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Recent research: six studies on depression – bereavement, pregnancy, bipolar disorder, suicide, & stress in hospital staff

Five of these six studies are from last month's American Journal of Psychiatry.  Kendler et al discuss the many similarities and only occasional differences between bereavement-related and other life event-related depression - an issue explored further in Maj's editorial.  Li et al show that depression in pregnancy (exacerbated further by stressful life events and obesity) increases the risk of preterm delivery.  Miklowitz reviews research on the value of adjunctive psychotherapy for bipolar disorder sufferers (already taking medication) and discusses the various ways it can be helpful.  Oquendo et al (in a freely viewable editorial) argue that suicidal behaviour should be placed on a "separate axis" in the next version of the DSM diagnostic system.  Finally Vertanen et al, in an interesting study, demonstrate that increased hospital overcrowding - measured by bed occupancy rates - is associated with increased use of antidepressants by hospital staff.

Kendler, K. S., J. Myers, et al. (2008). "Does Bereavement-Related Major Depression Differ From Major Depression Associated With Other Stressful Life Events?" Am J Psychiatry 165(11): 1449-1455.  [Abstract/Full Text]  
OBJECTIVE: Of the stressful life events influencing risk for major depression, DSM-III and DSM-IV assign a special status to bereavement. A depressive episode that is bereavement-related and has clinical features and course characteristic of normal grief is not diagnosed as major depression. This study evaluates the empirical validity of this exclusion criterion. METHOD: To determine the similarities of bereavement-related depression and depression related to other stressful life events, the authors identified and compared cases on a range of validators in a large-population-based sample of twins. The authors evaluated whether cases of bereavement-related depression that also met DSM criteria for "normal grief" were qualitatively distinct from other depressive cases. RESULTS: Eighty-two individuals with confirmed bereavement-related depression and 224 with confirmed depression related to other stressful life events were identified. The two groups did not differ in age at onset of major depression, number of prior episodes, duration of index episode, number of endorsed "A criteria," risk for future episodes, pattern of comorbidity, levels of extraversion, risk for major depression in their co-twin, or the proportion meeting criteria for "normal grief." However, individuals with bereavement-related depression were slightly older, and more likely to be female, and had lower levels of neuroticism, treatment-seeking, and guilt and higher levels of fatigue and loss of interest. Interaction analyses failed to find unique features of people whose illness met criteria for both bereavement-related depression and normal grief compared to those whose illness was related to other life stressors. CONCLUSIONS: The similarities between bereavement-related depression and depression related to other stressful life events substantially outweigh their differences. These results question the validity of the bereavement exclusion for the diagnosis of major depression.

Li, D., L. Liu, et al. (2008). "Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study." Hum. Reprod.: den342.   [Abstract/Full Text
BACKGROUND: The impact of prenatal depression on pregnancy outcomes is largely unknown.  METHODS: We conducted a population-based prospective cohort study among pregnant women of the Kaiser Permanente Medical Care Program to examine the impact of prenatal depression on the risk of preterm delivery. We interviewed pregnant women in their early pregnancy. Women's depressive symptoms were ascertained using the standard Center for Epidemiological Studies Depression Scale (CESD). The presence of significant prenatal depressive symptoms and severe depressive symptoms was determined by CESD scores 16 and 22, respectively.  RESULTS: Among the 791 participants who answered CESD questions and delivered a live birth, after controlling for potential confounders using the Cox proportional hazard regression, women with CESD scores 16 had almost twice the risk of preterm delivery compared with women without depressive symptoms: adjusted hazard ratio (aHR) = 1.9, 95% confidence interval (CI) 1.0-3.7. The risk of preterm delivery increased with increasing severity of depression: aHR = 1.6 (CI 0.7-3.6) for CESD 16-21 and aHR = 2.2 (CI 1.1-4.7) for CESD 22. The risk of preterm delivery associated with prenatal depression appears to be exacerbated by low educational level, a history of fertility problems and the presence of obesity and stressful events. The observed associations were not confounded by the use of antidepressants, although some of the associations did not reach statistical significance.  CONCLUSIONS: Our findings show that pregnant women with depressive symptoms are at increased risk of preterm delivery and, in addition, provide preliminary evidence that social and reproductive risk factors as well as obesity and stressful events may exacerbate the effect.

Maj, M. (2008). "Depression, Bereavement, and "Understandable" Intense Sadness: Should the DSM-IV Approach Be Revised?" Am J Psychiatry 165(11): 1373-1375.   [Free Full Text
The issue of the differentiation between depression and "understandable" intense sadness (representing a "normal" response to an adverse life event) has significant clinical, scientific, political, and ethical implications, which have become particularly visible in the past few decades, in parallel with the escalation of the prevalence rates of depression in the community, of the estimated social costs of depression, of the number of people on treatment for depression, and of the prescriptions of antidepressant medications. Psychiatry has been accused of inappropriately medicalizing the ordinary experience of sadness in order to expand the range of its jurisdiction, and the high prevalence rates of depression reported by community studies have been regarded as unbelievable even by some prominent psychiatrists, who have emphasized the risk to misdiagnose "normal reactions to a difficult environment" as a mental disorder ... Further research is clearly needed to explore the applicability and reliability of a "contextual" criterion in the diagnosis of major depression and the clinical utility of such a criterion for the prediction of treatment response and clinical outcome. The limited available research evidence suggests that definite "situational" major depression does not differ from definite "nonsituational" major depression on many clinical and psychosocial variables and that response to antidepressant medications is unrelated to whether or not major depression is preceded by a life event. At the present state of knowledge, it may be therefore unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event.  On the other hand, the removal of the bereavement exclusion criterion from the DSM-V diagnosis of major depression-a move that may be perceived as a further step in psychiatry's attempt to pathologize normal human processes-requires strong and unequivocal research evidence. Some differences between bereavement-related and other life stressor-related depression found by Kendler et al. (the lower percentage of bereaved individuals who sought treatment; the lower levels of neuroticism in those people) and by Wakefield et al. (the lower proportion of bereaved people who reported that their condition interfered with life a lot) seem to point in the DSM-IV direction and deserve further investigation. Moreover, bereavement may be a quite different experience after the death, for instance, of a son or a friend (these events were included in the same category in the study by Kendler et al.) or in the elderly compared to younger people (the mean age at index episode, in Kendler et al.'s sample, was 35 years). Finally, if we expect DSM-V to be more widely used in various cultural contexts than DSM-IV, some cross-cultural validation of Kendler et al.'s findings is probably warranted.

Miklowitz, D. J. (2008). "Adjunctive Psychotherapy for Bipolar Disorder: State of the Evidence." Am J Psychiatry 165(11): 1408-1419.  [Abstract/Full Text] 
OBJECTIVE: Psychotherapy has long been recommended as adjunctive to pharmacotherapy for bipolar disorder, but it is unclear which interventions are effective for which patients, over what intervals, and for what domains of outcome. This article reviews randomized trials of adjunctive psychotherapy for bipolar disorder. METHOD: Eighteen trials of individual and group psychoeducation, systematic care, family therapy, interpersonal therapy, and cognitive-behavioral therapy are described. Relevant outcome variables include time to recovery, recurrence, duration of episodes, symptom severity, and psychosocial functioning. RESULTS: The effects of the treatment modalities varied according to the clinical condition of patients at the time of random assignment and the polarity of symptoms at follow-up. Family therapy, interpersonal therapy, and systematic care appeared to be most effective in preventing recurrences when initiated after an acute episode, whereas cognitive-behavioral therapy and group psychoeducation appeared to be most effective when initiated during a period of recovery. Individual psychoeducational and systematic care programs were more effective for manic than depressive symptoms, whereas family therapy and cognitive-behavioral therapy were more effective for depressive than manic symptoms. CONCLUSIONS: Adjunctive psychotherapy enhances the symptomatic and functional outcomes of bipolar disorder over 2-year periods. The various modalities differ in content, structure, and associated mediating mechanisms. Treatments that emphasize medication adherence and early recognition of mood symptoms have stronger effects on mania, whereas treatments that emphasize cognitive and interpersonal coping strategies have stronger effects on depression. The placement of psychotherapy within chronic care algorithms and its role as a preventative agent in the early stages of the disorder deserve investigation.

Oquendo, M. A., E. Baca-Garcia, et al. (2008). "Issues for DSM-V: Suicidal Behavior as a Separate Diagnosis on a Separate Axis." Am J Psychiatry 165(11): 1383-1384.  [Free Full Text]
Suicidal behavior (death and attempts) is usually a complication of psychiatric conditions, most commonly mood disorders (1). However, it also occurs in schizophrenia, substance use disorders (particularly with alcohol), and personality and anxiety disorders, among others (1). About 10% of those who commit or attempt suicide have no identifiable psychiatric illness. However, our current nomenclature considers suicidal behavior a symptom of major depressive episode or borderline personality disorder ... We recommend that suicidal behavior be considered a separate diagnostic category documented on a sixth axis. Suicidal behavior meets the criteria for diagnostic validity set forth by Robins and Guze (3), and it does so as well as most conditions we treat. It is clinically well described (4), research has identified postmortem and in vivo laboratory markers (1), it can be subjected to a strict differential diagnosis (4), follow-up studies confirm its presence at higher rates in those with a past diagnosis (2), and it is familial (5). With suicidal behavior in a sixth axis, it would be identified through review-of-systems questions, in addition to inquiry during the mental status examination.  This proposed solution would address both conceptual and practical issues. Suicidal behavior might be conceptualized as an impulse-control disorder not elsewhere classified, but it is not always impulsive. Classification among "other conditions that may be a focus of clinical attention" diminishes its hierarchical position among diagnoses. Practically, an axis for suicidal acts would compel clinical and administrative structures to determine the suicide risk status of individuals assessed in psychiatric settings. In this manner, suicide risk can be documented as part of a multiaxial diagnosis, giving it the prominence that it deserves in written reports and treatment planning for vulnerable patients.

Virtanen, M., J. Pentti, et al. (2008). "Overcrowding in Hospital Wards as a Predictor of Antidepressant Treatment Among Hospital Staff." Am J Psychiatry 165(11): 1482-1486.  [Abstract/Full Text
OBJECTIVE: This report assessed whether hospital ward overcrowding predicts antidepressant use among hospital staff. METHOD: The extent of hospital ward overcrowding was determined using administrative records of monthly bed occupancy rates between 2000 and 2004 in 203 somatic illness wards in 16 Finnish hospitals providing specialized health care. Information on job contracts for personnel was obtained from the employers' registers. Comprehensive daily data on purchased antidepressant prescriptions (World Health Organization's Anatomical Therapeutic Chemical classification code N06A) for nurses (N=6,699) and physicians (N=641) was derived from national registers. Cox proportional hazards models were used to examine the association between bed occupancy rate and subsequent antidepressant treatment. Monthly bed occupancy rates were used as a time-dependent exposure that could change in value over the course of observation. Hazard ratios were adjusted for sex, age, occupation, type and length of employment contract, hospital district, specialty, and calendar year. RESULTS: Exposure over 6 months to an average bed occupancy rate over 10% in excess of the recommended limit was associated with new antidepressant treatment. This association followed a dose-response pattern, with increasing bed occupancy associated with an increasing likelihood of antidepressant use. There was no evidence of reverse causality; antidepressant treatment among employees did not predict subsequent excess bed occupancy. CONCLUSIONS: The increased risk of antidepressant use observed in this study suggests that overcrowding in hospital wards may have an adverse effect on the mental health of staff.


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