items of BDI, MDQ, SPQ-B and MSI (rφ varied from 0.2 to 0.5; P<0.001). Symptoms of anxiety, mania or hypomania and BPD were significant predictors of the "frequency of positive symptoms" score of CAPE-42. CONCLUSIONS: Several, state- and trait-related factors may underlie self-reported PEs among mood disorder patients. These include cognitive-perceptual distortions of SPD; distrustfulness, identity disturbance, dissociative and affective symptoms of BPD; and cognitive biases related to depressive or manic symptoms.

Solar insolation in springtime influences age of onset of bipolar I disorder.

OBJECTIVE: To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder. METHOD: Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density. RESULTS: There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001). CONCLUSION: A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

Mediating role of borderline personality disorder traits in the effects of childhood maltreatment on suicidal behaviour among mood disorder patients.

BACKGROUND: Substantial evidence supports an association between childhood maltreatment and suicidal behaviour. However, few studies have examined factors mediating this relationship among patients with unipolar or bipolar mood disorders. METHODS: Depressive disorder and bipolar disorder (ICD-10-DCR) patients (n=287) from the Helsinki University Psychiatric Consortium (HUPC) Study were surveyed on self-reported childhood experiences, current depressive symptoms, borderline personality disorder traits, and lifetime suicidal behaviour. Psychiatric records served to complement the information on suicide attempts. We examined by formal mediation analyses whether (1) the effect of childhood maltreatment on suicidal behaviour is mediated through borderline personality disorder traits and (2) the mediation effect differs between lifetime suicidal ideation and lifetime suicide attempts. RESULTS: The impact of childhood maltreatment in multivariate models on either lifetime suicidal ideation or lifetime suicide attempts showed comparable total effects. In formal mediation analyses, borderline personality disorder traits mediated all of the total effect of childhood maltreatment on lifetime suicide attempts, but only one fifth of the total effect on lifetime suicidal ideation. The mediation effect was stronger for lifetime suicide attempts than for lifetime suicidal ideation (P=0.002) and independent of current depressive symptoms. CONCLUSIONS: The mechanisms of the effect of childhood maltreatment on suicidal ideation versus suicide attempts may diverge among psychiatric patients with mood disorders. Borderline personality disorder traits may contribute to these mechanisms, although the influence appears considerably stronger for suicide attempts than for suicidal ideation.

Level of functioning, perceived work ability, and work status among psychiatric patients with major mental disorders.

BACKGROUND: Major mental disorders are highly disabling conditions that result in substantial socioeconomic burden. Subjective and objective measures of functioning or ability to work, their concordance, or risk factors for them may differ between disorders. METHODS: Self-reported level of functioning, perceived work ability, and current work status were evaluated among psychiatric care patients with schizophrenia or schizoaffective disorder (SSA, n=113), bipolar disorder (BD, n=99), or depressive disorder (DD, n=188) within the Helsinki University Psychiatric Consortium Study. Correlates of functional impairment, subjective work disability, and occupational status were investigated using regression analysis. RESULTS: DD patients reported the highest and SSA patients the lowest perceived functional impairment. Depressive symptoms in all diagnostic groups and anxiety in SSA and BD groups were significantly associated with disability. Only 5.3% of SSA patients versus 29.3% or 33.0% of BD or DD patients, respectively, were currently working. About half of all patients reported subjective work disability. Objective work status and perceived disability correlated strongly among BD and DD patients, but not among SSA patients. Work status was associated with number of hospitalizations, and perceived work disability with current depressive symptoms. CONCLUSIONS: Psychiatric care patients commonly end up outside the labour force. However, while among patients with mood disorders objective and subjective indicators of ability to work are largely concordant, among those with schizophrenia or schizoaffective disorder they are commonly contradictory. Among all groups, perceived functional impairment and work disability are coloured by current depressive symptoms, but objective work status reflects illness course, particularly preceding psychiatric hospitalizations.

Maintenance pharmacotherapy for recurrent major depressive disorder in primary care: A 5-year follow-up study.

BACKGROUND: Most practice guidelines recommend maintenance antidepressant treatment for recurrent major depressive disorder. However, the degree to which such guidance is actually followed in primary health care has remained obscure. We investigated the provision of maintenance antidepressant treatment within a representative primary care five-year cohort study. METHODS: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up. A graphic life chart enabling evaluation of the longitudinal course of episodes plus duration of pharmacotherapies was used. In accordance with national guidelines, an indication for maintenance treatment was defined to exist after three or more lifetime major depressive episodes (MDEs); maintenance treatment was to commence four months after onset of full remission. RESULTS: Of the cohort patients, 34% (46/137) had three or more lifetime MDEs, thus indicating the requirement for maintenance pharmacotherapy. Of these, half (54%, 25/46) received maintenance treatment, for only 29% (489/1670) of the months indicated. CONCLUSIONS: In this cohort of depressed primary care patients, half of patients with indications for maintenance treatment actually received it, and only for a fraction of the time indicated. Antidepressant maintenance treatment for the prevention of recurrences is unlikely to be subject to large-scale actualization as recommended, which may significantly undermine the potential public health benefits of treatment.

Prevalence of current anxiety disorders in people with bipolar disorder during euthymia: a meta-analysis.

BACKGROUND: Anxiety disorders are highly prevalent in people with bipolar disorder, but it is not clear how many have anxiety disorders even at times when they are free of major mood episodes. We aimed to establish what proportion of euthymic individuals with bipolar disorder meet diagnostic criteria for anxiety disorders. METHOD: We performed a random-effects meta-analysis of prevalence rates of current DSM-III- and DSM-IV-defined anxiety disorders (panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder, specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and anxiety disorder not otherwise specified) in euthymic adults with bipolar disorder in studies published by 31 December 2015. RESULTS: Across 10 samples with 2120 individuals with bipolar disorder, 34.7% met diagnostic criteria for one or more anxiety disorders during euthymia [95% confidence interval (CI) 23.9-45.5%]. Direct comparison of 189 euthymic individuals with bipolar disorder and 17 109 population controls across three studies showed a 4.6-fold increase (risk ratio 4.60, 95% CI 2.37-8.92, p < 0.001) in prevalence of anxiety disorders in those with bipolar disorder. CONCLUSIONS: These findings suggest that anxiety disorders are common in people with bipolar disorder even when their mood is adequately controlled. Euthymic people with bipolar disorder should be routinely assessed for anxiety disorders and anxiety-focused treatment should be initiated if indicated.

Health-related quality of life of primary care patients with depressive disorders.

BACKGROUND: Depressive disorders are known to impair health-related quality of life (HRQoL) both in the short and long term. However, the determinants of long-term HRQoL outcomes in primary care patients with depressive disorders remain unclear. METHODS: In a primary care cohort study of patients with depressive disorders, 82% of 137 patients were prospectively followed up for five years. Psychiatric disorders were diagnosed with SCID-I/P and SCID-II interviews; clinical, psychosocial and socio-economic factors were investigated by rating scales and questionnaires plus medical and psychiatric records. HRQoL was measured with the generic 15D instrument at baseline and five years, and compared with an age-standardized general population sample (n=3707) at five years. RESULTS: Depression affected the 15D total score and almost all dimensions at both time points. At the end of follow-up, HRQoL of patients in major depressive episode (MDE) was particularly low, and the association between severity of depression (Beck Depression Inventory [BDI]) and HRQoL was very strong (r=-0.804). The most significant predictors for change in HRQoL were changes in BDI and Beck Anxiety Inventory (BAI) scores. The mean 15D score of depressive primary care patients at five years was much worse than in the age-standardized general population, reaching normal range only among patients who were in clinical remission and had virtually no symptoms. CONCLUSIONS: Among depressive primary care patients, presence of current depressive symptoms markedly reduces HRQoL, with symptoms of concurrent anxiety also having a marked impact. For HRQoL to normalize, current depressive and anxiety symptoms must be virtually absent.

Anxiety symptoms in a major mood and schizophrenia spectrum disorders.

BACKGROUND: Comorbid anxiety symptoms and disorders are present in many psychiatric disorders, but methodological variations render comparisons of their frequency and intensity difficult. Furthermore, whether risk factors for comorbid anxiety symptoms are similar in patients with mood disorders and schizophrenia spectrum disorders remains unclear. METHODS: The Overall Anxiety Severity and Impairment Scale (OASIS) was used to measure anxiety symptoms in psychiatric care patients with schizophrenia or schizoaffective disorder (SSA, n=113), bipolar disorder (BD, n=99), or depressive disorder (DD, n=188) in the Helsinki University Psychiatric Consortium Study. Bivariate correlations and multivariate linear regression models were used to examine associations of depressive symptoms, neuroticism, early psychological trauma and distress, self-efficacy, symptoms of borderline personality disorder, and attachment style with anxiety symptoms in the three diagnostic groups. RESULTS: Frequent or constant anxiety was reported by 40.2% of SSA, 51.5% of BD, and 55.6% of DD patients; it was described as severe or extreme by 43.8%, 41.4%, and 41.2% of these patients, respectively. SSA patients were significantly less anxious (P=0.010) and less often avoided anxiety-provoking situations (P=0.009) than the other patients. In regression analyses, OASIS was associated with high neuroticism, symptoms of depression and borderline personality disorder and low self-efficacy in all patients, and with early trauma in patients with mood disorders. CONCLUSIONS: Comorbid anxiety symptoms are ubiquitous among psychiatric patients with mood or schizophrenia spectrum disorders, and in almost half of them, reportedly severe. Anxiety symptoms appear to be strongly related to both concurrent depressive symptoms and personality characteristics, regardless of principal diagnosis.

Response style and severity and chronicity of depressive disorders in primary health care.

BACKGROUND: Response styles theory of depression postulates that rumination is a central factor in occurrence, severity and maintaining of depression. High neuroticism has been associated with tendency to ruminate. We investigated associations of response styles and neuroticism with severity and chronicity of depression in a primary care cohort study. METHODS: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up with a graphic life chart enabling evaluation of the longitudinal course of episodes. Neuroticism was measured with the Eysenck Personality Inventory (EPI-Q). Response styles were investigated at five years using the Response Styles Questionnaire (RSQ-43). RESULTS: At five years, rumination correlated significantly with scores of Hamilton Depression Rating Scale (r=0.54), Beck Depression Inventory (r=0.61), Beck Anxiety Inventory (r=0.50), Beck Hopelessness Scale (r=0.51) and Neuroticism (r=0.58). Rumination correlated also with proportion of follow-up time spent depressed (r=0.38). In multivariate regression, high rumination was significantly predicted by current depressive symptoms and neuroticism, but not by anxiety symptoms or preceding duration of depressive episodes. CONCLUSIONS: Among primary care patients with depression, rumination correlated with current severity of depressive symptoms, but the association with preceding episode duration remained uncertain. The association between neuroticism and rumination was strong. The findings are consistent with rumination as a state-related phenomenon, which is also strongly intertwined with traits predisposing to depression.

Self-reported symptoms of schizotypal and borderline personality disorder in patients with mood disorders.

BACKGROUND: Distinguishing between symptoms of schizotypal (SPD) and borderline personality disorders (BPD) is often difficult due to their partial overlap and frequent co-occurrence. We investigated correlations in self-reported symptoms of SPD and BPD in questionnaires at the levels of both total scores and individual items, examining overlapping dimensions. METHODS: Two questionnaires, the McLean Screening Instrument (MSI) for BPD and the Schizotypal Personality Questionnaire Brief (SPQ-B) for SPD, were filled in by patients with mood disorders (n=282) from specialized psychiatric care in a study of the Helsinki University Psychiatric Consortium. Correlation coefficients between total scores and individual items of the MSI and SPQ-B were estimated. Multivariate regression analysis (MRA) was conducted to examine the relationships between SPQ-B and MSI. RESULTS: The Spearman's correlation between total scores of the MSI and SPQ-B was strong (rho=0.616, P<0.005). Items of MSI reflecting disrupted relatedness and affective dysregulation correlated moderately (rφ varied between 0.2 and 0.4, P<0.005) with items of SPQ. Items of MSI reflecting behavioural dysregulation correlated only weakly with items of SPQ. In MRA, depressive symptoms, sex and MSI were significant predictors of SPQ-B score, whereas symptoms of anxiety, age and SPQ-B were significant predictors of MSI score. CONCLUSIONS: Items reflecting cognitive-perceptual distortions and affective symptoms of BPD appear to overlap with disorganized and cognitive-perceptual symptoms of SPD. Symptoms of depression may aggravate self-reported features of SPQ-B, and symptoms of anxiety features of MSI. Symptoms of behavioural dysregulation of BPD and interpersonal deficits of SPQ appear to be non-overlapping.

Differences and overlap in self-reported symptoms of bipolar disorder and borderline personality disorder.

BACKGROUND: Differential diagnosis between bipolar disorder (BD) and borderline personality disorder (BPD) is often challenging due to some overlap in symptoms and comorbidity of disorders. We investigated correlations in self-reported symptoms of BD and BPD in screening questionnaires at the levels of both total scores and individual items and explored overlapping dimensions. METHODS: The McLean Screening Instrument (MSI) for BPD and the Mood Disorder Questionnaire (MDQ) for BD were filled in by patients with unipolar and bipolar mood disorders (n=313) from specialized psychiatric care within a pilot study of the Helsinki University Psychiatric Consortium. Pearson's correlation coefficients between total scores and individual items of the MSI and the MDQ were estimated. Relationships between MDQ and MSI were evaluated by exploratory factor analysis (EFA). RESULTS: The correlation between total scores of the MDQ and MSI was moderate (r=0.431, P<0.001). Significant correlations were found between the MSI items of "impulsivity" and "mood instability" and all MDQ items (P<0.01). In the EFA, the MSI "impulsivity" and "mood instability" items had significant cross-loadings (0.348 and 0.298, respectively) with the MDQ factor. The MDQ items of "irritability", "flight of thoughts" and "distractibility" (0.280, 0.210 and 0.386, respectively) cross-loaded on the MSI factor. CONCLUSIONS: The MDQ and MSI items of "affective instability", "impulsivity", "irritability", "flight of thoughts" and "distractibility" appear to overlap in content. The other scale items are more disorder-specific, and thus, may help to distinguish BD and BPD.

Influence of birth cohort on age of onset cluster analysis in bipolar I disorder.

PURPOSE: Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database. METHODS: The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared. RESULTS: There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups. CONCLUSION: These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.

A 5-year prospective study of predictors for functional and work disability among primary care patients with depressive disorders.

OBJECTIVE: To study prevalence of and predictors for functional and work disability among primary care (PC) patients with depressive disorders in prospective long-term follow-up. METHODS: The Vantaa Primary Care Depression Study followed up prospectively 137 patients with depressive disorders for 5 years with a life chart. Information on level of functioning in general and in different dimensions, employment, sick leaves and disability pensions were obtained from interviews and patient records. RESULTS: Level of functioning and work ability were strongly associated with time spent depressed and/or current severity of depression. Patients who belonged to the labour force at baseline spent one-third of the follow-up off work due to depression; two-thirds were granted sick leaves, and one-tenth a disability pension due to depression. Longer duration of depression, co-morbid disorders and having received social assistance predicted dropping out from work. CONCLUSION: Duration of depressive episodes appears decisive for long-term disability among PC patients with depression. Patients spent one-third of the follow-up off work due to depression, and remaining outside the labour force is a common outcome. Psychiatric and somatic co-morbidities, education and socio-economic means influence the level of functioning and ability to work, but are not equally important for all areas of life.

Incidence and predictors of suicide attempts among primary-care patients with depressive disorders: a 5-year prospective study.

BACKGROUND: No previous study has prospectively investigated incidence and risk factors for suicide attempts among primary care patients with depression. METHOD: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients was screened for depression, and Structured Clinical Interviews for DSM-IV used to diagnose Axis I and II disorders. A total of 137 patients were diagnosed with a DSM-IV depressive disorder. Altogether, 82% of patients completed the 5-year follow-up. Information on timing of suicide attempts, plus major depressive episodes (MDEs) and partial or full remission, or periods of substance abuse were examined with life charts. Incidence of suicide attempts and their stable and time-varying risk factors (phases of depression/substance abuse) were investigated using Cox proportional hazard and Poisson regression models. RESULTS: During the follow-up there were 22 discrete suicide attempts by 14/134 (10.4%) patients. The incidence rates were 0, 5.8 and 107 during full or partial remission or MDEs, or 22.2 and 142 per 1000 patient-years during no or active substance abuse, respectively. In Cox models, current MDE (hazard ratio 33.5, 95% confidence interval 3.6-309.7) was the only significant independent risk factor. Primary care doctors were rarely aware of the suicide attempts. CONCLUSIONS: Of the primary care patients with depressive disorders, one-tenth attempted suicide in 5 years. However, risk of suicidal acts was almost exclusively confined to MDEs, with or without concurrent active substance abuse. Suicide prevention among primary care patients with depression should focus on active treatment of major depressive disorder and co-morbid substance use, and awareness of suicide risk.

Five-year outcome of major depressive disorder in primary health care.

BACKGROUND: Primary health care provides treatment for most patients with depression. Despite their importance for organizing services, long-term course of depression and risk factors for poor outcome in primary care are not well known. METHOD: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients representing primary care patients in a Finnish city was screened for depression with the Primary Care Evaluation of Mental Disorders. SCID-I/P and SCID-II interviews were used to diagnose Axis I and II disorders. The 137 patients with DSM-IV depressive disorder were prospectively followed up at 3, 6, 18 and 60 months. Altogether, 82% of patients completed the 5-year follow-up, including 102 patients with a research diagnosis of major depressive disorder (MDD) at baseline. Duration of the index episode, recurrences, time spent in major depressive episodes (MDEs) and partial or full remission were examined with a life-chart. RESULTS: Of the MDD patients, 70% reached full remission, in a median time of 20 months. One-third had at least one recurrence. The patients spent 34% of the follow-up time in MDEs, 24% in partial remission and 42% in full remission. Baseline severity of depression and substance use co-morbidity predicted time spent in MDEs. CONCLUSIONS: This prospective, naturalistic, long-term study of a representative cohort of primary care patients with depression indicated slow or incomplete recovery and a commonly recurrent course, which need to be taken into account when developing primary care services. Severity of depressive symptoms and substance use co-morbidity should be systematically evaluated in planning treatment.

A prospective latent analysis study of Axis I psychiatric co-morbidity of DSM-IV major depressive disorder.

BACKGROUND: We tested the degree to which longitudinal observations fit two hypotheses of psychiatric co-morbidity in DSM-IV major depressive disorder (MDD) among adult patients: (1) Axis I co-morbidity is dependent on major depressive episode (MDE) course, and (2) Axis I co-morbidity is independent of MDE course. METHOD: In the Vantaa Depression Study (VDS), 269 psychiatric secondary-care patients with a DSM-IV MDD were evaluated with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) at intake and at 6 and 18 months. Three evaluations of co-morbidity were available for 193 out of 259 living patients (75%). A latent curve model (LCM) was used to examine individual-level changes in depressive and anxiety symptoms across time. Outcome of MDD was modeled in terms of categorical DSM-IV diagnosis and Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HAMD) scores, and co-morbidity in terms of categorical DSM-IV anxiety and alcohol use disorder (AUD) diagnoses and Beck Anxiety Inventory (BAI) scores. RESULTS: Depression and anxiety correlated cross-sectionally at baseline. Longitudinally, changes in depression and anxiety correlated in both the 0-6 and 6-18 months time windows. Higher baseline depression raised the likelihood of an AUD at 6 months, and patients with more depressive symptoms in the 0-6 months time window were more likely to have had an AUD at 6 months, which further linked to less improvement in depression symptoms in the 6-18 months time window. CONCLUSIONS: Longitudinal and individual-level courses of both internalizing and externalizing disorders in adult patients with MDD seem to be dependent, albeit to differing degrees, on the course of depressive symptoms.

Method of assessment determines prevalence of suicidal ideation among patients with depression.

BACKGROUND: How different ways of assessing suicidal ideation influence its prevalence, correlates and predictive validity among patients with major depressive disorder (MDD) remains unclear. METHODS: Within the Vantaa Primary Care Depression Study (PC-VDS, 91 patients) and the Vantaa Depression Study (VDS, 153 psychiatric out-and 41 inpatients), suicidal ideation was assessed with the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9, and by asking whether patients had seriously considered suicide during the episode. The positive and negative predictive values (PPV, NPV) for suicide attempts during a six-month follow-up were investigated. RESULTS: Depending on the setting, 56-88% of patients had suicidal ideation in some of the assessments, but only 8-44% in all of them. Agreement ranged from negligible to moderate (kappa 0.06-0.64), being lowest among primary care patients. The correlates of suicidal ideation overlapped. No assessment had optimal sensitivity, specificity, PPV and NPV. Nevertheless, PPVs ranged up to 43%. CONCLUSIONS: Which MDD patient is classified as having suicidal ideation depends strongly on the method of assessment, with the greatest variation likely in primary care. Differences in assessments may cause inconsistency in risk factors. Predicting suicide attempts is difficult, but not futile.