MEDLINE search on
Subsyndromal Mood Disorders.

By, Ivan Goldberg, M.D.

1. Psychiatry Res. 2010 Mar 9. [Epub ahead of print]

Impaired theory of mind performance in patients with recurrent bipolar disorder:
Moderating effect of cognitive load.

McKinnon MC, Cusi AM, Macqueen GM.

Mood Disorders Program, St. Joseph’s Healthcare, Department of Psychiatry and
Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.

The aim of this study was to investigate theory of mind (ToM) performance on
tasks that varied in the demands they placed on cognitive processing resources in
a sample of 14 bipolar patients with subsyndromal illness and 14 controls.
Patients showed impaired performance on cognitively demanding second-order ToM
tasks. Reduced ToM performance was associated with longer illness duration, and
with increased symptom severity. Copyright © 2010 Elsevier Ltd. All rights

PMID: 20223523 [PubMed – as supplied by publisher] 2. Am J Addict. 2010 Mar 1;19(2):147-54.

The effects of current subsyndromal psychiatric symptoms or past psychopathology
on alcohol dependence treatment outcomes and acamprosate efficacy.

Mason BJ, Lehert P.

Committee on the Neurobiology of Addictive Disorders, Pearson Center for
Alcoholism and Addiction Research, The Scripps Research Institute, La Jolla,

This secondary analysis of the first U.S. acamprosate trial (N = 601) for alcohol
dependence examines the effects of subsyndromal psychiatric symptoms or history
of severe psychopathology on alcoholism treatment outcomes and any mitigating
effects of acamprosate. Psychiatric antecedents were documented using a
protocol-specific interview. Current psychiatric symptoms were assessed using
Hamilton Anxiety and Depression (HAM-A, HAM-D) rating scales. Predictors of good
response, defined as abstinence for >/=90% of trial duration, were identified
using logistic regression. Subsyndromal anxiety (as determined by HAM-A “Anxious
Mood” item) and the presence of >/=1 psychiatric antecedent were significant
negative predictors of good response. Lower pretreatment drinking intensity,
baseline motivation to have abstinence as a goal, and treatment with acamprosate
were significant positive predictors of good response. No significant
interactions among predictors were detected, indicating that they are
independent, additive factors. Thus, the beneficial effects of acamprosate
treatment in combination with motivational therapy may offset the liabilities for
alcoholism recovery that are associated with current anxiety symptoms and/or a
significant past psychiatric history. (Am J Addict 2010;00:1-8).

PMID: 20163387 [PubMed – in process] 3. Am J Geriatr Psychiatry. 2010 Mar;18(3):227-35.

Outcomes of subsyndromal depression in older primary care patients.

Grabovich A, Lu N, Tang W, Tu X, Lyness JM.

Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
14642, USA.

OBJECTIVES: Most older persons in primary care suffering clinically significant
depressive symptoms do not meet criteria for major or minor depression. The
authors tested the hypothesis that patients with subsyndromal depression (SSD)
would have poorer psychiatric, medical, and functional outcomes at follow-up than
nondepressed patients but not as poor as those with minor or major depression.
The authors also explored the relative outcomes of three definitions of SSD to
determine their relative prognostic value. DESIGN: Prospective observational
cohort study. SETTING: Primary care practices in Monroe County, NY. PARTICIPANTS:
Four hundred eighty-one primary care patients aged 65 years and older who
completed research assessments at intake and at least 1 year of follow-up
evaluation. MEASUREMENTS: Depression diagnoses and three definitions of SSD were
determined by the Structured Clinical Interview for Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, and the 24-item Hamilton Depression
Rating Scale. Other validated measures assessed anxiety, cognition, medical
burden, and functional status. RESULTS: Patients with SSD had poorer 1-year
lagged outcomes than nondepressed subjects in terms of psychiatric symptoms and
functional status, often not significantly different than major or minor
depression. Two of the SSD definitions identified subjects with poorer
psychiatric and functional outcomes than the third SSD definition. CONCLUSIONS:
Clinicians should be vigilant in caring for patients with SSD, monitoring for
persistent, or worsening depressive symptoms including suicidality, anxiety,
cognitive impairment, and functional decline. Researchers may use particular SSD
definitions to identify individuals at higher risk of poor outcomes, to better
understand the relationships of SSD to functional disability, and to test
innovative preventive and therapeutic interventions.

PMCID: PMC2827819 [Available on 2011/3/1] PMID: 20173424 [PubMed – in process] 4. Am J Geriatr Psychiatry. 2010 Mar;18(3):221-6.

Exergames for subsyndromal depression in older adults: a pilot study of a novel

Rosenberg D, Depp CA, Vahia IV, Reichstadt J, Palmer BW, Kerr J, Norman G, Jeste

Joint Doctoral Program in Clinical Psychology University of California San Diego
(UCSD)/San Diego State University (SDSU), San Diego, CA, USA.

OBJECTIVES: Subsyndromal depression (SSD) is several times more common than major
depression in older adults and is associated with significant negative health
outcomes. Physical activity can improve depression, but adherence is often poor.
The authors assessed the feasibility, acceptability, and short-term efficacy and
safety of a novel intervention using exergames (entertaining video games that
combine game play with exercise) for SSD in older adults. METHODS:
Community-dwelling older adults (N = 19, aged 63-94 years) with SSD participated
in a 12-week pilot study (with follow-up at 20-24 weeks) of Nintendo’s Wii
sports, with three 35-minute sessions a week. RESULTS: Eight-six percent of
enrolled participants completed the 12-week intervention. There was a significant
improvement in depressive symptoms, mental health-related quality of life (QoL),
and cognitive performance but not physical health-related QoL. There were no
major adverse events, and improvement in depression was maintained at follow-up.
CONCLUSIONS: The findings provide preliminary indication of the benefits of
exergames in seniors with SSD. Randomized controlled trials of exergames for
late-life SSD are warranted.

PMCID: PMC2827817 [Available on 2011/3/1] PMID: 20173423 [PubMed – in process] 5. Am J Geriatr Psychiatry. 2010 Mar;18(3):189-92.

Subsyndromal depression and services delivery: at a crossroad?

Bruce ML.

PMID: 20173422 [PubMed – in process] 6. Br J Psychiatry. 2010 Feb;196(2):87-8.

Predicting onset of bipolar disorder from subsyndromal symptoms: a signal

Parker G.

This issue reports a community-based study quantifying the extent to which
subthreshold hypomanic or depressive symptoms in childhood or adolescence
predicted subsequent formal bipolar disorder status and mental health service
attendance. This editorial emphasises the low predictive power of the signal and
considers early intervention implications.

PMID: 20118448 [PubMed – in process] 7. Int J Geriatr Psychiatry. 2010 Feb;25(2):183-90.

Treatment of subsyndromal depressive symptoms in middle-aged and older adults
with schizophrenia: effect on functioning.

Kasckow J, Lanouette N, Patterson T, Fellows I, Golshan S, Solorzano E, Zisook S.

VA Pittsburgh Health Care System MIRECC and Behavioral Health Service, 7180
Highland Dr., Pittsburgh, PA, USA.

BACKGROUND: Subsyndromal symptoms of depression (SSD) in patients with
schizophrenia are common and clinically important. SSRI’s appear to be helpful in
alleviating depressive symptoms in patients with schizophrenia who have SSD in
patients age 40 and greater. It is not known whether SSRI’s help improve
functioning in this population. We hypothesized that treating this population
with the SSRI citalopram would lead to improvements in social, mental and
physical functioning as well as improvements in medication management and quality
of life. METHODS: Participants were 198 adults > or = 40 years old with
schizophrenia or schizoaffective disorder who met study criteria for subsyndromal
depression based on having two or more of the nine DSM-IV symptoms of a major
depressive episode, for at least 2 weeks, and a Hamilton depression rating scale
(HAM-D 17) score > or = 8. Patients were randomly assigned to flexible-dose
treatment with citalopram or placebo augmentation of their current antipsychotic
medication(s) which was stable for 1 month. Subjects were assessed with the
following functional scales at baseline and at the end of the 12-week trial: (1)
social skills performance assessment (SSPA), (2) medication management ability
assessment (MMAA), (3) mental and physical components of the medical outcomes
study SF-12 Scale, and (4) the Heinrichs quality of life scale (QOLS). Analysis
of covariance (ANCOVA) was used to compare differences between endpoint scores of
the citalopram and placebo treated groups, controlling for site and baseline
scores. ANCOVAs were also used to compare differences in the above endpoint
scores in responders versus non-responders (responders = those with > 50%
reduction in depressive symptoms). RESULTS: Overall, the citalopram group had
significantly higher SSPA, mental functioning SF-12, and quality of life scale
(QOLS) scores compared to the placebo group. There was no effect on MMAA or
physical functioning SF-12 scores. Responders had significantly better endpoint
mental SF-12 and QOLS scores compared to non-responders. Response to citalopram
in terms of depressive symptoms mediated the effect of citalopram on mental
functioning, but not on the quality of life. CONCLUSIONS: Citalopram augmentation
of antipsychotic treatment in middle aged and older patients with schizophrenia
and subsyndromal depression appears to improve social and mental health
functioning as well as quality of life. Thus it is important for clinicians to
monitor these aspects of functioning when treating this population of patients
with schizophrenia with SSRI agents.

PMID: 19711335 [PubMed – in process] 8. J Child Adolesc Psychopharmacol. 2010 Feb;20(1):25-32.

Psychotropic medication exposure and age at onset of bipolar disorder in
offspring of parents with bipolar disorder.

Chang KD, Saxena K, Howe M, Simeonova D.

Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, California 94305-5540, USA.

OBJECTIVE: Exposure to psychotropic medications before the onset of bipolar
disorder (BD) in children may have profound effects on the course of illness.
Both antidepressant and stimulant exposure have been proposed to hasten the
course of BD development, whereas mood stabilizers have been proposed as
protective. We sought to describe psychotropic medication exposure in a cohort of
children at risk for BD and retrospectively determine the effect of medication
exposure on age at onset (AAO) of BD. METHODS: Subjects were 106 children and
adolescents who had at least 1 parent with BD. Of these, 63 had BD I or BD II and
43 had subsyndromal symptoms of BD. AAO was determined as nearest month of first
manic or hypomanic episode. Past psychotropic medication exposure prior to AAO
was determined through interview and chart review. RESULTS: Both groups had high
rates of exposure to psychotropic medications. Antidepressant or stimulant
exposure was not correlated with an earlier AAO of BD. However, mood stabilizer
exposure was associated with a later AAO. CONCLUSIONS: Children with full or
subsyndromal BD are frequently exposed to a variety of psychotropic medications
before their first manic episode. Our findings do not support that early
stimulant or antidepressant exposure leads to an earlier AAO of BD. However,
early mood stabilizer exposure may be associated with delayed AAO. Longitudinal
studies are needed to clarify these results.

PMID: 20166793 [PubMed – in process] 9. J Clin Psychiatry. 2010 Feb;71(2):e05.

Course and impact of bipolar disorder in young patients.

Chang KD.

Department of Psychiatry and Behavioral Sciences and the Bipolar Disorders
Program, Stanford University School of Medicine, Stanford, California, USA.

The presentation of bipolar disorder in children and adolescents may vary from
its presentation in adults. Rage, irritability, and long episodes are common
manifestations of mania in young people with bipolar disorder. Frequent comorbid
disorders in young patients include ADHD and anxiety disorders. Prodromal and
subsyndromal states of bipolar disorder, such as bipolar disorder NOS, present
opportunities for early intervention and prevention. Early recognition and
intervention are crucial, because untreated pediatric bipolar disorder becomes
chronic, has a high incidence of relapse, and has a poor prognosis. Copyright
2010 Physicians Postgraduate Press, Inc.

PMID: 20193644 [PubMed – in process] 10. Curr Opin Psychiatry. 2010 Jan;23(1):12-8.

Current research on affective temperaments.

Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS.

Department of Clinical and Theoretical Mental Health, Faculty of Medicine,
Semmelweis University, Kútvölgyi út 4, Budapest, Hungary.

PURPOSE OF REVIEW: The aim of this review is to highlight the relationship
between affective temperaments and clinical mood disorders and to summarize the
earlier and most recent studies on affective temperaments in both clinical and
nonclinical populations. RECENT FINDINGS: Current research findings show that
specific affective temperament types (depressive, cyclothymic, hyperthymic,
irritable and anxious) are the subsyndromal (trait-related) manifestations and
commonly the antecedents of minor and major mood disorders. Up to 20% of the
population has some kind of marked affective temperaments; depressive,
cyclothymic and anxious temperament is more frequent in women, whereas
hyperthymic and irritable temperaments predominate among men. Molecular genetic
studies show a strong involvement of the central serotonergic (depressive,
cyclothymic, irritable and anxious temperaments) and dopaminergic (hyperthymic
temperament) regulation, suggesting that the genetic potential of major mood
episodes lies in these temperaments. SUMMARY: Premorbid affective temperament
types have an important role in the clinical evolution of minor and major mood
episodes including the direction of the polarity and the symptom formation of
acute mood episodes. They can also significantly affect the long-term course and
outcome including suicidality and other forms of self-destructive behaviours such
as substance use and eating disorders.

PMID: 19809321 [PubMed – indexed for MEDLINE] 11. J Affect Disord. 2010 Jan;120(1-3):86-93.

Early improvement is a predictor of treatment outcome in patients with mild
major, minor or subsyndromal depression.

Tadi? A, Helmreich I, Mergl R, Hautzinger M, Kohnen R, Henkel V, Hegerl U.

Department of Psychiatry and Psychotherapy, University of Mainz, Germany.

BACKGROUND: There is substantial evidence that early improvement (EI) under
antidepressant treatment is a clinically useful predictor of later treatment
outcome in patients with major depressive disorders. The aim of this study was to
test whether EI can also be used as a predictor for treatment outcome in patients
with mild major, minor or subsyndromal depression, i.e. patients, who are
typically treated by general practitioners. METHODS: Analyses were carried out
using data from 223 patients of a 10-weeks randomized, placebo-controlled trial
comparing the effectiveness of sertraline and cognitive-behavioural therapy (CBT)
in patients with mild major, minor or subsyndromal depression. EI was defined as
a reduction of > or =20% on the 17-item Hamilton Rating Scale for Depression
(HAMD-17) compared with baseline within the first 2 weeks of treatment. The
predictive value of EI for stable response at week 8 and 10 (> or =50% HAMD-17
sum score reduction at weeks 8 and 10) and stable remission (HAMD-17 sum score <
or =7 at weeks 8 and 10) was evaluated. RESULTS: In both the sertraline- and
CBT-treatment group, EI was a highly sensitive predictor for later stable
response (76% and 82%, respectively) and stable remission (70% and 75%,
respectively). In patients without EI, only a small proportion of sertraline or
CBT-treated patients achieved stable response (20.9% and 5.9%, respectively) or
stable remission (18.6% and 8.8%, respectively). Patients with EI were by far
more likely to achieve stable response or stable remission than patients without
as indicated by high odds ratios (95% confidence interval) of 8.1 (3.0-21.8) and
3.8 (1.4-10.1) for sertraline, and 11.1 (2.1-58.4) and 7.2 (1.7-30.8) for
CBT-treated patients, respectively. LIMITATIONS: Sample sizes were relatively low
in different treatment groups. CONCLUSION: The identification of early
improvement might be useful in clinical decision making in the early course of
treatment of patients with mild major, minor and subthreshold depression.

PMID: 19428118 [PubMed – in process] 12. Psychopathology. 2010;43(1):1-7. Epub 2009 Nov 6.

Subsyndromal mood symptoms: a useful concept for maintenance studies of bipolar

Bauer M, Glenn T, Grof P, Schmid R, Pfennig A, Whybrow PC.

Department of Psychiatry and Psychotherapy, Universitatsklinikum Carl Gustav
Carus, Technische Universitat Dresden, Dresden, Germany.

OBJECTIVE: To explore the measurement of subsyndromal mood symptoms in relation
to studies of maintenance therapy for bipolar disorder. METHODS: Literature
review of the Medline database using the following selection criteria: (1)
‘bipolar disorder’ plus ‘inter-episode or interepisode or subsyndromal or
subclinical or residual or subthreshold’ and (2) ‘bipolar disorder’ plus
‘maintenance or prophylaxis or longitudinal’. Studies of children or adolescents
and non-English-language reports were excluded. RESULTS: Of the studies published
between 1987 and October 2007, 77 articles about subsyndromal mood symptoms and
257 studies of maintenance therapy agents were found. Only 11 of the 257 studies
of maintenance therapy agents discussed subsyndromal mood symptoms. Of the 77
articles, two thirds were published after 2000. Inconsistent definitions of
subsyndromal mood symptoms and different evaluation tools and methodologies were
used in the studies. CONCLUSIONS: There is a need to standardize definitions and
validate measuring approaches for subsyndromal mood symptoms. However, when
measured in both naturalistic studies and clinical trials, subsyndromal mood
symptoms were frequently reported by patients receiving maintenance therapy and
were associated with poor functioning. As with other chronic illnesses, knowledge
of the patient’s perspective of daily morbidity is important for improving the
clinical outcome. Studies of maintenance therapy for bipolar disorder, regardless
of the approach, should measure subsyndromal mood symptoms as an additional
outcome. Copyright 2009 S. Karger AG, Basel.

PMID: 19893338 [PubMed – in process] 13. Eur Arch Psychiatry Clin Neurosci. 2009 Dec 18. [Epub ahead of print]

Altered sleep architecture and higher incidence of subsyndromal depression in low
endogenous melatonin secretors.

Rahman SA, Marcu S, Kayumov L, Shapiro CM.

Sleep Research Laboratory, University Health Network, Toronto, ON, Canada,

Melatonin secretion is synchronized to the sleep/wake cycle and has been
suggested to have somnogenic properties. Sleep/wake cycle disruption and
alterations in the secretary pattern of melatonin is present in various
psychiatric disorders. The objective of this study was to investigate the sleep
architecture and the presence of depression in individuals with low endogenous
melatonin levels. The study included 16 participants (mean age 30.3 +/- 14.9
years). The first night of testing included psychiatric evaluation followed by
melatonin secretion profile evaluation by Dim Light Melatonin Onset test and then
standard montage polysomnographic testing. On the second night, only
polysomnographic testing was carried out with an imposed sleep period of 8 h. Low
endogenous melatonin secretors (LEMS) showed no discernible peaks in melatonin
secretion compared to normal secretors (controls). LEMS demonstrated significant
alterations in rapid eye movement sleep but not in non-rapid eye movement sleep
along with poor sleep initiation and quality compared to controls. 55.6% of the
low melatonin secretors group presented with subsyndromal depression. Melatonin
has significant bearing on sleep architecture and a lack of melatonin may
desynchronize endogenous rhythms allowing subsyndromal depression to manifest.

PMID: 20016908 [PubMed – as supplied by publisher] 14. Am J Psychiatry. 2009 Dec;166(12):1375-83. Epub 2009 Oct 15.

Risks for depression onset in primary care elderly patients: potential targets
for preventive interventions.

Lyness JM, Yu Q, Tang W, Tu X, Conwell Y.

Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden
Blvd., Rochester, NY 14642, USA.

Comment in:
Am J Psychiatry. 2009 Dec;166(12):1312-4.

OBJECTIVE: Prevention of late-life depression, a common, disabling condition with
often poor outcomes in primary care, requires identification of seniors at
highest risk of incident episodes. The authors examined a broad range of
clinical, functional, and psychosocial predictors of incident depressive episodes
in a well-characterized cohort of older primary care patients. METHOD: In this
observational cohort study, patients age >/=65 years without current major
depression, recruited from practices in general internal medicine, geriatrics,
and family medicine, received annual follow-up assessments over a period of 1 to
4 years. Of 617 enrolled subjects, 405 completed the 1-year follow-up evaluation.
The Structured Clinical Interview for DSM-IV (SCID) determined incident major
depressive episodes. Each risk indicator’s predictive utility was examined by
calculating the risk exposure rate, incident risk ratio, and population
attributable fraction, leading to determination of the number needed to treat in
order to prevent incident depression. RESULTS: A combination of risks, including
minor or subsyndromal depression, impaired functional status, and history of
major or minor depression, identified a group in which fully effective treatment
of five individuals would prevent one new case of incident depression.
CONCLUSIONS: Indicators routinely assessed in primary care identified a group at
very high risk for onset of major depressive episodes. Such markers may inform
current clinical care by fostering the early detection and intervention critical
to improving patient outcomes and may serve as the basis for future studies
refining the recommendations for screening and determining the effectiveness of
preventive interventions.

PMID: 19833788 [PubMed – indexed for MEDLINE] 15. J Gerontol A Biol Sci Med Sci. 2009 Dec;64(12):1325-32. Epub 2009 Sep 23.

Longitudinal association between depressive symptoms and disability burden among
older persons.

Barry LC, Allore HG, Bruce ML, Gill TM.

Department of Internal Medicine, Yale University School of Medicine, Section of
Geriatrics, 367 Cedar Street, PO Box 208025, New Haven, CT 06520-8025, USA.

BACKGROUND: Although depressive symptoms in older persons are common, their
association with disability burden is not well understood. The authors evaluated
the association between level of depressive symptoms and severity of subsequent
disability over time and determined whether this relationship differed by sex.
METHODS: Participants included 754 community-living persons aged 70 years or
older who underwent monthly assessments of disability in four essential
activities of daily living for up to 117 months. Disability was categorized each
month as none, mild, and severe. Depressive symptoms, assessed every 18 months,
were categorized as low (referent group), moderate, and high. Multinomial logit
models invoking Generalized Estimating Equation were used to calculate odds
ratios and 95% confidence intervals. RESULTS: Moderate (odds ratio = 1.30; 95%
confidence interval: 1.18-1.43) and high (odds ratio = 1.68; 95% confidence
interval: 1.50-1.88) depressive symptoms were associated with mild disability,
whereas only high depressive symptoms were associated with severe disability
(odds ratio = 2.05; 95% confidence interval: 1.76-2.39). Depressive symptoms were
associated with disability burden in both men and women, with modest differences
by sex; men had an increased likelihood of experiencing severe disability at both
moderate and high levels of depressive symptoms, whereas only high depressive
symptoms were associated with severe disability in women. CONCLUSIONS: Levels of
depressive symptoms below the threshold for subsyndromal depression are
associated with increased disability burden in older persons. Identifying and
treating varying levels of depressive symptoms in older persons may ultimately
help to reduce the burden of disability in this population.

PMCID: PMC2773818 [Available on 2010/12/1] PMID: 19776217 [PubMed – indexed for MEDLINE] 16. J Nerv Ment Dis. 2009 Dec;197(12):879-86.

Differentiating generalized anxiety disorder from anxiety disorder not otherwise

Lawrence AE, Brown TA.

Center for Anxiety and Related Disorders, Boston University, Boston, MA 02215,

The diagnostic criteria for generalized anxiety disorder (GAD) have elicited
numerous criticisms and suggestions for revision. Several researchers have noted
that many patients fail to meet full criteria for the disorder, but nevertheless
experience clinically significant symptoms. These “subsyndromal” cases are
labeled anxiety disorder not otherwise specified (AnxNOS) under the current
diagnostic system. The purpose of the this study was to determine the diagnostic
criteria most often “missed” in cases that resemble GAD, but do not meet full
criteria for the diagnosis. Individuals diagnosed with AnxNOS (n = 146) were
compared with those diagnosed with GAD (n = 146) and other anxiety disorders (n =
146) on self-report measures, clinician ratings, and rates of comorbidity.
Although individuals with AnxNOS reported clinically significant symptoms, they
reported less worry, negative affect, depression, and comorbidity than
individuals diagnosed with GAD. Findings are discussed with regard to their
implications for revisions to the diagnostic criteria for GAD.

PMID: 20010022 [PubMed – indexed for MEDLINE] 17. Synapse. 2009 Dec;63(12):1089-99.

GABAA-benzodiazepine receptor availability in smokers and nonsmokers:
relationship to subsyndromal anxiety and depression.

Esterlis I, Cosgrove KP, Batis JC, Bois F, Kloczynski TA, Stiklus SM, Perry E,
Tamagnan GD, Seibyl JP, Makuch R, Krishnan-Sarin S, O’Malley S, Staley JK.

Department of Psychiatry, Yale University School of Medicine, Veteran’s Affairs
Connecticut Healthcare System (VACHS), 116A6 West Haven, Connecticut 06516, USA.

Many smokers experience subsyndromal anxiety symptoms while smoking and during
acute abstinence, which may contribute to relapse. We hypothesized that cortical
gamma aminobutyric acid(A)-benzodiazepine receptor (GABA(A)-BZR) availability in
smokers and nonsmokers might be related to the expression of subsyndromal
anxiety, depressive, and pain symptoms. Cortical GABA(A)-BZRs were imaged in 15
smokers (8 men and 7 women), and 15 healthy age and sex-matched nonsmokers, and 4
abstinent tobacco smokers (3 men; 1 woman) using [(123)I]iomazenil and single
photon emission computed tomography (SPECT). Anxiety and depressive symptoms were
measured using the Spielberger’s State-Trait Anxiety Index (STAI) and the Center
for Epidemiology Scale for Depressive Symptoms (CES-D). The cold pressor task was
administered to assess pain tolerance and sensitivity. The relationship between
cortical GABA(A)-BZR availability, smoking status, and subsyndromal depression
and anxiety symptoms, as well as pain tolerance and sensitivity, were evaluated.
Surprisingly, there were no statistically significant differences in overall
GABA(A)-BZR availability between smokers and nonsmokers or between active and
abstinent smokers; however, cortical GABA(A)-BZR availability negatively
correlated with subsyndromal state anxiety symptoms in nonsmokers but not in
smokers. In nonsmokers, the correlation was seen across many brain areas with
state anxiety [parietal (r = -0.47, P = 0.03), frontal (r = -0.46, P = 0.03),
anterior cingulate (r = -0.47, P = 0.04), temporal (r = -0.47, P = 0.03),
occipital (r = -0.43, P = 0.05) cortices, and cerebellum (r = -0.46, P = 0.04)],
trait anxiety [parietal (r = -0.72, P = 0.02), frontal (r = -0.72, P = 0.02), and
occipital (r = -0.65, P = 0.04) cortices] and depressive symptoms [parietal (r =
-0.68; P = 0.02), frontal (r = -0.65; P = 0.03), anterior cingulate (r = -0.61; P
= 0.04), and temporal (r = -0.66; P = 0.02) cortices]. The finding that a similar
relationship between GABA(A)-BZR availability and anxiety symptoms was not
observed in smokers suggests that there is a difference in GABA(A)-BZR function,
but not number, in smokers. Thus, while subsyndromal anxiety and depressive
symptoms in nonsmokers may be determined in part by GABA(A)-BZR availability,
smoking disrupts this relationship. Aberrant regulation of GABA(A)-BZR function
in vulnerable smokers may explain why some smokers experience subsyndromal
anxiety and depression. (c) 2009 Wiley-Liss, Inc.

PMCID: PMC2778224 [Available on 2010/12/1] PMID: 19642218 [PubMed – indexed for MEDLINE] 18. Am J Geriatr Psychiatry. 2009 Nov;17(11):943-52.

Depression outcome among a biracial sample of depressed urban elders.

Cohen CI, Goh KH, Yaffee RA.

Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, New York, NY
11203, USA.

OBJECTIVES: There are a paucity of long-term studies from the United States
concerning predictors of outcome among depressed older community adults. This
article examines predictors of depression in a biracial sample of older persons
in Brooklyn, NY. METHODS: The authors conducted a naturalistic study of 110
persons aged 55 years and older living in randomly selected block groups who had
a Center for Epidemiologic Studies-Depression (CES-D) score of > or = 8 at
baseline. Persons were reassessed on an average of 3 years later. Their mean age
was 69 years, 52% were women, and 35% were whites, and 65% were blacks, among
whom 71% were African Caribbeans. Using George’s Social Antecedent Model of
Depression, the authors examined the impact of 13 predictor variables on two
outcome measures: presence of either subsyndromal or syndromal depression (CES-D
score > or = 8) and presence of syndromal depression (CES-D score > or = 16). To
control for design effects, the authors used SUDAAN for the data analysis.
RESULTS: On follow-up, 82% and 88% of subsyndromally and syndromally depressed
persons at baseline, respectively, were depressed (CES-D > or = 8). In logistic
regression, baseline depressive symptoms, baseline anxiety symptoms, greater
increase in anxiety symptoms during the follow-up period, and higher locus of
control were predictors of any level of depression. These four variables along
with greater paranoid ideation and/or psychoses and more reliable social contacts
were significant predictors of syndromal depression on follow-up. There were no
inter- or intraracial differences in outcome. CONCLUSION: Depressed community
elders in Brooklyn have highly unfavorable outcomes. Preventive strategies that
target at-risk persons-i.e., especially those with baseline subsyndromal
depression, greater anxiety symptoms, and more paranoid ideation and/or
psychoses-may reduce the development of severe or persistent depression.

PMID: 19855198 [PubMed – in process] 19. Eur Psychiatry. 2009 Oct;24(7):464-9. Epub 2009 Sep 29.

Impulsivity, personality and bipolar disorder.

Lewis M, Scott J, Frangou S.

Section of Neurobiology of Psychosis, PO66 Institute of Psychiatry, King’s
College London, De Crespigny Park, London SE5 8AF, UK.

BACKGROUND: Increased impulsivity is a diagnostic feature of mania in bipolar
disorder (BD). However it is unclear whether increased impulsivity is also a
trait feature of BD and therefore present in remission. Trait impulsivity can
also be construed as a personality dimension but the relationship between
personality and impulsivity in BD has not been explored. The aim of this study
was to examine the relationship of impulsivity to clinical status and personality
characteristics in patients with BD. METHODS: We measured impulsivity using the
Barratt Impulsiveness Scale (BIS-11) and personality dimensions using Eysenck
Personality Questionnaire in 106 BD patients and demographically matched healthy
volunteers. Clinical symptoms were assessed in all participants using the
Clinical Global Impressions Scale, the Montgomery-Asberg Depression Rating Scale
and the Young Mania Rating Scale. Based on their clinical status patients were
divided in remitted (n = 36), subsyndromal (n = 25) and syndromal (n = 45).
RESULTS: There was no difference in BIS-11 and EPQ scores between remitted
patients and healthy subjects. Impulsivity, Neuroticism and Psychoticism scores
were increased in subsyndromal and syndromal patients. Within the BD group, total
BIS-11 score was predicted mainly by symptoms severity followed by Psychoticism
and Neuroticism scores. CONCLUSIONS: Increased impulsivity may not be a trait
feature of BD. Symptom severity is the most significant determinant of
impulsivity measures even in subsyndromal patients.

PMID: 19793639 [PubMed – indexed for MEDLINE] 20. J Clin Psychiatry. 2009 Oct;70(10):1424-31.

Olanzapine/fluoxetine combination for the treatment of mixed depression in
bipolar I disorder: a post hoc analysis.

Benazzi F, Berk M, Frye MA, Wang W, Barraco A, Tohen M.

Hecker Psychiatry Research Center, Forli, Italy.

OBJECTIVE: Mixed depression (ie, co-occurrence of syndromal depression and
subsyndromal mania/hypomania) is a common variant of bipolar depression. However,
its treatment is much understudied. The aim of the study was to assess the
efficacy of the antipsychotic and mood-stabilizing agent olanzapine and the
efficacy of the combination of an antidepressant (fluoxetine) and olanzapine
(olanzapine/fluoxetine combination; OFC) for the treatment of bipolar I mixed
depression. METHOD: We carried out a post hoc analysis of an 8-week, double-blind
trial of adult bipolar I depression treated with placebo (n = 355), olanzapine
(5-20 mg/d; n = 351), or OFC (olanzapine/fluoxetine doses: 6/25, 6/50, 12/50
mg/d; n = 82). Studying mixed depression was not a previous goal of the
double-blind trial. Subjects in the trial were diagnosed according to DSM-IV and
were randomly assigned to treatment during the period June 2000 to December 2001.
Mixed depression was defined as the co-occurrence of a major depressive episode
and > or = 2 manic/hypomanic symptoms (ie, > or = 2 Young Mania Rating Scale
[YMRS] items scoring > or = 2). Response was defined as a > or = 50% reduction in
Montgomery-Asberg Depression Rating Scale score and < 2 concurrent
manic/hypomanic symptoms. Switching to mania/hypomania was defined as a YMRS
score > or = 15. RESULTS: Frequency of mixed depression was 45.1% in the OFC arm,
49.3% in the olanzapine arm, and 46.8% in the placebo arm (P = .705). The most
frequent manic/ hypomanic symptoms of mixed depression were irritability, reduced
need for sleep, talkativeness, and racing thoughts. Response rates in patients
with nonmixed depression versus patients with mixed depression were the
following: in the OFC arm, 48.9% versus 43.2% (OR = 1.24; 95% CI, 0.51-2.98); in
the olanzapine arm, 39.9% versus 26.6% (OR = 1.84; 95% CI, 1.17-2.90); in the
placebo arm, 27.5% versus 16.3% (OR = 1.94; 95% CI, 1.15-3.28). Response rates in
the samples of patients with mixed depression were the following: OFC versus
olanzapine, OR = 2.00 (95% CI, 0.96-4.19); OFC versus placebo, OR = 3.91 (95% CI,
1.80-8.49); olanzapine versus placebo, OR = 1.95 (95% CI, 1.14-3.34). It was
found that no baseline manic/hypomanic symptom of mixed depression predicted
treatment response. A higher number of baseline concurrent manic/hypomanic
symptoms predicted a lower response rate in the olanzapine and placebo arms, but
not in the OFC arm. The rates of switching were the following: in the OFC arm,
8.5%; in the olanzapine arm, 6.8%; and in the placebo arm, 7.9% (P = .808). The
rates of dropouts in patients with mixed depression versus patients with nonmixed
depression were not significantly different within any of the treatment arms. The
rates of dropouts in the samples of patients with mixed depression were the
following: in the OFC arm, 29.7%; in the olanzapine arm, 53.8%; and in the
placebo arm, 59.6% (olanzapine vs OFC: OR = 2.66; 95% CI, 1.23-5.75; placebo vs
OFC: OR = 3.48; 95% CI, 1.61-7.54; placebo vs olanzapine: OR = 1.30; 95% CI,
0.84-2.01). CONCLUSION: Olanzapine/fluoxetine combination may be an effective
treatment for bipolar I mixed depression. Statistically, the efficacy of OFC was
not significantly different from that of olanzapine, but inspection of the 95% CI
showed a trend in favor of a possible superiority of OFC. Supporting the study
findings are the similar efficacy of OFC in bipolar mixed depression independent
of the number of concurrent manic/hypomanic symptoms, a lower dropout rate, and a
similarly low switching rate compared to olanzapine. Contrary to other current
limited evidence, an antidepressant (fluoxetine) showed efficacy and did not
worsen bipolar mixed depression if combined with a mood-stabilizing agent
(olanzapine). Copyright 2009 Physicians Postgraduate Press, Inc.

PMID: 19906346 [PubMed – indexed for MEDLINE] 21. Psychol Med. 2009 Oct;39(10):1697-707. Epub 2009 Mar 2.

Course and outcome of depressive disorders in primary care: a prospective
18-month study.

Vuorilehto MS, Melartin TK, Isometsä ET.

Department of Mental Health and Alcohol Research, National Public Health
Institute, Finland.

BACKGROUND: Depressive disorders are known to often be chronic and recurrent both
in the general population and in psychiatric settings. However, despite its
importance for public health and services, the outcome of depression in primary
care is not well known. METHOD: In The Vantaa Primary Care Depression Study
(PC-VDS), 1111 consecutive primary-care patients were screened for depression
with the Prime-MD screen, and 137 diagnosed with DSM-IV depressive disorders by
interviewing with the Structured Clinical Interview for DSM-IV (SCID)-I/P and
SCID-II. This cohort was prospectively followed-up at 3, 6 and 18 months.
Altogether 123 patients (90%) completed the 18-month follow-up, including 79 with
major depressive disorder (MDD) and 44 with subsyndromal disorders. Duration of
the index episode and the timing of relapses/recurrences were examined using a
life-chart. RESULTS: Of the patients with MDD, only a quarter [25% (20/79)] achieved and remained in full remission, while another quarter [25% (20/79)] persisted in major depressive episode for 18 months. The remaining 49% (39/79)
suffered from residual symptoms or recurrences. In Cox regression models, time to
remission and recurrences were robustly predicted by severity of depression, and
less consistently by co-morbid substance-use disorder, chronic medical illness or
cluster C personality disorder. Of the subsyndromal patients, 25% (11/44)
proceeded to MDD. CONCLUSIONS: This prospective medium-term study verified the
high rate of recurrences and chronicity of depression also in primary care.
Severity of depressive symptoms and co-morbidity are important predictors of
outcome. Development of chronic disease management for depression is warranted in
primary care.

PMID: 19250580 [PubMed – indexed for MEDLINE] 22. Psychiatr Danub. 2009 Sep;21(3):320-6.

Depressive phenomenology in regard to depersonalization level.

Ziki? O, Ciri? S, Mitkovi? M.

Clinic for Mental Health Protection, UCC Nis, 18000 Nis, Serbia.

BACKGROUND: It has been found that in patients suffering from unipolar
depression, associated depersonalization symptomatology is more intense compared
to healthy controls, and also that there is a positive correlation between
depression and depersonalization. According to data that may be found in the
literature, there is a relatively high prevalence of depersonalization
symptomatology in unipolar depressions. Our study was aimed at finding whether
the presence of depersonalization was related to a specific phenomenological
expression of depressive symptomatology in unipolar depression. SUBJECTS AND
METHODS: The study included 84 subjects suffering from unipolar depression
without psychotic features. Based on the Cambridge Depersonalization Scale (CDS)
score, the subjects were divided into two groups – a group with associated
depersonalization (CDS>or=70) (40 subjects) and a group with subsyndromal
depersonalization (CDS<70) (44 subjects), the later one being treated as a
control group. The groups were compared in regard to the intensity of depressive
symptomatology, depressive symptoms frequency and the depressive symptoms
duration. The General Socio-Demographic Questionnaire, the Cambridge
Depersonalization Scale and The Patient Health Questionnaire – 9 were used.
RESULTS: The depressive patients with depersonalization had predominantly severe
episodes, almost all patients had feelings of sadness, insomnia, and decrease of
energetic potentials. The biggest difference between the groups, in terms of
greater number of manifest symptoms in the patients with depersonalization, was
for psychomotor disturbances (agitation or retardation), insomnia, decrease of
energetic potentials and concentration. At the same time, 75% of the subjects
with associated depersonalization had anhedonia, sadness/dysphoria, insomnia and
decrease of energetic potentials continuously present. Unlike this group, the
control group subjects experienced sadness, appetite problems, concentration and
motor behavior changes almost half as frequently. Particularly significant were
the differences regarding suicidal thoughts. It was shown that in the group with
depersonalization there was a higher percentage of patients with suicidal
thoughts, mostly continuously present, which represent a significant suicidal
risk factor. CONCLUSION: Unipolar depression, associated with depersonalization
is more severe in its intensity .It has a bigger number of manifest symptoms
which have a tendency to continuous duration. A special focus is on the negative
impact on the occurrence and lasting presence of suicidal thoughts.

PMID: 19794348 [PubMed – indexed for MEDLINE] 23. Psychosomatics. 2009 Sep-Oct;50(5):506-14.

Symptoms of depression and delirium assessed serially in palliative-care

Leonard M, Spiller J, Keen J, MacLullich A, Kamholtz B, Meagher D.

Department of Adult Psychiatry, Midwestern Regional Hospital, Limerick, Ireland.

BACKGROUND: Delirium occurs in approximately 1 in 5 general hospital admissions
and up to 85% of patients with terminal illness, but can be difficult to
differentiation from other disorders, such as depression. OBJECTIVE: The authors
assessed and compared mood states as they relate to onset of delirium. METHOD:
Symptoms of depression and delirium were assessed in 100 consecutive
palliative-care admissions immediately after admission and 1 week later. RESULTS:
Overall, 51% experienced either major depression or delirium. Most patients with
syndromal delirium also met criteria for major depressive illness, and 50% of
those with depression had delirium or subsyndromal delirium (SSD). Delirium
symptoms were less common in patients with major depression than depressive
symptoms in patients with delirium or SSD. DISCUSSION: Delirium should be
considered in patients with altered mood states, and screening for depression
should initially rule out delirium. Sustained alterations in mood may be more
frequent in delirium than previously recognized.

PMID: 19855037 [PubMed – indexed for MEDLINE] 24. Bipolar Disord. 2009 Aug;11(5):453-73.

The International Society for Bipolar Disorders (ISBD) Task Force report on the
nomenclature of course and outcome in bipolar disorders.

Tohen M, Frank E, Bowden CL, Colom F, Ghaemi SN, Yatham LN, Malhi GS, Calabrese
JR, Nolen WA, Vieta E, Kapczinski F, Goodwin GM, Suppes T, Sachs GS, Chengappa
KR, Grunze H, Mitchell PB, Kanba S, Berk M.

Department of Psychiatry, Division of Mood and Anxiety Disorders, University of
Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San
Antonio, TX 78229, USA.

OBJECTIVES: Via an international panel of experts, this paper attempts to
document, review, interpret, and propose operational definitions used to describe
the course of bipolar disorders for worldwide use, and to disseminate consensus
opinion, supported by the existing literature, in order to better predict course
and treatment outcomes. METHODS: Under the auspices of the International Society
for Bipolar Disorders, a task force was convened to examine, report, discuss, and
integrate findings from the scientific literature related to observational and
clinical trial studies in order to reach consensus and propose terminology
describing course and outcome in bipolar disorders. RESULTS: Consensus opinion
was reached regarding the definition of nine terms (response, remission,
recovery, relapse, recurrence, subsyndromal states, predominant polarity, switch,
and functional outcome) commonly used to describe course and outcomes in bipolar
disorders. Further studies are needed to validate the proposed definitions.
CONCLUSION: Determination and dissemination of a consensus nomenclature serve as
the first step toward producing a validated and standardized system to define
course and outcome in bipolar disorders in order to identify predictors of
outcome and effects of treatment. The task force acknowledges that there is
limited validity to the proposed terms, as for the most part they represent a
consensus opinion. These definitions need to be validated in existing databases
and in future studies, and the primary goals of the task force are to stimulate
research on the validity of proposed concepts and further standardize the
technical nomenclature.

PMID: 19624385 [PubMed – indexed for MEDLINE] 25. Parkinsonism Relat Disord. 2009 Aug;15(7):511-5. Epub 2009 Jan 31.

Involuntary emotional expression disorder (IEED) in Parkinson’s disease.

Phuong L, Garg S, Duda JE, Stern MB, Weintraub D.

Parkinson’s Disease Research, Education and Clinical Center, Philadelphia
Veterans Affairs Medical Center, Philadelphia, PA, USA.

OBJECTIVE: To estimate the frequency and correlates of involuntary emotional
expression disorder (IEED) in Parkinson’s disease (PD) using the Center for
Neurologic Study-Lability Scale (CNS-LS) and recently-proposed diagnostic
criteria for IEED. BACKGROUND: IEED is characterized by uncontrollable emotional
episodes, typically unrelated to or in excess of the underlying mood, and
occurring with minimal or no stimulus. IEED has been reported to occur in many
neurological disorders and neurodegenerative diseases, but its prevalence and
correlates in PD have not been well studied. Additionally, there is no published
research using recently-proposed IEED diagnostic criteria in any population.
METHODS: 193 patients with idiopathic PD were assessed with a neuropsychiatric
battery, including the CNS-LS and the 15-item Geriatric Depression Scale
(GDS-15). A subset (N=100) was also administered a diagnostic interview by a
blinded rater that applied criteria for both IEED and Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) depressive disorders. RESULTS: Applying
formal diagnostic criteria, 7.0% of patients were diagnosed with IEED, and an
additional 7.0% had subsyndromal IEED symptoms. Applying recommended CNS-LS
cutoff scores from other populations, either 42.5% (cutoff > or =13) or 16.6%
(cutoff > or =17) screened positive for IEED. Depressive symptoms were associated
with higher CNS-LS scores (B[SE]=0.27[.08], P=.001) but not with a diagnosis of
IEED (odds ratio=1.1, [95% CI=1.0-1.3], P=.16). The CNS-LS had poor discriminant
validity for an IEED diagnosis (AUC=.79, no cutoff value with sensitivity and
specificity both >60%). CONCLUSIONS: IEED and depression are overlapping but
distinct disorders in PD. IEED symptoms may occur in up to 15% of PD patients,
but a disorder occurs in only half of those, suggesting that often IEED symptoms
are not clinically significant in this population. The CNS-LS does not appear to
be a good screening instrument for IEED in PD, in part due to its high
correlation with depressive symptoms.

PMID: 19181560 [PubMed – indexed for MEDLINE] 26. Acta Psychiatr Scand. 2009 Jul;120(1):10-3. Epub 2009 Jan 31.

Depressive relapse during lithium treatment associated with increased serum
thyroid-stimulating hormone: results from two placebo-controlled bipolar I
maintenance studies.

Frye MA, Yatham L, Ketter TA, Goldberg J, Suppes T, Calabrese JR, Bowden CL,
Bourne E, Bahn RS, Adams B.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.

OBJECTIVE: To assess the relationship between depressive relapse and change in
thyroid function in an exploratory post hoc analysis from a controlled
maintenance evaluation of bipolar I disorder. METHOD: Mean thyroid-stimulating
hormone (TSH) and outcome data were pooled from two 18-month, double-blind,
placebo-controlled, maintenance studies of lamotrigine and lithium monotherapy. A
post hoc analysis of 109 subjects (n = 55 lamotrigine, n = 32 lithium, n = 22
placebo) with serum TSH values at screening and either week 52 (+/-14 days) or
study drop-out was conducted. RESULTS: Lithium-treated subjects who required an
intervention for a depressive episode had a significantly higher adjusted mean
TSH level (4.4 microIU/ml) compared with lithium-treated subjects who did not
require intervention for a depressive episode (2.4 microIU/ml). CONCLUSION:
Lithium-related changes in thyroid function are clinically relevant and should be
carefully monitored in the maintenance phase of bipolar disorder to maximize mood
stability and minimize the risk of subsyndromal or syndromal depressive relapse.

PMID: 19183414 [PubMed – indexed for MEDLINE] 27. Am J Psychiatry. 2009 Jul;166(7):795-804. Epub 2009 May 15.

Four-year longitudinal course of children and adolescents with bipolar spectrum
disorders: the Course and Outcome of Bipolar Youth (COBY) study.

Birmaher B, Axelson D, Goldstein B, Strober M, Gill MK, Hunt J, Houck P, Ha W,
Iyengar S, Kim E, Yen S, Hower H, Esposito-Smythers C, Goldstein T, Ryan N,
Keller M.

Western Psychiatric Institute and Clinic, 3811 O’Hara St., Pittsburgh, PA 15213,

OBJECTIVE: The authors sought to assess the longitudinal course of youths with
bipolar spectrum disorders over a 4-year period. METHOD: At total of 413 youths
(ages 7-17 years) with bipolar I disorder (N=244), bipolar II disorder (N=28),
and bipolar disorder not otherwise specified (N=141) were enrolled in the study.
Symptoms were ascertained retrospectively on average every 9.4 months for 4 years
using the Longitudinal Interval Follow-Up Evaluation. Rates and time to recovery
and recurrence and week-by-week symptomatic status were analyzed. RESULTS:
Approximately 2.5 years after onset of their index episode, 81.5% of the
participants had fully recovered, but 1.5 years later 62.5% had a syndromal
recurrence, particularly depression. One-third of the participants had one
syndromal recurrence, and 30% had two or more. The polarity of the index episode
predicted that of subsequent episodes. Participants were symptomatic during 60%
of the follow-up period, particularly with subsyndromal symptoms of depression
and mixed polarity, with numerous changes in mood polarity. Manic symptomatology,
especially syndromal, was less frequent, and bipolar II was mainly manifested by
depressive symptoms. Overall, 40% of the participants had syndromal or
subsyndromal symptoms during 75% of the follow-up period, and 16% of the
participants experienced psychotic symptoms during 17% the follow-up period.
Twenty-five percent of youths with bipolar II converted to bipolar I, and 38% of
those with bipolar disorder not otherwise specified converted to bipolar I or II.
Early onset, diagnosis of bipolar disorder not otherwise specified, long illness
duration, low socioeconomic status, and family history of mood disorders were
associated with poorer outcomes. CONCLUSIONS: Bipolar spectrum disorders in
youths are characterized by episodic illness with subsyndromal and, less
frequently, syndromal episodes with mainly depressive and mixed symptoms and
rapid mood changes.

PMCID: PMC2828047 [Available on 2010/7/1] PMID: 19448190 [PubMed – indexed for MEDLINE] 28. J Affect Disord. 2009 Jul;116(1-2):37-42. Epub 2008 Nov 25.

Neurocognitive and symptomatic predictors of functional outcome in bipolar
disorders: a prospective 1 year follow-up study.

Martino DJ, Marengo E, Igoa A, Scápola M, Ais ED, Perinot L, Strejilevich SA.

Bipolor Disorder Program, Neurosciences Institute, Favaloro Foundation, Buenos
Aires, Argentina.

BACKGROUND: The aim of this study was to estimate the predictive value of
cognitive impairments and time spent ill in long-term functional outcome of
patients with bipolar disorder (BD). METHODS: Thirty five patients with euthymic
BD completed a neurocognitive battery to assess verbal memory, attention, and
executive functions at study entry. The course of illness was documented
prospectively for a period longer than 12 months using a modified life charting
technique based on the NIMH life-charting method. Psychosocial functioning was
assessed with the General Assessment of Functioning (GAF) and the Functioning
Assessment Short Test (FAST) at the end of follow-up period when patients were
euthymic. RESULTS: Impairments in verbal memory and in attention, as well as
subsyndromal depressive symptomatology were independent predictors of GAF score
at the end of the study explaining 43% of variance. Similarly, impairments in
attention and executive functioning were independent predictors of FAST score
explaining 28% of variance. LIMITATIONS: We did not control factors that could
affect functional outcome such as psychosocial interventions, familiar support
and housing and financial resources. CONCLUSIONS: Both cognitive impairments and
time spent with subsyndromal depressive symptomatology may be illness features
associated with poorer long-term functional outcome. Developing strategies to
treat these illness features might contribute to enhance long-term functional
outcome among patients with BD.

PMID: 19033081 [PubMed – indexed for MEDLINE] 29. Soc Psychiatry Psychiatr Epidemiol. 2009 Jul;44(7):515-22. Epub 2008 Nov 13.

Frequency of subsyndromal symptoms and employment status in patients with bipolar

Bauer M, Glenn T, Grof P, Rasgon NL, Marsh W, Sagduyu K, Alda M, Lewitzka U,
Sasse J, Kozuch-Krolik E, Whybrow PC.

Dept. of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus,
Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.

OBJECTIVE: This study investigated the frequency of episodes and subsyndromal
symptoms based on employment status in patients with bipolar disorder. METHODS:
Patients with bipolar disorder (n = 281) provided daily self-reported mood
ratings for 5 months, returning 46,292 days of data. Data were analyzed using
three employment status groups: disabled (n = 75), full-time employee or
full-time student (n = 135), and other (n = 71). Demographic characteristics were
compared by employment status. A univariate general linear model with employment
status and other demographic variables as fixed factors and covariates was used
to analyze the percent of days in episodes and percent of days with subsyndromal
symptoms. RESULTS: While there was no significant difference in the percent of
days in episodes among the employment groups, disabled patients suffered
subsyndromal symptoms of depression twice as frequently as those in the full-time
group. Disabled patients spent 15% more days either in episodes or with
subsyndromal symptoms than those in the full-time group, equivalent to about 45
extra sick days a year. CONCLUSION: Frequent subsyndromal symptoms, especially
depressive, may preclude full-time responsibilities outside the home and
contribute to disability in bipolar disorder. Additional treatments to reduce the
frequency of subsyndromal symptoms are needed.

PMID: 19011720 [PubMed – indexed for MEDLINE] 30. Soc Sci Med. 2009 Jul;69(1):14-20. Epub 2009 May 27.

The promotion of olanzapine in primary care: an examination of internal industry

Spielmans GI.

Department of Psychology, Metropolitan State University, 1450 Energy Park Drive,
St. Paul, MN 55108, USA.

Media reports have discussed how olanzapine was marketed off-label for dementia
and subsyndromal bipolar disorder. Much of this marketing occurred in primary
care settings. However, these reports have provided few details. In legal
proceedings, Lilly disclosed internal documents that detail the strategies
utilized to market olanzapine. The current paper addresses the marketing of
olanzapine in detail based upon a review of these documents. All 358 documents
released by Lilly are publicly available online. Documents were utilized for this
review if they were relevant to the marketing of olanzapine in primary care
settings in the United States. It was found that olanzapine was marketed
off-label in primary care settings for relatively mild symptoms that were framed
as bipolar disorder and schizophrenia. A key strategy in this campaign was the
use of hypothetical patient profiles in detailing visits, most of which clearly
failed to meet diagnostic criteria for any recognized mental disorder. Evidence
emerged that olanzapine was also marketed off-label as a treatment for dementia.

PMID: 19481322 [PubMed – indexed for MEDLINE] 31. Am J Med Genet B Neuropsychiatr Genet. 2009 Jun 5;150B(4):581-4.

Candidate region linkage analysis in twins discordant or concordant for
depression symptomatology.

Christiansen L, Tan Q, Kruse TA, McGue M, Christensen K.

Epidemiology, Institute of Public Health, University of Southern Denmark, Odense,

Genetic risk factors contribute considerably to both clinical affective disorders
and subsyndromal mood level. There is moreover evidence to suggest that the
genetic basis of bipolar disorder and unipolar depression overlap to some extent,
and several linkage analyses have suggested evidence for a common susceptibility
locus in affective disorders on chromosome 12q24. In this study we investigated
the chromosome 12 candidate region for linkage to the mean level of depression
symptomatology, over a 10-year follow-up, using a highly informative sample of
concordant and discordant twin pairs selected from 4,731 participants of the
Longitudinal Study of Ageing Danish Twins. Our results showed suggestive evidence
of linkage to this region with a peak LOD score of 1.91 for marker D12S1634
located at 148 cM, and thus indicates that the previously identified disease
locus at 12q24 is also a general vulnerability locus affecting the normal range
of mood.

PMID: 18698577 [PubMed – indexed for MEDLINE] 32. J Affect Disord. 2009 Jun;115(3):347-54. Epub 2008 Oct 22.

Prevalence of self-reported seasonal affective disorders and the validity of the
seasonal pattern assessment questionnaire in young adults Findings from a Swiss
community study.

Steinhausen HC, Gundelfinger R, Winkler Metzke C.

Aalborg Psychiatric Clinic, Aarhus University Hospital, Denmark.

BACKGROUND: The objective of this study was to expand the knowledge on the
prevalence of self-reported Seasonal Affective Disorder (SAD) and to further
study the validity of the Seasonal Pattern Assessment Questionnaire (SPAQ).
METHODS: A total of N=844 young adults were assessed in a Swiss community study
by use of the SPAQ, a Seasonal Affective Disorders Questionnaire (SADQ), the
Young Adult Self Report (YASR), the Centre for Epidemiologic Depression Scale
(CES-D), and scales for measuring self-esteem, self-awareness and life events. At
a second stage, a total of N=534 screen positives and controls were subjected to
the Composite International Diagnostic Interview (M-CIDI) for the assessment of
mental disorders. According to the SPAQ classification a group of SAD subjects
and a group of subsyndromal SAD subjects (S-SAD) were defined. In addition, a
third group of high-scoring depressives (HSD) subjects scoring above the 75th
percentile of the CES-D was defined. Comparisons included these three groups and
the rest of the sample serving as controls. RESULTS: The weighted prevalence for
SAD in this sample was 7.84% based on the SPAQ alone. With the addition of the
SADQ, weighted prevalence rates dropped to 2.22%. Weighted subsyndromal SAD was
33.04%. Across the vast majority of scales, the SAD group was indistinguishable
from the HSD group. These two groups scored highest, whereas the S-SAD group had
an intermediate position and the controls had the lowest scores. SAD was best
predicted by the CES-D total score. CONCLUSIONS: The SPAQ as a single measure
leads to an overestimation of SAD which, nevertheless, is a rather common
phenomenon also in this central European population. The findings on the validity
of the SPAQ are extended by showing that predominantly general aspects of
depression are measured.

PMID: 18947880 [PubMed – indexed for MEDLINE] 33. Psychosom Med. 2009 Jun;71(5):549-56. Epub 2009 May 4.

Chronic fatigue syndrome and high allostatic load: results from a
population-based case-control study in Georgia.

Maloney EM, Boneva R, Nater UM, Reeves WC.

Chronic Viral Diseases Branch, National Center for Zoonotic, Vector-borne and
Enteric Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road,
MS A-15, Atlanta, GA 30333, USA.

OBJECTIVE: To confirm the association of chronic fatigue syndrome (CFS) with high
allostatic load (AL) level, examine the association of subsyndromal CFS with AL
level, and investigate the effect of depression on these relationships and the
association of AL with functional impairment, fatigue, symptom severity, fatigue
duration, and type of CFS onset. AL represents the cumulative physiologic effect
of demands to adapt to stress. METHODS: Population-based case-control study of 83
persons with CFS, 202 persons with insufficient symptoms or fatigue for CFS
(ISF), and 109 well controls living in Georgia. Unconditional logistic regression
was used to generate odds ratios (ORs) as measures of the association of AL with
CFS. RESULTS: Relative to well controls, each 1-point increase in allostatic load
index (ALI) was associated with a 26% increase in likelihood of having CFS
(OR(adjusted) = 1.26, 95% Confidence Interval (CI) = 1.00, 1.59). This
association remained in the presence and absence of depression (OR(adjusted) =
1.35, CI = 1.07, 1.72; OR(adjusted) = 1.35, CI = 1.10, 1.65). Compared with the
ISF group, each 1-point increase in ALI was associated with a 10% increase in
likelihood of having CFS (OR(adjusted) = 1.10, CI = 0.93, 1.31). Among persons
with CFS, the duration of fatigue was inversely correlated with ALI (r = -.26, p
= .047). CONCLUSIONS: Compared with well controls, persons with CFS were
significantly more likely to have a high AL. AL increased in a gradient across
well, ISF, and CFS groups.

PMID: 19414615 [PubMed – indexed for MEDLINE] 34. Afr J Psychiatry (Johannesbg). 2009 May;12(2):115-28.

HIV infection and psychiatric illness.

Owe-Larsson B, Säll L, Salamon E, Allgulander C.

Karolinska Institutet, Department of Clinical Neuroscience, Section of Psychiatry
at Karolinska University Hospital Huddinge, Stockholm, Sweden.

OBJECTIVE: To review the clinical features and current knowledge on the treatment
of psychiatric symptoms and disorders in patients with human immunodeficiency
virus (HIV) infection. METHOD: We searched the PubMed database combining HIV/AIDS
with different keywords for psychiatric diagnoses and symptoms (e.g. depression,
mania, anxiety, psychosis, dementia, substance abuse) and for
psychopharmacological treatment. The years covered by these searches included
1980 to 2008. RESULTS: Patients with HIV infection are at an increased risk of
psychiatric illness. Major depressive disorder and subsyndromal depressive
symptoms, as well as anxiety disorder and substance abuse are more prevalent
among HIV infected individuals than among the general population. HIV-associated
neurocognitive disorders (HAND) are common among HIV patients, and HIV-associated
dementia (HAD) is a serious condition during the acquired immune deficiency
syndrome (AIDS) stage of HIV disease. Secondary mania and psychosis might be the
first clinical symptom of HIV dementia. The introduction of highly active
anti-retroviral therapy (HAART) has resulted in significant decreases in
morbidity and mortality for HIV infected patients. HAART has also decreased the
incidence of HAD, but does not give complete protection from this condition. The
utility of psychotropic medications in HIV patients has not been studied
sufficiently as a basis for guidelines, and more controlled trials are needed.
CONCLUSION: Psychiatric illness is common in HIV infected individuals, and
underlines the importance for screening not only for cognitive impairment but
also for co morbid mental disease in HIV-positive patients. Further studies of
the neuropsychiatric complications during HIV disease and the use of
psychotropics under these circumstances are clearly needed. A better
understanding of the pathogenesis of HAD is essential to identify additional
therapeutic strategies for prevention and treatment of this neurodegenerative
disease. Studies are also needed for optimizing effective utilization of
antiretrovirals into the CNS. Mania and psychosis secondary to HAD may be used as
an indicator to initiate HAART, irrespective of CD4 count. Further research on
the utility of HAART in the treatment of such acute neuropsychiatric symptoms
associated with HIV infection should be initiated.

PMID: 19582313 [PubMed – indexed for MEDLINE] 35. CNS Spectr. 2009 May;14(5):262-6.

Lifetime subthreshold mania is related to suicidality in posttraumatic stress

Dell’osso L, Carmassi C, Rucci P, Ciapparelli A, Paggini R, Ramacciotti CE,
Conversano C, Balestrieri M, Marazziti D.

Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
University of Pisa, Pisa, Italy.

INTRODUCTION: Although the association between mood disorders, and particularly
bipolar disorders, comorbidity and suicidality in posttraumatic (PTSD) patients
is well established, less information is available on the impact of subsyndromal
mood symptoms. The aim of the present study was, thus, to explore the frequency
and relationship between subthreshold mood symptoms, assessed by a specific and
validated questionnaire, and suicidality in PTSD patients. METHOD: Sixty-five
PTSD outpatients without bipolar disorders and 65 healthy control subjects were
asked to complete the Mood Spectrum-SR-Lifetime Version (MOODS-SR), a
questionnaire exploring the presence of subthreshold affective symptoms. Logistic
regression models were used to analyze the relationships between suicidality,
explored by six items of the MOODS-SR combined and dichotomized to denote the
presence or absence of suicidal ideations/plans and/or attempts, and the number
of manic/hypomanic or depressive symptoms. RESULTS: Statistically significant and
positive associations were found between the presence of manic/hypomanic and
depressive symptoms and the likelihood of suicidal ideation or attempts.
CONCLUSION: Besides depressive, even subthreshold manic/hypomanic features seem
to be associated with higher suicidality in PTSD patients.

PMID: 19407725 [PubMed – indexed for MEDLINE] 36. J Psychiatr Res. 2009 May;43(8):798-802. Epub 2009 Jan 19.

Increased depressive symptoms in menopausal age women with bipolar disorder: age
and gender comparison.

Marsh WK, Ketter TA, Rasgon NL.

Department of Psychiatry, University of Massachusetts Medical School, Worcester,
MA 01655, USA.

OBJECTIVE: Emerging data suggest the menopausal transition may be a time of
increased risk for depression. This study examines the course of bipolar disorder
focusing on depressive symptoms in menopausal transition age women, compared to
similar-aged men as well as younger adult women and men. METHODS: Outpatients
with bipolar disorder were assessed with the systematic treatment enhancement
program for bipolar disorder (STEP-BD) affective disorders evaluation and
longitudinally monitored during naturalistic treatment with the STEP-BD clinical
monitoring form. Clinical status (syndromal/subsyndromal depressive symptoms,
syndromal/subsyndromal elevation or mixed symptoms, and euthymia) was compared
between menopausal transition age women (n=47) and pooled similar-aged men (n=30)
45-55 years old, younger women (n=48) and men (n=39) 30-40 years old. RESULTS:
Subjects included 164 bipolar disorder patients (67 type I, 82 type II, and 15
not otherwise specified), 34% were rapid cycling and 58% women. Bipolar II
disorder/bipolar NOS was more common in women. Monitoring averaged 30+/-22
months, with an average of 0.9+/-0.5 clinic visits/month. Menopausal age women
had a significantly greater proportion of visits with depressive symptoms
(p<0.05), significantly fewer euthymic visits (p<0.05) and no difference in
proportion of visits with elevated/mixed symptoms compared to pooled comparison
group. CONCLUSIONS: Menopausal transition age women with bipolar disorder
experience a greater proportion of clinic visits with depressive symptoms
compared to similarly aged men, and younger women and men with bipolar disorder.
Further systematic assessment on the influence of the menopausal transition and
reproductive hormones upon mood is needed to better inform clinical practice in
treating women with bipolar disorder.

PMID: 19155021 [PubMed – indexed for MEDLINE] 37. Nervenarzt. 2009 May;80(5):532-4, 536-9.

[Subdiagnostic depression. Are there treatments with clinically relevant
effects?] [Article in German]

Hegerl U, Schönknecht P.

Klinik und Poliklinik für Psychiatrie, Universitätsklinikum Leipzig AöR,
Semmelweis-Strasse 10, 04103, Leipzig.

Minor depression, subsyndromal depression and subthreshold depression are
frequent conditions in primary care which do not fulfil the criteria of a
depressive disorder but are associated with functional disability, impairment of
quality of life, and health care use. This paper reviews studies on the clinical
evidence of pharmacotherapy, psychotherapy, and interventions to improve primary
care. In this regard, whether clinical relevance of antidepressant therapies can
be concluded from differences between placebo and active treatment is critically
discussed. Due to lacking clinical evidence, aspects of a pragmatic therapeutic
approach in those patients are presented.

PMID: 19396419 [PubMed – indexed for MEDLINE] 38. Med J Aust. 2009 Apr 6;190(7 Suppl):S71-4.

The role of post-traumatic stress disorder and depression in predicting
disability after injury.

O’Donnell ML, Holmes AC, Creamer MC, Ellen S, Judson R, McFarlane AC, Silove DM,
Bryant RA.

Department of Psychiatry, Australian Centre for Posttraumatic Mental Health,
University of Melbourne, Melbourne, VIC, Australia.

OBJECTIVES: To examine the relationship between psychological response to injury
at 1 week and 3 months, and disability at 12 months. DESIGN: Multisite,
longitudinal study. PARTICIPANTS AND SETTING: 802 adult patients admitted to
trauma services at four Australian hospitals from 13 March 2004 to 21 February
2006 were assessed before discharge and followed up at 3 and 12 months. MAIN
OUTCOME MEASURE: Disability, measured with the 12-item version of the World
Health Organization Disability Assessment Schedule II. RESULTS: Logistic
regression identified the degree to which high levels of depression and
post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted
disability at 12 months. After controlling for demographic variables and
characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week
were 2.4 times more likely, and those with depression at 1 week were 1.9 times
more likely to have high disability levels at 12 months. PTSD at 3 months was
associated with 3.7 times, and depression at 3 months with 3.4 times the risk of
high disability at 12 months. CONCLUSIONS: PTSD and depression at 1 week and at 3
months after injury significantly increased the risk of disability at 12 months.
Routine assessment of symptoms of depression and PTSD in patients who have been
physically injured may facilitate triage to evidence-based treatments, leading to
improvement in both physical and psychological outcomes.

PMID: 19351297 [PubMed – indexed for MEDLINE] 39. Child Adolesc Psychiatr Clin N Am. 2009 Apr;18(2):273-89, vii.

Phenomenology, longitudinal course, and outcome of children and adolescents with
bipolar spectrum disorders.

Sala R, Axelson D, Birmaher B.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of
Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.

Pediatric bipolar disorder (BPD) significantly affects the normal emotional,
cognitive, and social development. The course of children and adolescents with
BPD is manifested by frequent changes in symptoms polarity showing a dimensional
continuum of bipolar symptoms severity from subsyndromal to mood syndromes
meeting full DSM-IV criteria. Thus, early diagnosis and treatment of pediatric
bipolar is of utmost importance.

PMCID: PMC2713171 [Available on 2010/4/1] PMID: 19264264 [PubMed – indexed for MEDLINE] 40. J Affect Disord. 2009 Apr;114(1-3):58-67. Epub 2008 Aug 15.

The functional impact of subsyndromal depressive symptoms in bipolar disorder:
data from STEP-BD.

Marangell LB, Dennehy EB, Miyahara S, Wisniewski SR, Bauer MS, Rapaport MH, Allen

Mood Disorders Center, Menninger Department of Psychiatry, Baylor College of
Medicine, Houston, TX, United States.

BACKGROUND: This report describes baseline characteristics and functional
outcomes of subjects who have prospectively observed subsyndromal symptoms after
a major depressive episode (MDE). METHODS: All subjects were participants in the
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We
identified subjects with at least 2 years of observation whose prior or current
episode was a MDE, and who were in a stable clinical state of either recovered
(no more than 2 moderate symptoms for at least 8 weeks), a MDE by DSM-IV
criteria, or with continued subsyndromal symptoms. The subsyndromal group was
defined a priori as 3 or more moderate affective symptoms but without meeting
diagnostic criteria for major depression. RESULTS: The final cohort included 1094
recovered, 112 subsyndromal, and 310 individuals in a MDE. The average time spent
in each clinical status ranged from 120 to 132 days. The subsyndromal group was
most similar to those in a MDE, differing only on the intensity of depressive
symptoms and the number of work days missed due to ongoing symptoms. Reported
sadness, inability to feel and lassitude were each associated with multiple
measures of impairment. LIMITATIONS: This study is limited by the cross-sectional
approach to defining outcomes. CONCLUSIONS: These findings are consistent with
studies in unipolar major depression that indicate that functional impairment
observed in the context of subsyndromal depressive symptoms is comparable to that
of a full episode. This work underscores the need to include subsyndromal
symptoms in study outcomes and to target full remission in clinical practice.

PMCID: PMC2704060 [Available on 2010/4/1] PMID: 18708263 [PubMed – indexed for MEDLINE] 41. J Clin Psychiatry. 2009 Apr;70(4):500-8. Epub 2009 Apr 7.

Late-onset depression in elderly subjects from the Vienna Transdanube Aging
(VITA) study.

Mossaheb N, Weissgram S, Zehetmayer S, Jungwirth S, Rainer M, Tragl KH, Fischer

Medical University of Vienna, Department of Psychiatry and Psychotherapy,
Division of Biological Psychiatry, Vienna, Austria.

OBJECTIVES: To assess whether prevalence of depression increases with age. To
determine possible risk factors of late-onset depression. METHOD: The Vienna
Transdanube Aging (VITA) study is a community-based cohort study investigating
every inhabitant of the area on the left shore of the river Danube, in Vienna,
Austria, born between May 1925 and June 1926. It includes a thorough neurologic,
psychiatric, and neuropsychological battery. Occurrence of a current depressive
episode was diagnosed according to a DSM-IV-based questionnaire, the Hamilton
Rating Scale for Depression, and the Short Geriatric Depression Scale. A
gerontopsychiatric life events scale was used for the assessment of life events.
1505 subjects were contacted and 606 participated. At baseline, 406 nondemented
and never-depressed individuals were included in the study. Follow-up after 30
months was possible in 331 of the 406 participants. Baseline data were collected
from May 2000 to December 2002, and 30-month follow-up data were collected from
November 2002 to September 2005. RESULTS: Of the 331 participants who were not
depressed at baseline, 31.4% had developed a subsyndromal, minor, or major
depressive episode at the 30-month follow-up; 14.2% were diagnosed with mild
cognitive impairment at follow-up, 42.5% of whom were also diagnosed with
new-onset depression. In the multiple analyses, “troubles with relatives” was a
significant variable (p = .018, OR = 0.5, 95% CI = 0.28 to 0.89, R(2) = 0.16).
Summative scores on the Fuld Object Memory Evaluation showed a significant
influence (p = .048, OR = 0.9, 95% CI = 0.88 to 0.99, R(2) = 0.01) on the
occurrence of newly onset depression. None of the other investigated possible
risk factors had a significant influence on the new occurrence of depression.
CONCLUSION: Prevalence of late-onset depression increases with age. Having severe
troubles with relatives and pre-existing cognitive impairments may enhance the
probability of developing a late-onset depression. 2009 Physicians Postgraduate
Press, Inc.

PMID: 19358786 [PubMed – indexed for MEDLINE] 42. J Clin Psychiatry. 2009 Apr;70(4):562-71. Epub 2008 Dec 16.

Citalopram augmentation for subsyndromal symptoms of depression in middle-aged
and older outpatients with schizophrenia and schizoaffective disorder: a
randomized controlled trial.

Zisook S, Kasckow JW, Golshan S, Fellows I, Solorzano E, Lehman D, Mohamed S,
Jeste DV.

University of California, San Diego, Department of Psychiatry, San Diego, CA
92161, USA.

BACKGROUND: Subsyndromal symptoms of depression (SSD) in older outpatients with
schizophrenia are common and clinically important. While many physicians
prescribe antidepressants to patients with schizophrenia and schizoaffective
disorder who have SSD, evidence for their effectiveness and safety has been
meager. We describe a randomized placebo-controlled trial of citalopram in 198
patients. METHOD: Participants in this 2-site study, conducted from September 1,
2001, to August 31, 2007, were men and women with DSM-IV schizophrenia or
schizoaffective disorder who were 40 years of age or older and who met study
criteria for SSD. Patients were randomly assigned to flexible-dose treatment with
citalopram or placebo augmentation of their current antipsychotic medication.
Analysis of covariance was used to compare improvement in scores on the Hamilton
Rating Scale for Depression and Calgary Depression Rating Scale between treatment
groups; secondary efficacy analyses compared improvement in several other
dimensions of schizophrenia. RESULTS: Augmentation with citalopram was
significantly more effective than with placebo in improving depressive (p = .002)
and negative (p = .049) symptoms, mental functioning (p = .000), and quality of
life (p = .046). There were no significant differences between citalopram and
placebo in suicidal ideation, positive symptoms, cognition, general medical
health, physical functioning, or symptoms of movement disorders. No adverse
events were more frequent in participants receiving citalopram than in those
receiving placebo, and only 4 participants from each treatment group terminated
early because of side effects. CONCLUSIONS: Subsyndromal symptoms of depression
in middle aged and older patients with schizophrenia responded to treatment with
citalopram with lessening of depressive symptoms and improved functioning and
quality of life. It may be important for clinicians to identify and treat SSD in
middle-aged and older patients with chronic schizophrenia. TRIAL REGISTRATION: Identifier: NCT00047450. 2009 Physicians Postgraduate Press,

PMID: 19192468 [PubMed – indexed for MEDLINE] 43. J Psychiatr Res. 2009 Apr;43(7):680-6. Epub 2008 Nov 8.

Schedule for affective disorders and schizophrenia for school-age children
(K-SADS-PL) for the assessment of preschool children–a preliminary psychometric

Birmaher B, Ehmann M, Axelson DA, Goldstein BI, Monk K, Kalas C, Kupfer D, Gill
MK, Leibenluft E, Bridge J, Guyer A, Egger HL, Brent DA.

University of Pittsburgh Medical Center, Western Psychiatric Institute and
Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213, USA.

OBJECTIVE: To assess the psychometrics of the schedule for affective disorders
and schizophrenia for school-age children present and lifetime version
(K-SADS-PL) in diagnosing DSM-IV psychiatric disorders and subsyndromal
symptomatology in preschool children. METHOD: Parents were interviewed about
their children using the K-SADS-PL, and they completed the early childhood
inventory-4 (ECI-4) and child behavior checklist for ages 1(1/2)-5 years (CBCL).
Discriminant, divergent, and convergent validity of the K-SADS-PL were evaluated
in 204 offspring ages 2-5 years old of parents from an ongoing study. Inter-rater
reliability as well as predictive validity of intake diagnoses at second
assessment approximately two years after intake were evaluated. Fourteen children
were also assessed by the preschool age psychiatric assessment (PAPA). RESULTS:
Children who were diagnosed with oppositional defiant disorder, attention deficit
hyperactivity disorder, anxiety, mood, or elimination disorders had significantly
higher scores on the ECI-4 than children without these disorders. Significant
correlations were found for all convergent CBCL scales. Divergent validity was
acceptable for emotional disorders. Inter-rater kappa coefficients for all
diagnoses were good. Above noted results were similar for children with at least
one positive K-SADS-PL key screen symptom. A significantly higher percentage of
children with an intake diagnosis had a diagnosis approximately two years after
intake compared to those without an intake disorder. Overall, there was
consistency between the PAPA and the K-SADS-PL. CONCLUSIONS: Pending further
testing, the K-SADS-PL may prove useful for the assessment of psychopathology in

PMCID: PMC2736874 [Available on 2010/4/1] PMID: 19000625 [PubMed – indexed for MEDLINE] 44. J Clin Psychiatry. 2009 Mar 20;70(3):e05. doi: 10.4088/JCP.7128cc8c.e05.

Diagnosing and treating patients with symptoms of depression.

Nierenberg AA.

Depression Clinical and Research Program and the Bipolar Clinic and Research
Program, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Because patients with bipolar disorder spend more time experiencing depression
than mania, bipolar disorder may be incorrectly diagnosed as unipolar depression.
Patients presenting with depressive symptoms should be evaluated for present and
lifetime mania symptomatology to ensure a correct diagnosis. Once a bipolar
disorder diagnosis has been made, appropriate treatment choices, including mood
stabilizers, antipsychotics, psychotherapy, and, in some cases, adjunctive
antidepressants, can be made. After a patient has been stabilized, long-term
treatment is necessary to prevent episode recurrence and to control subsyndromal

PMID: 19317955 [PubMed – indexed for MEDLINE] 45. Actas Esp Psiquiatr. 2009 Mar-Apr;37(2):101-5.

Residual symptoms in depression.

Iglesias C, Alonso M.

Servicio de Psiquiatría, Hospital Valle del Nalón, Pol. de Riaño s/n. Langreo.
33920, Asturias, Spain.

Despite successful response to therapy, subsyndromal depressive symptoms appear
to be the rule in unipolar depression. Residual symptoms are present in more than
30% of patients who respond to antidepressants, specifically in subjects with
more severe initial illness. The most prevalent residual symptoms are affective,
somatic, cognitive and sleep disturbance. It has been shown that such persistent
symptoms are associated with a higher risk of relapse, chronicity and functional
impairment; associated with neuroanatomical changes. It is important to consider
the possibility of persistence subthreshold symptoms and look for new therapeutic
strategies for improving the level of remission in the treatment of major
depressive disorder.

PMID: 19401858 [PubMed – indexed for MEDLINE] 46. J Clin Psychiatry. 2009 Mar;70(3):334-43. Epub 2009 Feb 24.

Relationship of nicotine dependence, subsyndromal and pathological gambling, and
other psychiatric disorders: data from the National Epidemiologic Survey on
Alcohol and Related Conditions.

Grant JE, Desai RA, Potenza MN.

Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN
55454, USA.

OBJECTIVE: Nicotine dependence frequently co-occurs with subsyndromal and
pathological levels of gambling. The relationship of nicotine dependence, levels
of gambling pathology, and other psychiatric disorders, however, is incompletely
understood. METHOD: To use nationally representative data from the National
Epidemiologic Survey on Alcohol and Related Conditions to examine the influence
of DSM-IV nicotine dependence on the association between pathological gambling
severities and other psychiatric disorders. Face-to-face interviews were
conducted with 43,093 adults living in households and group-quarters in the
United States. The main outcome measure was the co-occurrence of current nicotine
dependence and Axis I and II disorders and severity of gambling based on the 10
inclusionary diagnostic criteria for pathological gambling. The study was
conducted from 2001 to 2002. RESULTS: Among non-nicotine-dependent respondents,
increasing gambling severity was associated with greater psychopathology for the
majority of Axis I and II disorders. This pattern was not uniformly observed
among nicotine-dependent subjects. Significant nicotine-by-gambling-group
interactions were observed for multiple Axis I and II disorders. All significant
interactions involved stronger associations between gambling and psychopathology
in the non-nicotine-dependent group. CONCLUSIONS: In a large national sample,
nicotine dependence influences the associations between gambling and multiple
psychiatric disorders. Subsyndromal levels of gambling are associated with
significant psychopathology. Nicotine dependence accounts for some of the
elevated risks for psychopathology associated with subsyndromal and
problem/pathological levels of gambling. Additional research is needed to examine
specific prevention and treatment for individuals with problem/pathological
gambling with and without nicotine dependence.

PMID: 19254518 [PubMed – indexed for MEDLINE] 47. Am J Psychiatry. 2009 Feb;166(2):173-81. Epub 2009 Jan 2.

Manic symptoms during depressive episodes in 1,380 patients with bipolar
disorder: findings from the STEP-BD.

Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB,
Calabrese JR, Nierenberg AA, Sachs GS.

Departmentof Psychiatry, Mount Sinai School of Medicine, New York, USA.

Comment in:
Am J Psychiatry. 2009 Feb;166(2):127-30.

OBJECTIVE: Little is known about how often bipolar depressive episodes are
accompanied by subsyndromal manic symptoms in bipolar I and II disorders. The
authors sought to determine the frequency and clinical correlates of manic
symptoms during episodes of bipolar depression. METHOD: From among 4,107
enrollees in the National Institute of Mental Health’s Systematic Treatment
Enhancement Program for Bipolar Disorder (STEP-BD), 1,380 individuals met
criteria for bipolar I or II depressive syndromes at the time of enrollment and
were assessed for concomitant manic symptoms. Illness characteristics were
compared in patients with pure bipolar depressed episodes and those with mixed
depressive presentations. RESULTS: Two-thirds of the subjects with bipolar
depressed episodes had concomitant manic symptoms, most often distractibility,
flight of ideas or racing thoughts, and psychomotor agitation. Patients with any
mixed features were significantly more likely than those with pure bipolar
depressed episodes to have early age at illness onset, rapid cycling in the past
year, bipolar I subtype, history of suicide attempts, and more days in the
preceding year with irritability or mood elevation. CONCLUSIONS: Manic symptoms
often accompany bipolar depressive episodes but may easily be overlooked when
they appear less prominent than depressive features. Subsyndromal manic symptoms
during bipolar I or II depression demarcate a more common, severe, and
psychopathologically complex clinical state than pure bipolar depression and
merit recognition as a distinct nosologic entity.

PMID: 19122008 [PubMed – indexed for MEDLINE] 48. Bipolar Disord. 2009 Feb;11(1):63-9.

Emotional hyper-reactivity in normothymic bipolar patients.

M’bailara K, Demotes-Mainard J, Swendsen J, Mathieu F, Leboyer M, Henry C.

Département de Psychiatrie Adulte, CHS Charles Perrens, Bordeaux, France.

BACKGROUND: Normothymic states in bipolar disorders are generally considered to
be devoid of severe symptoms. However, bipolar patients present subsyndromal
symptoms for half of their lives, and often have comorbid psychiatric disorders.
If we go beyond the concept of temperamental features, can we identify certain
emotional characteristics distinguishing normothymic bipolar patients from normal
controls? We previously showed, using self-completed questionnaires, that
normothymic bipolar patients display higher levels of emotional lability and
intensity than controls. OBJECTIVES: The aim of this study was to assess the
emotional reactivity of normothymic bipolar patients, comparing such patients
with a normal control group during an experimental mood induction procedure.
METHOD: We evaluated the subjective emotional reactivity of 145 subjects (90
control subjects and 55 normothymic bipolar patients), using an emotional
induction method based on the viewing of a set of 18 pictures (6 positive, 6
negative, 6 neutral) extracted from the International Affective Picture System.
Subjective valence and arousal were recorded with the Self-Assessment Manikin. We
also recorded startle reflexes, triggered by a tone occurring during the viewing
of two-thirds of the pictures. We controlled for confounding factors, such as
concurrent treatments, in all analyses. RESULTS: Normothymic bipolar patients and
normal controls assessed valence and arousal similarly for positive and negative
images. However, neutral images were considered more pleasant [F(1,143) = 8.4; p
= 0.004] and induced a higher level of arousal [F(1,143) = 12.3; p = 0.001] in
normothymic bipolar patients than in control subjects. Neutral pictures also
triggered a stronger startle reflex in normothymic bipolar patients compared to
controls [F(3,123) = 3.1; p = 0.03]. CONCLUSION: Normothymic bipolar patients
displayed emotional hyper-reactivity, mostly evidenced in neutral situations.
This feature may be linked to emotional dysregulation and is a potential
endophenotype and/or a risk factor for bipolar disorders. This trait may be
responsible for vulnerability to minor stressful events in everyday life. These
findings have potential implications for the daily management of bipolar disorder
between crises.

PMID: 19133967 [PubMed – indexed for MEDLINE] 49. Int Psychogeriatr. 2009 Feb;21(1):60-8. Epub 2008 Sep 12.

One-year outcomes of minor and subsyndromal depression in older primary care

Lyness JM, Chapman BP, McGriff J, Drayer R, Duberstein PR.

Geriatric Psychiatry Program, Department of Psychiatry, University of Rochester
Medical Center, Rochester, NY 14642, USA.

BACKGROUND: Despite the high prevalence and morbidity of minor and subsyndromal
depression in primary care elderly people, there are few data to identify those
at highest risk of poor outcomes. The goal of this observational cohort study was
to characterize the one-year outcomes of minor and subsyndromal depression,
examining the predictive strength of a range of putative risks including
clinical, functional and psychosocial variables. METHODS: Patients aged > or = 65
years were recruited from primary care medicine and family medicine practices. Of
750 enrollees, 484 (64.5%) completed baseline and one-year follow-up assessments
of depression diagnosis (major depression vs. minor and subsyndromal depression
vs. non-depressed) by the Structured Clinical Interview for DSM-IV, depressive
symptom severity (Hamilton Rating Scale for Depression), and validated measures
of other predictors. RESULTS: Patients with baseline minor and subsyndromal
depression were more depressed than the non-depressed group at follow-up: They
had a 7.0-fold (95% CI 4.5-10.8) risk of developing major depression, and a
one-year adjusted Hamilton Depression Score of 11.0 (95% CI 10.2-11.8) compared
with 7.8 (95% CI 7.1-8.5) for the non-depressed group; these outcomes were less
severe than those of the major depression group. Independent predictors of
depression outcomes included race, psychiatric and physical functioning, and
social support. CONCLUSIONS: Minor and subsyndromal depression are likely to
persist, and pose an elevated risk of worsening over one year. Clinicians and
preventive interventions researchers should focus on modifiable risks, such as
psychiatric functioning or social support, in elders suffering clinically
significant depressive symptoms.

PMCID: PMC2745243
PMID: 18786280 [PubMed – indexed for MEDLINE] 50. J Clin Psychiatry. 2009 Feb;70(2):177-84. Epub 2009 Jan 27.

A multidimensional tool to quantify treatment resistance in depression: the
Maudsley staging method.

Fekadu A, Wooderson S, Donaldson C, Markopoulou K, Masterson B, Poon L, Cleare

King’s College London, Institute of Psychiatry, Section of Neurobiology of Mood
Disorders, Department of Psychological Medicine and Psychiatry, London, UK.

Comment in:
J Clin Psychiatry. 2009 Oct;70(10):1476; author reply 1476.

OBJECTIVE: Treatment resistance is a common clinical phenomenon in depression.
However, current unitary models of staging fail to represent its complexity. We
aimed to devise a model to stage treatment-resistant depression, taking into
account the core factors contributing to treatment failure. METHOD: We reviewed
the literature to identify factors consistently associated with treatment
resistance. We also analyzed data from a subgroup of patients discharged from a
specialist inpatient unit for whom adequate data were obtainable. RESULTS: We
present a points-based staging model incorporating 3 factors: treatment, severity
of illness, and duration of presenting episode. In this model, the rating of
symptom severity ranges from subsyndromal depression (score 1) to severe
syndromal depression with psychosis (score 5). Antidepressant treatment is rated
on a 5-point subscale based on number of medications used, while duration of the
presenting episode is rated on a 3-point subscale. The overall level of
resistance estimated using this model varies from minimal resistance (score of 3)
to severe resistance (score of 15). The rating system allows the overall severity
of treatment resistance to be summarized either as a single numeric score or
under a single descriptive category. It may also be possible to specify
categories (mild, moderate, and severe) based on severity of resistance. Analysis
of inpatient data indicates that the factors incorporated in the model and the
model itself have some predictive validity. CONCLUSION: This staging model has
reasonable face and predictive validity and may have better utility in staging
treatment resistance than currently available methods. Copyright 2009 Physicians
Postgraduate Press, Inc.

PMID: 19192471 [PubMed – indexed for MEDLINE] 51. J Gerontol A Biol Sci Med Sci. 2009 Feb;64(2):230-6. Epub 2009 Feb 5.

Effects of changes in depressive symptoms and cognitive functioning on physical
disability in home care elders.

Li LW, Conwell Y.

University of Michigan School of Social Work, 1080 S University, Ann Arbor, MI
48109-1106, USA.

BACKGROUND: This study sought to investigate the effect of changes in depression
status on physical disability in older persons receiving home care, examine
whether the effect is due to concomitant changes in cognitive status, and test
whether affective state and cognitive ability interact to influence physical
disability. METHODS: Multilevel analyses were conducted using longitudinal data
collected about every 3 months from older participants in Michigan’s
community-based long-term care programs (N = 13,129). The data set provided an
average of nine repeated measures of depressive symptoms, cognitive functioning,
and physical disability. We estimated the lag effects of within-person changes in
depression and cognitive status, and their interaction, on physical disability
measured by activities of daily living (ADL) and instrumental activities of daily
living (IADL), controlling for health-related events that occurred in the
interim. RESULTS: Changes between not having and having depressive symptoms,
including subsyndromal symptoms, are critical to physical disability for home
care elders. The effects are independent of concomitant changes in cognitive
status, which also have significant adverse effects on physical disability. There
is some evidence that improvement of depression buffers the adverse effect of
cognitive decline on IADL disability. CONCLUSIONS: Providers should monitor
changes in depression and cognitive status in home care elders. Early detection
and treatment of subthreshold depression, as well as efforts to prevent worsening
of cognitive status in home care elders, may have a meaningful impact on their
ability to live at home.

PMCID: PMC2655022
PMID: 19196904 [PubMed – indexed for MEDLINE] 52. Med Hypotheses. 2009 Feb;72(2):166-8. Epub 2008 Oct 16.

Is dysfunction of the tissue plasminogen activator (tPA)-plasmin pathway a link
between major depression and cardiovascular disease?

Hou SJ, Yen FC, Tsai SJ.

Division of Psychiatry, Cheng-Hsin Rehabilitation and Medical Center, Taipei,
Taiwan, Republic of China.

Epidemiological, genetic and clinical studies have demonstrated an association
between major depressive disorder (MDD) and cardiovascular disease (CVD). For
example, MDD is a risk factor for the development of CVD, while around one fifth
of patients with CVD have MDD and a significantly larger percentage have
subsyndromal symptoms of depression. Furthermore, patients with CVD and
depression have an increased risk of future cardiac events compared to similar
cohorts without depression, independent of baseline cardiac dysfunction. Despite
evidence that CVD and MDD are epidemiologically linked, the cause of this
correlation is still unknown. Several risk factors including physical and
psychological stress, smoking, physical inactivity and inflammation have been
proposed to mediate the interaction between MDD and CVD. The tissue-type
plasminogen activator (tPA)-plasminogen proteolytic cascade is widely expressed
in the brain. Accumulating evidence from preclinical and clinical studies
suggests that tPA and its inhibitor, plasminogen activator inhibitor-1, are
related to stress reaction and depression. In addition, brain-derived
neurotrophic factor (BDNF) is important for the pathogenesis of MDD and the
tPA-plasminogen proteolytic cascade has been implicated in the cleavage of
proBDNF to BDNF in the brain, by which the direction of BDNF action is
controlled. Thus, it is proposed that tPA-plasmin pathway dysfunction may play a
role in the link between MDD and CVD. Future study of the components in the
tPA-plasminogen system in CVD patients comorbid with MDD may lead to new,
potentially important insights into the link between MDD and CVD, and might also
contribute to novel strategies for the management of these two common and
devastating diseases.

PMID: 18929445 [PubMed – indexed for MEDLINE] 53. Am J Geriatr Psychiatry. 2009 Jan;17(1):24-9.

Modulation of a human memory circuit by subsyndromal depression in late life: a
functional magnetic resonance imaging study.

Woo SL, Prince SE, Petrella JR, Hellegers C, Doraiswamy PM.

Department of Psychiatry, Center for Study of Aging and School of Medicine, Duke
University Medical Center, Duke University, Durham, NC 27710-3808, USA.

OBJECTIVE: Functional deactivation of the posteromedial cortex (PMC) seems to be
a physiologic process underlying normal memory. The authors examined whether
older subjects with subsyndromal depressive symptoms show impaired PMC
deactivation. DESIGN: Subjects underwent 4T functional magnetic resonance imaging
scan while performing a novel and familiar face-name associative encoding task.
The Beck-II Depression Inventory (BDI) was used to self-rate depression symptoms.
A novel-minus-familiar encoding contrast was built into a simple regression model
showing brain activation magnitudes that covaried with BDI score. A
region-of-interest mask was applied to isolate the PMC and other midline
structures of the default-mode network. SETTING: The study was conducted at a
university-based medical center. PARTICIPANTS: Participants included 62
nondemented subjects aged 55-85, with and without mild memory deficits. BDI
scores ranged from 0 to 17. RESULTS: Analysis revealed a distinct PMC cluster
confined to the dorsal posterior cingulate cortex (BA 31) whose activity
correlated significantly with BDI score. A multiple regression model further
showed that BDI score, as well as a history of depression and current use of
antidepressants, had a significant effect on cluster variance, while age,
education, gender, and mini-mental state exam scores did not. CONCLUSIONS: Our
findings raise the hypothesis that subsyndromal depressive symptoms in late life
may impair physiological PMC deactivation in the dorsal posterior cingulate
cortex. A prospective study of a full spectrum of depressed patients may be

PMCID: PMC2614878
PMID: 18790875 [PubMed – indexed for MEDLINE] 54. Compr Psychiatry. 2009 Jan-Feb;50(1):1-8. Epub 2008 Aug 23.

Functional outcomes in first-episode patients with bipolar disorder: a
prospective study from the Systematic Treatment Optimization Program for Early
Mania project.

Kauer-Sant’Anna M, Bond DJ, Lam RW, Yatham LN.

Department of Psychiatry, Mood Disorders Centre, University of British Columbia,
Vancouver, Canada.

BACKGROUND: Bipolar disorder causes substantial psychosocial morbidity, as it
frequently affects independent living, vocational, and social activities.
However, there is a relative dearth of research on functional outcomes and their
predictors in first-episode manic patients from prospective studies early in the
course of bipolar disorder. METHODS: The Systematic Treatment Optimization
Program for Early Mania (STOP-EM) project recruited 53 patients who recently
experienced their first episode of mania with or without psychosis.
Multidimensional Scale of Independent Functioning (MSIF) was used as the main
measure of functional outcome. Of the 53 patients recruited, 35 completed the
6-month follow-up assessment. RESULTS: At entry, 62.3% of patients had met
criteria for full remission of mood symptoms. Despite this, the mean baseline
MSIF score was 4.5 points; 62.3% of the patients had at least moderate
disability. A significant improvement in functioning was noted at 6 months
relative to entry as indicated by the reduction in mean MSIF scores from 4.5 to
2.6 (t = 4.1, df = 34, P < .001). The proportion of patients with at least
moderate disability was reduced from 62.3% to 25.7% at 6 months. Remission of
depressive symptoms at 6 months was associated with better functioning (P < .01).
In a regression model, only depressive symptoms were significantly correlated
with the MSIF global functional scores at 6 months. Even subsyndromal depressive
symptoms were significantly correlated with disability (r = 0.3, P < .05).
CONCLUSION: The findings highlight the deleterious impact of depressive symptoms
on functional recovery after a first manic episode even when they are
subsyndromal. Considered together, these results emphasize the importance of an
aggressive treatment of subsyndromal depressive symptoms for functional recovery.

PMID: 19059506 [PubMed – indexed for MEDLINE] 55. Psychopathology. 2009;42(3):148-56. Epub 2009 Mar 10.

Influence of clinical and neuropsychological variables on the psychosocial and
occupational outcome of remitted bipolar patients.

Mur M, Portella MJ, Martinez-Aran A, Pifarre J, Vieta E.

Mental Health Service, Santa Maria Hospital, IRBLleida, Institute for Research in
Biomedicine, University of Lleida, Lleida, Spain.

OBJECTIVE: To measure the impact of the clinical course, the residual mood
symptoms and the cognitive variables on the psychosocial and occupational
functioning in bipolar disorder patients in remission. METHOD: Forty-four
euthymic DSM-IV-TR bipolar lithium-treated outpatients were assessed with a
clinical interview and neuropsychological testing. To assess psychosocial
function, some psychometric scales were administered (Global Assessment of
Functioning Scale and World Health Organization Disability Assessment Schedule),
and to evaluate occupational function, the sample was divided according to the
current work status (active vs. inactive). Cognitive assessment was performed by
means of a neuropsychological test battery tapping into the main cognitive
domains (executive function, attention, processing speed, verbal memory and
visual memory). RESULTS: Measures of psychosocial functioning were significantly
correlated with cognition (processing speed, p = 0.004), clinical severity (p =
0.03) and residual depressive symptoms (p = 0.05). Occupational functioning
showed a significant effect with a cognitive domain (visual memory, p = 0.006)
and a clinical variable (chronicity, p = 0.04) but not with residual mood
symptoms (p > 0.2). CONCLUSIONS: Remission in bipolar disorder is not synonymous
with recovering in psychosocial and occupational functioning. Cognitive deficits,
clinical course and persistent subsyndromal symptoms may compromise psychosocial
functioning, and neurocognitive symptoms and chronicity may particularly affect
occupational functioning. Copyright 2009 S. Karger AG, Basel.

PMID: 19276630 [PubMed – indexed for MEDLINE] 56. Psychother Psychosom. 2009;78(5):285-97. Epub 2009 Jul 11.

Functioning and disability in bipolar disorder: an extensive review.

Sanchez-Moreno J, Martinez-Aran A, Tabarés-Seisdedos R, Torrent C, Vieta E,
Ayuso-Mateos JL.

Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS,
Barcelona, Spain.

BACKGROUND: Bipolar disorder has generally been regarded as having a better
functional outcome than schizophrenia. However, studies have suggested low
functioning in bipolar patients even when they are in clinical remission. Our aim
was to determine the degree of functioning and disability in bipolar patients.
Secondly, we reviewed factors potentially associated with the low functioning of
bipolar patients. METHOD: The authors conducted an extensive Medline and Pubmed
search of the published literature from 1980 up to December 2007, using a variety
of search terms to find relevant articles. Bibliographies of retrieved papers
were further analysed for publications of interest. Articles that reported
clinically significant findings on functioning and disability, and research
reports were reviewed in detail. RESULTS: From these articles, we determined that
bipolar disorder is associated with significant impairment in work, family and
social life, beyond the acute phases of the illness. The aspects that appear to
increase the risk of low functioning and disability in bipolar patients are
mainly subsyndromal symptoms and neurocognitive impairment, among others.
CONCLUSIONS: Suitable pharmacological and psychological interventions may improve
the level of functioning and reduce the disability in bipolar patients. Potential
targets to be considered for intervention should be residual symptoms, comorbid
conditions and neurocognitive deficits. Further research is required to better
identify the factors that best predict functioning in bipolar patients. Copyright
2009 S. Karger AG, Basel.

PMID: 19602917 [PubMed – indexed for MEDLINE] 57. Encephale. 2008 Dec;34(6):577-83. Epub 2008 Apr 2.

[Prevalence of trauma-related disorders in the French WHO study: Santé mentale en
population générale (SMPG)] [Article in French]

Vaiva G, Jehel L, Cottencin O, Ducrocq F, Duchet C, Omnes C, Genest P, Rouillon
F, Roelandt JL.

Secteur des urgences psychiatriques, pôle des urgences, CHRU de Lille, Lille,

INTRODUCTION: Trauma-related disorders are disabling affections of which
epidemiological data change according to the country, population and measuring
instruments. The prevalence of posttraumatic stress disorder (PTSD) appears to
have increased over the past 15 years, but one cannot tell whether it has indeed
increased or whether the standardized procedure has improved. Moreover, very few
epidemiologic studies among the general population have been conducted in Europe,
notably in France. DESIGN OF THE STUDY: The “Santé mentale en population
générale” (SMPG) survey, that took place in France between 1999 and 2003 among
more than 36 000 individuals, gives an estimation of the prevalence of
psychotraumatic disorders in the general population. Multi-varied analyses were
performed on PTSD-related variables and comorbid disorders. The instantaneous
prevalence (past month) of PTSD was of 0.7% among the whole SMPG sample, with
almost the same proportion of men (45%) and women (55%). There was a high rate of
comorbidity among PTSD individuals, notably with mood disorders, anxiety
disorders and addictive behaviour. There was an obvious relationship with
suicidal behaviour, with 15-fold more suicide attempts during the past month
among the PTSD population. RESULTS: This survey analysed the consequences of a
psychic traumatism over and above complete PTSD according to DSM-IV criteria,
observing for instance the consequences for people exposed both to a trauma and
suffering from at least one psychopathological symptom since the trauma. Those
who suffered from a psychotraumatic syndrome, according to our enlarged
definition, represented 5.3% of the population, half suffered from daily
discomfort and a third of them used medication. Then, we compared those
psychotraumatic syndromes to complete PTSD from a sociodemographic, functional
and type of care point of view. There was little difference in prevalence of PTSD
between men and women in the SMPG survey (45% vs 55%), which is clearly distinct
from the other epidemiologic surveys named above. Regarding age, as in the ESEMeD
survey, anxiety disorders appeared to be more frequent among younger people. The
originality of the SMPG survey is obviously in the fact that it studied the
functional impact of the psychic disorder, the type of care and the satisfaction
level after care. Only 50% of the PTSD population feels sick which is, however,
twice as high as for the psychotraumatized population. This doesn’t fit either
with the fact that 100% of the PTSD population say they feel uncomfortable with
other people. The type of care is in the same vein: 50% of psychotherapies and
75% of medication, but also 25% of mild medicines and 25% of traditional
medicines. Moreover, among the drugs, antidepressants (that are still the first
choice treatment in all international recommendations) represent only 30%,
whereas anxiolytics, hypnotics and phytotherapy represent the remaining 70%.
DISCUSSION: Regarding the type of care, the differences between the
psychotraumatized population and the PTSD population are obvious. They are
obvious in that which concerns the type of care, since the medication is similar.
From a very global point of view, patients suffering from a subsyndromal PTSD
rarely choose medical care (religion, mild or traditional medicine), while full
PTSD patients definitely choose classical medical care (drugs, psychotherapy, and
30% of hospitalization). The prevalence of those who ask for care is very close
to that observed in the ESEMeD survey, which was four individuals out of 10
suffering from PTSD. CONCLUSION: The SMPG data show that its necessary to
maintain the distinction between subsyndromal PTSD and full PTSD since the
populations differ, but both need care.

PMID: 19081454 [PubMed – indexed for MEDLINE] 58. J Behav Ther Exp Psychiatry. 2008 Dec;39(4):515-25. Epub 2008 Jan 18.

Suicidal ideation and anxiety disorders: elevated risk or artifact of comorbid

Norton PJ, Temple SR, Pettit JW.

University of Houston, Houston, TX 77096, USA.

Research into the possible relationship between anxiety disorders and suicidal
ideation has yielded mixed results, leading some to suggest that the positive
findings between anxiety and suicidal ideation might simply be a by-product of
comorbid depression. Recent work has suggested that having an anxiety disorder
without history of mood disorder does convey increased risk for suicidal
ideation, although the study could not assess for the possible impact of
subsyndromal depressiveness. This current study, therefore, examined the
relationship between anxiety disorder symptoms and suicidality using continuous
scales and controlling for depressiveness. Data regarding the severity of panic,
social anxiety, generalized anxiety, and obsessive-compulsive symptoms were
obtained from a sample of 166 college students. Results generally supported the
conclusions that anxiety disorders convey risk for suicidal ideation above and
beyond any co-occurring depressiveness, and anxiety and depression together
conveyed an additional interactive risk.

PMID: 18294614 [PubMed – indexed for MEDLINE] 59. J Nerv Ment Dis. 2008 Dec;196(12):884-90.

Suicidal ideation and suicide attempts among middle-aged and older patients with
schizophrenia spectrum disorders and concurrent subsyndromal depression.

Montross LP, Kasckow J, Golshan S, Solorzano E, Lehman D, Zisook S.

Argosy University, San Diego Campus, Psychology Program, San Diego, California,

This study examines the prevalence and correlates of current suicidal ideation
and past suicide attempts among patients aged 40 and older with schizophrenia
spectrum disorders and concurrent depressive symptoms. Nearly half the sample (n
= 132) reported having attempted suicide once or more in their lifetime; those
who had attempted, exhibited greater depression and psychopathology. A regression
analysis revealed that only past suicide attempts and hopelessness significantly
accounted for the presence of current suicidal ideation. Surprisingly, current
suicidal ideation did not differ by diagnosis, race/ethnicity, marital status,
living situation, age, education, or severity of medical illness. Overall,
suicidal ideation and the presence of past suicide attempts were remarkably
prevalent, highlighting the need for continued clinical vigilance with this
patient population. The impact of hopelessness and general psychopathology, as
well as the insignificance of demographic characteristics and medical illness
severity warrant further investigation.

PMID: 19077855 [PubMed – indexed for MEDLINE] 60. Ann Intern Med. 2008 Nov 18;149(10):734-50.

Comparative benefits and harms of second-generation antidepressants: background
paper for the American College of Physicians.

Gartlehner G, Gaynes BN, Hansen RA, Thieda P, DeVeaugh-Geiss A, Krebs EE, Moore
CG, Morgan L, Lohr KN.

Danube University, Krems, Austria.

Comment in:
Evid Based Med. 2009 Jun;14(3):82.

Summary for patients in:
Ann Intern Med. 2008 Nov 18;149(10):I56.

BACKGROUND: Second-generation antidepressants dominate the management of major
depressive disorder, dysthymia, and subsyndromal depression. Evidence on the
comparative benefits and harms is still accruing. PURPOSE: To compare the
benefits and harms of second-generation antidepressants (bupropion, citalopram,
duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone,
paroxetine, sertraline, trazodone, and venlafaxine) for the treatment of
depressive disorders in adults. DATA SOURCES: MEDLINE, EMBASE, PsychLit, Cochrane
Central Register of Controlled Trials, and International Pharmaceutical Abstracts
from 1980 to April 2007, limited to English-language articles. Reference lists of
pertinent review articles were manually searched and the Center for Drug
Evaluation and Research database was explored to identify unpublished research.
STUDY SELECTION: Abstracts and full-text articles were independently reviewed by
2 persons. Six previous good- or fair-quality systematic reviews or meta-analyses
were included, as were 155 good- or fair-quality double-blind,
placebo-controlled, or head-to-head randomized, controlled trials of at least 6
weeks’ duration. For harms, 35 observational studies with at least 100
participants and follow-up of at least 12 weeks were also included. DATA
EXTRACTION: Using a standard protocol, investigators abstracted data on study
design and quality-related details, funding, settings, patients, and outcomes.
DATA SYNTHESIS: If data were sufficient, meta-analyses of head-to-head trials
were conducted to determine the relative benefit of response to treatment and the
weighted mean differences on specific depression rating scales. If sufficient
evidence was not available, adjusted indirect comparisons were conducted by using
meta-regressions and network meta-analyses. Second-generation antidepressants did
not substantially differ in efficacy or effectiveness for the treatment of major
depressive disorder on the basis of 203 studies; however, the incidence of
specific adverse events and the onset of action differed. The evidence is
insufficient to draw conclusions about the comparative efficacy, effectiveness,
or harms of these agents for the treatment of dysthymia and subsyndromal
depression. LIMITATION: Adjusted indirect comparisons have methodological
limitations and cannot conclusively rule out differences in efficacy. CONCLUSION:
Current evidence does not warrant the choice of one second-generation
antidepressant over another on the basis of differences in efficacy and
effectiveness. Other differences with respect to onset of action and adverse
events may be relevant for the choice of a medication.

PMID: 19017592 [PubMed – indexed for MEDLINE] 61. Ann Intern Med. 2008 Nov 18;149(10):725-33.

Using second-generation antidepressants to treat depressive disorders: a clinical
practice guideline from the American College of Physicians.

Qaseem A, Snow V, Denberg TD, Forciea MA, Owens DK; Clinical Efficacy Assessment
Subcommittee of American College of Physicians.

American College of Physicians, Philadelphia, PA 19106, UAS.

Erratum in:
Ann Intern Med. 2009 Jan 20;150(2):148.

Summary for patients in:
Ann Intern Med. 2008 Nov 18;149(10):I56.

DESCRIPTION: The American College of Physicians developed this guideline to
present the available evidence on the pharmacologic management of the acute,
continuation, and maintenance phases of major depressive disorder; dysthymia;
subsyndromal depression; and accompanying symptoms, such as anxiety, insomnia, or
neurovegetative symptoms, by using second-generation antidepressants. METHODS:
Published literature on this topic was identified by using MEDLINE, EMBASE,
PsychLit, the Cochrane Central Register of Controlled Trials, and International
Pharmaceutical Abstracts from 1980 to April 2007. Searches were limited to
English-language studies in adults older than 19 years of age. Keywords for
search included terms for depressive disorders and 12 specific second-generation
antidepressants-bupropion, citalopram, duloxetine, escitalopram, fluoxetine,
fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and
venlafaxine-and their specific trade names. This guideline grades the evidence
and recommendations by using the American College of Physicians clinical practice
guidelines grading system. RECOMMENDATION 1: The American College of Physicians
recommends that when clinicians choose pharmacologic therapy to treat patients
with acute major depression, they select second-generation antidepressants on the
basis of adverse effect profiles, cost, and patient preferences (Grade: strong
recommendation; moderate-quality evidence). RECOMMENDATION 2: The American
College of Physicians recommends that clinicians assess patient status,
therapeutic response, and adverse effects of antidepressant therapy on a regular
basis beginning within 1 to 2 weeks of initiation of therapy (Grade: strong
recommendation; moderate-quality evidence). RECOMMENDATION 3: The American
College of Physicians recommends that clinicians modify treatment if the patient
does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the
initiation of therapy for major depressive disorder (Grade: strong
recommendation; moderate-quality evidence). RECOMMENDATION 4: The American
College of Physicians recommends that clinicians continue treatment for 4 to 9
months after a satisfactory response in patients with a first episode of major
depressive disorder. For patients who have had 2 or more episodes of depression,
an even longer duration of therapy may be beneficial (Grade: strong
recommendation; moderate-quality evidence).

PMID: 19017591 [PubMed – indexed for MEDLINE] 62. Curr Opin Psychiatry. 2008 Nov;21(6):540-5.

The many faces of geriatric depression.

Heok KE, Ho R.

Department of Psychological Medicine, National University of Singapore,

PURPOSE OF REVIEW: Recent studies on five aspects of geriatric depression, namely
subsyndromal depression, risk factors and association with chronic pain,
cardiovascular disease and cognitive impairment, are reviewed. RECENT FINDINGS:
Subsyndromal depression in the elderly population is not uncommon in east Asia;
the prevalence is about 8-9%. Risk factors of geriatric depression include poor
health, brain injury, low folate and vitamin B12 and raised plasma homocysteine
levels. Depressed elderly with chronic pain are prone to suicidal ideation.
Depression is a risk factor for cardiovascular diseases and mortality in coronary
heart disease. SUMMARY: The growing interest in research on geriatric depression
could focus on early diagnosis to help doctors treat depression better at primary
care level.

PMID: 18852559 [PubMed – indexed for MEDLINE] 63. Eur Neuropsychopharmacol. 2008 Nov;18(11):787-93. Epub 2008 Aug 24.

Cognitive impairment in bipolar disorder: neurodevelopment or neurodegeneration?
An ECNP expert meeting report.

Goodwin GM, Martinez-Aran A, Glahn DC, Vieta E.

University Department of Psychiatry, Warneford Hospital, Oxford, UK.

This is a report arising from an ECNP expert meeting. Recent studies have
focussed on cognitive problems in manic-depressive illness and a few have
addressed premorbid neuropsychological functioning. The results are not fully
consistent but seem to point to a neurodegenerative model, rather than a
neurodevelopmental one, for some cognitive domains. There is agreement that
cognitive dysfunction is highly correlated with psychosocial functioning. The
neurobiological and clinical implications of recent findings will be discussed.
Treatments to reduce subsyndromal symptoms and relapses may indirectly improve
neurocognitive deficits and this should be better documented. Moreover,
neurocognitive impairment in bipolar disorder should be considered a potential
therapeutic target, so that research should focus on new drugs and psychological
interventions, including neurocognitive rehabilitation, addressed to improve not
only the cognition but also the functional outcome of this population.

PMID: 18725178 [PubMed – indexed for MEDLINE] 64. Gerontologist. 2008 Oct;48(5):593-602.

Impact of major depression and subsyndromal symptoms on quality of life and
attitudes toward aging in an international sample of older adults.

Chachamovich E, Fleck M, Laidlaw K, Power M.

Department of Psychiatry, University of Rio Grande do Sul, Brazil.

PURPOSE: The impact of major depression on quality of life (QOL) and aging
experiences in older adults has been reported. Studies have demonstrated that the
clinical diagnosis of major depression is the strongest predictor for QOL. We
postulate that some findings are biased because of the use of inadequate
instruments. Although subsyndromal depression is more prevalent than major
depression, there are no reports on its impact on QOL or attitudes toward aging.
In the present study we aim at assessing the association of major and
subsyndromal depression on QOL and attitudes toward aging in a large
international sample. DESIGN AND METHODS: Our cross-sectional study assessed
4,316 respondents in 20 countries from five continents. The study used the World
Health Organization Quality of Life (WHOQOL) Assessment for Older Adults, known
as the WHOQOL-OLD; the brief version of the WHOQOL instrument, known as the
WHOQOL-BREF; and the Attitudes to Ageing Questionnaire. Statistical analyses
involved hierarchical multiple regression, as well as comparison of means.
RESULTS: Even relatively minor levels of depression are associated with a
significant decrease in all QOL domains and with a pattern of negative attitudes
toward aging (overall WHOQOL-OLD R(2) change =.421). QOL and attitudes toward
aging scores are lower as depression intensity is increased, even in subsyndromal
levels (overall WHOQOL-OLD mean scores of 95.7 vs 86.4, p <.001). This phenomenon
happens not only for clinically depressed individuals but also for subsyndromic
individuals. IMPLICATIONS: Present findings suggest that classifying a respondent
as nondepressed is not sufficient and is still not informative about his or her
QOL and attitudes toward aging status.

PMID: 18981276 [PubMed – indexed for MEDLINE] 65. J Med Assoc Thai. 2008 Oct;91 Suppl 3:S69-75.

Assessment of psychopathological consequences in children at 3 years after
tsunami disaster.

Ularntinon S, Piyasil V, Ketumarn P, Sitdhiraksa N, Pityaratstian N,
Lerthattasilp T, Bunpromma W, Booranasuksakul T, Reuangsorn S, Teeranukul S,
Pimratana W.

Division of Child and Adolescent Psychiatry, Department of Pediatrics, Queen
Sirikit National Institute of Child Health, College of Medicine, Rangsit
University, Bangkok, Thailand.

BACKGROUND: At 1 year after the Tsunami disaster, 30% of students in two high
risk schools at Takuapa district of Phang Nga Province still suffered from post
traumatic stress disorder (PTSD). The number ofpatients was sharply declined
after 18 months. The psychological consequences in children who diagnosed PTSD
after the event were reinvestigated again at 3 years, as there were reports of
significant comorbidity and continuing of subsyndromal post traumatic stress
symptoms in children suffered from other disasters. OBJECTIVE: To assess
psychological outcomes and factors contributed at 3-year follow up time in
children diagnosed PTSD at 1-year after the Tsunami disaster MATERIAL AND METHOD:
There were 45 students who were diagnosed PTSD at 1-year after the disaster At
3-year follow up time, clinical interview for psychiatric diagnosis was done by
psychiatrists. RESULTS: 11.1% of students who had been diagnosed as PTSD at
1-year after Tsunami still had chronic PTSD and 15% had either depressive
disorder or anxiety disorder 25% of students completely recovered from mental
disorders. Nearly 50% ofstudents were categorized in partial remission or
subsyndromal PTSD group. Factors which influenced long-term outcomes were prior
history of trauma and severe physical injury from the disaster. CONCLUSION:
Although the point prevalence of PTSD in children affected by Tsunami was
declined overtime, a significant number of students still suffer from post
traumatic stress symptoms, depressive disorder or anxiety disorder which need
psychological intervention.

PMID: 19253499 [PubMed – indexed for MEDLINE] 66. J Psychiatr Res. 2008 Oct;42(13):1131-6. Epub 2008 Jan 11.

Temperament and character dimensions in bipolar I disorder: a comparison to
healthy controls.

Loftus ST, Garno JL, Jaeger J, Malhotra AK.

The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore Long
Island Jewish Health System, 75-59 263rd Street, Glen Oaks, NY 11004, United

Research on phenotypic markers of vulnerability to bipolar disorder has focused
on the identification of personality traits uniquely associated with the illness.
To expand knowledge in this area, we compared Cloninger’s seven temperament and
character dimensions in 85 euthymic/subsyndromal bipolar I inpatients and
outpatients and 85 age and sex matched community controls. We also examined
associations between Cloninger’s personality traits and mood state in the patient
group. Bipolar subjects were administered the Structured Clinical Interview for
DSM-IV (SCID), Hamilton Rating Scale for Depression, and Clinician-Administered
Rating Scale for Mania. Controls received the SCID, a family psychiatric history
questionnaire, and urine toxicology screen to confirm healthy status. Both groups
competed the 240-item Temperament and Character Inventory (TCI). A multivariate
analysis of covariance, accounting for demographic factors, was conducted to
compare the groups on the TCI. Bipolar I patients scored higher on harm
avoidance, lower on self-directedness, and higher on self-transcendence compared
to controls. Harm avoidance and self-directedness were correlated with residual
depressive symptoms positively and negatively, respectively; persistence was
correlated with residual manic symptoms; and selftranscendence was correlated
with residual psychotic symptoms in patients. The results indicate that bipolar I
subjects do possess personality traits that are significantly different from
non-ill individuals. However, only a prospective, longitudinal study may
determine whether these traits mark a vulnerability to the disorder, or represent
the scarring effect of affective episodes and chronic subsyndromal symptoms.

PMID: 18191148 [PubMed – indexed for MEDLINE] 67. Neuropsychiatr Dis Treat. 2008 Oct;4(5):977-86.

Validity and reliability of the Structured Clinical Interview for
Depersonalization-Derealization Spectrum (SCI-DER).

Mula M, Pini S, Calugi S, Preve M, Masini M, Giovannini I, Conversano C, Rucci P,
Cassano GB.

Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies,
University of Pisa, Italy.

TO ASSESS SYMPTOMS OF DEPERSONALIZATION: the Structured Clinical Interview for
the Depersonalization-Derealization Spectrum (SCI-DER). The instrument is based
on a spectrum model that emphasizes soft-signs, sub-threshold syndromes as well
as clinical and subsyndromal manifestations. Items of the interview include, in
addition to DSM-IV criteria for depersonalization, a number of features derived
from clinical experience and from a review of phenomenological descriptions.
Study participants included 258 consecutive patients with mood and anxiety
disorders, 16.7% bipolar I disorder, 18.6% bipolar II disorder, 32.9% major
depression, 22.1% panic disorder, 4.7% obsessive compulsive disorder, and 1.5%
generalized anxiety disorder; 2.7% patients were also diagnosed with
depersonalization disorder. A comparison group of 42 unselected controls was
enrolled at the same site. The SCI-DER showed excellent reliability and good
concurrent validity with the Dissociative Experiences Scale. It significantly
discriminated subjects with any diagnosis of mood and anxiety disorders from
controls and subjects with depersonalization disorder from controls. The
hypothesized structure of the instrument was confirmed empirically.

PMCID: PMC2626926
PMID: 19183789 [PubMed – in process] 68. Perspect Psychiatr Care. 2008 Oct;44(4):275-84.

Self-reported psychopathological symptoms and quality of life in outpatients with
bipolar disorder.

Goossens PJ, Hartong EG, Knoppert-van der Klein EA, van Achterberg T.

Mental Health Care, Deventer, The Netherlands, and Senior Researcher, Radboud
University Nijmegen Medical Centre, Nijmegen, The Netherlands.

PURPOSE: Patients with bipolar disorder in a euthymic mood state can suffer from
subsyndromal or residual symptoms of depression or hypomania. This study was
undertaken to gain insight into the broader spectrum of psychopathological
symptoms and quality of life. DESIGN AND METHODS: Participants (n = 157)
completed the Symptoms Checklist-90, the World Health Organization Quality of
Life Assessment Instrument-Bref, and a questionnaire addressing demographic and
clinical characteristics. FINDINGS: Outpatients with bipolar disorder reported
fewer symptoms of psychopathology than psychiatric outpatients in general, but
relative to the general population, a significantly lower quality of life was
reported. The number of symptoms showed consistently negative correlations with
the quality of life. PRACTICE IMPLICATIONS: The results of this study urge nurses
to not settle for treatment response in terms of reduced manic or depressive
episodes, but instead to strive for full remission of all symptoms.

PMID: 18826466 [PubMed – indexed for MEDLINE] 69. Sante Ment Que. 2008 Autumn;33(2):151-84.

[Interpersonal psychotherapy and social rhythm therapy for bipolar II disorder:
treatment development and case examples] [Article in French]

Swartz HA, Frank E, Frankel D.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of
Pittsburgh, Pittsburgh, Pennsylvania, USA.

Bipolar II (BP II) disorder is a common, recurrent, and disabling psychiatric
illness. Individuals suffering from this disorder comprise a large segment of the
outpatient mental health treatment population, and yet little is known about how
best to manage it. Psychotherapy, although untested in this population,
represents a potentially important treatment modality for individuals suffering
from this disorder. Because BP II disorder is characterized by subsyndromal,
non-psychotic, episodes of mania (hypomania), there are no clear
contraindications to the use of psychotherapy as monotherapy in BP II disorder
(in contrast to BP I disorder where the risk of mania makes medication the sine
qua non of treatment). In addition, unlike medication, psychotherapy has the
potential to help patients address the multiple psychosocial problems associated
with this chronic illness. Thus, an effective psychotherapy for BP II disorder
may provide an appealing alternative for patients, especially for those who
prefer to avoid the risks and discomfort associated with current
pharmacotherapeutic options. Interpersonal and social rhythm therapy (IPSRT), a
treatment combining a behavioral approach to increasing the regularity of daily
routines with interpersonal psychotherapy (IPT), has demonstrated efficacy BP I
disorder when in combination with medication. The current report gives brief
overviews of BP II disorder and IPSRT, describes the process of adapting IPSRT
for the treatment of BP II disorder, and then presents a series of vignettes
based on our experience using IPSRT as monotherapy for the acute treatment of BP
II depression. We argue that IPSRT warrants further systematic study to formally
assess its efficacy as a treatment for BP II disorder.

PMID: 19370262 [PubMed – indexed for MEDLINE] 70. Actas Esp Psiquiatr. 2008 Sep-Oct;36(5):277-84.

[Profile of bipolar disorder outpatients: a cross-sectional study in the Madrid
Community] [Article in Spanish]

Montes JM, Sáiz J, de Dios C, Ezquiaga E, García A, Argudo I, Carrillo A,
Cebollada A, Ramos J, Valle J.

Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid.

INTRODUCTION: The purpose of this cross-sectional study is to obtain a
sociodemographic, clinical, psychosocial functioning and therapeutic profile of
bipolar outpatients in the Madrid Community. METHODS: A total of 115 outpatients
were consecutively recruited by 10 psychiatrists. RESULTS: Mean time between
initial symptoms and an accurate bipolar diagnosis was of 7.6 years. A depressive
episode was the onset of the illness in most patients independently of clinical
subtype. Syndromal or subsyndromal symptoms were present in 47% of the patient
population, dominating the depressive polarity (33.1%). A subjectively reduced
perception of quality of life was associated to the presence of depressive
symptoms and a worse clinical outcome last year. More than half of the patients
(58.2%) were overweight or obese. Lithium was the most frequently used mood
stabilizer (71.3%), whereas 41% of the patients were taking at least three
psychotropic drugs. CONCLUSIONS: Results of this study widely confirm previous
data on bipolar disorder. Reduction in quality of life of bipolar patients
associated to depressive symptoms must be highlighted. It is necessary to
optimize treatments in bipolar disorder in order to improve prognosis.

PMID: 18568453 [PubMed – indexed for MEDLINE] 71. Am J Geriatr Psychiatry. 2008 Aug;16(8):660-3.

Functioning in middle aged and older patients with schizophrenia and depressive
symptoms: relationship to psychopathology.

Kasckow J, Patterson T, Fellows I, Golshan S, Solorzano E, Mohamed S, Zisook S.

VA Pittsburgh Health Care System MIRECC and Behavioral Health Service; 7180
Highland Dr., Pittsburgh, PA 15206, USA.;

BACKGROUND: Depressive symptoms are common in middle aged and older patients with
schizophrenia. The authors hypothesized that worse functioning in these patients
would be associated with worse psychopathology. METHODS: Outpatients with
schizophrenia were > or =40 years old with subsyndromal depression and Hamilton
Depression Rating Scale Scores of > or =8. Exclusions were dementia, two months
of either mania or major depression or 1 month active substance abuse/dependence.
The authors administered performance based functional assessments, the Positive
and Negative Syndrome Scale of Schizophrenia [PANSS], and Calgary Depression
Rating Scale. RESULTS: PANSS (-) scores were negatively correlated with the UCSD
Performance Skills Based Assessment, Social Skills Performance Assessment and
Medication Management Ability Assessment total error (MMAA) scores. Digit symbol
scores served as a moderator of the relationship between MMAA and PANSS (-)
scores. CONCLUSIONS: Negative symptoms were associated with functioning. The
relationship between negative symptoms and medication errors seem to weaken in
subjects with quicker processing speed.

PMID: 18669944 [PubMed – indexed for MEDLINE] 72. Br J Psychol. 2008 Aug;99(Pt 3):413-26. Epub 2007 Sep 29.

Understanding the impact of prior depression on stress generation: examining the
roles of current depressive symptoms and interpersonal behaviours.

Shih JH, Eberhart NK.

Department of Psychology, Saint Joseph’s University, Philadelphia, PA 19131, USA.

Stress generation is a process in which individuals contribute to stressful life
events. While research has supported an association between current depression
and stress generation, it has been noted that individuals with prior depression
tend to contribute to stressors even when they are no longer experiencing a
depressive episode. The aim of the study is to elucidate the pathways through
which prior major depression predicts interpersonal stress generation in women.
Specifically, we examined current subsyndromal depressive symptoms and
problematic interpersonal behaviours as potential mediators. Fifty-one college
women were followed prospectively for 6 weeks. Participants were interviewed to
assess current and past depression as well as stressful life events they
experienced over the 6-week period. The findings suggest that prior major
depression continues to have an impact even after the episode has ended, as the
disorder continues to contribute to stress generation through residual depressive

PMID: 17908367 [PubMed – indexed for MEDLINE] 73. Int J Geriatr Psychiatry. 2008 Aug;23(8):773-81.

Naturalistic outcomes of minor and subsyndromal depression in older primary care

Lyness JM.

Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
14642, USA.

OBJECTIVE: To review the literature regarding the naturalistic outcomes of minor
and subsyndromal depression (‘Min/SSD’) in older primary care patients,
synthesizing and critiquing findings and discussing avenues for future research.
DESIGN: The author obtained relevant articles from repeated computer-assisted
literature searches over the past 15 years, and by reviewing the reference
citations of the articles so obtained. RESULTS: A variety of relevant outcome
domains were identified, as were important putative predictors, moderators, and
mediators of outcome. In general, minor and subsyndromal depression each have
comparable outcomes, outcomes that are clearly worse than non-depressed subjects,
with substantially elevated risk of worsening into major depression, albeit not
as poor as those with major depression. CONCLUSIONS: Min/SSD is common and of
real clinical importance in primary care seniors. Several definitions of SSD may
be used, each with overlapping but distinguishable utility in identifying
patients. While the evidence base has expanded greatly in the past decade,
considerable work remains to be done. Naturalistic studies of several outcome
domains are needed, focusing on the predictive, moderating, and mediating roles
of a wide range of psychopathological, medical, functional, and psychosocial
factors. Such work will complement interventions and biomarker research

PMID: 18200611 [PubMed – indexed for MEDLINE] 74. Dev Psychopathol. 2008 Summer;20(3):881-97.

Prevention of bipolar disorder in at-risk children: theoretical assumptions and
empirical foundations.

Miklowitz DJ, Chang KD.

Department of Psychology, University of Colorado at Boulder, Boulder, CO 80309,

This article examines how bipolar symptoms emerge during development, and the
potential role of psychosocial and pharmacological interventions in the
prevention of the onset of the disorder. Early signs of bipolarity can be
observed among children of bipolar parents and often take the form of
subsyndromal presentations (e.g., mood lability, episodic elation or
irritability, depression, inattention, and psychosocial impairment). However,
many of these early presentations are diagnostically nonspecific. The few studies
that have followed at-risk youth into adulthood find developmental
discontinuities from childhood to adulthood. Biological markers (e.g., amygdalar
volume) may ultimately increase our accuracy in identifying children who later
develop bipolar I disorder, but few such markers have been identified. Stress, in
the form of childhood adversity or highly conflictual families, is not a
diagnostically specific causal agent but does place genetically and biologically
vulnerable individuals at risk for a more pernicious course of illness. A
preventative family-focused treatment for children with (a) at least one
first-degree relative with bipolar disorder and (b) subsyndromal signs of bipolar
disorder is described. This model attempts to address the multiple interactions
of psychosocial and biological risk factors in the onset and course of bipolar

PMCID: PMC2504732
PMID: 18606036 [PubMed – indexed for MEDLINE] 75. Int J Geriatr Psychiatry. 2008 Jul;23(7):760-5.

Insight, quality of life, and functional capacity in middle-aged and older adults
with schizophrenia.

Roseman AS, Kasckow J, Fellows I, Osatuke K, Patterson TL, Mohamed S, Zisook S.

University of Texas MD Anderson Cancer Center, Houston, TX 77230-1439, USA.

OBJECTIVE: The quality of life (QOL) for individuals with schizophrenia is
determined by a number of factors, not limited to symptomatology. The current
study examined lack of insight as one such factor that may influence subjective
QOL or functional capacity. It was hypothesized that insight would significantly
interact with symptom severity to influence subjective QOL. Insight was not
expected to influence the relation between symptom severity and functional
capacity. METHODS: Participants were middle-aged and older outpatients who met
diagnostic criteria for schizophrenia or schizoaffective disorder, and
subsyndromal depression. Insight, psychopathology, and subjective QOL were
assessed via semi-structured interviews and functional capacity was assessed via
performance-based measures. RESULTS: Insight interacts with negative symptom
severity to predict subjective QOL. Severity of negative symptoms and insight
contribute directly to functional capacity. CONCLUSIONS: Individuals with intact
insight may be better able to manage their symptoms, resulting in improved QOL.
Treatment implications for improving the QOL of middle age and older adults with
schizophrenia are discussed.

PMID: 18205246 [PubMed – indexed for MEDLINE] 76. Am J Geriatr Psychiatry. 2008 Jun;16(6):460-8.

Preventing depression in later life: translation from concept to experimental
design and implementation.

Sriwattanakomen R, Ford AF, Thomas SB, Miller MD, Stack JA, Morse JQ, Kasckow J,
Brown C, Reynolds CF 3rd.

Advanced Center for Interventions and Services Research for Late-Life Mood
Disorders, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

OBJECTIVE: The authors detail the public health need for depression prevention
research and the decisions made in designing an experiment testing problem
solving therapy as “indicated” preventive intervention for high-risk older adults
with subsyndromal depression. Special attention is given to the recruitment of
African Americans because of well-documented inequalities in mental health
services and depression treatment outcomes between races. METHODS: A total of 306
subjects (half white, half African American) with scores of 16 or higher on the
Center for Epidemiological Studies of Depression Scale, but with no history of
major depressive disorder in the past 12 months, are being recruited and randomly
assigned to either problem solving therapy-primary care or to a dietary education
control condition. Time to, and rate of, incident episodes of major depressive
disorder are to be modeled using survival analysis. Level of depressive symptoms
will be analyzed via a mixed models approach. RESULTS: Twenty-two subjects have
been recruited into the study, and to date eight have completed the randomly
assigned intervention and postintervention assessment. Four of 22 have exited
after developing major depressive episodes. None have complained about study
procedures or demands. Implementation in a variety of community settings is going
well. CONCLUSION: The data collected to date support the feasibility of
translating from epidemiology to RCT design and implementation of empirical
depression prevention research in later life.

PMCID: PMC2766668
PMID: 18515690 [PubMed – indexed for MEDLINE] 77. J Altern Complement Med. 2008 Jun;14(5):537-44.

Correlates of complementary and alternative medicine utilization in depressed,
underserved african american and Hispanic patients in primary care settings.

Bazargan M, Ani CO, Hindman DW, Bazargan-Hejazi S, Baker RS, Bell D, Rodriquez M.

Department of Family Medicine, Charles Drew University of Medicine & Science, Los
Angeles, CA 90059, USA.

OBJECTIVES: This study seeks to examine the correlates of complementary and
alternative medicine (CAM) use in depressed underserved minority populations
receiving medical care in primary care settings. METHODS: A prospective study
using interviewer-administered surveys and medical record reviews was conducted
at 2 large outpatient primary care clinics providing care primarily to
underserved African American and Hispanic individuals located in Los Angeles,
California. A total of 2321 patients were screened for depression. Of these, 315
met the Patient Health Questionnaire-9 criteria for mild to severe depression.
RESULTS: Over 57% of the sample reported using CAM sometimes or often (24%) and
frequently (33%) for treatment of their depressive symptoms. Controlling for
demographic characteristics, lack of health care coverage remained one of the
strongest predictors of CAM use. Additionally, being moderately depressed, using
psychotherapeutic prescription medications, and poorer self-reported health
status were all associated with increased frequency of CAM utilization for
treating depression. CONCLUSIONS: The underserved African American and Hispanic
individuals meeting the diagnostic criteria for depression or subsyndromal
depression use CAM extensively for symptoms of depression. CAM is used as a
substitute for conventional care when access to care is not available or limited.
Since CAM is used so extensively for depression, understanding domains, types,
and correlates of such use is imperative. This knowledge could be used to design
interventions aimed at improving care for depression.

PMID: 18537468 [PubMed – indexed for MEDLINE] 78. Am J Geriatr Psychiatry. 2008 May;16(5):406-15.

Outcomes and predictors of late-life depression trajectories in older primary
care patients.

Cui X, Lyness JM, Tang W, Tu X, Conwell Y.

Geriatric Psychiatry Program, Department of Psychiatry, University of Rochester
Medical Center, Rochester, NY 14642, USA.

OBJECTIVES: The naturalistic outcomes of depression in older primary care
patients have been poorly characterized. The authors sought to identify
depressive trajectories over 2 years and to examine specified outcome predictors.
DESIGN: Two-year observational cohort study. SETTING: University-based and
independent practice primary care practices in greater Rochester. PARTICIPANTS:
All patients aged >65 years presenting for care on selected recruitment days were
eligible to participate. Of 392 subjects enrolled, 316 (80.6%) completed study
measures over a 2-year follow-up. MEASUREMENTS: Depression trajectories were
derived by applying longitudinal cluster analysis to weekly depression status
from the Longitudinal Interval Follow-up Evaluation. RESULTS: The authors
identified six distinct trajectory clusters that followed clinically intuitive
patterns. Although subjects initially nondepressed or in the subsyndromal to
minor depression range had a range of possible outcomes over 2 years, the cluster
initially near the major depression level remained at that level over time.
Consistent predictors of depression trajectory were baseline depressive symptom
severity, medical burden, and psychiatric functional status; for some clusters,
previous history of depression and perceived social support also had prognostic
significance. CONCLUSION: The “real-world” outcomes of patients with more severe
depressive symptoms are strikingly poor. Given the diverse outcomes of those with
subsyndromal to mild forms of minor depression, clinicians might focus treatments
on those at highest risk of poor outcome, i.e., those with greater depressive
symptoms and medical burden and lower psychiatric functioning and social support.
Preventive interventions research might focus on developing treatments to
mitigate potentially modifiable risks such as deficits in social support.

PMID: 18448851 [PubMed – indexed for MEDLINE] 79. J Psychiatr Res. 2008 May;42(6):451-7. Epub 2007 Jul 12.

Adjunctive zonisamide for weight loss in euthymic bipolar disorder patients: a
pilot study.

Wang PW, Yang YS, Chandler RA, Nowakowska C, Alarcon AM, Culver J, Ketter TA.

Stanford University School of Medicine, 401 Quarry Road, Suite 2117, Stanford, CA
94305-5723, United States.

OBJECTIVE: To assess the effectiveness and tolerability of open adjunctive
zonisamide in treatment of obesity in euthymic bipolar disorder (BD) patients.
METHOD: Zonisamide was administered to recovered, overweight BD outpatients
assessed with the Systematic Treatment Enhancement Program for Bipolar Disorders
(STEP-BD) Affective Disorders Evaluation and followed with the STEP-BD Clinical
Monitoring Form. Weight changes (Body Mass Index (BMI) and BMI percentage
changes) were assessed prospectively at four weekly visits, one bi-weekly visit,
and then five monthly visits, for a maximal duration of six months. Weight loss
was assessed with random effects modeling to maximize all available data for
analysis. RESULTS: Twenty-five BD (10 BD-type I, 15 BD-type II) patients (mean
age 41.0+/-10.4 years, 64% female, 96% Caucasian) on a mean of 2.8+/-1.5
prescription psychotropic and 1.3+/-1.4 prescription non-psychotropic medications
received zonisamide for a mean duration of 14.2+/-8.5 weeks, with a mean final
dose of 375+/-206 (range 75-800) mg/day. Slope of weight loss was 0.078 BMI
points per week, and non-zero (p<0.0005). Mean weight loss was 1.2+/-1.9 BMI
points (baseline BMI 34.2+/-3.1 to final BMI 33.0+/-3.5, p<0.003). Eighteen
patients (72%) discontinued study participation early, 11/25 (44%) due to
emergent mood symptoms (eight depression, two mania, one subsyndromal mixed
symptoms) requiring treatment intervention, 5/25 (20%) due to adverse physical
events, and 2/25 (8%) due to patient choice, but none due to weight loss
inefficacy. CONCLUSION: Adjunctive zonisamide appeared effective and generally
physically tolerated, but had high rates of mood adverse events, in obese BD
patients. Controlled trials are warranted to systematically explore these
preliminary naturalistic observations.

PMID: 17628595 [PubMed – indexed for MEDLINE] 80. J Trauma. 2008 May;64(5):1349-56.

Major depression and posttraumatic stress disorder symptoms following severe burn
injury in relation to lifetime psychiatric morbidity.

Dyster-Aas J, Willebrand M, Wikehult B, Gerdin B, Ekselius L.

Departments of Neurosciences Psychiatry, University Hospital, Uppsala, Sweden.

BACKGROUND: Psychiatric history has been suggested to have an impact on long-term
adjustment in burn survivors. A rigorous, prospective, longitudinal approach was
used to study psychiatric history in a population-based burn sample and its
impact on symptomatology of depression and posttraumatic stress disorder (PTSD)
at a 12-month follow-up. METHODS: Seventy-three consecutive patients admitted to
the Uppsala Burn Unit were assessed with the Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for
psychiatric disorders, of whom 64 were also assessed after 12 months. RESULTS:
Forty-eight patients (66%) presented with at least one lifetime psychiatric
diagnosis; major depression (41%), alcohol abuse or dependence (32%), simple
phobia (16%), and panic disorder (16%) were most prevalent. At 12-months
postburn, 10 patients (16%) met criteria for major depression, 6 (9%) for PTSD,
and 11 (17%) for subsyndromal PTSD. Patients with lifetime anxiety disorder and
with lifetime psychiatric comorbidity were more likely to be depressed at 12
months, whereas those with lifetime affective disorder, substance use disorder
and psychiatric comorbidity were more likely to have symptoms of PTSD.
CONCLUSIONS: Two-thirds of burn survivors exhibit a history of lifetime
psychiatric disorders. Those with a psychiatric history have a higher risk of
postburn psychiatric problems.

PMID: 18469660 [PubMed – indexed for MEDLINE] 81. Arch Gen Psychiatry. 2008 Apr;65(4):386-94.

Residual symptom recovery from major affective episodes in bipolar disorders and
rapid episode relapse/recurrence.

Judd LL, Schettler PJ, Akiskal HS, Coryell W, Leon AC, Maser JD, Solomon DA.

Department of Psychiatry, University of California-San Diego, 9500 Gilman Dr, La
Jolla, CA 92093-0603, USA.

CONTEXT: Both bipolar disorder type I and type II are characterized by frequent
affective episode relapse and/or recurrence. An increasingly important goal of
therapy is reducing chronicity by preventing or delaying additional episodes.
OBJECTIVES: To determine whether the continued presence of subsyndromal residual
symptoms during recovery from major affective episodes in bipolar disorder is
associated with significantly faster episode recurrence than asymptomatic
recovery and whether this is the strongest correlate of early episode recurrence
among 13 variables examined. DESIGN: An ongoing prospective, naturalistic, and
systematic 20-year follow-up investigation of mood disorders: the National
Institute of Mental Health Collaborative Depression Study. SETTING: Five academic
tertiary care centers. PARTICIPANTS: Two hundred twenty-three participants with
bipolar disorder (type I or II) were followed up prospectively for a median of 17
years (mean, 14.1 [SD, 6.2] years). MAIN OUTCOME MEASURE: Participants defined as
recovered by Research Diagnostic Criteria from their index major depressive
episode and/or mania were divided into residual vs asymptomatic recovery groups
and were compared according to the time to their next major affective episodes.
RESULTS: Participants recovering with residual affective symptoms experienced
subsequent major affective episodes more than 3 times faster than asymptomatic
recoverers (hazard ratio, 3.36; 95% confidence interval, 2.25-4.98; P < .001).
Recovery status was the strongest correlate of time to episode recurrence (P <
.001), followed by a history of 3 or more affective episodes before intake (P =
.007). No other variable examined was significantly associated with time to
recurrence. CONCLUSIONS: In bipolar disorder, residual symptoms after resolution
of a major affective episode indicate that the individual is at significant risk
for a rapid relapse and/or recurrence, suggesting that the illness is still
active. Stable recovery in bipolar disorder is achieved only when asymptomatic
status is achieved.

PMID: 18391127 [PubMed – indexed for MEDLINE] 82. J Affect Disord. 2008 Apr;107(1-3):169-74. Epub 2007 Sep 17.

Subsyndromal depressive symptoms in patients with bipolar and unipolar disorder
during clinical remission.

Vieta E, Sánchez-Moreno J, Lahuerta J, Zaragoza S; EDHIPO Group (Hypomania
Detection Study Group).

Bipolar Disorder Programme, Institut Clínic de Neurociencies, Hospital Clinic,
Universitat de Barcelona, IDIBAPS, REM-TAP, Barcelona, Spain.

BACKGROUND: Subsyndromal depressive symptoms seem to be quite prevalent in mood
disorders although very few studies have assessed them in patients considered to
be in remission by clinical and psychometric criteria. This study sought to
evaluate the presence of subsyndromal depressive symptoms in bipolar and unipolar
patients in clinical remission. METHODS: One-hundred seventy-six patients with
DSM-IV bipolar (62 bipolar I, 58 bipolar II) or unipolar mayor depression (n=58)
in clinical remission and 60 healthy subjects were assessed using several
psychometric instruments including the 17 items Hamilton Depression Rating Scale
(HDRS). To be considered in clinical remission patients assessed with the
Clinical Impression for Bipolar Disorder-Modified (CGI-BP-M) had to be stable for
6 months and scoring 6 or less in the Young Mania Rating Scale (YMRS) and 8 or
less in the HDRS. RESULTS: Both Unipolar Disorder (UD) and Bipolar Disorder (BD)
patients in clinical remission presented statistically significant higher HRSD
scores, than healthy subjects. The HRSD scores were statistically higher in UD
patients under remission than in BD patients. The subsyndromal symptoms more
strongly associated with a clinical diagnosis of either UD or BD were Depressed
Mood, Somatic Anxiety, Impact on Work and Activities, Psychic Anxiety,
Gastrointestinal and Somatic Symptoms, Retardation during the Interview and
Genital Symptoms. CONCLUSION: Subsyndromal depressive symptoms are present in
affective disorder patients, both UD and BD, who apparently are in clinical
remission. Remitted unipolar patients may have more residual symptoms than
bipolar patients, particularly in items related to anxiety and somatic

PMID: 17870184 [PubMed – indexed for MEDLINE] 83. J Clin Child Adolesc Psychol. 2008 Apr;37(2):376-85.

Life stress and the accuracy of cognitive appraisals in depressed youth.

Krackow E, Rudolph KD.

University of Illinois at Urbana-Champaign, USA.

This study investigated the accuracy of depressed youths’ appraisals of naturally
occurring life events. Participants (49% girls; M age = 12.44 years) with
clinical diagnoses of depression (n = 24), subsyndromal symptoms of depression (n
= 29), and no symptoms of psychopathology (n = 36) completed semi-structured
interviews of life stress. As predicted, depressed youth experienced more
independent and self-generated interpersonal stress than did nonsymptomatic
youth. Consistent with a cognitive bias, clinically depressed youth overestimated
the stressfulness of events and overestimated their contribution to events
relative to nonsymptomatic youth. Youth with subsyndromal symptoms demonstrated
similar, although typically less severe, impairment than those with clinical
depression. Results contribute to cognitive-interpersonal models of depression by
illustrating the need to consider both realistic interpersonal difficulties and
biased appraisals of experiences.

PMID: 18470774 [PubMed – indexed for MEDLINE] 84. Mov Disord. 2008 Mar 15;23(4):538-46.

A validation study of depressive syndromes in Parkinson’s disease.

Starkstein SE, Merello M, Jorge R, Brockman S, Bruce D, Petracca G, Robinson RG.

School of Psychiatry and Clinical Neurosciences, University of Western Australia,
Western Australia, Australia.

The validity, sensitivity, and specificity of depressive symptoms for the
diagnosis of major depression, minor depression, dysthymic disorder, and
subsyndromal depression in Parkinson’s disease (PD) were examined. A consecutive
series of 173 patients with PD attending a Movement Disorders Clinic underwent a
comprehensive psychiatric and neurological assessment. The symptoms of loss of
interest/pleasure, changes in appetite or weight, changes in sleep, low energy,
worthlessness or inappropriate guilt, psychomotor retardation/agitation,
concentration deficits, and suicide ideation were all significantly associated
with the presence of the DSM-IV depressed mood criterion for major depression.
The symptoms of changes in appetite, changes in sleep, low energy, low
self-esteem, poor concentration, and hopelessness were all significantly
associated with the presence of the DSM-IV criterion of sad mood for dysthymic
disorder. Thirty percent of our sample met DSM-IV diagnostic criteria for major
depression, 20% met diagnostic criteria for dysthymic disorder, 10% met
diagnostic criteria for minor depression, and 8% met clinical criteria for
subsyndromal depression. Patients with either major or minor depression had
significantly more severe deficits in activities of daily living, more severe
cognitive impairments, and more severe Parkinsonism than patients with either
dysthymic disorder or no depression. This study provides validation to the DSM-IV
diagnostic criteria for major depression and dysthymic disorder for use in PD.
The categories of minor and subsyndromal depression may need further validation.
(c) 2007 Movement Disorder Society.

PMID: 18074376 [PubMed – indexed for MEDLINE] 85. Compr Psychiatry. 2008 Mar-Apr;49(2):113-20. Epub 2007 Dec 21.

Adjustment disorders, posttraumatic stress disorder, and depressive disorders in
old age: findings from a community survey.

Maercker A, Forstmeier S, Enzler A, Krüsi G, Hörler E, Maier C, Ehlert U.

Department of Psychopathology and Clinical Intervention, University of Zurich,
CH-8050 Zurich, Switzerland.

Based on a new psychopathological model of adjustment disorders (AJD), we propose
that AJDs are particular forms of stress response syndromes, in which intrusions,
avoidance of reminders, and failure to adapt are core symptoms. We aim to
demonstrate that these AJD symptom groups constitute a disorder that is distinct
from posttraumatic stress disorder (PTSD), complicated grief disorder, major
depressive disorder, and subsyndromal depression, by estimating their prevalence
and comorbidities. A representative sample of elderly persons from Zurich, aged
65 to 96 years, was assessed by standardized interviews or self-report
questionnaires. Index events for AJD were indicated by 52% of the sample set,
with a 2.3% current prevalence of AJD. Prevalence rates for other disorders were
0.7% PTSD, 4.2% subsyndromal PTSD, 4.2% complicated grief disorder, 2.3% major
depressive disorder, and 9.3% subsyndromal depression. The comorbidity rate for
AJD and other Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition disorders is 46%, and that between AJD and subsyndromal disorders is 38%.
Use of mental health care for AJD is low. This article concludes that the new
concept of AJD constitutes a meaningful psychopathological model and thus
warrants a place in standardized psychiatric taxonomies. Although this study was
restricted to a sample of the elderly, it provides evidence regarding AJD
prevalence, comorbidity, and associated health care use, all of which indicate
its utility.

PMID: 18243882 [PubMed – indexed for MEDLINE] 86. Soc Psychiatry Psychiatr Epidemiol. 2008 Mar;43(3):173-83. Epub 2007 Dec 15.

Gender differences in the associations between past-year gambling problems and
psychiatric disorders.

Desai RA, Potenza MN.

Dept. of Psychiatry and Women and Addictive Disorders, Core of Women’s Health
Research, Yale University School of Medicine, New Haven, CT, USA.

BACKGROUND: Psychiatric disorders frequently co-occur with pathological gambling.
The extent to which co-occurence extends to subsyndromal levels of gambling or
differs between women and men is incompletely understood. AIM: To examine whether
the association between psychiatric disorders and past-year gambling problems is
stronger in women than men. METHODS: Data from the national epidemiological
survey of alcoholism and related disorders (NESARC) (n = 43,093) were analyzed.
RESULTS: Increasing severity of past-year gambling problems was associated with
increasing odds of most past-year Axis I and lifetime Axis II disorders,
regardless of gender. Associations between gambling problems and major
depression, dysthymia, panic disorder, and nicotine dependence were statistically
stronger in women than in men. CONCLUSIONS: A severity-related association exists
between past-year gambling problems and psychiatric disorders. The stronger
associations in women suggest that gambling research, prevention and treatment
efforts consider gender differences.

PMID: 18080792 [PubMed – indexed for MEDLINE] 87. Int J Clin Pract. 2008 Feb;62(2):325-33. Epub 2007 Dec 11.

Massage therapy for the treatment of depression: a systematic review.

Coelho HF, Boddy K, Ernst E.

Complementary Medicine, Peninsula Medical School, Universities of Exeter and
Plymouth, Exeter, UK.

BACKGROUND: People with depressive disorders or subsyndromal symptoms of
depression (SSD) often use complementary and alternative therapies, including
massage therapy (MT). This systematic review evaluates the evidence, from
randomised clinical trials (RCTs), for the effectiveness of multiple sessions of
classical European (Swedish) MT for the treatment of depression. METHODS:
Eligible RCTs were identified via eight electronic databases and manual searches
of references. Two reviewers independently selected trials, assessed trial
quality and extracted data. RESULTS: Four RCTs met our inclusion criteria. Three
of these RCTs compared MT with relaxation therapies, but provided insufficient
data and analyses to contribute meaningfully to the evaluation of MT for
depression. The fourth included RCT used MT as a control condition to evaluate a
depression-specific acupuncture treatment. This trial provided limited evidence
that, in the early stages of treatment, MT is less effective than acupuncture for
treating depression, a treatment which itself is not accepted for this condition.
CONCLUSIONS: Despite previous research suggesting that MT may be an effective
treatment for depression, there is currently a lack of evidence to support this
assertion from RCTs that have selected participants for depression or SSD.

PMID: 18081800 [PubMed – indexed for MEDLINE] 88. Int Psychogeriatr. 2008 Feb;20(1):188-200. Epub 2007 Sep 21.

Subsyndromal depression in old age: clinical significance and impact in a
multi-ethnic community sample of elderly Singaporeans.

Chuan SK, Kumar R, Matthew N, Heok KE, Pin NT.

Department of Psychological Medicine, National University of Singapore.

OBJECTIVE: This cross-sectional study examined the clinical significance and
impact of subsyndromal depression in a sample of elderly people living in the
community in Singapore. METHOD: Data were analyzed from a population survey (the
Singapore National Mental Health Survey of the Elderly). A total of 1092
respondents from a nationally representative multi-ethnic (Chinese, Malay and
Indian) stratified random sample of older adults aged 60 and above were examined
for depression using the Geriatric Mental State Examination (GMS). Diagnostic
confidence levels of 3-5 indicated a DSM-IV diagnosis of syndromal depression,
and 1-2 indicated subsyndromal depression. Other variables included
sociodemographic characteristics, psychiatric and medical comorbidities, MMSE,
health awareness, health and functional status. RESULTS: Subjects with
subsyndromal depression were more likely to have poor socioeconomic status,
cognitive impairment, anxiety, and measures of poor mental, physical and
functional status compared with non-depressed subjects, and were similar to or
worse than syndromal cases. In multivariate analyses that controlled for age,
gender, ethnicity, education and several other sociodemographic factors, both
subsyndromal and syndromal depression were significantly associated with higher
numbers of medical comorbidities, diagnoses of comorbid dementia and anxiety,
lower MMSE scores, self-reported mental health problem, functional disability and
poor health status. CONCLUSION: In this Asian population, subsydromal depression
had the same clinical significance and health impact as syndromal depression,
similar to findings in the West.

PMID: 17888199 [PubMed – indexed for MEDLINE] 89. CNS Drugs. 2008;22(5):367-88.

Aripiprazole in the treatment of depressive and anxiety disorders: a review of
current evidence.

Pae CU, Serretti A, Patkar AA, Masand PS.

Department of Psychiatry, Kangnam St Mary’s Hospital, The Catholic University of
Korea College of Medicine, Seoul, South Korea.

Despite the availability of different classes of drugs for the treatment of
depressive and anxiety disorders, there are a number of clinically significant
unmet needs, such as a high prevalence of treatment resistance, partial response,
subsyndromal symptomatology, recurrence and relapse. With the approval of
atypical antipsychotics, which are associated with a lower adverse effect burden
than typical antipsychotics, consideration of their off-label use for the
treatment of affective disorders and various other psychiatric disorders has
become a viable option. However, consideration should be given to the US FDA
black box warning indicating that atypical antipsychotics may increase mortality
risk, particularly in the elderly population with dementia-related psychosis.
There has been much conjecture about the utility of these atypical drugs to
facilitate traditional antidepressant therapy, either in combination (from the
initiation of therapy) or as adjunctive therapy (in the case of
partial/incomplete response). Nevertheless, at present, available evidence from
randomized, placebo-controlled trials is sparse, and a formal risk/benefit
assessment of the use of these agents in a nonpsychotic patient population is not
yet possible. As a representative agent from the atypical antipsychotic class
with a novel mechanism of action and a relatively low adverse effect burden,
aripiprazole represents an interesting potential treatment for depressive and
anxiety disorders. In this review, we focus on the rationale for the use of
aripiprazole in these disorders. Preclinical data suggests that aripiprazole has
a number of possible mechanisms of action that may be important in the treatment
of depressive and anxiety disorders. Such mechanisms include aripiprazole action
at serotonin (5-HT) receptors as a 5-HT1A partial receptor agonist, a 5-HT2C
partial receptor agonist and a 5-HT2A receptor antagonist. Aripiprazole also acts
as a dopamine D2 partial receptor agonist, and has a possible action at
adrenergic receptors. Furthermore, aripiprazole may have possible neuroprotective
effects. Clinical studies demonstrate that aripiprazole may be useful in the
treatment of bipolar depression, major depressive disorder, treatment-resistant
depression and possibly anxiety disorders. Clinical data also suggest that
aripiprazole may have a lower adverse effect burden than the other atypical
drugs. Future research may confirm the potential utility of aripiprazole in the
treatment of depressive and anxiety disorders.

PMID: 18399707 [PubMed – indexed for MEDLINE] 90. Cognit Ther Res. 2008;32(4):542.

Dispositional Rumination in Individuals with a Depression History.

McMurrich SL, Johnson SL.

Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd. 5th
Floor, Coral Gables, FL 33146, USA.

Many studies show that rumination is related to current depressive episodes but
very few studies have examined whether rumination is elevated among those with a
history of diagnosed depression. The goal of the current study was to examine
whether a history of diagnosable major depressive disorder (MDD) is related to
rumination among undergraduates. In addition, individual difference variables
(i.e. problem-solving abilities, neuroticism and self-esteem) that might help
explain rumination were examined. Participants were interviewed with the SCID to
diagnose MDD. Fifty-one had no history of MDD and 41 had a MDD history.
Depression history was significantly related to rumination, even after
controlling for subsyndromal symptoms. Rumination was related to negative
problem-solving orientation. Major limitations of this study are the
cross-sectional design, undergraduate sample and the relatively small sample
size, particularly for multidimensional analyses.

PMCID: PMC2814435
PMID: 20126425 [PubMed] 91. Dialogues Clin Neurosci. 2008;10(2):215-28.

Current research in child and adolescent bipolar disorder.

Demeter CA, Townsend LD, Wilson M, Findling RL.

Department of Psychiatry, University Hospitals Case Medical Center/Case Western
Reserve University, Cleveland, Ohio 44106-5080, USA.

Although recently more research has considered children with bipolar disorder
than in the past, much controversy still surrounds the validity of the diagnosis.
Furthermore, questions remain as to whether or not childhood expressions of
bipolarity are continuous with adult manifestations of the illness. In order to
advance current knowledge of bipolar disorders in children, researchers have
begun to conduct phenomenological, longitudinal, treatment, and neuroimaging
studies in youths who exhibit symptoms of bipolar illness, as well as offspring
of parents with bipolar disorders. Regardless of the differences between research
groups regarding how bipolar disorder in children is defined, it is agreed that
pediatric bipolarity is a serious and pernicious illness. With early intervention
during the period of time in which youths are exhibiting subsyndromal symptoms of
pediatric bipolarity, it appears that the progression of the illness to the more
malignant manifestation of the disorder may be avoided. This paper will review
what is currently known and what still is left to learn about clinically salient
topics that pertain to bipolar disorder in children and adolescents.

PMID: 18689291 [PubMed – indexed for MEDLINE] 92. Drugs Aging. 2008;25(8):631-47.

Co-occurring depressive symptoms in the older patient with schizophrenia.

Kasckow JW, Zisook S.

VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania 15206,

Clinicians treating older patients with schizophrenia are often challenged by
patients presenting with both depressive and psychotic features. The presence of
co-morbid depression impacts negatively on quality of life, functioning, overall
psychopathology and the severity of co-morbid medical conditions. Depressive
symptoms in patients with schizophrenia include major depressive episodes (MDEs)
that do not meet criteria for schizoaffective disorder, MDEs that occur in the
context of schizoaffective disorder and subthreshold depressive symptoms that do
not meet criteria for MDE. Pharmacological treatment of patients with
schizophrenia and depression involves augmenting antipsychotic medications with
antidepressants. Recent surveys suggest that clinicians prescribe antidepressants
to 30% of inpatients and 43% of outpatients with schizophrenia and depression at
all ages. Recent trials addressing the efficacy of this practice have evaluated
selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline,
fluvoxamine and citalopram. These trials have included only a small number of
subjects and few older subjects participated; furthermore, the efficacy results
have been mixed. Although no published controlled psychotherapeutic studies have
specifically targeted major depression or depressive symptoms in older patients
with schizophrenia, psychosocial interventions likely play a role in any
comprehensive management plan in this population of patients.Our recommendations
for treating the older patient with schizophrenia and major depression involve a
stepwise approach. First, a careful diagnostic assessment to rule out medical or
medication causes is important as well as checking whether patients are adherent
to treatments. Clinicians should also consider switching patients to an atypical
antipsychotic if they are not taking one already. In addition, dose optimization
needs to be targeted towards depressive as well as positive and negative
psychotic symptoms. If major depression persists, adding an SSRI is a reasonable
next step; one needs to start with a low dose and then cautiously titrate upward
to reduce depressive symptoms. If remission is not achieved after an adequate
treatment duration (8-12 weeks) or with an adequate dose (similar to that used
for major depression without schizophrenia), switching to another agent or adding
augmenting therapy is recommended.We recommend treating an acute first episode of
depression for at least 6-9 months and consideration of longer treatment for
patients with residual symptoms, very severe or highly co-morbid major
depression, ongoing episodes or recurrent episodes. Psychosocial interventions
aimed at improving adherence, quality of life and function are also recommended.
For patients with schizophrenia and subsyndromal depression, a similar approach
is recommended.Psychosis accompanying major depression in patients without
schizophrenia is common in elderly patients and is considered a primary mood
disorder; for these reasons, it is an important syndrome to consider in the
differential diagnosis of older patients with mood and thought disturbance.
Treatment for this condition has involved electroconvulsive therapy (ECT) as well
as combinations of antidepressant and antipsychotic medications. Recent evidence
suggests that combination treatment may not be any more effective than
antidepressant treatment alone and ECT may be more efficacious overall.

PMID: 18665657 [PubMed – indexed for MEDLINE] 93. Int J Eat Disord. 2008 Jan;41(1):82-7.

Suicidal behavior in adolescents: relationship to weight status, weight control
behaviors, and body dissatisfaction.

Crow S, Eisenberg ME, Story M, Neumark-Sztainer D.

Department of Psychiatry, University of Minnesota Medical School, Minneapolis,
Minnesota 55454-1495, USA.

OBJECTIVE: Suicide is associated with full syndromal eating disorders, but it is
unclear whether subsyndromal eating disorders carry the same risk. This study
examined associations between suicidal behaviors and extreme and less extreme
weight control behaviors (EWCB and LWCB, such as fasting, vomiting, meal
skipping, etc.), body dissatisfaction, and weight status in adolescents. METHOD:
Data on body dissatisfaction, depressive symptoms, suicidal ideation and
attempts, and body mass index (BMI) were drawn from Project EAT, a survey of
4,746 7th-12th grade students. Multivariate logistic regression examined
associations between eating- and weight-related variables and suicidality.
RESULTS: Suicidal ideation and suicide attempts were more commonly observed in
adolescents with EWCB (boys: ideation OR = 2.12, attempts OR = 4.10; girls:
ideation OR = 1.66, attempts OR = 2.29), LWCB (boys: ideation OR = 1.33, attempts
OR = 1.76; girls: ideation OR = 1.77, attempts OR = 1.80), as well as body
dissatisfaction (boys: ideation OR = 1.75, attempts OR = 2.23; girls: ideation OR
= 1.77, attempts OR = 1.81), even after controlling for depressive symptoms. No
association was observed between BMI and suicidal attempts or ideation.
CONCLUSION: Thus, it appears that suicidal behavior in adolescents is associated
even with low-level eating disorder symptoms.

PMID: 17922538 [PubMed – indexed for MEDLINE] 94. Int J Psychiatry Med. 2008;38(3):297-306.

Incidence of posttraumatic stress disorder (PTSD) after myocardial infarction
(MI) and predictors of ptsd symptoms post-MI–a brief report.

Rocha LP, Peterson JC, Meyers B, Boutin-Foster C, Charlson ME, Jayasinghe N,
Bruce ML.

Cornell University, New York, USA.

OBJECTIVES: The objectives of this pilot study were to determine the incidence of
Posttraumatic Stress Disorder (PTSD) one to two months after Myocardial
Infarction (MI), and to evaluate potential predictors of PTSD symptoms post-MI.
METHODS: A convenience sample of 31 patients hospitalized for treatment of acute
MI was interviewed during hospitalization and one to two months later. The
assessments included socio-demographic questions, questions related to clinical
history and hospitalization, assessment of depressive symptoms using the Center
for Epidemiologic Studies-Depression (CES-D) scale, medical comorbidity using the
Charlson Comorbidity Index (CCI), and perceived social support using the Medical
Outcomes Study (MOS) scale. Medical records were reviewed for collection of
clinical data. Symptoms of PTSD were evaluated using the Structured Clinical
Interview for DSM-IV (SCID) and the Impact of Events Scale-Revised (IES-R).
RESULTS: While one patient (4.0%) met DSM IV criteria for PTSD; additional 16% of
the patients had significant symptoms of PTSD as measured by the IES-R (scoring
above 24). Higher scores of PTSD symptoms were significantly associated (p <
0.05) with younger age, black race, depressive symptoms in baseline, and
self-reported anxiety during the MI. CONCLUSIONS: The incidence of PTSD following
MI was low, but 16% of MI patients developed subsyndromal PTSD. The emotional
status of the patients at the time of the MI and their subjective reaction to the
event were important factors in the development of PTSD symptoms. Black and
younger patients were in increased risk of developing PTSD symptoms post-MI.

PMID: 19069574 [PubMed – indexed for MEDLINE] 95. Prim Care Companion J Clin Psychiatry. 2008;10(3):222-8.

Combination Treatment With Benzodiazepines and SSRIs for Comorbid Anxiety and
Depression: A Review.

Dunlop BW, Davis PG.

Department of Psychiatry and Behavioral Sciences, Emory University, School of
Medicine, Atlanta, Ga. ; and Medical Communications, Inc., Tequesta, Fla.

Objective: To review the literature on the co-occurrence of anxiety with
depressive disorders and the rationale for and use of combination treatment with
benzodiazepines and selective serotonin reuptake
inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) for
treating comorbid anxiety and depression.Data Sources: PubMed and PsycINFO were
searched using terms identified as relevant based on existing practice
guidelines. The primary search terms were anxiety, anxiety disorders, depression,
depressive disorders, comorbidity, epidemiology, benzodiazepines,
antidepressants, pharmacology, clinical trials, and pharmacotherapy. Reference
lists of identified articles were also reviewed to ensure capture of relevant
literature.Study Selection: Publications were selected for inclusion in the
review if they applied to adult populations and specifically addressed the
comorbidity of anxiety and depression, their epidemiology, or their management.
Case reports and case series were not considered for inclusion.Data Extraction:
Each author assessed the publications independently for content related to the
review topics. Findings considered relevant to the clinical understanding and
management of comorbid anxiety and depression were incorporated into the
review.Data Synthesis: Comorbidity is very common among patients with anxiety and
depressive disorders, and, even when full criteria for 2 separate disorders are
not met, subsyndromal symptoms are often present. Little controlled research has
explored how benzodiazepines and SSRIs/SNRIs may be usefully combined, yet their
combination is frequently employed in clinical practice. Patients with
comorbidities are likely to have poorer treatment outcomes and have greater
utilization of health care resources. Currently SSRIs/SNRIs are considered
first-line therapy and are effective in both anxiety and depressive states.
Nevertheless, many patients have only a partial response or have difficulty
tolerating efficacious doses of antidepressant monotherapy. Benzodiazepines
appear to improve treatment outcomes when an anxiety disorder co-occurs with
depression or for depression characterized by anxious features. Specifically,
they may provide benefits both in terms of speed of response and overall
response.Conclusions: Long-term management plans for anxiety disorder with or
without comorbid depression should include strategies for acute or short-term
care, long-term maintenance, and episodic or breakthrough symptoms. Combination
therapy with benzodiazepines and antide-pressants in appropriate clinical
settings may improve outcomes over monotherapy in some patients.

PMCID: PMC2446479
PMID: 18615162 [PubMed – in process] 96. Prim Care Companion J Clin Psychiatry. 2008;10(1):31-7.

Psychological impact of the tsunami on children and adolescents from the andaman
and nicobar islands.

Math SB, Tandon S, Girimaji SC, Benegal V, Kumar U, Hamza A, Jangam K, Nagaraja

Department of Psychiatry ; the Department of Clinical Psychology ; the Department
of Psychiatric Social Work ; and the Department of Neurology , National Institute
of Mental Health and Neurosciences , Bangalore, India.

Objective: The aim of this article is to present the assessment of the
presentation of symptoms and psychiatric morbidity of children and adolescents
from the Andaman and Nicobar islands during the first 3 months following the
December 2004 earthquake and tsunami.Method: According to predefined criteria, a
primary survivor is one who was exposed directly to the earthquake and tsunami, a
secondary survivor is one with close family and personal ties to primary
survivors, and tertiary survivors are individuals from the communities beyond the
impact area, a majority of which were exposed to the earthquake only. This study
included 37 primary and secondary survivors (aged or =3 on the Psychiatric Status Rating Scale for anorexia nervosa or bulimia
nervosa). In logistic and hierarchical regression analyses, the Difficulty
Identifying Feelings factor of the TAS-20 emerged as a significant predictor of
treatment outcome, independent of depressive symptoms and eating disorder
severity. CONCLUSIONS: The results of this study indicate that difficulty in
identifying feelings can act as a negative prognostic factor of the long-term
outcome of patients with eating disorders. Professionals should carefully monitor
emotional identification and expression in patients with eating disorders and
develop specific strategies to encourage labeling and sharing of emotions.

PMID: 17905043 [PubMed – indexed for MEDLINE] 105. Med J Aust. 2007 Oct 1;187(7 Suppl):S47-52.

Responding to experiences of young people with common mental health problems
attending Australian general practice.

Hickie IB, Fogarty AS, Davenport TA, Luscombe GM, Burns J.

Brain and Mind Research Institute, University of Sydney, Sydney, NSW, Australia.

The development of evidence-based (“collaborative care”) mental health services
in primary care for young people with anxiety, depression and alcohol or other
substance misuse is a major challenge. Data from two clinical audits of selected
Australian general practices (1998-1999 and 2000-2002) were analysed to explore
actual experiences of care among people aged 16-25 years. Syndromal (1998-1999:
31.0% [n = 1849/5957]; 2000-2002: 37.8% [n = 148/392]) and subsyndromal
(1998-1999: 27.4% [n = 1635/5957]; 2000-2002: 29.1% [114/392]) mental disorders
are very common among young people presenting to general practitioners. However,
a mental health diagnosis (1998-1999: 42.6% [n = 740/1736]; 2000-2002: 52.0% [n =
77/148]) or provision of formal treatment (1998-1999: 36.1% [n = 600/1661];
2000-2002: 51.7% [n = 74/143]) occurs in only about half of the patients with
syndromal conditions. While some active treatment was received by 19.4%
(1998-1999 [n = 1018/5236]) and 35.9% (2000-2002 [n = 133/370]) of the young
people, respectively, the most commonly reported interventions were
non-pharmacological alone (1998-1999: 13.1% [n = 687/5236]; 2000-2002: 22.4% [n =
83/370]) or non-pharmacological and pharmacological combinations (1998-1999: 4.1%
[n = 214/5236]; 2000-2002: 10.3% [n = 38/370]). Only rarely is pharmacological
treatment alone provided (1998-1999: 2.2% [n = 117/5236]; 2000-2002: 3.2% [n =
12/370]). New systems of primary care for young people need to be based on proven
collaborative care models and encourage presentations for care, increase
detection rates, and promote access to information and effective e-health
services. Improved access to specific psychological treatments should remain a

PMID: 17908026 [PubMed – indexed for MEDLINE] 106. Ther Umsch. 2007 Oct;64(10):567-74.

[Chronic fatigue syndrome–a functional somatic syndrome] [Article in German]

Linde A.

Abteilung für Psychosomatik, Bereich Medizin, Universitätsspital Basel.

Chronic fatigue can be categorized as a functional somatic syndrome (fss),
because there are findings of typical preconditions, trigger mechanisms and
maintaining conditions. With relevance for therapy it makes sense to see it as an
medical-psychiatric interface-disorder Subsyndromal short episodes of chronic
fatigue are many more frequent as three or six month during clearly diagnosed
episodes of “neurasthenia” or “chronic fatigue syndrome”. Their descriptions are
very similar and obvious those means the same matter. For original aetiological
assumptions it wasn’t any evidence. But there are findings of charcteristical
patterns of changed neurhumeral and immunological interactions for the chronic
fatigue syndrome, common for fss. Especially changes of HPA-Axis and its
interactions with other systems of functional regulation. Another importent fact
are increased senzitation in neuronal and neurocognitive regulation. Increased
critical appraisal of somatic funtions and dysfunctional coping strategies are
maintaining factors at least. Patterns of dysfuntional coping are not a problem
of patients alone. There are also experiences, that some doctors shows the same
dysfunctional somatizing management of fss in general and especially for chronic
fatigue. In fact, a single and specific cause of chronic fatigue doesn’t exist.
But the above-mentioned facts allows a starting point for a more successful
treatment. There are reviews that shows a good evidence for therapeutic
procedures wich are calling for acticvity by patients, such cognitive behavioral
therapy and graduated activation. Antidepressants, especialy SSRI, are helpful
with a small evidence. They can be used to increase treatment effects. There is
no evidence for therapies without patients activation.

PMID: 18214210 [PubMed – indexed for MEDLINE] 107. J Affect Disord. 2007 Sep;102(1-3):131-6. Epub 2007 Feb 1.

Psychopathology in children of bipolar parents.

Singh MK, DelBello MP, Stanford KE, Soutullo C, McDonough-Ryan P, McElroy SL,
Strakowski SM.

Division of Bipolar Disorders Research, University of Cincinnati College of
Medicine, Cincinnati, Ohio, USA.

BACKGROUND: Few studies have examined the psychopathological profiles of child
offspring of bipolar parents. Such investigations are useful as a first step to
identifying potential prodromal manifestations of bipolar disorder. METHODS: The
presence of psychopathology in 37 children with at least one parent with bipolar
I disorder and 29 demographically matched children with parents free of any
DSM-IV Axis I psychopathology was evaluated using the Washington University in
St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U
KSADS). RESULTS: Twenty-nine (78%) of 37 high-risk children were diagnosed with
at least one DSM-IV Axis I diagnosis as compared to seven (24%) of 29 children of
healthy control parents (Fisher’s exact test, p < 0.0001, odds ratio=11, 95%
CI=3.33, 33). Sixteen percent (N=6) of high-risk offspring met DSM-IV criteria
for bipolar I disorder as compared to none of the healthy control offspring
(Fisher’s exact test, p < 0.03). High-risk offspring also had statistically
significant elevations in rates of other affective and disruptive behavior
disorders as well as subsyndromal manifestations of psychopathology. CONCLUSIONS:
Children of bipolar parents had an elevated risk for developing bipolar and other
psychiatric disorders. The study of children of bipolar parents who are at high
risk for developing bipolar disorder themselves is essential to identify
potential prodromal manifestations of the disorder and to eventually establish
targeted early intervention strategies. Longitudinal studies to confirm the
prodromal manifestations of bipolar disorder and risk factors associated with the
development of specific diagnoses in children are needed.

PMID: 17275096 [PubMed – indexed for MEDLINE] 108. Psychol Addict Behav. 2007 Sep;21(3):415-9.

Baseline reaction time predicts 12-month smoking cessation outcome in formerly
depressed smokers.

Kassel JD, Yates M, Brown RA.

Psychology Department, University of Illinois-Chicago, Chicago, IL 40506-0044,

Burgeoning evidence points to a positive association between cigarette smoking
and depression. Moreover, depressive symptomatology, whether historical, current,
or subsyndromal, appears to negatively influence smoking cessation efforts.
Whereas depression is typically assessed via clinical interview or self-report,
rarely are the known neurocognitive deficits linked to depression (e.g., global
slowing) assessed in the context of smoking cessation research. Hence, this study
examined whether simple reaction time — color naming of affectively neutral
words — is predictive of 12-month smoking cessation outcome among a sample of
formerly depressed smokers (N = 28). Results revealed a significant, positive
correlation between reaction time and depressive symptoms such that those who
exhibited slower reaction times were at heightened risk to relapse. Baseline
depressive symptoms, as assessed via self-report, neither correlated with nor
predicted smoking cessation outcome. Results from logistic regression analyses
further showed that reaction time added incremental variance to the prediction of
smoking cessation outcome. Therefore, simple reaction time may capture aspects of
depression not typically assessed in self-report questionnaires. These results
are discussed in terms of their theoretical and clinical implications for smoking
cessation research.

PMID: 17874893 [PubMed – indexed for MEDLINE] 109. Expert Rev Neurother. 2007 Aug;7(8):919-25.

Maintenance treatment in bipolar disorder: a focus on aripiprazole.

McIntyre RS, Woldeyohannes HO, Yasgur BS, Soczynska JK, Miranda A, Konarski JZ.

University of Toronto, Department of Psychiatry, Department of Pharmacology,
Toronto, ON, Canada.

Bipolar disorders (BD) are chronic medical syndromes heterogeneous in
phenomenology, pathophysiology and treatment. The longitudinal course of bipolar
disorders is often characterized by nonrecovery, subsyndromal symptoms, enduring
cognitive deficits and impairment in psychosocial function. The risk for
premature mortality from unnatural (e.g., suicide) as well as natural causes
(e.g., cardiovascular disease) is significantly higher than the general
population. The therapeutic objectives of maintenance therapy are to prevent
relapse/recurrence, reduce the risk for premature mortality, promote functional
restoration and enhance quality of life. A chronic disease management model,
which includes pharmacologic and manual-based psychosocial interventions as
paradigmatic components, provides a framework for best practice and optimal
patient outcome. This article provides a succinct review of treatments approved
by the US FDA for maintenance in bipolar disorders, with a focus on the most
recently approved atypical antipsychotic, aripiprazole.

PMID: 17678485 [PubMed – indexed for MEDLINE] 110. J Abnorm Psychol. 2007 Aug;116(3):475-83.

Dysfunctional attitudes and episodes of major depression: Predictive validity and
temporal stability in never-depressed, depressed, and recovered women.

Otto MW, Teachman BA, Cohen LS, Soares CN, Vitonis AF, Harlow BL.

Center for Anxiety and Related Disorders, Boston University, MA 02215, USA.

In a large, community-based sample of women (N = 750), the authors examined the
nature of associations between dysfunctional attitudes and depression.
Dysfunctional attitudes were evaluated both as a vulnerability factor for
depression and as a consequence of depression. A link was found between past
depression and baseline elevations in dysfunctional attitudes that was
independent of current subsyndromal symptoms, but intensification of
dysfunctional attitudes following prospectively evaluated episodes of depression
(depressive “scarring”) was not observed. Although baseline dysfunctional
attitudes predicted an episode of major depression over 3 years of prospective
study, this prediction, considered alone or in interaction with negative life
events, was redundant with that offered by history of past depression. Further,
no significant prediction was evident for the Dysfunctional Attitude Scale (A. N.
Weissman & A. T. Beck, 1978) when the formerly depressed and never-depressed
cohorts were considered separately. Implications for cognitive theories are
discussed. (c) 2007 APA, all rights reserved

PMID: 17696703 [PubMed – indexed for MEDLINE] 111. J Affect Disord. 2007 Aug;101(1-3):131-8. Epub 2007 Jan 16.

Bipolar spectrum disorders in severely obese patients seeking surgical treatment.

Alciati A, D’Ambrosio A, Foschi D, Corsi F, Mellado C, Angst J.

Department of Psychiatry, Luigi Sacco University Hospital, Milan, Italy.

BACKGROUND: Much of the literature investigating the link between mood disorders
and obesity has focused on depression whereas historic polarity of mood has not
been previously carefully assessed. The aim of the present study has been to
evaluate the prevalence of the entire bipolar spectrum, by including subsyndromal
hypomania, and its related demographic and clinical correlates, in severely obese
patients seeking surgical treatment. METHODS: Eighty-three consecutive bariatric
patients who presented for presurgical psychiatric consultation were
systematically interviewed with both the SCID-CV questionnaire and, as a
self-assessment instrument, with the Hypomania Symptom Checklist (HCL-32) on all
past hypomanic behaviours (focusing more on prior overactivity than on mood
changes) regardless of duration and initial negative response to the screening
question on mood. RESULTS: A bipolar spectrum disorder was found in 89% of
severely obese patients, with the highest prevalence rates for bipolar II
disorder. Comorbidity with panic disorder was observed in 30% of bipolar spectrum
patients. LIMITATIONS: The lack of normal-weight or general medical control
groups and the reliance on self-report, retrospective assessment for the
collection of some parameters warrant some caution in the interpretation of
substantive findings. CONCLUSIONS: These findings suggest that bipolar spectrum
illness, in particular a hypomanic condition characterized by overactivity, is
very common in severely obese subjects, thus contradicting previous evidence of
low levels of physical activity in this population. Given the high prevalence
rates of bipolar spectrum in morbid obesity, this study encourages further
research on the causal association.

PMID: 17229468 [PubMed – indexed for MEDLINE] 112. J Affect Disord. 2007 Aug;101(1-3):269-74. Epub 2007 Jan 12.

Mood-worsening with high-pollen-counts and seasonality: a preliminary report.

Guzman A, Tonelli LH, Roberts D, Stiller JW, Jackson MA, Soriano JJ, Yousufi S,
Rohan KJ, Komarow H, Postolache TT.

Mood and Anxiety Program, Department of Psychiatry, University of Maryland School
of Medicine, Baltimore, MD, USA.

BACKGROUND: Because aeroallergens produce inflammation in the respiratory
airways, and inflammation triggers depression in vulnerable individuals, we
hypothesized that mood sensitivity to pollen, the most seasonal aeroallergen,
will be associated with a greater seasonality of mood. Since pollen is absent
during winter, we specifically predicted that mood sensitivity to tree pollen
will predict non-winter SAD but not winter SAD. METHODS: A convenience sample of
African and African American college students who lived in the Washington DC
metropolitan area for at least the past 3 years completed the Seasonal Pattern
Assessment Questionnaire (SPAQ), from which the Global Seasonality Score (GSS)
was calculated, a diagnosis of cumulative SAD (syndromal or subsyndromal SAD) was
derived, a seasonal pattern (winter vs non-winter) identified, and self-reported
mood changes during high pollen counts obtained. A Mann-Whitney test was used to
compare GSS between participants with vs without mood worsening during high
pollen counts. The capability of mood worsening with high pollen counts, gender,
ethnicity, and age to predict non-winter SAD was analyzed with logistic
regressions. RESULTS: GSS was greater (z=5.232, p<0.001) in those who reported
mood worsening with high pollen counts. Mood sensitivity to pollen predicted
non-winter SAD (p=0.017), but not winter SAD. LIMITATIONS: The SPAQ is not a
definitive tool to assess seasonality, and self-reported mood worsening with high
pollen counts relies on recollection. No direct measures of depression scores or
pollen counts were collected. The non-winter SAD concept has not been previously
established. CONCLUSIONS: Our study, which should be considered preliminary in
light of its limitations, suggests that self-reported mood-worsening with high
pollen count is associated with a greater seasonality of mood, and predicts SAD
of non-winter type.

PMCID: PMC1949487
PMID: 17222915 [PubMed – indexed for MEDLINE] 113. ScientificWorldJournal. 2007 Jun 12;7:880-7.

Seasonal changes in sleep duration in African American and African college
students living in Washington, D.C.

Volkov J, Rohan KJ, Yousufi SM, Nguyen MC, Jackson MA, Thrower CM, Postolache TT.

District of Columbia Department of Mental Health and St. Elizabeths Hospital,
Residency Training Program, Washington, DC 20032, USA.

Duration of nocturnal melatonin secretion, a marker of “biological night” that
relates to sleep duration, is longer in winter than in summer in patients with
seasonal affective disorder (SAD), but not in healthy controls. In this study of
African and African American college students, we hypothesized that students who
met criteria for winter SAD or subsyndromal SAD (S-SAD) would report sleeping
longer in winter than in summer. In addition, based on our previous observation
that Africans report more “problems” with change in seasons than African
Americans, we expected that the seasonal changes in sleep duration would be
greater in African students than in African American students. Based on Seasonal
Pattern Assessment Questionnaire (SPAQ) responses, African American and African
college students in Washington, D.C. (N = 575) were grouped into a winter
SAD/S-SAD group or a no winter diagnosis group, and winter and summer sleep
length were determined. We conducted a 2 (season) x 2 (sex) x 2 (ethnicity) x 2
(winter diagnosis group) ANCOVA on reported sleep duration, controlling for age.
Contrary to our hypothesis, we found that African and African American students
with winter SAD/S-SAD report sleeping longer in the summer than in the winter. No
differences in seasonality of sleep were found between African and African
American students. Students with winter SAD or S-SAD may need to sacrifice sleep
duration in the winter, when their academic functioning/efficiency may be
impaired by syndromal or subsyndromal depression, in order to meet seasonally
increased academic demands.

PMID: 17619774 [PubMed – indexed for MEDLINE] 114. ScientificWorldJournal. 2007 Jun 12;7:870-9.

Seasonal variations in mood and behavior in Romanian postgraduate students.

Soriano JJ, Ciupagea C, Rohan KJ, Neculai DB, Yousufi SM, Guzman A, Postolache

Mood and Anxiety Program, Department of Psychiatry, University of Maryland,
Baltimore, MD 21201, USA.

To our knowledge, this paper is the first to estimate seasonality of mood in a
predominantly Caucasian sample, living in areas with hot summers and a relative
unavailability of air conditioning. As a summer pattern of seasonal depression
was previously associated with a vulnerability to heat exposure, we hypothesized
that those with access to air conditioners would have a lower rate of summer
seasonal affective disorder (SAD) compared to those without air conditioning. A
convenience sample of 476 Romanian postgraduate students completed the Seasonal
Pattern Assessment Questionnaire (SPAQ), which was used to calculate a global
seasonality score (GSS) and to estimate the rates of winter- and summer-type SAD.
The ratio of summer- vs. winter-type SAD was compared using multinomial
probability distribution tests. We also compared the ratio of summer SAD in
individuals with vs. without air conditioners. Winter SAD and winter subsyndromal
SAD (S-SAD) were significantly more prevalent than summer SAD and summer S-SAD.
Those with access to air conditioners had a higher, rather than a lower, rate of
summer SAD. Our results are consistent with prior studies that reported a lower
prevalence of summer than winter SAD in Caucasian populations. Finding an
increased rate of summer SAD in the minority of those with access to air
conditioners was surprising and deserves replication.

PMID: 17619773 [PubMed – indexed for MEDLINE] 115. Bipolar Disord. 2007 Jun;9(4):324-38.

Early identification and high-risk strategies for bipolar disorder.

Correll CU, Penzner JB, Lencz T, Auther A, Smith CW, Malhotra AK, Kane JM,
Cornblatt BA.

The Zucker Hillside Hospital, Psychiatry Research, North Shore – Long Island
Jewish Health System, Glen Oaks, NY 11004, USA.

OBJECTIVES: To describe and compare the relative merits of different
identification strategies for individuals at risk for bipolar disorder (BPD).
METHODS: Selective review of data that support early identification in BPD, with
a particular focus on emerging clinical high-risk strategies. RESULTS: Early
detection of individuals at risk for BPD can utilize genetic, endophenotypic and
clinical methods. Most published work focuses on genetic familial endophenotypic
risk markers for BPD. However, despite encouraging results, problems with
specificity and sensitivity limit the application of these data to early
prevention programs. In addition, offspring studies of BPD patients
systematically exclude the majority of subjects without a first-degree bipolar
relative. On the other hand, emerging work in the clinical-high-risk arena has
already produced encouraging results. Although still preliminary, the
identification of individuals in subsyndromal or attenuated symptom ‘prodromal’
stages of BPD seems to be an under-researched area that holds considerable
promise deserving increased attention. Required next steps include the
development of rating tools for attenuated and subsyndromal manic and depressive
symptoms and of prodromal criteria that will allow prodromal symptomatology to be
systematically studied in patients with recent-onset bipolar, as well as in
prospective population-based phenomenology trials and attenuated symptom-based
high-risk studies. CONCLUSIONS: Given the current limitations of each early
identification method, combining clinical, endophenotypic and genetic strategies
will increase prediction accuracy. Since reliable biological markers for BPD have
not been established and since most patients with BPD lack a first-degree
relative with this disorder, clinical high-risk approaches have great potential
to inform early identification and intervention programs.

PMID: 17547579 [PubMed – indexed for MEDLINE] 116. J Affect Disord. 2007 Jun;100(1-3):163-9. Epub 2006 Nov 28.

Subsyndromal depression: an impact on quality of life?

da Silva Lima AF, de Almeida Fleck MP.

Hospital de Clínicas de Porto Alegre, Brazil.

OBJECTIVE: The objective of this study was to demonstrate the association between
quality of life and subsyndromal depression in a primary care clinic in a
Brazilian sample. METHODS: This was a cross-sectional study. The cases were
divided into three groups according to the severity of depressive symptoms: 1)
subjects with major depressive disorder; 2) subjects with subsyndromal
depression; 3) subjects without depressive symptoms–controls. The participants
completed the World Health Organization Instrument to Assess Quality of Life
(WHOQOL-BREF), the Quality of Life–Depression (QLDS), the Centers for
Epidemiologic Studies–Depression instrument (CES-D), and the Composite
International Diagnostic Interview (CIDI). RESULTS: The sample consisted of 438
primary care users (35.2% of them had subsyndromal depression). The subjects with
major depression presented the worst impairment of quality of life, which was
measured by the WHOQOL-BREF and the QLDS. The patients with subsyndromal
depression had a smaller impact on their quality of life and the subjects without
depression presented an even lower impact. The hierarchical linear regression
involving demographic variables and the severity of depressive symptoms showed
that the severity of depression was the variable with higher correlation with
quality of life dimensions, presenting increased variation in the domains (from
9% to 24%). CONCLUSIONS: The results suggest that subsyndromal depression causes
impairment of the quality of life in primary care patients of a Brazilian sample.

PMID: 17126913 [PubMed – indexed for MEDLINE] 117. Schizophr Bull. 2007 May;33(3):703-14. Epub 2007 May 2.

Differentiation in the preonset phases of schizophrenia and mood disorders:
evidence in support of a bipolar mania prodrome.

Correll CU, Penzner JB, Frederickson AM, Richter JJ, Auther AM, Smith CW, Kane
JM, Cornblatt BA.

Albert Einstein College of Medicine, Department of Psychiatry, Bronx, NY, USA.

OBJECTIVE: The presence and specificity of a bipolar prodrome remains questioned.
We aimed to characterize the prodrome prior to a first psychotic and nonpsychotic
mania and to examine the phenotypic proximity to the schizophrenia prodrome.
METHODS: Using a semi-structured interview, the Bipolar Prodrome Symptom
Scale-Retrospective, information regarding the mania prodrome was collected from
youth with a research diagnosis of bipolar I disorder and onset before 19 years
of age, and/or their caregivers. Only newly emerging, at least moderately severe,
symptoms were analyzed. Prodromal characteristics were compared between patients
with and without subsequent psychotic mania and with published bipolar and
schizophrenia prodrome data. RESULTS: In 52 youth (age at first mania: 13.4 +/-
3.3 years), the prodrome onset was predominantly “insidious” (>1 year, 51.9%) or
“subacute” (1-12 months, 44.2%), while “acute” presentations (<1 month, 3.8%)
were rare. The prodrome duration was similar in patients with (1.7 +/- 1.8 years,
n = 34) and without (1.9 +/- 1.5 years, n = 18) subsequent psychotic mania (P =
.70). Attenuated positive symptoms emerging late in the prodrome and increased
energy/goal-directed activity were significantly more common in patients with
later psychotic mania. Mania and schizophrenia prodrome characteristics
overlapped considerably. However, subsyndromal unusual ideas were significantly
more likely part of the schizophrenia prodrome, while obsessions/compulsions,
suicidality, difficulty thinking/communicating clearly, depressed mood, decreased
concentration/memory, tiredness/lack of energy, mood lability, and physical
agitation were more likely part of the mania prodrome. CONCLUSIONS: A lengthy and
symptomatic prodrome makes clinical high-risk research a feasible goal for
bipolar disorder. The phenotypic overlap with the schizophrenia prodrome
necessitates the concurrent study of both illness prodromes.

PMCID: PMC2526140
PMID: 17478437 [PubMed – indexed for MEDLINE] 118. BMC Psychiatry. 2007 Apr 10;7:12.

Web-based tools can be used reliably to detect patients with major depressive
disorder and subsyndromal depressive symptoms.

Lin CC, Bai YM, Liu CY, Hsiao MC, Chen JY, Tsai SJ, Ouyang WC, Wu CH, Li YC.

Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan.

BACKGROUND: Although depression has been regarded as a major public health
problem, many individuals with depression still remain undetected or untreated.
Despite the potential for Internet-based tools to greatly improve the success
rate of screening for depression, their reliability and validity has not been
well studied. Therefore the aim of this study was to evaluate the test-retest
reliability and criterion validity of a Web-based system, the Internet-based
Self-assessment Program for Depression (ISP-D). METHODS: The ISP-D to screen for
major depressive disorder (MDD), minor depressive disorder (MinD), and
subsyndromal depressive symptoms (SSD) was developed in traditional Chinese.
Volunteers, 18 years and older, were recruited via the Internet and then assessed
twice on the online ISP-D system to investigate the test-retest reliability of
the test. They were subsequently prompted to schedule face-to-face interviews.
The interviews were performed by the research psychiatrists using the
Mini-International Neuropsychiatric Interview and the diagnoses made according to
DSM-IV diagnostic criteria were used for the statistics of criterion validity.
Kappa (kappa) values were calculated to assess test-retest reliability. RESULTS:
A total of 579 volunteer subjects were administered the test. Most of the
subjects were young (mean age: 26.2 +/- 6.6 years), female (77.7%), single
(81.6%), and well educated (61.9% college or higher). The distributions of MDD,
MinD, SSD and no depression specified were 30.9%, 7.4%, 15.2%, and 46.5%,
respectively. The mean time to complete the ISP-D was 8.89 +/- 6.77 min. One
hundred and eighty-four of the respondents completed the retest (response rate:
31.8%). Our analysis revealed that the 2-week test-retest reliability for ISP-D
was excellent (weighted kappa = 0.801). Fifty-five participants completed the
face-to-face interview for the validity study. The sensitivity, specificity,
positive, and negative predictive values for major depressive disorder were 81.8%
and 72.7%, 66.7%, and 85.7% respectively. The overall accuracy was 76.4%.
CONCLUSION: The evidence indicates the ISP-D is a reliable and valid online tool
for assessing depression. Further studies should test the ISP-D in clinical
settings to increase its applications in clinical environments with different
populations and in a larger sample size.

PMCID: PMC1855926
PMID: 17425774 [PubMed – indexed for MEDLINE] 119. Epidemiol Psichiatr Soc. 2007 Apr-Jun;16(2):144-51.

Clinical vs. structured interview on anxiety and affective disorders by primary
care physicians. understanding diagnostic discordance.

Balestrieri M, Baldacci S, Bellomo A, Bellantuono C, Conti L, Perugi G, Nardini
M, Borbotti M, Viegi G.

Clinica di Psichiatria e PMP, Dipartimento di Patologia e Medicina Sperimentale e
Clinica, University of Udine, Udine, Italy.

AIMS: To assess in a national sample the ability of GPs to detect psychiatric
disorders using a clinical vs. a standardized interview and to characterize the
patients that were falsely diagnosed with an anxiety or affective disorder.
METHODS: This is a national, cross-sectional, epidemiological survey, carried out
by GPs on a random sample of their patients. The GPs were randomly divided into
two groups. Apart from the routine clinical interview, the experimental group
(group A) had to administer the Mini-International Neuropsychiatric Interview
(MINI). RESULTS: Data was collected by 143 GPs. 17.2% of all patients had a
clinical diagnosis of an affective disorder, and 25.4% a clinical diagnosis of an
anxiety disorder. In group A, the number of clinical diagnoses was about twice
that of MINI diagnoses for affective disorders and one and a half times that for
anxiety disorders. The majority of clinical diagnoses were represented by MINI
subsyndromal cases (52.3%). Females showed a higher OR of being over-detected by
GPs with anxiety disorders or of not being diagnosed with an affective disorder.
Being divorced/separated/widowed increased the OR of over-detection of affective
and anxiety disorders. The OR of over-detection of an affective or an anxiety
disorder was higher for individuals with a moderate to poor quality of life.
CONCLUSIONS: In the primary care a gap exists between clinical and standardized
interviews in the detection of affective and anxiety disorders. Some experiential
and social factors can increase this tendency. The use of a psycho.

PMID: 17619546 [PubMed – indexed for MEDLINE] 120. J Affect Disord. 2007 Apr;99(1-3):133-8. Epub 2006 Oct 4.

Quality of life in unaffected twins discordant for affective disorder.

Vinberg M, Bech P, Kyvik KO, Kessing LV.

Department of Psychiatry, Rigshospitalet, University Hospital of Copenhagen,
Blegdamsvej 9, DK-2100 Copenhagen, Denmark.

BACKGROUND: The disability and hardship associated with affective disorder is
shared by the family members of affective patients and might affect the family
member’s quality of life. METHOD: In a cross-sectional, high-risk, case-control
study, monozygotic (MZ) and dizygotic (DZ) twins with (High-Risk twins) and
without (the control group/Low-Risk twins) a co-twin history of affective
disorder were identified through nationwide registers. The aim of the present
study was to investigate the hypothesis that a genetic liability to affective
disorder is associated with a lower perception of quality of life. RESULTS:
Univariate analyses showed that quality of life in all domains was impaired for
the 121 High-Risk twins compared to the 84 Low-Risk twins. In multiple regression
analyses, the differences remained significant after adjustment for sex, age,
marital status and years of education. Adjusted for the effect of subclinical
anxiety and depressive symptoms, the differences were significant on the domain
environment and total WHOQoL-BREF and marginally significant on the domain
physical health and overall quality of life. LIMITATIONS: It is not possible from
the cross-sectional analyses to distinguish between subsyndromal state and trait
scores. CONCLUSIONS: Perceived health related quality of life might share common
familial vulnerability with affective disorders. Having a co-twin with affective
disorder seem to have a negative influence on quality of life of the healthy
co-twin and this influence might be due to the genetic liability to affective
disorder. These findings need to be replicated in future family studies.

PMID: 17023051 [PubMed – indexed for MEDLINE] 121. Am J Geriatr Psychiatry. 2007 Mar;15(3):214-23. Epub 2007 Jan 9.

The clinical significance of subsyndromal depression in older primary care

Lyness JM, Kim J, Tang W, Tu X, Conwell Y, King DA, Caine ED.

Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
14642, USA.

OBJECTIVE: Many seniors experience depressive symptoms not meeting standard
diagnostic criteria. The authors sought to examine the clinical correlates of
older primary care patients with “subsyndromal depression” (SSD), hypothesizing
that SSD subjects have greater symptoms and functional impairment than
nondepressed patients, but not as severe as those with major or minor depression,
and to explore the characteristics of subjects captured by three different
definitions of SSD used in prior published work. METHODS: The authors conducted a
cross-sectional case comparison study that enrolled 662 primary care patients age
>or=65 years. Outcomes were validated measures of psychopathology, medical
illness burden, and functional status. RESULTS: All three SSD groups captured
patients with greater symptoms and functional impairment than the nondepressed
group. SSD subjects were as ill as those with minor or major depression on some
measures (e.g., medical burden). Each SSD group definition captured some subjects
unique to that group. CONCLUSIONS: Subsyndromal depression is common and
associated with symptoms or impairments of clinical importance. Sole reliance on
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions
of major or minor depression omit a substantial proportion of seniors with
clinically significant depressive symptoms. Longitudinal study is needed to help
clinicians identify those at greatest risk for poor outcomes, while researchers
testing mechanistic models should include patients with SSD to determine whether
they share pathogenetic underpinnings with more severe mood disorders.

PMID: 17213374 [PubMed – indexed for MEDLINE] 122. Psychiatry Clin Neurosci. 2007 Feb;61(1):124-6.

CLOCK gene 3111C/T polymorphism is not associated with seasonal variations in
mood and behavior in Korean college students.

Paik JW, Lee HJ, Kang SG, Lim SW, Lee MS, Kim L.

Department of Psychiatry, Korea University College of Medicine, Seoul, Korea.

The present study tested the potential association between the 3111C/T
polymorphism of the CLOCK gene and seasonal variations in mood and behavior. A
total of 297 Korean college students were genotyped for the CLOCK polymorphism
and the seasonal variation was evaluated using the Seasonal Pattern Assessment
Questionnaire (SPAQ). The seasonality scores were not different between CLOCK
gene variants (P > 0.05). Comparison between seasonals (syndromal plus
subsyndromal seasonal affective disorder according to SPAQ) and non-seasonals
found no significant difference in frequencies of genotypes (P > 0.05). These
findings suggest that the CLOCK polymorphism does not play a major role in
susceptibility to seasonal variations in a Korean population.

PMID: 17239050 [PubMed – indexed for MEDLINE] 123. Biol Psychiatry. 2007 Jan 15;61(2):223-30. Epub 2006 Jun 27.

Candidate gene polymorphisms in the serotonergic pathway: influence on depression
symptomatology in an elderly population.

Christiansen L, Tan Q, Iachina M, Bathum L, Kruse TA, McGue M, Christensen K.

Department of Epidemiology, Institute of Public Health, University of Southern
Denmark, Odense, Denmark.

BACKGROUND: Depressed mood is a major concern in the elderly, with consequences
for morbidity and mortality. Previous studies have demonstrated that genetic
factors in depression and subsyndromal depressive symptoms are no less important
in the elderly than during other life stages. Variations in genes included in the
serotonin system have been suggested as risk factors for various psychiatric
disorders but may also serve as candidates for normal variations in mood.
METHODS: This study included 684 elderly Danish twins to investigate the
influence of 11 polymorphisms in 7 serotonin system genes on the mean level of
depression symptomatology assessed over several years, reflecting individuals’
underlying mood level. RESULTS: A suggestive association of sequence variations
in genes responsible for the synthesis (TPH), recognition (5-HTR2A), and
degradation (MAOA) of serotonin with depression symptomatology was found,
although the effect was generally restricted to men. We also found that a
specific haplotype in VMAT2, the gene encoding the vesicular monoamine
transporter, was significantly associated with depression symptoms in men (p=
.007). CONCLUSIONS: These results suggest that variations in genes encoding the
components of serotonin metabolism may influence the basic mood level and that
different genetic factors may apply in men and women.

PMID: 16806099 [PubMed – indexed for MEDLINE] 124. Acta Psychiatr Scand Suppl. 2007;(433):85-9.

Epidemiology of subtypes of depression.

Kessing LV.

Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet,
Copenhagen Ø, Denmark.

OBJECTIVE: There is a general clinical impression that depression differs
qualitatively from non-depressive conditions, and that it can be identified as a
categorical entity. In contrast, epidemiological studies support the view that
depression is dynamic in nature and develops on a continuous scale. The present
article reviews selected epidemiological studies of depressive subtypes. METHOD:
A selective review. RESULTS: Prior studies have found no clear differences in
clinical presentation or long-term outcome between patients with melancholic and
with neurotic/reactive depression. In addition, recent studies suggest that there
is no clear demarcation between mild, moderate, and severe depression, pointing
toward a continuity rather than categories of illness. For the individual
patient, depressive symptoms seem to change over time, fulfilling criteria for
major depression, minor depression, dysthymia, and subsyndromal states; the
association between stressful life events and depression appears to diminish with
the number of depressive episodes. Finally, recent genetic findings are congruent
with a model indicating that the majority of depressions develop in the interplay
between genes and stressful experiences, whereas ‘reactive’ depressions and
‘endogenous’ depressions apparently exist at a lower prevalence. CONCLUSION:
Further longitudinal, analytical, and genetic epidemiologic studies are needed to
reveal which conditions are mild and transient, and which may be precursors of
more severe and substantial illness such as melancholia.

PMID: 17280574 [PubMed – indexed for MEDLINE] 125. Adv Psychosom Med. 2007;28:72-108.

Psychological factors affecting cardiologic conditions.

Rafanelli C, Roncuzzi R, Ottolini F, Rigatelli M.

Department of Psychology, University of Bologna, Bologna, Italy.

There are substantial data supporting a strong relationship between
cardiovascular diseases and psychological conditions. However, the criteria for
scientific validation of the entities currently subsumed under the DSM-IV
category of ‘Psychological factors affecting a medical condition’ have never been
clearly enumerated and the terms ‘psychological symptoms’ and ‘personality
traits’ that do not satisfy traditional psychiatric criteria are not well
defined; moreover, it is difficult to measure these subtypes of distress and
there is always the need for a clinical judgment. In recent years psychosomatic
research has focused increasing attention on these clinical and methodological
issues. Psychosocial variables that were derived from psychosomatic research were
then translated into operational tools, such as Diagnostic Criteria for
Psychosomatic Research; among these, demoralization, irritable mood, type A
behavior are frequently detected in cardiac patients. The joint use of DSM-IV
criteria and Diagnostic Criteria for Psychosomatic Research allow then to
identify psychological factors that seem to affect cardiologic condition. There
remains the need to further investigate if treating both clinical and
subsyndromal psychological conditions can improve quality of life and reduce the
risk of morbidity and mortality in these patients.

PMID: 17684321 [PubMed – indexed for MEDLINE] 126. Behav Modif. 2007 Jan;31(1):32-51.

Prediction of “fear” acquisition in healthy control participants in a de novo
fear-conditioning paradigm.

Otto MW, Leyro TM, Christian K, Deveney CM, Reese H, Pollack MH, Orr SP.

Center for Anxiety and Related Disorders, Boston University, MA, USA.

Studies using fear-conditioning paradigms have found that anxiety patients are
more conditionable than individuals without these disorders, but these effects
have been demonstrated inconsistently. It is unclear whether these findings have
etiological significance or whether enhanced conditionability is linked only to
certain anxiety characteristics. To further examine these issues, the authors
assessed the predictive significance of relevant subsyndromal characteristics in
72 healthy adults, including measures of worry, avoidance, anxious mood,
depressed mood, and fears of anxiety symptoms (anxiety sensitivity), as well as
the dimensions of Neuroticism and Extraversion. Of these variables, the authors
found that the combination of higher levels of subsyndromal worry and lower
levels of behavioral avoidance predicted heightened conditionability, raising
questions about the etiological significance of these variables in the
acquisition or maintenance of anxiety disorders. In contrast, the authors found
that anxiety sensitivity was more linked to individual differences in orienting
response than differences in conditioning per se.

PMCID: PMC1764631
PMID: 17179530 [PubMed – indexed for MEDLINE] 127. CNS Drugs. 2007;21(12):971-81.

Cognitive dysfunction in bipolar disorder: future place of pharmacotherapy.

Burdick KE, Braga RJ, Goldberg JF, Malhotra AK.

Department of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island
Jewish Health System, Glen Oaks, New York 11004, USA.

Bipolar disorder is an episodic affective illness, once believed to involve
complete inter-episode remission. More recent data have highlighted the presence
of persistent symptoms during purported periods of wellness, including
subsyndromal affective symptoms and neurocognitive impairment. These unremitting
symptoms are of extreme clinical importance, as they are directly related to a
worsening of clinical course, functional impairments and psychosocial
difficulties in patients with bipolar disorder. Although there is now substantial
evidence demonstrating the prevalence of neurocognitive impairment during
euthymia, there have been few studies, to date, targeting this disabling aspect
of the illness using pharmacological strategies. While treatment approaches have
previously focused on primary affective and psychotic symptoms of the disease, it
is important to consider the debilitating impact that impaired cognition has on
patients with bipolar disorder. A recent focus has been placed on the significant
need for large-scale clinical trials designed to specifically target cognitive
impairment in patients with schizophrenia, with a parallel need existing in the
field of bipolar research. There is now early evidence for the presence of
neurocognitive deficits in patients with bipolar disorder and a relationship
between these impairments and functional disability, making this a symptom domain
that requires immediate clinical attention. Convergent data indicate a compelling
need for formal assessment of cognition in patients with bipolar disorder, and
for researchers and clinicans alike to consider the necessity for treatment
specific to cognition in this population. Although limited data exist from
cognitive enhancement trials in this population, there are a number of potential
pharmacotherapy targets based on evidence from neuroimaging, molecular genetic,
pharmacological and animal studies related to the pathophysiology of bipolar
disorder. Future directions for potential cognitive enhancement strategies in
bipolar disorder may include medications that influence dopaminergic or
glutamatergic neurotransmission; however, further work is needed to adequately
assess the safety and effectiveness of these agents in bipolar patients. Finally,
psychosocial intervention and/or cognitive remediation should be considered as
alternatives to medications, although these techniques will also require
additional systematic study.

PMID: 18020478 [PubMed – indexed for MEDLINE] 128. CNS Drugs. 2007;21(9):727-40.

Bipolar II disorder : epidemiology, diagnosis and management.

Benazzi F.

Hecker Psychiatry Research Center, a University of California at San Diego (USA)
Collaborating Center at Forli, Italy.

Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of
depression and hypomania. Hypomania, according to DSM-IV, requires elevated
(euphoric) and/or irritable mood, plus at least three of the following symptoms
(four if mood is only irritable): grandiosity, decreased need for sleep,
increased talking, racing thoughts, distractibility, overactivity (an increase in
goal-directed activity), psychomotor agitation and excessive involvement in risky
activities. This observable change in functioning should not be severe enough to
cause marked impairment of social or occupational functioning, or to require
hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is
not clearcut. The symptoms of mania (defining BP-I) and hypomania (defining
BP-II) are the same, apart from the presence of psychosis in mania, and the
distinction is based on the presence of marked impairment associated with mania,
i.e. mania is more severe and may require hospitalisation. This is an unclear
boundary that can lead to misclassification; however, the fact that hypomania
often increases functioning makes the distinction between mania and hypomania
clearer. BP-II depression can be syndromal and subsyndromal, and it is the
prominent feature of BP-II. It is often a mixed depression, i.e. it has
concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that
usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I,
BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which
includes very rapid cycling and recurrent hypomania) are now considered to be
part of the ‘bipolar spectrum’. This is not included in DSM-IV, but is thought to
also include antidepressant/substance-associated hypomania, cyclothymic
temperament (a trait of highly unstable mood, thinking and behaviour), unipolar
mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed
in clinical practice, and its pharmacological treatment is understudied.
Underdiagnosis is demonstrated by recent epidemiological studies. While, in
DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%,
epidemiological studies have instead found that it has a lifetime community
prevalence (including the bipolar spectrum) of around 5%. In depressed
outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II
in research settings is related to several factors, including the introduction of
the use of semi-structured interviews by trained research clinicians, a
relaxation of diagnostic criteria such that the minimum duration of hypomania is
now less than the 4 days stipulated by DSM-IV, and a probing for a history of
hypomania focused more on overactivity (increased goal-directed activity) than on
mood change (although this is still required for a diagnosis of hypomania).
Guidelines on the treatment of BP-II are mainly consensus based and tend to
follow those for the treatment of BP-I, because there have been few controlled
studies of the treatment of BP-II. The current, limited evidence supports the
following lines of treatment for BP-II. Hypomania is likely to respond to the
same agents useful for mania, i.e. mood-stabilising agents such as lithium and
valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine,
risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if
associated with overfunctioning, because a depression often soon follows
hypomania (the hypomania-depression cycle). For the treatment of acute BP-II
depression, two controlled studies of quetiapine have not found clearcut positive
effects. Naturalistic studies, although open to several biases, have found
antidepressants in acute BP-II depression to be as effective as in unipolar
depression; however, one recent large controlled study (mainly in patients with
BP-I) has found antidepressants to be no more effective than placebo. Results
from naturalistic studies and clinical observations on mixed depression, while in
need of replication in controlled studies, indicate that antidepressants may
worsen the concurrent intradepression hypomanic symptoms. The only preventive
treatment for both depression and hypomania that is supported by several, albeit
older, controlled studies is lithium. Lamotrigine has shown some efficacy in
delaying depression recurrences, but there have also been several negative
unpublished studies of the drug in this indication.

PMID: 17696573 [PubMed – indexed for MEDLINE] 129. Depress Anxiety. 2007;24(4):244-50.

Demographic and clinical characteristics of motor vehicle accident victims in the
community general health outpatient clinic: a comparison of PTSD and non-PTSD

Kupchik M, Strous RD, Erez R, Gonen N, Weizman A, Spivak B.

Ness-Ziona Mental Health Center, Ness-Ziona, Israel.

Motor vehicle accidents (MVAs) are the leading cause of posttraumatic stress
disorder (PTSD) in the general population, often with enduring symptomatology.
This study details epidemiological and clinical features that characterize PTSD
among MVA victims living in a nonhospitalized community setting long after the
MVA event, and includes exploration of premorbid and peritraumatic factors. MVA
victims (n=60; 23 males, 37 females) identified from the registry of a community
general health outpatient clinic during a 7-year period were administered an
extensive structured battery of epidemiological, diagnostic and clinical ratings.
Results indicated that 30 subjects (50%; 12 males, 18 females) had MVA-related
PTSD (MVAR-PTSD). Among those with PTSD, 16 individuals exhibited PTSD in partial
remission, and six, in full remission. There were no significant demographic or
occupational function differences between PTSD and non-PTSD groups. The most
common comorbid conditions with MVAR-PTSD were social phobia (20%), generalized
anxiety disorder (7.8%) and obsessive-compulsive disorder (0.5%). Previous MVA’s
were not predictive of PTSD. Subjects with MVAR-PTSD scored worse on the
Clinician-Administered Posttraumatic Stress Disorder Scale, Part 2 (CAPS-2),
Impact of Event Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating
Scale, Impulsivity Scale, and Toronto Alexithymia Rating Scale. Study
observations indicate a relatively high rate of PTSD following an MVA in a
community-based sample. The relatively high rate of partially remitted MVAR-PTSD
(N=16) underscores the importance of subsyndromal forms of illness. Alexithymia
may be an adaptive method of coping with event stress. The development of PTSD
appears not to be associated with the severity of MVA-related physical injury.

PMID: 17001628 [PubMed – indexed for MEDLINE] 130. Depress Anxiety. 2007;24(3):219-22.

Preliminary open trial of interpersonal counseling for subsyndromal depression
following miscarriage.

Neugebauer R, Kline J, Bleiberg K, Baxi L, Markowitz JC, Rosing M, Levin B, Keith

Epidemiology of Developmental Brain Disorders Department, New York State
Psychiatric Institute, New York, New York 10032, USA.

Miscarriage occurs in 10-20% of clinically recognized pregnancies and is
associated with two- to fourfold increases in depressive symptoms. No counseling
programs for depressed miscarrying women have been manualized or evaluated for
safety and efficacy. We investigated whether depressive symptoms decline
substantially among miscarrying women receiving one to six weekly sessions of
manualized, telephone-administered interpersonal counseling (IPC), a variant of
interpersonal psychotherapy (IPT) in an open trial. Depressive symptom levels
were measured with the Center for Epidemiologic Studies-Depression (CES-D) scale.
Of 65 women evaluated, 24 were study eligible; 17 consented to participate.
Change in symptom levels was evaluated by comparing baseline to postintervention
CES-D scores in an intention to treat (ITT) sample (n=17) and a completer
subsample (n=9). The latter sample comprised women reevaluated postintervention.
In the ITT sample, the CES-D mean score declined from 25.4 to 18.8 [mean
within-subject change=6.6, 95% confidence interval (CI)=1.4-11.6]; in the
completer subsample, it declined from 23.6 to 11.2 (mean within-subject
change=12.3, 95% CI=4.0-20.7). Findings from this small open trial suggest that
IPC decreases depressive symptoms after miscarriage. A randomized, controlled
trial of IPC’s safety and efficacy with depressed miscarrying women is warranted.

PMID: 16988939 [PubMed – indexed for MEDLINE] 131. Depress Anxiety. 2007;24(1):62-5.

A three-year follow-up of major depression, dysthymia, minor depression and
subsyndromal depression: results from a population-based study.

Forsell Y.

Institution of Public Health, Division of Social Medicine, Karolinska Institutet,
Stockholm, Sweden.

This study examined the 3-year outcome of major depression (MD)/dysthymic
disorder (DD), minor depression (MinD), and subsyndromal symptomatic depression
(SSD) in a population-based sample. The aims were to study the fluctuating nature
of the symptoms of depression and to analyze the risk of fulfilling the criteria
for MD/DD at the follow-up. An extensive questionnaire was sent out to persons
ages 20-64 years registered in Stockholm County. Depression was assessed with the
Major Depression Inventory. After 3 years the procedure was repeated, and 8,622
persons participated in both waves. Diagnoses of MD/DD, MinD, or SSD were made.
Highest 3-year stability in fulfilling the criteria for a specific depressive
category was found in MD/DD, and of those affected, only 35.9% had one or fewer
symptoms of depression at the 3-year follow-up. The frequency of those with one
or fewer symptom of depression was equal in MinD (58.9%) and in SSD (56.5%). The
relative risk (RR) of fulfilling the criteria for MD/DD at Wave 2 was highest for
those affected by MD/DD (RR=22.4) at Wave 1, whereas those fulfilling the
criteria for MinD or SSD had similar rates (RR=4.8 and 5.0, respectively). This
study supports the view that depression is a dimensional illness, with the
affected persons moving in and out of diagnostic subtypes. The 3-year prognosis
was severe in half of the affected persons in all three diagnostic depression

PMID: 16947910 [PubMed – indexed for MEDLINE] 132. Psychopharmacol Bull. 2007;40(3):7-14.

Defining the clinical course of bipolar disorder: response, remission, relapse,
recurrence, and roughening.

Hirschfeld RM, Calabrese JR, Frye MA, Lavori PW, Sachs G, Thase ME, Wagner KD.

Psychiatry and Behavioral Sciences, The University of Texas Medical Branch,
Galveston, TX.

Objective: This manuscript presents working definitions for key clinical course
indicators for bipolar disorder, including response, remission, relapse,
recurrence, and roughening. Method: A work group of experts in bipolar disorder
reviewed prior efforts to define clinical course indicators for unipolar
depression and for schizophrenia. Using these efforts as templates, the work
group developed consensus operational definitions. The rationale for each of the
definitions was a point of time when a treatment decision needed to be made.
Results: The group defined response as a 50% reduction in a score from a standard
rating scale of symptomatology from an appropriate baseline, regardless of index
episode type (manic, depressed, or mixed). In addition, the other pole cannot be
significantly worsened during response. Remission was defined as absence or
minimal symptoms of both mania and depression for at least 1 week. Sustained
remission requires at least eight consecutive weeks of remission, and perhaps as
many as 12 weeks. A relapse/recurrence was defined as a return to the full
syndrome criteria of an episode of mania, mixed episode, or depression following
a remission of any duration. Roughening was defined as a return of symptoms at a
subsyndromal level, perhaps representing a prodrome of an impending episode.
Conclusions: The work group recommends that all reports of clinical trials in
bipolar disorder include results using these definitions. This will introduce
standards for such reports. Hopefully, the definitions will be revised and
improved over time.

PMID: 18007564 [PubMed – in process] 133. Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):497-503. Epub 2006 Aug 17.

Onset and maintenance of psychiatric disorders after serious accidents.

Kühn M, Ehlert U, Rumpf HJ, Backhaus J, Hohagen F, Broocks A.

Department of Psychiatry and Psychotherapy, University of Schleswig-Holstein,
Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.

The purpose of this study was to prospectively investigate the onset, course, and
remission of psychiatric disorders in the first 6 months after a serious accident
for consecutive patients in a hospital emergency department. Participants were 58
patients aged 18-65 who were assessed shortly after attending a hospital
emergency department and were followed up 6 months afterwards. Patients were
interviewed with regard to past and current psychiatric history using different
instruments (e.g. SCID for DSM-IV). Prior to their accidents, 35% of all subjects
had experienced one or more psychiatric disorders (lifetime prevalence). Shortly
after the accident, the incidence of Acute Stress Disorder (7%), subsyndromal
Acute Stress Disorder (12%), and adjustment disorder (1.5%) was increased as a
reaction to the accident. At this time, 29% of all patients suffered from an
acute psychiatric disorder. Six-months after the accident, 10% of the subjects
met criteria for Major Depression, 6% for PTSD, 4% for subsyndromal PTSD, and
1.5% for Specific Phobia as newly developed disorders. The course of the
psychiatric disorders shows that those patients who met criteria for any
psychiatric diagnosis shortly after the accident ran a much higher risk for
developing new or comorbid psychiatric disorders in the future.

PMID: 16917684 [PubMed – indexed for MEDLINE] 134. J Clin Psychiatry. 2006 Dec;67(12):e17.

Long-term management strategies to achieve optimal function in patients with
bipolar disorder.

Keck PE.

Department of Psychiatry, University of Cincinnati College of Medicine,
Cincinnati, Ohio, USA.

Predictors of poor functional outcome in patients with bipolar disorder include
psychiatric and medical comorbidity, interepisode subsyndromal symptoms,
psychosis during manic or mixed episode, and low premorbid functioning. Cognitive
dysfunction may also contribute to functional impairment. Psychosocial
intervention has shown success in improving syndromal outcomes for people with
bipolar disorder. Lithium, lamotrigine, olanzapine, and aripiprazole have all
shown substantial improvements in relapse rates compared with placebo.
Combination therapy with antipsychotics and antidepressants has also been shown
to produce improvement in symptoms in people with bipolar disorder. However,
limited evidence is available for the effects of these treatments on cognitive
outcomes. This review discusses treatment strategies for the long-term management
of bipolar disorder and functional outcome measures associated with these

PMID: 17201028 [PubMed – indexed for MEDLINE] 135. Evid Based Ment Health. 2006 Nov;9(4):94.

One in 10 elderly people with minor or subsyndromal depression develops major
depression within a year.

Areán PA.

UCSF Department of Psychiatry, San Francisco, California, USA.

Comment on:
Ann Intern Med. 2006 Apr 4;144(7):496-504.

PMID: 17065291 [PubMed] 136. J Clin Psychiatry. 2006 Nov;67(11):1721-8.

Incidence and time course of subsyndromal symptoms in patients with bipolar I
disorder: an evaluation of 2 placebo-controlled maintenance trials.

Frye MA, Yatham LN, Calabrese JR, Bowden CL, Ketter TA, Suppes T, Adams BE,
Thompson TR.

Mood Disorders Research Program, University of California at Los Angeles, USA.

BACKGROUND: Subsyndromal symptoms in bipolar disorder can cause significant
functional impairment and are associated with relapse. METHOD: In this post hoc
analysis from 2 randomized, double-blind, 18-month, placebo-controlled
maintenance trials for bipolar I disorder (both trials were conducted between
August 1997 and August 2001 and used DSM-IV criteria), the incidence, time
course, and impact of pharmacotherapy on subsyndromal symptoms were examined.
RESULTS: Subsyndromal symptoms occurred in approximately 25% of all visits.
Compared with placebo (54.8%), a significantly higher mean percentage of visits
in remission were observed with lamotrigine treatment (63.0%, p = .020) but not
with lithium treatment (60.0%, p = .165). The median time to onset of
subsyndromal symptoms for lamotrigine (N = 223), lithium (N = 164), and placebo
(N = 188) was 15, 15, and 9 days, respectively. Compared with placebo, both
lamotrigine and lithium significantly delayed the time from randomization to
onset of subsyndromal symptoms (p = .046, lamotrigine vs. placebo; p = .033,
lithium vs. placebo; p = .763, lamotrigine vs. lithium) and the time from onset
of subsyndromal symptoms to subsequent mood episode (p = .037, lamotrigine vs.
placebo; p = .023, lithium vs. placebo; p = .845, lamotrigine vs. lithium).
Agreement between the polarities of the first-observed subsyndromal symptom and
subsequent intervention for mood episode was statistically significant (p <
.001). CONCLUSION: Subsyndromal symptoms are common during maintenance treatment
and appear to be associated with relapse into an episode of the same polarity.
Both lithium and lamotrigine delayed the onset of subsyndromal symptoms and the
time from onset of subsyndromal symptoms to subsequent relapse. Further study to
assess whether treatment intervention can minimize subsyndromal symptoms or
prevent relapse is encouraged.

PMID: 17196051 [PubMed – indexed for MEDLINE] 137. J Nerv Ment Dis. 2006 Nov;194(11):833-7.

The association between seasonal and premenstrual symptoms is continuous and is
not fully accounted for by depressive symptoms.

Portella AT, Haaga DA, Rohan KJ.

American University, Washington, DC 20016-8062, USA.

Seasonal affective disorder (SAD) frequently co-occurs with premenstrual
dysphoric disorder. Explanations of this comorbidity highlighting the cyclical
nature of female sex hormones imply that seasonal and premenstrual symptoms
should correlate positively even in nonclinical samples. In a sample of 91 female
college students, we found a sizable positive correlation (r = .45; p < 0.001)
between seasonal and premenstrual symptoms. This relation held up even in a
subsample selected on the basis of not qualifying for SAD or subsyndromal SAD on
a screening measure. Although the correlation was reduced when depressive symptom
severity was statistically controlled, it remained positive and significant.
Future research testing possible explanations of the co-occurrence of seasonal
and premenstrual symptoms should incorporate the full range of severity on
symptom variables, treating them as continua rather than solely as binary

PMID: 17102707 [PubMed – indexed for MEDLINE] 138. Womens Health Issues. 2006 Nov-Dec;16(6):380-8.

An examination of depression through the lens of spinal cord injury. Comparative
prevalence rates and severity in women and men.

Kalpakjian CZ, Albright KJ.

University of Michigan Model Spinal Cord Injury Care System, Ann Arbor, Michigan
48109, USA.

PURPOSE: This study describes the prevalence of probable major depressive
disorder (MDD) as well as other depressive disorders (ODD) and severity of
depressive symptoms in a national sample of women with spinal cord injury (SCI)
and compares them with a case-matched sample of men with SCI. METHODS: A sample
of 585 women was drawn and case-matched with men from the SCI Model System
National SCI Database according to level/completeness of injury, follow-up year,
and age. The outcome measure of depression was the Patient Health Questionnaire.
MAIN FINDINGS: Prevalence rates for women were 7.9% for probable MDD and 9.7% for
ODD; rates for men were 9.9% and 10.3%, respectively. Logistic regression
revealed that women who were divorced or at year 1 follow-up had a higher odds of
having probable MDD (odds ratio [OR], 3.4 and 2.9, respectively). Employed women
and men had significantly lower odds of probable MDD (OR, 0.274 and 0.358,
respectively). Statistically significant differences were not found in gender
comparisons for either probable MDD or symptom severity, which also were not
associated with injury characteristics. CONCLUSION: The most significant, and
unexpected, research finding is the absence of gender differences in probable MDD
and symptom severity. Results challenge notions that depression will necessarily
follow SCI; that injury characteristics determine the development and severity of
depression; and that women experience a greater burden of depression than men.
The main clinical implication is that depression screening and referral should be
a routine feature of health care for women living with SCI, as well as for their
male counterparts. Furthermore, nearly one fourth of women and men reported
experiencing some or greater difficulty in daily life and relationships in the
absence of probable depressive disorder, warranting monitoring of subsyndromal
depression as well.

PMID: 17188221 [PubMed – indexed for MEDLINE] 139. Bipolar Disord. 2006 Oct;8(5 Pt 2):526-42.

Rational approaches to the neurobiologic study of youth at risk for bipolar
disorder and suicide.

Sublette ME, Oquendo MA, Mann JJ.

Department of Neuroscience, New York State Psychiatric Institute, Columbia
University, New York, NY 10032, USA.

OBJECTIVES: The aims of this paper are to provide an overview of neuroimaging
findings specific to bipolar disorder and suicide, and to consider rational
approaches to the design of future in vivo studies in youth at risk. METHODS:
Neuroimaging and related neurobiological literature pertaining to bipolar
disorder and suicide in adult and pediatric samples was reviewed in a
non-quantitative manner. RESULTS: Specific structural and functional brain
findings in bipolar disorder are described, where possible in the context of
relevant current neurobiological theories of etiology. Diagnostic and prognostic
implications are discussed. CONCLUSIONS: The simultaneous use of complementary
neurobiological approaches may be a powerful way of identifying and validating
factors reliably associated with bipolar disorder and suicide. A profile of
neurobiological markers with which to screen for bipolar disorder and suicide
risk may provide for earlier and more accurate diagnosis, perhaps even in the
pre- or subsyndromal stages in high-risk youth.

PMID: 17042826 [PubMed – indexed for MEDLINE] 140. Dev Psychopathol. 2006 Fall;18(4):1023-35.

Course and outcome of bipolar spectrum disorder in children and adolescents: a
review of the existing literature.

Birmaher B, Axelson D.

Western Psychiatric Institute and Clinic, University of Pittsburgh Medical
Center, PA 15213, USA.

The longitudinal course of children and adolescents with bipolar disorder (BP) is
manifested by frequent changes in symptom polarity with a fluctuating course
showing a dimensional continuum of bipolar symptom severity from subsyndromal to
mood syndromes meeting full Diagnostic and Statistical Manual of Mental Disorders
criteria. These rapid fluctuations in mood appear to be more accentuated than in
adults with BP, and combined with the high rate of comorbid disorders and the
child’s cognitive and emotional developmental stage, may explain the difficulties
encountered diagnosing and treating BP youth. Children and adolescents with
early-onset, low socioeconomic status, subsyndromal mood symptoms, long duration
of illness, rapid mood fluctuation, mixed presentations, psychosis, comorbid
disorders, and family psychopathology appear to have worse longitudinal outcome.
BP in children and adolescents is associated with high rates of hospitalizations,
psychosis, suicidal behaviors, substance abuse, family and legal problems, as
well as poor psychosocial functioning. These factors, in addition to the enduring
and rapid changeability of symptoms of this illness from very early in life, and
at crucial stages in their lives, deprive BP children of the opportunity for
normal psychosocial development. Thus, early recognition and treatment of BP in
children and adolescents is of utmost importance.

PMID: 17064427 [PubMed – indexed for MEDLINE] 141. Expert Opin Pharmacother. 2006 Oct;7(15):2139-54.

Pregabalin for the treatment of generalised anxiety disorder.

Montgomery SA.

Imperial College School of Medicine, University of London, PO Box 8751, W13 8WH,

Pregabalin is a new anxiolytic that has been recently licensed for the treatment
of generalised anxiety disorder (GAD) in Europe. Short-term efficacy is based on
six positive placebo-controlled studies, all of which showed a significant early
separation from placebo in all of the doses used (150-600 mg) at the first week,
and the efficacy at the end of the treatment was comparable with the comparators
used in four of these studies. Pregabalin was effective in more or less severe
GAD, on psychic and somatic symptoms of GAD, and in treating the subsyndromal
depressive symptoms of GAD. Efficacy in the elderly was shown in a separate
placebo-controlled study. The effect on cognitive function was minimal and
notably less than that observed with benzodiazepines. The discontinuation
symptoms following abrupt treatment cessation were similar to the rates with
serotonin-noradrenaline re-uptake inhibitors and lower than with benzodiazepines
with no signals of tolerance or dependence.

PMID: 17020438 [PubMed – indexed for MEDLINE] 142. J Clin Psychiatry. 2006 Oct;67(10):1551-60.

Subsyndromal depressive symptoms are associated with functional impairment in
patients with bipolar disorder: results of a large, multisite study.

Altshuler LL, Post RM, Black DO, Keck PE Jr, Nolen WA, Frye MA, Suppes T, Grunze
H, Kupka RW, Leverich GS, McElroy SL, Walden J, Mintz J.

Department of Psychiatry, VA Greater Los Angeles Healthcare System, West Los
Angeles Healthcare Center, CA, USA.

OBJECTIVE: Studies of patients with unipolar depression have demonstrated a
relationship between subthreshold depressive symptoms and impairment in role
functioning. Research examining this relationship in persons with bipolar
disorder is rare. This study sought to evaluate the association between
subsyndromal depressive symptoms and role functioning in subjects with bipolar
disorder. METHOD: 759 adult outpatients with a DSM-IV diagnosis of bipolar
disorder were entered into this study at 7 different sites in the Stanley
Foundation Bipolar Network (SFBN) beginning in March 1996 and ending in November
2002 and were followed longitudinally for assessment of their course of illness.
Subsyndromal depression was operationalized using cutoff scores on the Inventory
for Depressive Symptomatology-Clinician Rated (IDS-C), and patients were divided
into 3 groups: not depressed (IDS-C score < 13), subsyndromally depressed (IDS-C
score 13 to 27), and syndromally depressed (IDS-C score >or= 28). Groups were
compared using a series of chi(2) analyses on degree of role function impairment
across 4 role domains (work, home duties, family life, and friendships) from the
Life Functioning Questionnaire. Logistic regression was used to estimate the
probability of any impairment in life functioning based on severity of depressive
symptoms. RESULTS: Subsyndromally depressed patients were significantly more
likely than those not depressed to report impairment in their work and home
functioning roles, as well as impairment in relations with family and friends (p
< .001). Across all domains of role function, the proportion of patients impaired
in the subsyndromally depressed group was more similar to the syndromally
depressed group than to the not depressed group. CONCLUSIONS: These findings
clearly demonstrate the public health significance of subsyndromal depression in
the bipolar population. The most appropriate interventions for subsyndromal
depressive symptoms in patients with bipolar disorder remain to be determined.

PMID: 17107246 [PubMed – indexed for MEDLINE] 143. Am J Psychiatry. 2006 Sep;163(9):1611-21.

Prevention of late-life depression in primary care: do we know where to begin?

Schoevers RA, Smit F, Deeg DJ, Cuijpers P, Dekker J, van Tilburg W, Beekman AT.

Mentrum Mental Health Care, 2e Constantijn Huijgensstraat 37, 1054 AG Amsterdam,
the Netherlands.

OBJECTIVE: This study attempted to compare two models for selective (people at
elevated risk) and indicated (those with subsyndromal depressive symptoms)
prevention and to determine the optimal strategy for prevention of late-life
depression. METHOD: Onset was assessed at 3 years with the Geriatric Mental State
AGECAT in a randomly selected cohort of 1,940 nondepressed and nondemented older
people in Amsterdam. Risk factors that can easily be identified in primary care
were used. RESULTS: The association of risk factors with depression incidence was
expressed in absolute and relative risk estimates, number needed to treat, and
population-attributable fractions. Prevention models were identified with
classification and regression tree analyses. In the indicated prevention model,
subsyndromal symptoms of depression were associated with a risk of almost 40% of
developing depression and a number needed to treat of 5.8, accounting for 24.6%
of new cases. Adding more risk factors raised the absolute risk to 49.3%, with a
lower number needed to treat but also lower attributable fraction values. In the
selective prevention model, spousal death showed the highest risk, becoming even
higher if the subjects also had a chronic illness. Overall, the attributable
fraction values in the indicated model were higher, identifying more people at
risk. CONCLUSIONS: Consideration of the costs and benefits of both models in the
context of the availability of evidence-based preventative interventions
indicated that prevention aimed at elderly people with depressive symptoms is
preferred. The focus on treatment should be readdressed; a new approach is
needed, with a stronger emphasis on prevention.

PMID: 16946188 [PubMed – indexed for MEDLINE] 144. Gen Hosp Psychiatry. 2006 Sep-Oct;28(5):379-86.

Influence of patient preference and primary care clinician proclivity for
watchful waiting on receipt of depression treatment.

Johnson MD, Meredith LS, Hickey SC, Wells KB.

Department of Psychiatry and Behavioral Sciences, University of Washington, P.O.
Box 356560, Seattle, WA 98195, USA.
OBJECTIVE: We examined whether patients’ preference for watchful waiting and
their primary care clinician’s proclivity for watchful waiting were associated
with decreased likelihood of receiving depression treatment. METHODS: In a
quality improvement intervention for depression in primary care, patients with
depressive symptoms were identified through screening in 46 clinics from June
1996 to March 1997. We analyzed baseline survey data completed by clinicians and
patients using logistic regression models. RESULTS: Of 1140 patients, 179 (16%)
preferred watchful waiting over active treatment. After controlling for
covariates, patients with depressive disorders who preferred watchful waiting
were less likely to report use of antidepressants (OR=0.86, 95% CI=0.77-0.95).
Among patients with depressive symptoms only, those who preferred watchful
waiting were less likely to report antidepressant use (OR=0.84, 95% CI=0.76-0.93)
or counseling (OR=0.84, 95% CI=0.77-0.95). Patients with less knowledge about
depression were less likely to receive depression treatment. Clinician proclivity
for watchful waiting was not associated with the likelihood that patients
received depression treatment. CONCLUSIONS: Patient preference for watchful
waiting is associated with lower rates of some depression treatments, especially
among patients with subsyndromal depression. Addressing patient preference for
watchful waiting in primary care may include active symptom monitoring and
patient education.

PMID: 16950372 [PubMed – indexed for MEDLINE] 145. Int J Obes (Lond). 2006 Sep;30(9):1408-14. Epub 2006 Mar 21.

Synergistic effects of depressed mood and obesity on long-term cardiovascular
risks in 1510 obese men and women: results from the MONICA-KORA Augsburg Cohort
Study 1984-1998.

Ladwig KH, Marten-Mittag B, Löwel H, Döring A, Wichmann HE.

GSF National Research Center for Environment and Health, Institute of
Epidemiology, Neuherberg, Germany.

OBJECTIVE: To examine the contribution of depressed mood in obese subjects on the
prediction of a future coronary heart disease event (CHD). DESIGN: A prospective
population-based cohort study of three independent cross-sectional surveys with
6239 subjects, 45-74 years of age and free of diagnosed CHD, stroke and cancer.
During a mean follow-up of 7 years, 179 CHD events occurred among men and 50
events among women. SUBJECTS: A total of 737 (23%) male and 773 (26%) female
subjects suffering from obesity (BMI >or=30 kg/m2). MEASUREMENTS: Body weight
determined by trained medical staff following a standardized protocol;
standardized questionnaires to assess subsyndromal depressive mood and other
psychosocial features. RESULTS: The main effect of obesity to predict a future
CHD (hazard ratio, HR=1.38, 95% CI 1.03-1.84; P=0.031) and the interaction term
of obesity by depression (HR=1.73, 95% CI 0.98-3.05; P=0.060) were borderline
significant, both covariate adjusted for multiple risk factors. Relative to the
male subgroup with normal body weight and no depression, the male obese group
with no depression was not at significantly increased risk for CHD events
(HR=1.17, 95% CI 0.76-1.80; P=0.473) whereas CHD risk in males with both obesity
and depressed mood was substantially increased (HR=2.32, 95% CI 1.45-3.72,
P>0.0001). The findings for women were similar, however, not significant probably
owing to lack of power associated with low event rates. Combining obesity and
depressed mood resulted in a relative risk to suffer from a future CHD event of
HR 1.84 (95% CI 0.79-4.26; P=0.158). CONCLUSIONS: Depressed mood substantially
amplifies the CHD risk of middle-aged obese, but otherwise apparently healthy
men. The impact of depression on the obesity risk in women is less pronounced.

PMID: 16552409 [PubMed – indexed for MEDLINE] 146. Schizophr Res. 2006 Sep;86(1-3):226-33. Epub 2006 Jun 5.

Depressive symptom patterns in patients with chronic schizophrenia and
subsyndromal depression.

Zisook S, Nyer M, Kasckow J, Golshan S, Lehman D, Montross L.

Department of Psychiatry, University of California, San Diego, La Jolla, CA
92093, USA.

BACKGROUND: Since subsyndromal depressive symptoms (SDS) are prevalent,
under-recognized and clinically important problems in patients with
schizophrenia, as well as in the elderly, the association and correlates of SDS
in mid-life and older age patients with schizophrenia deserves more
investigation. The purpose of this study is to learn more about the occurrence,
pattern of symptoms and associated features of subsyndromal depressive symptoms
in patients with chronic schizophrenia or schizoaffective disorder. METHOD: The
first 165 participants from the “Citalopram Augmentation in Older Adults with
Psychoses” (NIH RO1 # 63931) study comprised the sample. Inclusion criteria
included: age > or =40, DSM-IV diagnosis of schizophrenia or schizoaffective
disorder, outpatient status, >2 DSM-IV symptoms of MDE and Hamilton Depression
Rating Scale (HAM-D) score > or =8. Depressive symptoms were assessed using the
17-item version of the HAM-D and the Calgary Depression Rating Scale (CDRS).
RESULTS: The most prevalent symptoms cut across several domains of the depressive
syndrome: psychological (e.g., depressed mood, depressed appearance, psychic
anxiety); cognitive (e.g., guilt, hopelessness, self depreciation, loss of
insight); somatic (insomnia, anorexia, loss of libido, somatic anxiety);
psychomotor (e.g., retardation and agitation) and functional (diminished work and
activities). Participants diagnosed with schizoaffective disorder appeared more
depressed, endorsed more intense “guilty ideas of reference” and had higher total
CDRS scores than patients diagnosed with schizophrenia. CONCLUSION: This study
confirms the high prevalence of depressive symptoms in middle-aged and older
persons with schizophrenia and schizoaffective disorder who were selected on the
basis of having subsyndromal symptoms of depression.

PMID: 16750346 [PubMed – indexed for MEDLINE] 147. J Clin Psychiatry. 2006 Aug;67(8):1299-304.

Pilot randomized controlled trial of interpersonal counseling for subsyndromal
depression following miscarriage.

Neugebauer R, Kline J, Markowitz JC, Bleiberg KL, Baxi L, Rosing MA, Levin B,
Keith J.

Epidemiology of Developmental Brain Disorders Department, New York State
Psychiatric Institute, G H Sergievsky Center, Columbia University, New York, NY
10032, USA.

OBJECTIVE: Miscarriage, which occurs in 10% to 20% of clinically recognized
pregnancies, is associated with an increased risk for subsyndromal depression. We
examined whether Interpersonal Counseling (IPC) was superior to treatment as
usual (TAU) in reducing subsyndromal depression among miscarrying women and,
secondarily, superior to TAU in improving role functioning. METHOD: Nineteen of
20 eligible women participated in a randomized controlled trial of 1 to 6 weekly
telephone sessions of IPC versus TAU, which consisted of whatever lay counseling
or professional care women sought on their own initiative, from October 2001 to
April 2002. The 2 trial arms were compared on mean within-subject change in
Hamilton Rating Scale for Depression-17-item (HAM-D-17) scores and in role
functioning scale scores (a 5-item modification of the 36-item Medical Outcomes
Study questionnaire) from baseline to post-intervention. RESULTS: In the primary
intent-to-treat analysis, the baseline mean HAM-D-17 scores were 18.0 (SD +/-
8.4) and 14.8 (SD +/- 6.6) in the IPC (N = 10) and TAU (N = 9) arms,
respectively; post-intervention, the corresponding means were 11.6 (SD +/- 8.2)
and 12.9 (SD +/- 8.3). The mean within-subject decline in HAM-D-17 scores was
significantly greater in the IPC (6.4) than in the TAU (1.9) arm (difference in
mean within-subject score decline, adjusted for design features, baseline
HAM-D-17 scores and for baseline ethnic imbalance between study arms, 6.2 [95% CI
= 0.4 to 12.0]). In a subordinate completers’ analysis (N = 15), the
corresponding mean decline and difference in adjusted mean decline were 8.0, 2.4,
and 6.7 (95% CI = 0.4 to 13.1), respectively. Treatment was unrelated to improved
role functioning. CONCLUSION: The efficacy of telephone-administered IPC for
subsyndromal depression after miscarriage warrants testing in a full-scale
randomized controlled trial.

PMID: 16965211 [PubMed – indexed for MEDLINE] 148. BMC Psychiatry. 2006 Jul 6;6:29.

Dresden PTSD treatment study: randomized controlled trial of motor vehicle
accident survivors.

Maercker A, Zöllner T, Menning H, Rabe S, Karl A.

University of Zurich, Department of Psychopathology and Clinical Intervention,

BACKGROUND: We translated, modified, and extended a cognitive behavioral
treatment (CBT) protocol by Blanchard and Hickling (2003) for the purpose of
treating survivors of MVA with full or subsyndromal posttraumatic stress disorder
(PTSD) whose native language is German. The treatment manual included some
additional elements, e. g. cognitive procedures, imaginal reliving, and
facilitating of posttraumatic growth. The current study was conducted in order to
test the efficacy of the modified manual by administering randomized controlled
trial in which a CBT was compared to a wait-list control condition. METHODS:
Forty-two motor vehicle accident survivors with chronic or severe subsyndromal
posttraumatic stress disorder (PTSD) completed the treatment trial with two or
three detailed assessments (pre, post, and 3-month follow-up). RESULTS:
CAPS-scores showed significantly greater improvement in the CBT condition as
compared to the wait list condition (group x time interaction effect size d =
1.61). Intent-to-treat analysis supported the outcome (d = 1.34). Categorical
diagnostic data indicated clinical recovery of 67% (post-treatment) and 76% (3
months FU) in the treatment group. Additionally, patients of the CBT condition
showed significantly greater reductions in co-morbid major depression than the
control condition. At follow-up the improvements were stable in the active
treatment condition. CONCLUSION: The degree of improvement in our treatment group
was comparable to that in previously reported treatment trials of PTSD with
cognitive behavioral therapy. TRIAL REGISTRATION: ISRCTN66456536.

PMCID: PMC1543618
PMID: 16824221 [PubMed – indexed for MEDLINE] 149. J Affect Disord. 2006 Jul;93(1-3):159-67. Epub 2006 May 2.

Typus melancholicus: personality structure and the characteristics of major
unipolar depressive episode.

Stanghellini G, Bertelli M, Raballo A.

University of Chieti, Viale Don Minzoni 45, 50100 Florence, Italy.

BACKGROUND: The melancholic type of personality (TM) has long been considered in
continental and Japanese psychopathology as a relevant vulnerability trait
constellation for the development of depression. METHOD: The symptom presentation
in an outpatient population of 116 subjects suffering from a DSM-IV major
depressive episode was rated according to the standardized documentation system
of the Association for Methodology and Documentation in Psychiatry (AMDP).
Personality features were explored by means of the Criteria for Typus
Melancholicus (CTM). RESULTS: Statistically significant differences in
depression-related psychopathological scores (i.e. higher level of guilt
feelings, feeling of the loss of feelings, loss of vital drive and lower degrees
of irritability and dysphoria) were found between TM and non-TM subjects,
supporting the phenomenic specificity of TM depression at both symptom and
subsyndromal level. LIMITATION AND CONCLUSIONS: Although our results were
obtained in a selected sample of outpatients at an University Mental Health
Center, they are indicative of psychopathological differences between TM and NTM
in the core symptoms of depression. These differences highlight the importance of
including TM criteria for phenotypic characterization of depressive disorder,
suggesting that it may improve diagnostic and therapeutic practice and might be a
reasonable psychopathologic endophenotype in investigating affective-spectrum
vulnerability in at-risk populations.

PMID: 16650481 [PubMed – indexed for MEDLINE] 150. J Affect Disord. 2006 Jul;93(1-3):19-28. Epub 2006 Feb 24.

Appraisal of hypomania-relevant experiences: development of a questionnaire to
assess positive self-dispositional appraisals in bipolar and behavioural high
risk samples.

Jones S, Mansell W, Waller L.

School of Psychological Sciences, Academic Division of Clinical Psychology,
University of Manchester, Second Floor ERC, Wythenshawe Hospital, Manchester, M23
9LT, UK.

BACKGROUND: This paper reports two studies concerned with the development and
validation of the Hypomania Interpretations Questionnaire (HIQ) designed to
assess positive self-dispositional appraisals for hypomania-relevant experiences.
METHODS: Study 1: 203 late adolescent participants completed the HIQ along with
additional measures of general symptom interpretation, dysfunctional attitudes
and hypomanic personality. Study 2: 56 adults with a self-reported diagnosis of
bipolar disorder and 39 controls completed a revised HIQ and a measure of current
mood symptoms. RESULTS: Study 1: The final 10 item HIQ had two subscales: a)
positive self-dispositional appraisals (HIQ-H); and b) normalising appraisals
(HIQ-NE). Internal and test-retest reliability were adequate. Hypomanic
personality scores were significantly and uniquely predicted by recent
hypomania-relevant experiences and HIQ-H score. Study 2: HIQ remained internally
reliable within this sample. Bipolar participants (BD) reported more subsyndromal
mood symptoms than controls (C) and scored significantly higher on HIQ-H even
after covarying for these. HIQ-H was the primary predictor of diagnostic group.
Its ability to discriminate BD from C was confirmed by ROC analysis. LIMITATIONS:
The studies are cross-sectional and did not include non-bipolar psychiatric
control groups. CONCLUSIONS: HIQ appears to be a reliable and valid measure for
the assessment of positive self-dispositional appraisals which seem to be linked
to both hypomanic personality and bipolar disorder. The relevance of such
appraisals for symptom exacerbation, relapse and psychological treatment would
merit future investigation.

PMID: 16503056 [PubMed – indexed for MEDLINE] 151. Eur Psychiatry. 2006 Jun;21(4):262-9. Epub 2006 Jun 19.

Do antidepressants influence mood patterns? A naturalistic study in bipolar

Bauer M, Rasgon N, Grof P, Glenn T, Lapp M, Marsh W, Munoz R, Suwalska A, Baethge
C, Bschor T, Alda M, Whybrow PC.

Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin,
Campus Charité Mitte (CCM), Schumannstrasse 20/21, 10117 Berlin, Germany.

This prospective, longitudinal study compared the frequency and pattern of mood
changes between outpatients receiving usual care for bipolar disorder who were
either taking or not taking antidepressants. One hundred and eighty-two patients
with bipolar disorder self-reported mood and psychiatric medications for 4 months
using a computerized system (ChronoRecord) and returned 22,626 days of data. One
hundred and four patients took antidepressants, 78 did not. Of the
antidepressants taken, 95% were selective serotonin or norepinephrine reuptake
inhibitors, or second-generation antidepressants. Of the patients taking an
antidepressant, 91.3% were concurrently taking a mood stabilizer. The use of
antidepressants did not influence the daily rate of switching from depression to
mania or the rate of rapid cycling, independent of diagnosis of bipolar I or II.
The primary difference in mood pattern was the time spent normal or depressed.
Patients taking antidepressants frequently remained in a subsyndromal depression.
In this naturalistic study using self-reported data, patients with bipolar
disorder who were taking antidepressants–overwhelmingly not tricyclics and with
a concurrent mood stabilizer–did not experience an increase in the rate of
switches to mania or rapid cycling compared to those not taking antidepressants.
Antidepressants had little impact on the mood patterns of bipolar patients taking
mood stabilizers.

PMID: 16782312 [PubMed – indexed for MEDLINE] 152. Rev Bras Psiquiatr. 2006 Jun;28(2):93-6. Epub 2006 Jun 26.

Bipolar depression: the importance of being on remission.

Gazalle FK, Andreazza AC, Hallal PC, Kauer-Sant’anna M, Ceresér KM, Soares JC,
Santin A, Kapczinski F.

Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.

OBJECTIVE: The aim of the present study is to compare quality of life among
currently depressed, subsyndromal and remitted patients with bipolar disorder
(BD) and to assess whether the level of depression correlates with the scores of
quality of life in BD patients. METHOD: Sixty bipolar outpatients diagnosed using
the Structured Clinical Interview for DSM-IV who met criteria for diagnosis of BD
type I, II or not otherwise specified (BD-NOS), and who were not currently on a
manic or mixed episode were included. The main variables of interest were quality
of life (QOL) assessed using the 26-item World Health Organization QOL instrument
(WHOQOL-BREF) and depression assessed using the 17-item Hamilton Depression
Rating Scale (HDRS). RESULTS: A linear trend test showed a dose response
association between patients’ current mood state and all domains of quality of
life. Higher quality of life scores were found among remitted patients, followed
by subsyndromal patients; depressed patients presented lower scores of quality of
life, except for the social domain. The four domains of the WHOQOL scale
correlated negatively with the HDRS. CONCLUSIONS: Our findings suggest that
bipolar depression and residual symptoms of depression are negatively correlated
with QOL in BD patients.

PMID: 16810390 [PubMed – indexed for MEDLINE] 153. Ann Intern Med. 2006 Apr 4;144(7):496-504.

Outcomes of minor and subsyndromal depression among elderly patients in primary
care settings.

Lyness JM, Heo M, Datto CJ, Ten Have TR, Katz IR, Drayer R, Reynolds CF 3rd,
Alexopoulos GS, Bruce ML.

Department of Psychiatry, University of Rochester Medical Center, Rochester, New
York 14642, USA.

Comment in:
Evid Based Ment Health. 2006 Nov;9(4):94.
Ann Intern Med. 2006 Apr 4;144(7):528-30.

Summary for patients in:
Ann Intern Med. 2006 Apr 4;144(7):I28.

BACKGROUND: Although depressive conditions in later life are a major public
health problem, the outcomes of minor and subsyndromal depression are largely
unknown. OBJECTIVE: To compare outcomes among patients with minor and
subsyndromal depression, major depression, and no depression, and to examine
putative outcome predictors. DESIGN: Cohort study. SETTING: Patients from primary
care practices in greater New York City, and Philadelphia and Pittsburgh,
Pennsylvania. PATIENTS: 622 patients who were at least 60 years of age and
presented for treatment in primary care practices that provided usual care in a
randomized, controlled trial of suicide prevention. Of the 441 (70.9%) patients
who completed 1 year of follow-up, 122 had major depression, 205 had minor or
subsyndromal depression, and 114 did not have depression at baseline.
MEASUREMENTS: One year after a baseline evaluation, data were collected by using
the following tools: Hamilton Depression Rating Scale, the depressive disorders
section of the Structured Clinical Interview for DSM-IV (Diagnostic and
Statistical Manual of Mental Disorders, fourth edition), Charlson Comorbidity
Index, Multilevel Assessment Instrument for measuring instrumental activities of
daily living, Physical Component Summary of the Medical Outcomes Study Short
Form-36, and Duke Social Support Index. RESULTS: Patients with minor or
subsyndromal depression had intermediate depressive and functional outcomes. Mean
adjusted 1-year Hamilton depression score was 10.9 (95% CI, 9.6 to 12.2) for
those with initial major depression, 7.0 (CI, 5.9 to 8.1) for those with minor or
subsyndromal depression, and 2.9 (CI, 1.6 to 4.2) for those without depression (P
< 0.001 for each paired comparison). Compared with patients who were not
depressed, those who had minor or subsyndromal depression had a 5.5-fold risk
(CI, 3.1-fold to 10.0-fold) for major depression at 1 year after controlling for
demographic characteristics (P < 0.001). Cerebrovascular risk factors were not
associated with a diagnosis of depression at 1 year after controlling for overall
medical burden. Initial medical burden, self-rated health, and subjective social
support were significant independent predictors of depression outcome.
LIMITATIONS: Participants received care at practices that had personnel who had
been given enhanced education about depression treatment; 29.1% of participants
withdrew from the study before completing 1 year of follow-up. CONCLUSIONS: The
intermediate outcomes of minor and subsyndromal depression demonstrate the
clinical significance of these conditions and suggest that they are part of a
spectrum of depressive illness. Greater medical burden, poor subjective health
status, and poorer subjective social support confer a higher risk for poor

PMID: 16585663 [PubMed – indexed for MEDLINE] 154. Gen Hosp Psychiatry. 2006 Mar-Apr;28(2):178-80.

Preferences for treatment in primary care: a comparison of nondepressive,
subsyndromal and major depressive patients.

Backenstrass M, Joest K, Frank A, Hingmann S, Mundt C, Kronmüller KT.

Erratum in:
Gen Hosp Psychiatry. 2006 May-Jun;28(3):266.

Comment on:
Gen Hosp Psychiatry. 2004 May-Jun;26(3):184-9.

OBJECTIVE: In recent years, patients’ preferences concerning treatment of
emotional distress in general and of depression in particular have received more
emphasis in the clinical setting as well as in research. METHODS: The treatment
preferences of 607 primary care patients were assessed in a cross-sectional study
using a questionnaire. Besides having the opportunity to choose between
psychotherapy and pharmacological treatment, the patients could also decline or
choose both treatment options at one time. Moreover, the preferences of
subsyndromal, major depression and nondepressive patients were compared. RESULTS:
A total of 305 (51%) patients exclusively preferred psychotherapy and 110 (18%)
exclusively preferred pharmacological treatment. Although 70 (12%) patients
declined both forms of treatment, 113 (19%) could imagine using both treatment
options. Patients with subsyndromal depression did not differ from patients with
major depression in their preferences. Both groups, however, less frequently
declined pharmacological treatment compared to nondepressive patients.
CONCLUSIONS: Patients with subsyndromal and major depression are similar in the
primary care setting with regard to their treatment preferences. The preference
for combination treatment is rather low, which should be considered in routine
clinical care [corrected]

PMID: 16516070 [PubMed – indexed for MEDLINE] 155. Int Psychogeriatr. 2006 Mar;18(1):3-17. Epub 2006 Jan 3.

Awareness and behavioral problems in dementia patients: a prospective study.

Aalten P, van Valen E, de Vugt ME, Lousberg R, Jolles J, Verhey FR.

Department of Psychiatry and Neuropsychology, Brain and Behavior Institute,
University of Maastricht, Maastricht, the Netherlands.

BACKGROUND: The results of studies of the association between awareness and
clinical correlates in patients with dementia are inconclusive. The aims of this
study were to investigate whether awareness changed during the course of dementia
and to determine whether awareness was associated with certain behavioral
symptoms. Specifically, it was hypothesized that relatively intact awareness was
related to affective disorders. METHODS: One hundred and ninety-nine patients
with dementia were included in a prospective 18-month follow-up study. Behavioral
problems were assessed with the Neuropsychiatric Inventory and the Cornell Scale
for Depression in Dementia. Awareness was assessed by means of the Guidelines for
the Rating of Awareness Deficits. RESULTS: Cross-sectional analyses showed
awareness to be positively associated with age, gender, education and
socioeconomic status, and negatively associated with psychosis, apathy, and
overall behavioral disorders at baseline. After 1 year, a higher level of
awareness was related to depression and anxiety. The level of awareness at
baseline also predicted depression and anxiety after 1 year. Awareness decreased
during the study. CONCLUSIONS: A higher level of awareness is associated with
subsyndromal depression and anxiety, whereas lack of awareness is associated with
psychosis and apathy. The level of awareness decreases as dementia progresses.
Clinicians should be more alert to changes in awareness in patients with dementia
because psychosocial support might help to prevent the development of affective

PMID: 16388704 [PubMed – indexed for MEDLINE] 156. J Affect Disord. 2006 Mar;91(1):11-7. Epub 2006 Jan 19.

The detection of depression in medical setting: a study with PRIME-MD.

Fraguas R Jr, Henriques SG Jr, De Lucia MS, Iosifescu DV, Schwartz FH, Menezes
PR, Gattaz WF, Martins MA.

Department and Institute of Psychiatry, Faculty of Medicine, University of Sao
Paulo, Brazil.

Erratum in:
J Affect Disord. 2006 Nov;96(1-2):139. Gonsalves Henriques, Sergio Jr [corrected
to Henriques, Sergio Gonsalves Jr]; Rossi Menezes, Paulo [corrected to Menezes,
Paulo Rossi]; Farid Gattaz, Wagner [corrected to Gattaz, Wagner Farid]; Arruda
Martins, Milton [corrected to Martins, Milton Arruda].

BACKGROUND: Studies investigating the performance of instruments to detect major
depressive disorder (MDD) have reported inconsistent results. Subsyndromal
depression (SD) has also been associated to increased morbidity, and little is
known about its detection in primary care setting. This study aimed to
investigate the performance of the Primary Care Evaluation of Mental Disorders
(PRIME-MD) to detect MDD and any depression (threshold at SD) in an outpatient
unit of a teaching general hospital. METHODS: Nineteen primary care physicians
using the PRIME-MD evaluated 577 patients, 240 of them (75% female; mean age,
40.0 +/- 14.4), including all with MDD and a randomly subset of those without
MDD, were evaluated by 11 psychiatrists using the Structured Clinical Interview
Axis I Disorders, Patient Version (SCIDI/P) for DSM-IV as the standard
instrument. RESULTS: The kappa between the PRIME-MD and the SCID was 0.42 for the
diagnosis of any depression and 0.32 for MDD. The distribution of the number of
depressive symptoms per patient suggested the existence of a continuum between SD
and MDD, and a high frequency of subjects with 4-6 symptoms (close to the cutoff
for the diagnosis of MDD). LIMITATIONS: The sample has a modest size and is a
subset of an original one. CONCLUSION: A continuum between SD and MDD may in part
explain the relatively low agreement for the diagnosis of MDD in our sample and
possibly in other studies. Studies investigating the performance of screening
instruments to detect MDD, should consider the relevance of identifying SD, and
the influence of the distribution of the number of depressive symptoms in their

PMID: 16427132 [PubMed – indexed for MEDLINE] 157. Arch Gen Psychiatry. 2006 Feb;63(2):175-83.

Clinical course of children and adolescents with bipolar spectrum disorders.

Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N,
Leonard H, Hunt J, Iyengar S, Keller M.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of
Pittsburgh Medical Center, PA 15213, USA.

CONTEXT: Despite the high morbidity associated with bipolar disorder (BP), few
studies have prospectively studied the course of this illness in youth.
OBJECTIVE: To assess the longitudinal course of BP spectrum disorders (BP-I,
BP-II, and not otherwise specified [BP-NOS]) in children and adolescents. DESIGN:
Subjects were interviewed, on average, every 9 months for an average of 2 years
using the Longitudinal Interval Follow-up Evaluation. SETTING: Outpatient and
inpatient units at 3 university centers. PARTICIPANTS: Two hundred sixty-three
children and adolescents (mean age, 13 years) with BP-I (n = 152), BP-II (n =
19), and BP-NOS (n = 92). MAIN OUTCOME MEASURES: Rates of recovery and
recurrence, weeks with syndromal or subsyndromal mood symptoms, changes in
symptoms and polarity, and predictors of outcome. RESULTS: Approximately 70% of
subjects with BP recovered from their index episode, and 50% had at least 1
syndromal recurrence, particularly depressive episodes. Analyses of weekly mood
symptoms showed that 60% of the follow-up time, subjects had syndromal or
subsyndromal symptoms with numerous changes in symptoms and shifts of polarity,
and 3% of the time, psychosis. Twenty percent of BP-II subjects converted to
BP-I, and 25% of BP-NOS subjects converted to BP-I or BP-II. Early-onset BP,
BP-NOS, long duration of mood symptoms, low socioeconomic status, and psychosis
were associated with poorer outcomes and rapid mood changes. Secondary analyses
comparing BP-I youths with BP-I adults showed that youths significantly more time
symptomatic and had more mixed/cycling episodes, mood symptom changes, and
polarity switches. CONCLUSIONS: Youths with BP spectrum disorders showed a
continuum of BP symptom severity from subsyndromal to full syndromal with
frequent mood fluctuations. Results of this study provide preliminary validation
for BP-NOS.

PMID: 16461861 [PubMed – indexed for MEDLINE] 158. Bipolar Disord. 2006 Feb;8(1):28-39.

Stroop performance in bipolar disorder: further evidence for abnormalities in the
ventral prefrontal cortex.

Kronhaus DM, Lawrence NS, Williams AM, Frangou S, Brammer MJ, Williams SC, Andrew
CM, Phillips ML.

Institute for Adaptive and Neural Computation, School of Informatics, The
University of Edinburgh, Edinburgh, UK.

OBJECTIVES: Bipolar patients are impaired in Stroop task performance, a measure
of selective attention. Structural and functional abnormalities in
task-associated regions, in particular the prefrontal cortex (PFC), have been
reported in this population. We aimed to examine the relationship between
functional abnormalities, impaired task performance and the severity of
depressive symptoms in bipolar patients. METHODS: Remitted bipolar patients (n =
10; all medicated), either euthymic or with subsyndromal depression, and
age-matched control subjects (n = 11) viewed 10 alternating blocks of incongruent
Stroop and control stimuli, naming the colour of the ink. Neural response was
measured using functional magnetic resonance imaging. We computed between-group
differences in neural response and within-group correlations with mood and
anxiety. RESULTS: There were no significant between-group differences in task
performance. During the Stroop condition, controls demonstrated greater
activation of visual and dorsolateral and ventrolateral prefrontal cortical
areas; bipolar patients demonstrated relative deactivation within orbital and
medial prefrontal cortices. Depression scores showed a trend towards a negative
correlation with the magnitude of orbitofrontal cortex deactivation in bipolar
patients, whereas state anxiety correlated positively with activation of
dorsolateral PFC and precuneus in controls. CONCLUSIONS: Our findings confirm
previous reports of decreased ventral prefrontal activity during Stroop task
performance in bipolar patients, and suggest a possible negative correlation
between this and depression severity in bipolar patients. These findings further
highlight the ventromedial PFC as a potential candidate for illness related
dysfunction in bipolar disorder.

PMID: 16411978 [PubMed – indexed for MEDLINE] 159. Mov Disord. 2006 Feb;21(2):148-58.

Provisional diagnostic criteria for depression in Parkinson’s disease: report of
an NINDS/NIMH Work Group.

Marsh L, McDonald WM, Cummings J, Ravina B; NINDS/NIMH Work Group on Depression
and Parkinson’s Disease.

Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore,
Maryland 21287, USA.

Mood disorders are the most common psychiatric problem associated with
Parkinson’s disease (PD), and have a negative impact on disability and quality of
life. Accurate diagnosis of depressive disturbances in PD is critical and will
facilitate the testing and use of new interventions; however, there are no clear
diagnostic criteria for depressive disorders in PD. In their current form, strict
Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are
difficult to use in PD and require attribution of specific symptoms to PD itself
or the depressive syndrome. Additionally, DSM criteria for major depression and
dysthymia exclude perhaps half of PD patients with comorbid clinically
significant depression. This review summarizes an NIH-sponsored workshop and
describes recommended changes to DSM diagnostic criteria for depression for use
in PD. Participants also recommended: (1) an inclusive approach to symptom
assessment to enhance reliability of ratings in PD and avoid the need to
attribute symptoms to a particular cause; (2) the inclusion of subsyndromal
depression in clinical research studies of depression of PD; (3) the
specification of timing of assessments for PD patients with motor fluctuations;
and (4) the use of informants for cognitively impaired patients. The proposed
diagnostic criteria are provisional and intended to be defined further and
validated but provide a common starting point for clinical research in
PD-associated depression. Copyright (c) 2005 Movement Disorder Society.

PMID: 16211591 [PubMed – indexed for MEDLINE] 160. Am J Drug Alcohol Abuse. 2006;32(2):203-24.

Alcohol use, mental health status and psychological well-being 2 years after the
World Trade Center attacks in New York City.

Adams RE, Boscarino JA, Galea S.

Division of Health Policy, The New York Academy of Medicine, New York, New York,

Over the past 30 years, studies have shown that survivors of community-wide
disasters suffer from a variety of physical and mental health problems.
Researchers also have documented increased substance use in the aftermath of
these disasters. In the present study, we examined the relationship between
alcohol use and mental health status within the context of the terrorist attacks
on the World Trade Center in New York City (NYC). The data for the present report
come from a 2-wave panel study of adults living in NYC on the day of the attacks.
Wave 1 (W1) and Wave 2 (W2) interviews occurred one year and two years after the
attacks, respectively. Overall, 2,368 individuals completed the W1 survey
(cooperation rate, 63%) and 1,681 completed the W2 survey (re-interview rate,
71%). The alcohol use variables examined were binge drinking, alcohol dependence,
increased days drinking, and increased drinks per day. The outcomes examined
included measures of posttraumatic stress disorder (PTSD), major depression,
BSI-18-Global Severity and measures of SF12-mental and physical health status.
After controlling for demographic, stress, and resource factors, multivariate
logistic regressions indicated that all alcohol measures were related to one or
more of these outcomes. In particular, binge drinking was related to partial
PTSD, while alcohol dependence was associated subsyndromal PTSD, severity of
PTSD, depression, BSI-18 global severity, and SF-12 poor mental health status.
Increased post-disaster drinking was positively associated with subsyndromal PTSD
and negatively associated with SF-12 physical health. We discuss reasons for
these results and the negative consequences that heavy alcohol use may have on
the postdisaster recovery process.

PMCID: PMC2746081
PMID: 16595324 [PubMed – indexed for MEDLINE] 161. Am J Psychiatry. 2006 Jan;163(1):79-87.

Efficacy and tolerability of vardenafil in men with mild depression and erectile
dysfunction: the depression-related improvement with vardenafil for erectile
response study.

Rosen R, Shabsigh R, Berber M, Assalian P, Menza M, Rodriguez-Vela L, Porto R,
Bangerter K, Seger M, Montorsi F; Vardenafil Study Site Investigators.

Department of Psychiatry, University of Medicine and Dentistry of New
Jersey-Robert Wood Johnson Medical School, Piscataway, NJ 08854, USA.

Comment in:
Evid Based Ment Health. 2006 Aug;9(3):77.
Am J Psychiatry. 2006 Aug;163(8):1449.

OBJECTIVE: Erectile dysfunction and depression are highly associated. Previous
studies have shown benefits of phosphodiesterase-5 inhibitor treatment for
erectile dysfunction associated with antidepressant therapy or subsyndromal
depression. The present study assessed the safety and efficacy of vardenafil in
men with erectile dysfunction and untreated mild depression. METHOD: In this
12-week, multicenter, randomized, flexible-dose, parallel-group, double-blind
study, 280 men with erectile dysfunction for at least 6 months and untreated mild
major depression received placebo or vardenafil, 10 mg/day, for 4 weeks, with the
option to titrate to 5 mg/day or 20 mg/day after each of two consecutive 4-week
intervals. Endpoints included International Index of Erectile Function erectile
function domain and 17-item Hamilton Depression Rating Scale (HAM-D) scores.
RESULTS: Vardenafil produced statistically significant and clinically meaningful
improvement in all erectile function parameters. The International Index of
Erectile Function erectile function domain score was 22.9 with vardenafil
compared to 14.9 with placebo. The HAM-D score was lower in the vardenafil group
(7.9) than in the placebo group (10.1). Treatment with vardenafil was the most
important predictor for return to normal erectile function. Improvement in
International Index of Erectile Function erectile function domain score was the
most important predictor of remission in depressive symptoms. CONCLUSIONS:
Vardenafil was well tolerated and highly efficacious in men with erectile
dysfunction and untreated mild major depression. Significant improvements in
erectile function and depression were observed in patients treated with
vardenafil versus placebo. Erectile dysfunction treatment should be considered a
component of therapy for men with depression and erectile dysfunction.

PMID: 16390893 [PubMed – indexed for MEDLINE] 162. Am J Psychiatry. 2006 Jan;163(1):59-66.

Placebo-controlled trial of dehydroepiandrosterone (DHEA) for treatment of
nonmajor depression in patients with HIV/AIDS.

Rabkin JG, McElhiney MC, Rabkin R, McGrath PJ, Ferrando SJ.

New York State Psychiatric Institute, Columbia University College of Physicians
and Surgeons, New York, NY 10032, USA.

OBJECTIVE: Subsyndromal major depressive disorder is common among HIV-positive
adults. This study was designed to assess the efficacy of dehydroepiandrosterone
(DHEA) as a potential treatment. METHOD: One hundred forty-five patients with
subsyndromal depression or dysthymia were randomly assigned to receive either
DHEA or placebo; 90% (69 of 77) of the DHEA patients and 94% (64 of 68) of the
placebo patients completed the 8-week trial. The primary measure of efficacy was
a Clinical Global Impression improvement rating of 1 or 2 (much or very much
improved) plus a final Hamilton Depression Rating Scale score or=65
years, whereas clinically significant nonmajor or “subsyndromal” depression
affects approximately 15% of the ambulatory elderly. Risk of developing
subsyndromal depression increases as elderly people get older. Because they have
numerous distressing ailments, everyday life can be burdensome for many elderly
persons. Almost one third of Americans aged 75 years or older rate their health
as “fair to poor.” Yet, the physical discomforts experienced by so many elderly
individuals are unlikely to generate a clinically significant depression unless
other ingredients such as loneliness, impairment of mobility, loss of a spouse, a
serious financial reverse, and–probably most important–genetic susceptibility
are added to the psychophysiological mix. Because depression damages quality of
life and is usually eminently treatable, it is essential that physicians and
other health professionals be trained to recognize true depression and
distinguish it from confounding conditions caused by medications, organic brain
disease, or short-term grief reactions. In the medically ill elderly, depressive
symptoms may be overlooked because of the assumption that they are a part of the
concurrent medical illness. Diagnosis of depression in the elderly can be greatly
assisted by use of age-specific screening instruments such as the Geriatric
Depression Scale. Ultimately, brain imaging and biochemical and physiological
measurements may prove useful in diagnosis. The presence of somatic concomitants
of depression such as severe neck and low back pain should alert the clinician to
the possibility of an underlying mood disorder. Suicide and suicide attempts
occur all too frequently in the depressed elderly; therefore, screening for
late-life depression is urgently required among the elderly in primary and
residential health care settings.

PMID: 15877312 [PubMed – indexed for MEDLINE] 181. Bipolar Disord. 2005 Apr;7(2):176-86.

Actigraphic assessment of circadian activity and sleep patterns in bipolar

Jones SH, Hare DJ, Evershed K.

Academic Division of Clinical Psychology, University of Manchester, Wythenshawe
Hospital, Manchester, UK.

OBJECTIVES: Theoretical accounts and psychological interventions for bipolar
disorder indicate that disruption of circadian rhythms is important, both in
affective episodes and as a vulnerability factor in subsyndromal periods. This
study aims at assessing both circadian activity and sleep patterns using
actigraphy within a bipolar sample experiencing low levels of subsyndromal
symptoms. It is hypothesized that such participants will display circadian
activity disruption in spite of low levels of symptoms. METHODS: This study
employed a mixed design with cross-sectional assessment of mood and week-long
(7-day) recording of actigraphy data. All clinical participants were psychiatric
outpatients within a UK NHS Hospital. Nineteen bipolar patients and 19 age- and
gender-matched controls wore an actigraph for 7 days to obtain sleep and
circadian activity data. SCID was used to confirm DSM-IV diagnostic status.
Self-report measures of mood were obtained from both groups. RESULTS: Bipolar
patients were found to have less stable and more variable circadian activity
patterns than controls. Regression analysis indicated that variability alone was
a significant independent predictor of diagnostic group. There was evidence from
raw activity data that bipolar patients were also less active than controls.
These differences were not associated with levels of subsyndromal symptoms.
Bipolar patients did not differ from controls on any of the sleep indices used.
CONCLUSIONS: Circadian activity disruption is apparent in bipolar patients even
when not acutely ill. This finding is not associated with the presence of sleep
disturbance. Should such patterns be replicated interventions to address both
circadian instability and individual attributions for the effects of such
instability are likely to be relevant to successful psychological interventions.

PMID: 15762859 [PubMed – indexed for MEDLINE] 182. Rev Prat. 2005 Mar 15;55(5):481-5.

[Epidemiology of bipolar disorders] [Article in French]

Slama F.

Service de psychiatrie adulte, hôpitaux Albert Chenevier et Henri Mondor, 94010

Recent emerging data provide converging evidence for a high prevalence of bipolar
disorders (up to 5% of the general population). The proper recognition of the
entire clinical spectrum of bipolarity, including subsyndromal manic/hypomanic
symptoms is of major public health importance. Indeed, accurate diagnosis and
appropriate treatment still lag by many years, leading to greater psychosocial
impairments and higher suicidality. Earlier risk factor assessment could
therefore substantially decrease the occurrence of suicidal behaviors.

PMID: 15895949 [PubMed – indexed for MEDLINE] 183. J Clin Psychiatry. 2005 Mar;66(3):360-9.

Citalopram versus sertraline in late-life nonmajor clinically significant
depression: a 1-year follow-up clinical trial.

Rocca P, Calvarese P, Faggiano F, Marchiaro L, Mathis F, Rivoira E, Taricco B,
Bogetto F.

Department of Neurosciences, Psychiatric Section, University of Turin, Via
Cherasco, 11-10126 Turin, Italy.

OBJECTIVE: The aim of this study was to compare over 1 year the effect of
sertraline and citalopram on depressive symptoms and cognitive functions of
nondemented elderly patients with minor depressive disorder and subsyndromal
depressive symptomatology. METHOD: We recruited 138 consecutive non-demented
outpatients of either sex, aged > or =65 years, who were classified as meeting
research criteria for minor depressive disorder or sub-syndromal depressive
symptomatology using the Structured Clinical Interview for DSM-IV. Subjects were
assigned to receive citalopram 20 mg/day (66 patients) or sertraline 50 mg/day
(72 patients) orally for 1 year. Patients were assessed at baseline and after 1,
2, 3, and 6 months and at 1 year by raters masked with regard to patients’
treatment assignments. The Hamilton Rating Scale for Depression, the Geriatric
Depression Scale, and the Global Assessment of Functioning were administered to
assess the course of depressive symptoms and social functioning during the study.
Cognitive measures included Trail Making Test-Parts A and B, Wechsler Memory
Scale, Mini-Mental State Examination, and a verbal fluency test. Data were
collected from March 2000 to March 2003. RESULTS: The overall completion rate was
72%. Both treatments induced a significant, sustained, and comparable improvement
in depressive symptoms and in social functioning. Nearly half of the subjects in
the 2 groups achieved remitter status at study endpoint. Significant within-group
improvements also were observed in all cognitive measures. Both drugs were well
tolerated during the whole study period. CONCLUSION: Our results suggest that
sertraline and citalopram can improve depressive symptoms and cognitive functions
of minor depressive disorder and subsyndromal depressive symptomatology in
elderly nondemented patients.

PMID: 15766303 [PubMed – indexed for MEDLINE] 184. Am J Psychiatry. 2005 Jan;162(1):175-7.

Increase in interleukin-1beta in late-life depression.

Thomas AJ, Davis S, Morris C, Jackson E, Harrison R, O’Brien JT.

School of Neurology, Neurobiology and Psychiatry and the Institute for Ageing and
Health, University of Newcastle upon Tyne, UK.

OBJECTIVE: Depression has been associated with increases in circulating cytokines
in younger adults, and there is evidence for prefrontal inflammation in late-life
depression. The authors tested the hypothesis that levels of cytokine
interleukin-1beta (IL-1beta) would be higher in subjects with late-life major
depression. METHOD: Serum levels of IL-1beta were measured in three groups of
subjects who were older than 60: 19 subjects with major depression, 20 subjects
with subsyndromal depression, and 21 healthy comparison subjects. The
Montgomery-Asberg Depression Rating Scale and the Geriatric Depression Scale were
used to assess severity of depression. RESULTS: Compared with healthy subjects,
those with major depression had significantly higher levels of IL-1beta (170%);
the higher levels of IL-1beta strongly correlated with current depression
severity. There were no significant differences between subjects with
subsyndromal depression and the other two groups. CONCLUSIONS: These findings
support the existence of an inflammatory response, which may be state dependent,
in late-life depression.

PMID: 15625217 [PubMed – indexed for MEDLINE] 185. Bipolar Disord. 2005;7 Suppl 1:25-32.

The burden on informal caregivers of people with bipolar disorder.

Ogilvie AD, Morant N, Goodwin GM.

University Department of Psychiatry, Warneford Hospital, Oxford, UK.

Caregivers of people with bipolar disorder may experience a different quality of
burden than is seen with other illnesses. A better understanding of their
concerns is necessary to improve the training of professionals working with this
population. Conceptualizing caregiver burden in a conventional medical framework
may not focus enough on issues important to caregivers, or on cultural and social
issues. Perceptions of caregivers about bipolar disorder have important effects
on levels of burden experienced. It is important to distinguish between
caregivers’ experience of this subjective burden and objective burden as
externally appraised. Caregivers’ previous experiences of health services may
influence their beliefs about the illness. Caregiver burden is associated with
depression, which affects patient recovery by adding stress to the living
environment. The objective burden on caregivers of patients with bipolar disorder
is significantly higher than for those with unipolar depression. Caregivers of
bipolar patients have high levels of expressed emotion, including critical,
hostile, or over-involved attitudes. Several measures have been developed to
assess the care burden of patients with depressive disorders, but may be
inappropriate for patients with bipolar disorder because of its cyclical nature
and the stresses arising from manic and hypomanic episodes. Inter-episode
symptoms pose another potential of burden in patients with bipolar disorder.
Subsyndromal depressive symptoms are common in this phase of the illness,
resulting in severe and widespread impairment of function. Despite the importance
of assessing caregiver burden in bipolar disorder, relevant literature is scarce.
The specific effects of mania and inter-episode symptoms have not been adequately
addressed, and there is a lack of existing measures to assess burden adequately,
causing uncertainty regarding how best to structure family interventions to
optimally alleviate burden. The relatively few studies into caregiver burden in
bipolar disorder may largely reflect experiences in the US Veterans Affairs
health service, but the findings may be limited in their generalizability.
Nevertheless, available data suggest that caregiver burden is high and largely
neglected in bipolar disorder. Clinically effective, well-targeted and
practically viable interventions are needed. However, services cannot be enhanced
on a rational basis without an improved understanding and capacity to measure and
target caregiver burden the impact of any change in services be evaluated.

PMID: 15762866 [PubMed – indexed for MEDLINE] 186. Dement Geriatr Cogn Disord. 2005;20(2-3):77-81. Epub 2005 May 20.

Depressive symptoms predict slow cognitive decline in mild dementia.

Janzing JG, Naarding P, Eling P.

Department of Psychiatry, Radboud University Nijmegen Medical Centre; the
Nijmegen Institute for Cognition and Information, Apeldoorn, The Netherlands.

Depression may be a prognostic marker of subsequent cognitive decline in patients
with dementia. Earlier investigations did not find support for this hypothesis,
but these considered mainly syndromal depression. In this prospective study, 32
subjects with mild dementia were followed up for 12 months. The effects of
GMS-AGECAT syndromal depression, subsyndromal depression and dimensions of
depressive symptoms were studied. Higher levels of mood symptoms but not
(sub)syndromal depression predicted slower cognitive decline during follow-up. It
is hypothesized that the report of depressive symptoms by subjects with mild
dementia reflects relative intactness of cognitive functions, not accounted for
by cognitive screening instruments. Copyright (c) 2005 S. Karger AG, Basel.

PMID: 15908749 [PubMed – indexed for MEDLINE] 187. Bipolar Disord. 2004 Dec;6(6):530-9.

Bipolar depression: phenomenological overview and clinical characteristics.

Mitchell PB, Malhi GS.

School of Psychiatry, University of New South Wales and Mood Disorders Unit,
Black Dog Institute, Prince of Wales Hospital, Sydney, NSW, Australia.

OBJECTIVES: There has been increasing interest in the depressed phase of bipolar
disorder (bipolar depression). This paper aims to review the clinical
characteristics of bipolar depression, focusing upon its prevalence and
phenomenology, related neuropsychological dysfunction, suicidal behaviour,
disability and treatment responsiveness. METHODS: Studies on the prevalence of
depression in bipolar disorder, the comparative phenomenology of bipolar and
unipolar depression, as well as neuropsychology and brain imaging studies, are
reviewed. To identify relevant papers, a literature search using MEDLINE and
PubMed was undertaken. RESULTS: Depression is the predominant mood disturbance in
bipolar disorder, and most frequently presents as subsyndromal, minor or
dysthymic depression. Compared with major depressive disorder (unipolar
depression), bipolar depression is more likely to manifest with psychosis,
melancholic symptoms, psychomotor retardation (in bipolar I disorder) and
‘atypical’ symptoms. The few neuropsychological studies undertaken indicate
greater impairment in bipolar depression. Suicide rates are high in bipolar
disorder, with suicidal ideation, suicide attempts and completed suicides all
occurring predominantly in the depressed phase of this condition. Furthermore,
the depressed phase (even subsyndromal) appears to be the major contributant to
the disability related to this condition. CONCLUSIONS: The significance of the
depressed phase of bipolar disorder has been markedly underestimated. Bipolar
depression accounts for most of the morbidity and mortality due to this illness.
Current treatments have significant limitations. Blackwell Munksgaard, 2004

PMID: 15541069 [PubMed – indexed for MEDLINE] 188. J Clin Psychiatry. 2004 Dec;65(12):1696-707.

Remission rates in patients with anxiety disorders treated with paroxetine.

Ballenger JC.

Department of Psychiatry and Behavioral Science, Medical University of South
Carolina, Charleston, SC 29401, USA.

BACKGROUND: Approximately 50% to 60% of patients with depression and/or anxiety
respond to treatment, but only a minority achieve remission. The continued
presence of subsyndromal symptoms in treated depressed (and probably anxious)
patients leads to higher relapse rates and increased utilization of health care
resources. It is proposed that remission is the appropriate target in the
treatment of both depression and the anxiety disorders. AIMS: Rigorous criteria
for remission have been proposed for the anxiety disorders and are currently
being applied in clinical studies. Using these criteria, data from the paroxetine
clinical study database were retrospectively analyzed to determine remission
rates following paroxetine treatment across a range of anxiety disorders in the
largest analysis of remission data in the anxiety disorders to date. METHOD:
These analyses included data from 16 short-term and 6 long-term, randomized,
placebo-controlled studies in panic disorder, social anxiety disorder,
obsessive-compulsive disorder, posttraumatic stress disorder (short term only),
and generalized anxiety disorder (DSM-III-R or DSM-IV). Separate analyses were
performed for each disorder, with short- and long-term data analyzed separately.
RESULTS: In general, across the range of anxiety disorders studied, in both
short- and long-term studies, remission rates were higher for paroxetine compared
with placebo, using disorder-specific, global, and functional remission criteria
both individually and combined. Remission occurred in a moderate proportion of
paroxetine-treated patients after only 8 to 12 weeks of treatment, and
longer-term therapy led to even higher remission rates. CONCLUSION: Paroxetine
has demonstrated efficacy in treating patients to remission across the range of
anxiety disorders studied. Our findings strongly suggest that continuing
treatment with paroxetine (and probably other SSRI antidepressants) for 2 to 12
months increases the proportion of patients achieving clinical remission.

PMID: 15641876 [PubMed – indexed for MEDLINE] 189. Psychol Med. 2004 Nov;34(8):1507-17.

Depression in elderly homecare patients: patient versus informant reports.

McAvay GJ, Bruce ML, Raue PJ, Brown EL.

Yale University School of Medicine, New Haven, CT, USA.

BACKGROUND: This study compares patient and informant reports of depressive
disorders in a community sample of elderly medical homecare patients. The
associations between specific patterns of agreement/disagreement and other
patient and informant characteristics are examined. METHOD: A random sample of
355 elderly medical homecare patients and their informants were interviewed using
the current mood section of the Structured Clinical Interview for DSM-IV (SCID).
RESULTS: Thirty-seven patients (10.4 %) reported a depressive disorder (major or
subsyndromal) that was also identified by their informant while 27 (7.6 %)
patients self-reported depression that the informant did not identify. There were
250 patients (70.4 %) who were not depressed according to both patient and
informant report and 41 patients (11.5%) were identified as depressed by
informant report alone. Patients identified as depressed by informant report
alone were similar to patients who self-reported depression on a number of the
sociodemographic and clinical correlates of depression, but had significantly
poorer performance on items assessing orientation and short-term recall. These
patients also had poorer functioning in a number of domains (social, cognitive,
and functional) when compared with patients who were not depressed according to
both the patient and informant. Finally, patients with younger informants were
more likely to be identified as depressed by their informant. CONCLUSIONS:
Obtaining informant reports of depression may be a useful method for detecting
clinically significant cases of late-life depression that would otherwise be
missed when relying only on patient report.

PMID: 15724881 [PubMed – indexed for MEDLINE] 190. J Affect Disord. 2004 Oct 1;82(1):61-70.

A dual vulnerability hypothesis for seasonal depression is supported by the
seasonal pattern assessment questionnaire in relation to the temperament and
character inventory of personality in a general population.

Chotai J, Smedh K, Nilsson LG, Adolfsson R.

Division of Psychiatry, Department of Clinical Sciences, University Hospital of
Umeå, SE-901 85Umeå, Sweden.

BACKGROUND: Personality structure obtained from the psychobiological Temperament
and Character Inventory (TCI) was studied in relation to self-reported seasonal
variations in mood and behavior measured by the Seasonal Pattern Assessment
Questionnaire (SPAQ). METHODS: The subjects comprised 1761 adults (57.6% women)
in the age range 35-85 years, enrolled in the Betula prospective random cohort
study of Umea, Sweden. RESULTS: Personality profiles of subjects who reported the
occurrence of a high degree of seasonal variation as such were associated with a
combination of high self-transcendence (ST) and high persistence (PS),
irrespective of the level of harm avoidance (HA). Subjects who reported feeling
worst in winter were associated with high HA, irrespective of the levels of ST
and PS. Also, subjects feeling worst in summer or experiencing overall problems
with seasonal variation were associated with high HA in their personality
profiles. Using the SPAQ criteria to define seasonal affective disorder (SAD) or
subsyndromal SAD (S-SAD), subjects with these disorders often had combinations of
high self-transcendence (ST) and high persistence (PS), but with different
associations with HA. LIMITATIONS: No evaluations were made for SAD or
subsyndromal SAD according to the DSM-IV or ICD 10 criteria. CONCLUSIONS: Our
results relating SPAQ with TCI give support for a dual vulnerability hypothesis
for seasonal depression proposed in the literature, where it is attributed to a
combination of a seasonal factor and a depression factor. Examining the
literature regarding the relationships between the different TCI scales and
monoamine neurotransmitter functions, those relationships suggest that these two
vulnerability factors for seasonal depression may be modulated by different
neurotransmitter systems.

PMID: 15465577 [PubMed – indexed for MEDLINE] 191. J Am Acad Child Adolesc Psychiatry. 2004 Aug;43(8):1003-10.

School-based prevention of depressive symptoms in adolescents: a 6-month

Pössel P, Horn AB, Groen G, Hautzinger M.

Department of Clinical and Physiological Psychology, University of Tübingen,

OBJECTIVE: Depressive disorders in adolescents are a widespread problem with
extensive psychosocial consequences. The authors designed a school-based program
to prevent the increase in depressive symptoms. The authors expect the program to
reduce dysfunctional automatic thoughts and improve social skills and thus
prevent the increase in depressive symptoms. METHOD: The design includes a
training group and a nontreatment control group with pre- and post-measurement
and 3- and 6-month follow-up. The authors followed up 324 eighth graders in both
groups. School classes were randomly assigned to one of the two groups. The
prevention program, LISA-T, is based on cognitive-behavioral therapy concepts and
targets of cognitive and social aspects. It comprises 10 meetings of 1.5 hours in
a regular school setting. RESULTS: Increases in depressive symptoms in
nondepressed adolescents in the training group were prevented over a 6-month
period. Furthermore, adolescents with subsyndromal depression in the training
group reported fewer symptoms, whereas depressive symptoms within the control
group did not change. However, the groups did not differ with regard to social
skills, frequency of negative automatic thoughts, and depressive symptoms before
the prevention program. CONCLUSIONS: LISA-T is an effective school-based
prevention program for eighth graders with minimal to mild depressive symptoms,
but further research is needed.

PMID: 15266195 [PubMed – indexed for MEDLINE] 192. Health Qual Life Outcomes. 2004 Jul 30;2:40.

Sad, blue, or depressed days, health behaviors and health-related quality of
life, Behavioral Risk Factor Surveillance System, 1995-2000.

Kobau R, Safran MA, Zack MM, Moriarty DG, Chapman D.

Health Care and Aging Studies Branch, Division of Adult and Community Health,
National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, GA 30341, USA.

BACKGROUND: Mood disorders are a major public health problem in the United States
as well as globally. Less information exists however, about the health burden
resulting from subsyndromal levels of depressive symptomatology, such as feeling
sad, blue or depressed, among the general U.S. population. METHODS: As part of an
optional Quality of Life survey module added to the U.S. Behavioral Risk Factor
Surveillance System, between 1995-2000 a total of 166,564 BRFSS respondents
answered the question, “During the past 30 days, for about how many days have you
felt sad, blue, or depressed?” Means and 95% confidence intervals for sad, blue,
depressed days (SBDD) and other health-related quality of life (HRQOL) measures
were calculated using SUDAAN to account for the BRFSS’s complex sample survey
design. RESULTS: Respondents reported a mean of 3.0 (95% CI = 2.9-3.1) SBDD in
the previous 30 days. Women (M = 3.5, 95% CI = 3.4-3.6) reported a higher number
of SBDD than did men (M = 2.4, 95% CI = 2.2-2.5). Young adults aged 18-24 years
reported the highest number of SBDD, whereas older adults aged 60-84 reported the
fewest number. The gap in mean SBDD between men and women decreased with
increasing age. SBDD was associated with an increased prevalence of behaviors
risky to health, extremes of body mass index, less access to health care, and
worse self-rated health status. Mean SBDD increased with progressively higher
levels of physically unhealthy days, mentally unhealthy days, unhealthy days,
activity limitation days, anxiety days, pain days, and sleepless days.
CONCLUSION: Use of this measure of sad, blue or depressed days along with other
valid mental health measures and community indicators can help to assess the
burden of mental distress among the U.S. population, identify subgroups with
unmet mental health needs, inform the development of targeted interventions, and
monitor changes in population levels of mental distress over time.

PMCID: PMC514530
PMID: 15285812 [PubMed – indexed for MEDLINE] 193. J Am Med Womens Assoc. 2004 Summer;59(3):210-5.

The best is yet to be: preventing, detecting, and treating depression in older

Crossett JH.

Carver College of Medicine, University of Iowa, USA.

To live fully for as long as life lasts is our goal for aging and the challenge
we face as we age ourselves and help our patients age. Although we cannot prevent
depression, we have information about the correlates of depression or its
absence. There are nonmedical interventions that significantly lessen depressive
symptoms. We have data on successful aging in the community that suggest some
preventative measures. The article reviews information about the risk factors for
depression in older women, the prevalence of depression in older women, and the
concept of minor or subsyndromal depression. Finally, current concepts of
treatment and data on longitudinal outcomes are presented.

PMID: 15354375 [PubMed – indexed for MEDLINE] 194. Am J Psychiatry. 2004 Jun;161(6):1084-9.

Seasonal variation in mood in African American college students in the
Washington, D.C., metropolitan area.

Agumadu CO, Yousufi SM, Malik IS, Nguyen MC, Jackson MA, Soleymani K, Thrower CM,
Peterman MJ, Walters GW, Niemtzoff MJ, Bartko JJ, Postolache TT.

D.C. Department of Mental Health, Washington, D.C., USA.

OBJECTIVE: The authors attempted to estimate the occurrence, frequency, and
pattern (winter versus summer) of seasonal affective disorder in African American
college students. They hypothesized that winter seasonal affective disorder would
be more prevalent than summer seasonal affective disorder. METHOD: Undergraduate
and graduate college students who identified themselves as African Americans
living in the Washington, D.C., metropolitan area were invited to participate in
the study. The Seasonal Pattern Assessment Questionnaire was used to calculate a
global seasonality score and to estimate the frequency of seasonal affective
disorder and subsyndromal seasonal affective disorder. The frequency of the
summer versus winter pattern of seasonality of seasonal affective disorder was
compared by using multinomial probability distribution tests. The effects of
gender and the awareness of seasonal affective disorder were evaluated with a
two-way analysis of variance. RESULTS: Of 646 students who were invited to
participate, 597 returned the questionnaires, and 537 (83.1%) fully completed
them. Winter seasonal affective disorder was significantly more prevalent than
summer seasonal affective disorder. The mean global seasonality score was 8.3
(SD=5.3). The majority of the subjects (80%) were not aware of the existence of
seasonal affective disorder. CONCLUSIONS: The authors found that the frequency,
magnitude, and pattern of seasonality of mood in African American students were
similar to those previously reported in the general population at similar
latitude, but that awareness of the existence of seasonal affective disorder, a
condition with safe and effective treatment options, was lower.

PMID: 15169697 [PubMed – indexed for MEDLINE] 195. Bipolar Disord. 2004 Jun;6(3):224-32.

Cognitive impairment in euthymic bipolar patients: implications for clinical and
functional outcome.

Martínez-Arán A, Vieta E, Colom F, Torrent C, Sánchez-Moreno J, Reinares M,
Benabarre A, Goikolea JM, Brugué E, Daban C, Salamero M.

Bipolar Disorders Program, Clinical Institute of Psychiatry and Psychology,
Hospital Clinic, Barcelona Stanley Medical Research Institute Center, University
of Barcelona, IDIBAPS, Spain.

OBJECTIVE: Cognitive impairment in bipolar disorder may be a stable
characteristic of the illness, although discrepancies have emerged with regard to
what dysfunctions remain during remission periods. The aim of this study was to
ascertain whether euthymic bipolar patients would show impairment in verbal
learning and memory and in executive functions compared with healthy controls.
Secondly, to establish if there was a relationship between clinical data and
neuropsychological performance. METHODS: Forty euthymic bipolar patients were
compared with 30 healthy controls through a battery of neuropsychological tests
assessing estimated premorbid IQ, attention, verbal learning and memory, and
frontal executive functioning. The effect of subsyndromal symptomatology was
controlled. RESULTS: Remitted bipolar patients performed worse than controls in
several measures of memory and executive function, after controlling for the
effect of subclinical symptomatology, age and premorbid IQ. Verbal memory
impairment was related to global assessment of function scores, as well as to a
longer duration of illness, a higher number of manic episodes, and prior
psychotic symptoms. CONCLUSIONS: Results provide evidence of neuropsychological
impairment in euthymic bipolar patients, after controlling for the effect of
subsyndromal depressive symptoms, suggesting verbal memory and executive
dysfunctions. Cognitive impairment seems to be related to a worse clinical course
and poor functional outcome.

PMID: 15117401 [PubMed – indexed for MEDLINE] 196. Int J Geriatr Psychiatry. 2004 Apr;19(4):386-90.

The Hopkins Symptom Checklist-25 is a sensitive case-finder of clinically
important depressive states in elderly people in primary care.

Fröjdh K, Håkansson A, Karlsson I.

Research and Development Unit for Primary Health Care, VÃ¥rdcentralen Kronoparken,
Karlstad, Sweden.

OBJECTIVE: No depression rating scale has yet been designed to identify all
clinically important depressive states in elderly. Therefore, this study
investigated the Hopkins Symptom Checklist-25 (HSCL-25), a self-rating scale for
depression, to see if it was a sensitive indicator of major, minor and
subsyndromal depression. METHODS: Structured interviews of 37 people with a high
depressive score and an age and sex matched control group comprised of 37 persons
with a low depressive score in HSCL-25, in order to compare the HSCL-25 ratings
with the Montgomery-Asberg-Depression Rating Scale (MADRS) as well as with the
criteria for major, minor and subsyndromal depression. RESULTS: The sensitivity
for identifying any depression was 94% and the specificity was 94% for HSCL-25
compared to the diagnostic criteria for depressive disorders. CONCLUSIONS:
HSCL-25 is a sensitive case-finder of any depressive disorder and may be useful
in general practice and for screening studies of depression in elderly people.
Copyright 2004 John Wiley & Sons, Ltd.

PMID: 15065233 [PubMed – indexed for MEDLINE] 197. J Gerontol A Biol Sci Med Sci. 2004 Apr;59(4):378-84.

Case-finding for depression in elderly people: balancing ease of administration
with validity in varied treatment settings.

Blank K, Gruman C, Robison JT.

Braceland Center for Mental Health and Aging, Institute of Living, Hartford
Hospital’s Mental Health Network, Hartford, Connecticut 06106, USA.

BACKGROUND: Little is known about the performance of brief and ultrabrief (1- and
2-question) depression screens in older patients across varied treatment sites.
This study (1) assesses their validity in clinics, hospitals, and nursing homes
and (2) assesses cut-points for optimal clinical application. METHODS: 360
patients aged 60 years and older from 2 urban primary care practices (n = 125), 1
general hospital (n = 150), and 8 nursing homes (n = 85) were assessed using the
Yale 1-question screen, the 2-question instrument derived from the Primary Care
Evaluation of Mental Disorders, and long and short versions of the Center for
Epidemiologic Studies Depression (CES-D) scale and Geriatric Depression Scale
(GDS). Sensitivity and specificity were calculated for each screen compared with
the criterion standard Diagnostic Interview Schedule (DIS) depression diagnosis
and receiver operating characteristic curves generated. RESULTS: 9% of patients
met DIS criteria for major depression and 7% for subsyndromal depression.
Overall, the 10-item CES-D showed the best sensitivity/specificity for major
depression in clinics (79%/81%) and hospitals (92%/77%), and the short GDS in
nursing homes (86%/82%). Specificity of 1- and 2-question instruments was
generally low. Established cut-points generally worked best for the short
screens, while modifications were useful for longer versions. CONCLUSIONS:
Consideration of site of use is important in selecting brief case-finding
instruments for late-life depression, with the 10-item CES-D working best in
medical settings and the 15-item GDS in nursing homes.

PMID: 15071082 [PubMed – indexed for MEDLINE] 198. Soc Psychiatry Psychiatr Epidemiol. 2004 Apr;39(4):293-8.

Subsyndromal depression: prevalence, use of health services and quality of life
in an Australian population.

Goldney RD, Fisher LJ, Dal Grande E, Taylor AW.

University of Adelaide, Department of Psychiatry, The Adelaide Clinic, 33 Park
Terrace, 5081, Gilberton, South Australia.

BACKGROUND: A study of the prevalence, use of services and quality of life of
those with subsyndromal depression in a random and representative Australian
population. METHODS: A face-to-face Health Omnibus survey of 3010 respondents
administered the mood module of the PRIME-MD and the SF-36 and AQoL quality of
life instruments. RESULTS: Subsyndromal depressive symptoms were identified in
12.9% of respondents. There was a gradation of use of services from those with no
depression, to those with subsyndromal, other and major depressions. Those with
subsyndromal depression scored significantly worse on quality of life measures
than those with no depression, but the effect size was small and less than the
poorer functioning of those with other depressive syndromes, particularly major
depression. CONCLUSIONS: Subsyndromal depression is very prevalent in the
community and worthy of clinical consideration.

PMID: 15085331 [PubMed – indexed for MEDLINE] 199. J Affect Disord. 2004 Mar;78(3):185-92.

Mood swings in patients with anxiety disorders compared with normal controls.

Bowen R, Clark M, Baetz M.

Department of Psychiatry, University of Saskatchewan, 103 Hospital Drive,
Saskatoon, SK, Canada, S7N 0W8.

BACKGROUND: About 70-80% of patients with anxiety syndromes suffer from
depression. Mood variability including hypomania, cyclothymia and hyperthymia
have been described in 40-50% of patients with depression. There is an emerging
literature that such variability could also characterize anxiety disorders. The
aim of this study was to visually document and quantify mood variability in
patients with anxiety disorders. METHODS: Twenty patients with anxiety disorders
and 22 normal control subjects completed two visual analogue scales (VAS) on
depressed mood and high mood, twice per day for 14 days. The Beck Depression
Inventory and the Altman Self-Rating Mood Scale were used for concurrent
validity. RESULTS: On the VAS, patients showed higher levels of depressed and
high moods, and greater mood variability than the controls. Variability of
depressed and high moods was highly correlated. LIMITATIONS: This was a
relatively small sample from a single center. Patients were selected by
convenience and were under treatment. The control subjects were not interviewed.
CONCLUSIONS: Subsyndromal mood variability in patients with anxiety disorders can
be visually depicted and quantified. The mood variability of patients with
anxiety disorders who also complain of mood swings is greater than the mood
fluctuations described by normal subjects.

PMID: 15013242 [PubMed – indexed for MEDLINE]





1: J Affect Disord 2003 Jan;73(1-2):123-31

The prevalence and disability of bipolar spectrum disorders in the US
population: re-analysis of the ECA database taking into account subthreshold

Judd LL, Akiskal HS.

Department of Psychiatry, University of California, San Diego (UCSD), 9500
Gilman Drive, 92093-0603, La Jolla, CA, USA

BACKGROUND: Despite emerging international consensus on the high prevalence of
the bipolar spectrum in both clinical and community samples, many skeptics
contend that narrowly defined bipolar disorder with a lifetime rate of about 1%
represents a more accurate estimate of prevalence. This may in part be due to
the fact that higher figures proposed for the bipolar spectrum (5-8%) have not
been based on national data and have not included all levels of manic symptom
severity. In the present secondary analyses of the US National Epidemiological
Catchment Area (ECA) database, we provide further clarification on this
fundamental public health issue. METHODS: All respondents in the first wave
(first interview) of the ECA household five site sample (n=18,252) were
classified on the basis of DSM-III criteria into lifetime manic and hypomanic
episodes, as well as those with at least two lifetime manic/hypomanic symptoms
below the threshold for at least 1 week duration (subsyndromal manic symptoms
[SSM] group). Odds ratios were calculated on lifetime service utilization for
mental health problems, measures of adverse psychosocial outcome, and suicidal
behavior compared to subjects with no mental disorders or manic symptoms.
RESULTS: As originally reported nearly two decades ago by the primary
investigators of the ECA, the lifetime prevalence for manic episode was 0.8%,
and for hypomania, 0.5%. What is new here is the inclusion of subthreshold SSM
subjects, which accounted for 5.1%, yielding a total of 6.4% lifetime prevalence
for the bipolar spectrum. All three (manic, hypomanic and SSM) groups had
greater marital disruption. There were significant increases in lifetime health
service utilization, need for welfare and disability benefits and suicidal
behavior when the SSM, hypomanic and manic subjects were compared to the no
mental disorder group. Suicidal behavior was non-significantly highest in the
hypomanic (bipolar II) group. Otherwise, hypomanic and manic groups had
comparable level of service utilization and social disruption. LIMITATIONS:
Comorbid disorders, which might influence functioning, were not included in the
present analyses. CONCLUSION: These secondary analyses of the US National ECA
database provide convincing evidence for the high prevalence of a spectrum of
bipolarity in the community at 6.4%, and indicate that subthreshold cases are at
least five times more prevalent than DSM-based core syndromal diagnoses at about
1%. These SSM subjects, who met the criteria of “caseness” from the point of
view of harmful dysfunction, are of great theoretical and public health


2: Bipolar Disord 2002 Oct;4(5):328-34

Olanzapine in diverse syndromal and subsyndromal exacerbations of bipolar

Janenawasin S, Wang PW, Lembke A, Schumacher M, Das B, Santosa CM, Mongkolcheep
J, Ketter TA.

Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, CA 94305-5723, USA.

OBJECTIVE: To evaluate effects of olanzapine in diverse exacerbations of bipolar
disorders. METHODS: Twenty-five evaluable bipolar disorder [14 bipolar I (BPI),
10 bipolar II (BPII) and one bipolar disorder not otherwise specified (BP NOS)] outpatients received open olanzapine (15 adjunctive, 10 monotherapy). Thirteen
had elevated (11 syndromal, two subsyndromal) and 12 depressed (four syndromal,
eight subsyndromal) mood symptoms of at least mild severity, with Clinical
Global Impression-Severity (CGI-S) scores of at least 3. Only one had psychotic
symptoms. RESULTS: With open olanzapine (15 adjunctive, 10 monotherapy), overall
symptom severity (CGI-S) as well as mood elevation (Young Mania Rating Scale),
depression (Hamilton and Montgomery-Asberg Depression Rating Scales), and
anxiety (Hamilton Anxiety Rating Scale), rapidly decreased (significantly by
days 2-3). Patients with the greatest baseline severity (CGI-S) had the greatest
improvement. Fifteen of 25 (60%) patients responded. Time to consistent response
was bimodal, with five early (by 0.5 +/- 0.3 weeks) and 10 late (by 7.0 +/- 1.9
weeks) responders. Early compared with late responders had 51% lower final
olanzapine doses. Olanzapine was generally well tolerated, with sedation and
weight gain the most common adverse effects. CONCLUSIONS: Olanzapine was
effective in diverse exacerbations of bipolar disorders. The bimodal
distribution of time to response and different final doses are consistent with
differential mechanisms mediating early compared with late responses. Controlled
studies are warranted to further explore these preliminary observations.


3: Psychiatr Clin North Am 2002 Dec;25(4):685-98

The prevalence, clinical relevance, and public health significance of
subthreshold depressions.

Judd LL, Schettler PJ, Akiskal HS.

Department of Psychiatry, University of California, San Diego, 9500 Gilman
Drive, La Jolla, CA 92093-0603, USA.

Scientific evidence has accumulated during the last 15 years establishing that
SD symptoms have a high prevalence in the general population and in clinically
depressed patient cohorts studied cross-sectionally or followed longitudinally.
The clinical relevance and public health importance of SD symptoms were
confirmed when various investigators, including the authors’ group at University
of California, San Diego, found that SD symptoms are associated with a
significant and pervasive impairment of psychosocial function when compared to
no depressive symptoms. There is strong evidence that all levels of depressive
symptom severity of unipolar MDD are associated with significant psychosocial
impairment, which increases significantly and linearly with each increment in
level of symptom severity. It is only when MDD patients are completely symptom
free that psychosocial function returns to good or very good levels. The
disability associated with depression is state dependent, and disability returns
to good or normal levels only when all of the depressed patients’ symptoms
abate, because disability is present when even a few symptoms (i.e., SD
symptoms) are detected. There is strong evidence during the long-term course of
illness that major, minor, dysthymic, and subsyndromal symptoms wax and wane
within the same patient and that these symptomatic periods are interspersed in
the overall course with times when patients are remitted and symptom free. The
modal longitudinal symptom status of MDD patients involves primarily
subthreshold depressive symptoms, which are much more common than symptoms at
the syndromal MDE level. The longitudinal systematic examination of the clinical
relevance and high prevalence of SD symptoms helped establish the fact that the
long-term symptomatic expression of MDD is dimensional, not categorical, in
nature. Abatement of SD symptoms is of fundamental importance in defining full
remission or recovery of MDEs. Ongoing residual SD symptoms during the recovery
periods after an MDE are associated with psychosocial disability, more rapid MDE
relapse, and a more severe chronic future course of illness, all of which
indicate that when residual SD symptoms are present the MDE has not fully
remitted and the disease is still active. When all depressive symptoms of an MDE
abate for a minimum of 8 weeks, then full remission has been achieved. MDE
remission defined in this way is associated with significant delay or even
prevention of future episode relapse and a less severe, relapsing, and chronic
future course. The authors submit that the research reviewed in this article
heralds a new paradigm in understanding the progression of clinical depression
through various overlapping stages of severity, which begin at the seemingly
“subclinical” level of depressive symptoms. This conceptualization in turn
dictates a public health approach, which emphasizes that treatment of MDD even
at the deceptively mild levels of symptoms should be initiated or maintained.


4: J Clin Psychiatry 2002 Sep;63(9):807-11

Subsyndromal depression is associated with functional impairment in patients
with bipolar disorder.

Altshuler LL, Gitlin MJ, Mintz J, Leight KL, Frye MA.

Department of Psychiatry and Biobehavioral Sciences, University of California,
Los Angeles, USA.

BACKGROUND: The purpose of this study was to assess whether a relationship
exists between mild depressive symptoms and overall functioning in subjects with
bipolar disorder. METHOD: Twenty-five male subjects with bipolar I disorder
(DSM-III-R criteria), who had not experienced a DSM-III-R episode of mania,
hypomania, or major depression for 3 months as determined using the Structured
Clinical Interview for DSM-III-R, were evaluated for degree of depressive
symptoms using the Hamilton Rating Scale for Depression (HAM-D) and for overall
functional status using the Global Assessment of Functioning (GAF, DSM-IV Axis
V). RESULTS: GAF scores were significantly negatively correlated with HAM-D
scores (r = -0.61, df = 23, p = .001), despite the fact that no patient had a
HAM-D score high enough to be considered clinically depressed. CONCLUSION: The
results of this study support a relationship between subsyndromal depressive
symptoms and functional impairment in bipolar subjects, despite their not
meeting threshold criteria for a major depressive episode. These findings raise
the possibility that in some patients with bipolar disorder subsyndromal
depressive symptoms might contribute to ongoing functional impairment.


5: Psychother Psychosom 2001 Sep-Oct;70(5):232-8

Prevalence and clinical correlates of residual depressive symptoms in bipolar II

Benazzi F.

Department of Psychiatry, National Health Service (AUSL), Forli, Italy.

BACKGROUND: Most patients with unipolar and bipolar I disorder have residual
symptoms, despite successful treatment. The appraisal of subsyndromal
symptomatology has important implications for pathophysiological models of
disease and relapse prevention. Residual symptoms in bipolar II disorder were
studied insufficiently. The study of residual symptoms in bipolar II disorder is
important, because many depressed outpatients may suffer from it and because
bipolar II disorder may be distinct from type I. The study aims were to assess
the prevalence and clinical correlates of persistent residual depressive
symptoms in bipolar II disorder. METHODS: 138 consecutive patients with bipolar
II disorder and 83 unipolar disorder outpatients, presenting for major
depressive episode treatment in private practice, were interviewed with the
Structured Clinical Interview for DSM-IV Axis I Disorders – Clinician’s Version.
Study variables were persistent (more than 2 years) residual depressive
symptoms, age, gender, age at onset, illness duration, recurrences, axis I
comorbidity, severity, psychotic, melancholic and atypical features. RESULTS:
The prevalence of residual depressive symptoms was 44.9% in bipolar II disorder
and 43.3% in unipolar disorder. Residual depressive symptoms in bipolar II and
unipolar disorders were significantly and positively associated with illness
duration and recurrences. CONCLUSIONS: Persistent residual depressive symptoms
were common in bipolar II disorder. Residual unipolar and bipolar II depressive
symptoms were related to duration of illness and number of recurrences. Reducing
these variables could reduce and prevent residual symptoms. A mechanism of
kindling (more mood episodes leading to worse outcome) could be that of leaving
a larger and larger amount of residual symptoms after the acute episode has
subsided. Copyright 2001 S. Karger AG, Basel.


6: Am J Orthopsychiatry 2001 Jan;71(1):87-97

Subsyndromal depressive symptoms and major depression in postpartum women.

Weinberg MK, Tronick EZ, Beeghly M, Olson KL, Kernan H, Riley JM.

Department of Pediatrics, Harvard Medical School, Boston, USA.

This study documents differences in the psychosocial functioning of women three
months postpartum with subclinical depression, major depression prior to the
birth of the baby, major depression both pre- and post-birth, and no depression.
An understanding of these differences may have implications for intervention
insofar as maternal depression places at risk not only the mother’s functioning
but her infant’s development, as well.


7: J Affect Disord 2001 Mar;63(1-3):51-8

Subsyndromal depression in adolescents after a brief psychotherapy trial: course
and outcome.

Brent DA, Birmaher B, Kolko D, Baugher M, Bridge J.

Division of Child and Adolescent Psychiatry, Western Psychiatric Institute and
Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213, USA.

INTRODUCTION: Subsyndromal depression has been associated with an increased risk
of the development of major depressive disorder (MDD). Since treatment trials of
adolescent MDD often result in subsyndromal depression as the outcome, the
long-term course of these youth would be useful to understand. METHODS: 107
adolescents with MDD participated in a clinical psychotherapy trial, of whom 99
were followed up for two years after acute treatment. Those with subsyndromal
depression (2-3 symptoms) at the end of acute treatment were compared to those
who were well (< or =1 symptom) and those who were still depressed (> or =4
symptoms) on presentation at intake, the end of treatment, and over the two-year
follow-up. RESULTS: Of the 99 youth, at the end of acute treatment 26 were well,
18 were subsyndromal, and 55 were still depressed. A substantial proportion of
the subsyndromally depressed youth were functionally impaired (38%), and showed
a protracted time to recovery. The risk of recurrence was similar to those who
were without depression at the end of acute treatment (46% vs. 44%). Recurrence
was predicted by depressive symptom severity and family difficulties at the end
of acute treatment. LIMITATIONS: A large proportion of the subsyndromal groups
received open treatment that may have altered their course. Also, this was a
referred sample, rather than an epidemiological one. CONCLUSIONS: In clinical
samples treated with psychotherapy, subsyndromal depression poses a significant
risk for functional impairment and protracted recovery. Depressive recurrence
may be prevented by targeting reduction of symptom severity and of family


8: Depress Anxiety 2000;12(1):30-9

Subsyndromal symptomatic depression: a new concept.

Sadek N, Bona J.

Department of Psychiatry and Behavioral Sciences, Emory University School of
Medicine, Atlanta, Georgia, USA.

Although DSM-IV acknowledged the clinical significance of some subthreshold
forms of unipolar depression, such as minor depression (MinD) and recurrent
brief depression (RBD), clinicians continued to struggle with the concept of
“subthreshold” depression. A substantial number of patients continued to present
with depressive symptoms that still did not satisfy any DSM-IV diagnosis.
Generally, these patients failed to complain of anhedonia and depressed mood, a
criterion that DSM-IV mandates for any diagnosis of depression. Therefore,
researchers reexamined the question of whether this cluster of depressive
symptoms, in the absence of anhedonia and depressed mood, was clinically
significant. Some researchers labeled this cluster of symptoms, “subsyndromal
symptomatic depression” (SSD). Specifically, SSD is defined as a depressive
state having two or more symptoms of depression of the same quality as in major
depression (MD), excluding depressed mood and anhedonia. The symptoms must be
present for more than 2 weeks and be associated with social dysfunction. Using
Medline Search, the authors reviewed the literature on the epidemiology,
demographics, clinical characteristics, and psychosocial impairment of SSD. SSD
is found to be comparable in demographics and clinical characteristics to MD,
MinD, and dysthymia. SSD is also associated with significant psychosocial
dysfunction as compared with healthy subjects. Further; it has significant risk
for suicide and future MD. Few studies have been conducted on the treatment of
SSD. The high prevalence of SSD, the significant psychosocial impairment
associated with it, and the chronicity of its course make subsyndromal
symptomatic depression a matter for serious consideration by clinicians and


9: Subthreshold depression in the elderly: qualitative or quantitative distinction?

Geiselmann B, Bauer M.

Department of Behavioral Therapy and Psychosomatic Medicine, Klinik Seehof BfA,
Teltow, Germany.

Recent studies revealed that subthreshold depression (or “subclinical” or
“subsyndromal” depression) can have clinical validity because it is related to
dysfunction and disability and is a risk factor for major depression. However,
none of these studies focused on old age. Therefore, one aim of the psychiatric
part of the multidisciplinary Berlin Aging Study (BASE) was also to detect
milder forms of psychopathological syndromes, especially subthreshold
depression, compared with specified forms such as major depression and dysthymia
according to the DSM-III-R. The present evaluation shows that subthreshold
depression can be characterized in 2 ways: firstly, as a quantitatively minor
variant of depression or a depression-like state with fewer symptoms or with
less continuity; and secondly, as qualitatively different from major depression
with fewer suicidal thoughts or feelings of guilt or worthlessness, while
worries about health and weariness of living occur with a similar frequency.


10: Epidemiol Psichiatr Soc 1999 Oct-Dec;8(4):255-61

Subthreshold affective disorders: a useful concept in psychiatric epidemiology?

Schotte K, Cooper B.

Section of Old Age Psychiatry, Institute of Psychiatry, London, UK.

OBJECTIVE: In recent years an extensive literature has grown up around the
concepts of subthreshold, subsyndromal, minor and brief recurrent affective
disorder and their applications in population-based research. The aim of this
short review is to examine the definitions and current status of these proposed
categories with special reference to depression, and to assess their potential
contribution to psychiatric epidemiology. METHOD: A Medline search was carried
out for the period 1965-1999, based on the above four terms. Relevant references
found in all identified publications were also followed up. RESULTS: In great
measure these constructs have been developed as a response to deficiencies in
the DSM classification system and to a lesser extent in the ICD. The groups are
all defined by having fewer criterial symptoms, or a shorter duration of
symptoms, than the ‘official’ diagnostic categories. Use of these definitions
has resulted in widely varying prevalence estimates. CONCLUSION: Improved
methods are badly needed for classifying all those persons in the wider
community who are in need of medical treatment and help for psychological
disorder, but do not satisfy operational criteria laid down in the official
guidelines. This cannot, however, be achieved simply by lowering operational
thresholds in these systems. Further research on clinical and psycho-social
characteristics of the common mental disorders is called for, and in many
societies a favourable setting is that of primary health care, where a move
towards pragmatic, comprehensive classification of community health problems is
already under way.


11: Addict Behav 1999 Nov-Dec;24(6):781-94

History of depression and subsyndromal depression in women smokers.

Borrelli B, Marcus BH, Clark MM, Bock BC, King TK, Roberts M.

Brown University School of Medicine & The Miriam Hospital, Division of
Behavioral and Preventive Medicine, Providence, RI 02906, USA.

While Major Depressive Disorder (MDD) is associated with difficulty quitting
smoking, few studies have examined the role of subsyndromal depression (SubD).
We examined pretreatment differences in smoking, weight concerns, and negative
affect among three groups of women (N = 281) enrolling in a smoking cessation
program who responded to a self-report questionnaire about the lifetime presence
of MDD symptoms: self-report positive for MDD, self-report positive for SubD,
and self-report negative for depression (fulfilling either DSM-III-R symptom or
duration criteria, but not both). Compared to MDD Subjects (Ss), SubD Ss were
more likely to report eating disordered behaviors. Compared to Non-Depressed
(Non-Dep) Ss, SubD Ss initiated smoking earlier, and reported greater previous
withdrawal symptoms, more eating disordered behaviors, and higher anxiety,
depression, and stress. Compared to Non-Dep Ss, MDD Ss reported a greater
smoking rate during their heaviest usage period, greater previous withdrawal
symptoms, lower self-efficacy to manage food intake (especially during negative
affect situations), and greater depression and anxiety. Many of these
significant differences disappeared when SubD Ss were combined with Non-Dep Ss
and compared with MDD Ss as is done traditionally. SubD does not appear to be on
a continuum with Non-Dep and MDD groups, but rather warrants further
investigation as a discrete subset of smokers. The implications for assessment
and treatment are discussed.


12: Actas Esp Psiquiatr 1999 Jul-Aug;27(4):223-7

[Subsyndromal depressive semiology in severe alcoholism] [Article in Spanish]

Huertas D, Bautista S, Sanjoaquin A, Chamorro L, Gilaberte I.

Servicio de Psiquiatria, Hospital Universitario de Guadalajara, Guadalajara,
19002, Espana.

INTRODUCTION: Several investigations have communicated frequent association
between alcohol dependence and depression. METHOD: 21 subjects with DSM-IV
criteria for alcohol dependence were included in an open label trial for alcohol
withdrawal. At inclusion and along the follow-up none of the probands met DSM-IV
criteria for mood disorder. Follow-up included a 15-day detoxification period
and 195 days of withdrawal program, including treatment with 20 mg/d of
fluoxetine. Occurrence of depressive semiology was measured using the Beck
Depression Inventory (BDI) on day 15 (after detoxification), day 75 and day 210
(after withdrawal from ethanol of 195 days). RESULTS: 67% of the sample showed a
positive basal BDI (after-detoxification-BDI> 9). Global retention rate after
210 days of follow-up was 57%. All patients who dropped out the investigation
before completing the protocol showed a basal BDI in the depressive rank (BDI=
10-63), and maintained depressive scores in this instrument until their
abandonment. CONCLUSIONS: Prevalence of <> in
this population appears to be high. This clinical feature is frequently ignored
because most of the patients do not meet standardized diagnostic criteria for
mood disorders. Post-detoxification BDI could be used as a predictive factor of
therapeutic result in long-term alcohol withdrawal programs. In addition, in our
study fluoxetine showed efficacy in maintaining long-term alcohol abstinence.


13: J Am Geriatr Soc 1999 Jun;47(6):647-52

Comment in:
J Am Geriatr Soc. 1999 Jun;47(6):757-8.

The importance of subsyndromal depression in older primary care patients:
prevalence and associated functional disability.

Lyness JM, King DA, Cox C, Yoediono Z, Caine ED.

Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University
of Rochester School of Medicine and Dentistry, New York 14642, USA.

OBJECTIVE: Existing diagnostic categories for depression may not encompass the
majority of older people suffering clinically significant depressive symptoms.
We have described the prevalence of subsyndromal depressive symptoms and tested
the hypothesis that patients with subsyndromal depression have greater
functional disability and general medical burden than nondepressed subjects but
less than patients with diagnosable depressions. METHODS: Subjects were 224
patients, aged 60 years and older, recruited from private internal medicine
offices or a family medicine clinic. Validated measures of psychopathology,
medical burden, and functional status were used. The subsyndromal depression
group was defined by a score of more than 10 on the Hamilton Rating Scale for
Depression and by the absence of major or minor depressive disorder. Analyses
included multiple regression techniques to determine the presence of group
differences adjusted for demographic covariates. RESULTS: Subsyndromal
depression was common (estimated point prevalence of 9.9% compared with 6.5% for
major depression, 5.2% for minor depression, and .9% for dysthymic disorder),
associated with functional disability and medical comorbidity to a degree
similar to major or minor depression, and often treated with antidepressant
medications. CONCLUSIONS: Although depressive conditions are common and are
associated with considerable functional and medical morbidity in older primary
care patients, many patients with clinically significant depressive symptoms are
not captured by criteria-based syndromic diagnostic categories. Future work
should include intervention studies of subsyndromally depressed older persons as
well as attention to the course and biopsychosocial concomitants of diagnosable
and subsyndromal depressions in this population.


14: Encephale 1998 Sep-Oct;24(5):405-14

[Subthreshold depressive disorders: description and importance for secondary
prevention in psychiatry] [Article in French]

Castelnau C, Olie JP, Loo H.

Service Hospitalo-Universitaire de Sante Mentale et Therapeutique, Centre
Hospitalier Sainte-Anne, Paris.

“Subsyndromic” or “subthreshold” mood disorders belong to the category of mood
disorders. Because newly studied, few informations are available up to date. The
Appendix B of the DSM IV introduces six categories of research criteria which
characterize these disorders and give us the thread of our study. From
Hippocrate to contemporary specialists, many authors reported mild forms of mood
disorders, including the Kraepelin or the psychoanalyst authors views. Dysthymic
Disorder, Minor Depressive Disorder and Brief Recurrent Depressive Disorder are
different categories of subthreshold unipolar disorders. During their course,
these disorders overlap each other and with major mood disorders. Many studies,
carried out in primary care practice, pointed out the severe impairment in
social functioning, experienced by these patients. We propose a review of “Minor
Depressive Disorders”, focusing on some points: definitions, epidemiologic
studies, “functional impact” of this kind of disorders, comorbidity and
therapeutical considerations. Prevalence of suicide is extensive in non major
depressive disorders. We discuss interest of “subsyndromic concept” aiming at
the prevention of major mood disorders. Moreover, this concept leads to a new
clinical approach in the care of mood disorders and provides new fields for
psychopathological research.


15: Arch Gen Psychiatry 1998 Aug;55(8):694-700

Comment in:
Arch Gen Psychiatry. 1999 Aug;56(8):764-5.

A prospective 12-year study of subsyndromal and syndromal depressive symptoms in
unipolar major depressive disorders.

Judd LL, Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, Paulus MP,
Kunovac JL, Leon AC, Mueller TI, Rice JA, Keller MB.

Department of Psychiatry, University of California, San Diego, La Jolla
92093-0603, USA.

BACKGROUND: Investigations of unipolar major depressive disorder (MDD) have
focused primarily on major depressive episode remission/recovery and
relapse/recurrence. This is the first prospective, naturalistic, long-term study
of the weekly symptomatic course of MDD. METHODS: The weekly depressive symptoms
of 431 patients with MDD seeking treatment at 5 academic centers were divided
into 4 levels of severity: (1) depressive symptoms at the threshold for MDD; (2)
depressive symptoms at the threshold for minor depressive or dysthymic disorder
(MinD); (3) subsyndromal or subthreshold depressive symptoms (SSDs), below the
thresholds for MinD and MDD; and (4) no depressive symptoms. The percentage of
weeks at each level, number of changes in symptom level, and medication status
were analyzed overall and for 3 subgroups defined by mood disorder history.
RESULTS: Patients were symptomatically ill in 59% of weeks. Symptom levels
changed frequently (1.8/y), and 9 of 10 patients spent weeks at 3 or 4 different
levels during follow-up. The MinD (27%) and SSD (17%) symptom levels were more
common than the MDD (15%) symptom level. Patients with double depression and
recurrent depression had more chronic symptoms than patients with their first
lifetime major depressive episode (72% and 65%, respectively, vs 46% of
follow-up weeks). CONCLUSION: The long-term weekly course of unipolar MDD is
dominated by prolonged symptomatic chronicity. Combined MinD and SSD level
symptoms were about 3 times more common (43%) than MDD level symptoms (15%). The
symptomatic course is dynamic and changeable, and MDD, MinD, and SSD symptom
levels commonly alternate over time in the same patients as a symptomatic
continuum of illness activity of a single clinical disease.


16: J Affect Disord 1998 Mar;48(2-3):227-32

Minor depressive disorder and subsyndromal depressive symptoms: functional
impairment and response to treatment.

Rapaport MH, Judd LL.

Department of Psychiatry, University of California, San Diego, School of
Medicine, La Jolla 92037, USA.

BACKGROUND: This study quantifies functional impairment and depressive
symptomatology in patients with minor depressive disorder (MinD) and
subsyndromal depressive symptomatology (SSD) before and after 8 weeks of
treatment with fluvoxamine. Study patients were compared and contrasted with
archival data from a sample of the general population measured by the Medical
Outcome Survey Short Form 36. METHOD: Fifteen patients with MinD and 15 patients
with SSD were identified from primary care clinics, referrals and newspaper
advertisements. Patients signed informed consent and were offered open label
treatment with fluvoxamine 25-100 mg/day. Patients were seen biweekly and
measures of functional impairment and depressive symptomatology were gathered
systematically. RESULTS: MinD and SSD were associated with dysfunction and
disability when compared to archival normative data from the general population.
Eight week treatment with fluvoxamine was associated with a substantial decrease
in depressive symptomatology and a normalization of psychosocial functioning.
CONCLUSION: This is the first study to quantify functional impairment and the
severity of depressive symptomatology in a clinical sample of patients with MinD
and SSD, and to demonstrate that treatment with a selective serotonin reuptake
inhibitor decreases depressive symptomatology and improves psychosocial
functioning. Placebo-controlled double-blind confirmation of these preliminary
observations seems warranted.


17: Am J Psychiatry 1998 Feb;155(2):172-7

Boundaries of major depression: an evaluation of DSM-IV criteria.

Kendler KS, Gardner CO Jr.

Virginia Institute for Psychiatric and Behavioral Genetics, Medical College of
Virginia of Virginia Commonwealth University, Richmond, USA.

OBJECTIVE: Little is known about the boundaries between major depression and
milder subsyndromal depressive states. With respect to depressive symptoms, does
DSM-IV “carve nature at its joints”? METHOD: In personally interviewed female
twins from a population-based registry, the authors examined whether a range of
values along three dimensions of the depressive syndrome assessed in the last
year (number of symptoms listed in DSM-III-R under diagnostic criterion A for
major depressive episode, level of severity or impairment required to score
symptoms as present, and duration of episode) predicted future depressive
episodes in the index twin and risk of major depression in the co-twin. RESULTS:
An increasing number of criterion A symptoms predicted, in a monotonic fashion,
a greater risk for future depressive episodes in the index twin as well as a
greater risk for major depression in the co-twin. No such consistent
relationship was seen with duration of episode. For severity, a single monotonic
function predicted risk in the co-twin, while index twins with severe impairment
had a substantially higher risk for future episodes than did those with less
severe impairment. Four or fewer criterion A symptoms, syndromes composed of
symptoms involving no or minimal impairment, and episodes of less than 14 days’
duration all significantly predicted both future depressive episodes in the
index twin and risk of major depression in the co-twin. CONCLUSIONS: The authors
found little empirical support for the DSM-IV requirements for 2 weeks’
duration, five symptoms, or clinically significant impairment. Most functions
appeared continuous. These results suggest that major depression–as articulated
by DSM-IV–may be a diagnostic convention imposed on a continuum of depressive
symptoms of varying severity and duration.


18: J Affect Disord 1997 Aug;45(1-2):53-63

Subthreshold depressions: clinical and polysomnographic validation of dysthymic,
residual and masked forms.

Akiskal HS, Judd LL, Gillin JC, Lemmi H.

Department of Psychiatry, University of California at San Diego, USA.

We summarize clinical and polysomnographic findings in support of the existence
of a broad and prevalent spectrum of less than syndromal or subthreshold
depressive conditions that constitute subeffective disorders. Many of these
conditions were previously subsumed under such rubrics as ‘neurotic,’
‘characterological,’ and ‘existential’ depressions. Prospective follow-up
studies of neurotic depressions (defined by a predominance of the psychological
features of, in most instances, less than syndromal depression) have
demonstrated their transformation into moderate to melancholic or psychotic
depressive, and even bipolar, disorders. Many characterological depressives
(outpatients with early insidious onset and fluctuating chronicity of
subthreshold manifestations falling short of full syndromal depression), were
shown to have shortened REM latency, increased REM%, redistribution of REM to
the first part of the night, classic diurnality, high rates of family history
for mood disorders, positive response to antidepressants and sleep deprivation,
and prospective follow-up course leading to major affective episodes. Shortened
REM latency and related sleep neurophysiological disturbances have also been
reported to characterize so-called ‘borderline’ personality disorder even when
examined in the absence of concomitant major depression. Finally, among primary
care referrals to a sleep disorders center, short REM latency was found in a
large number of patients without subjective mood change but with somatic
manifestations of depression (meeting Probable Feighner Depression and/or lesser
subacute manifestations). Rather than being incidental, the REM disturbances in
the foregoing studies appear consistently on consecutive nights of
polysomnography in the subthreshold affective group; this was not the case for
patients with non-affective personality and anxiety disorders. The findings
overall tend to support a common neurophysiological substrate for subthreshold
and melancholic depressions and, interpreted in the context of clinical
observations, family history and follow-up course, uphold the validity of
dysthymic, intermittent and subsyndromal depressions.


19: J Abnorm Psychol 1995 May;104(2):381-4

Subsyndromal unipolar and bipolar disorders: comparisons on positive and
negative affect.

Lovejoy MC, Steuerwald BL.

Department of Psychology, Northern Illinois University, DeKalb 60115, USA.

The authors examined the mood patterns of young adults with cyclothymia,
intermittent depression, or no affective disorder in a nonclinical population.
In a conceptual replication and extension of R. A. Depue et al. (1981, Study 5),
participants completed a trait measure of mood and then completed daily mood
ratings for 28 days. Individuals in the intermittent depression and cyclothymia
groups were characterized by high levels of negative affect on trait and daily
ratings. Both groups were also characterized by high variability of negative
affect across days. Individuals with cyclothymia reported higher levels of trait
and daily positive affect than individuals with intermittent depression and also
exhibited high between-day variability on positive affect. Similarities and
differences with R. A. Depue et al. (1981) are described and the results are
discussed in terms of the common and differentiating features of the
subsyndromal affective disorders.


20: J Clin Psychiatry 1994 Apr;55 Suppl:18-28

Comment in:
J Clin Psychiatry. 1995 Jul;56(7):329.

Subsyndromal symptomatic depression: a new mood disorder?

Judd LL, Rapaport MH, Paulus MP, Brown JL.

San Diego Psychopharmacology Research Program, Department of Psychiatry,
University of California, La Jolla 92093-0603.

Secondary analyses in a subsample (N = 9160) of the National Institute of Mental
Health Epidemiologic Catchment Area Program data base revealed that 19.6% of the
general population reported one or more depressive symptoms in the previous
month. One-year prevalence of two or more depressive symptoms in the general
population was 11.8%, a prevalence figure exceeding the 9.5% 1-year prevalence
for all the DSM-III mood disorders combined. We have labeled this potential
clinical condition as subsyndromal symptomatic depression (SSD), defining it as
any two or more simultaneous symptoms of depression, present for most or all of
the time, at least 2 weeks in duration, associated with evidence of social
dysfunction, occurring in individuals who do not meet criteria for diagnoses of
minor depression, major depression, and/or dysthymia. SSD has a 1-year
prevalence in the general population of 8.4%, two thirds of whom are women
(63.4%). The most common SSD symptoms reported are insomnia (44.7%), feeling
tired out all the time (42.1%), recurrent thoughts of death (31.0%), trouble
concentrating (22.7%), significant weight gain (18.5%), slowed thinking (15.1%),
and hypersomnia (15.1%). Increased prevalence of disability and welfare benefits
was found in SSD as compared with respondents with no depressive symptoms. SSD
represents a significant clinical population not covered by any DSM-III,
DSM-III-R, or DSM-IV mood disorder diagnosis. Since SSD is also associated with
significant increases in social dysfunction and disability, we feel there is
good evidence to conclude that SSD is an unrecognized clinical condition of
considerable public health importance that is deserving of further
characterization and study.


21: Arch Gen Psychiatry 1992 May;49(5):371-6

Subsyndromal symptoms in bipolar disorder. A comparison of standard and low
serum levels of lithium.

Keller MB, Lavori PW, Kane JM, Gelenberg AJ, Rosenbaum JF, Walzer EA, Baker LA.

Department of Psychiatry and Human Behavior, Brown University, Providence, RI.

Ninety-four patients with bipolar disorder participating in a random-assignment,
double-blind, prospective maintenance trial of standard- (0.8 to 1.0 mmol/L) vs
low-range (0.4 to 0.6 mmol/L) serum lithium levels were assessed to determine
the presence and significance of subsyndromal symptoms during periods of
remission and recovery. A significant relationship was found between prescribed
serum lithium level and the probability of major affective relapse and the
occurrence of subsyndromal symptoms. Patients given lithium carbonate to achieve
low-range levels had 2.6 times the risk of major affective relapse as those
given lithium for standard-range levels and nearly twice the risk of developing
subsyndromal symptoms. Patients given the low-range therapy showed a greater
variance in weekly Psychiatric Status Rating measures, and their symptoms were
more likely to worsen at any time than were symptoms in their standard-level
group counterparts. The first occurrence of subsyndromal symptoms increased the
risk of major affective relapse fourfold. Following the onset of subsyndromal
symptoms, the patients originally randomized to receive standard-range lithium
therapy were still better protected from relapse than were patients randomized
to receive low-range lithium treatment. Patients were two times more likely to
develop depressive than hypomanic symptoms between acute episodes of illness.
However, onset of hypomanic symptoms predicted subsequent major affective
relapse twice as strongly as did depressive symptoms. Seventy-six percent of
patients who became hypomanic had a major affective relapse, compared with 39%
of patients who were subclinically depressed.