Anda Gershon

Gender, victimization, and psychiatric outcomes.

BACKGROUND Although gender differences in rates of internalizing disorders, particularly depression, are well documented, the causes of these differences are not well understood. One influential hypothesis [Cutler & Nolen-Hoeksema, Sex Roles (1991), 24, 425-438] proposes that higher rates of depression in females compared to males may be partially attributable to gender differences in the effects of childhood sexual abuse. The present study has evaluated this possibility by reviewing evidence for gender moderating the effects of childhood victimization on psychiatric outcomes. METHOD Literature search using PsycINFO and Medline, applying the following inclusion criteria: publication from 1996 to 2006, community-based sampling, adequate male-to-female sample ratio, use of clearly defined psychiatric outcomes, and a statistical test of gender differences in the effects of childhood victimization on psychiatric outcomes. RESULTS Thirty studies met inclusion criteria. Overall, the results were mixed. Nearly half of all studies find no gender differences. In studies that do observe gender differences, victimization tends to be associated with higher psychiatric risk in females in studies with adult samples, whereas in samples of youth, victimization tends to be associated with higher psychiatric risk in males. With respect to outcome, when gender differences were observed, outcomes were distributed across both internalizing and externalizing categories for both genders. CONCLUSIONS The gender differences in prevalence rates of internalizing disorders, such as depression, do not appear to be attributable to differential effects of childhood victimization.

The long-term impact of early adversity on late-life psychiatric disorders.

Early adversity is a strong and enduring predictor of psychiatric disorders including mood disorders, anxiety disorders, substance abuse or dependence, and posttraumatic stress disorder. However, the mechanisms of this effect are not well understood. The purpose of this review is to summarize and integrate the current research knowledge pertaining to the long-term effects of early adversity on psychiatric disorders, particularly in late life. We explore definitional considerations including key dimensions of the experience such as type, severity, and timing of adversity relative to development. We then review the potential biological and environmental mediators and moderators of the relationships between early adversity and psychiatric disorders. We conclude with clinical implications, methodological challenges and suggestions for future research.

Sleep disturbance in pediatric PTSD: current findings and future directions.

Many studies have provided strong evidence of a fundamental and complex role for sleep disturbances in adult posttraumatic stress disorder (PTSD). Investigations of adult PTSD using subjective and objective measures document sleep architecture abnormalities and high prevalence of sleep disordered breathing, periodic limb movement disorder, nightmares, and insomnia. PTSD treatment methods do appear to significantly improve sleep disturbance, and also studies suggest that treatments for sleep disorders often result in improvements in PTSD symptoms. Further, the most recent evidence suggests sleep abnormalities may precede the development of PTSD. Given the importance of sleep disorders to the onset, course, and treatment of adult PTSD, examination of sleep disturbances far earlier in the life course is imperative. Here we review the literature on what we know about sleep disturbances and disorders in pediatric PTSD. Our review indicates that the extant, empirical data examining sleep disturbance and disorders in pediatric PTSD is limited. Yet, this literature suggests there are significantly higher reports of sleep disturbances and nightmares in children and adolescents exposed to trauma and/or diagnosed with PTSD than in non-trauma-exposed samples. Sleep questionnaires are predominantly employed to assess sleep disorders in pediatric PTSD, with few studies utilizing objective measures. Given the important, complex relationship being uncovered between adult PTSD and sleep, this review calls for further research of sleep in children with PTSD using more specific subjective measures and also objective measures, such as polysomnography and eventually treatment trial studies.

Inter-episode affective intensity and instability: Predictors of depression and functional impairment in bipolar disorder

BACKGROUND AND OBJECTIVES Dysregulated affect is a hallmark feature of acute episodes of bipolar disorder (BD) and persists during inter-episode periods. Its contribution to course of illness is not yet known. The present report examines the prospective influence of inter-episode affect dysregulation on symptoms and functional impairment in BD. METHODS Twenty-seven participants diagnosed with inter-episode bipolar I disorder completed daily measures of negative and positive affect for 49 days (±8 days) while they remained inter-episode. One month following this daily assessment period, symptom severity interviews and a measure of functional impairment were administered by telephone. RESULTS More intense negative affect and positive affect during the inter-episode period were associated with higher depressive, but not manic, symptoms at the one-month follow-up assessment. More intense and unstable negative affect, and more unstable positive affect, during the inter-episode period were associated with greater impairment in home and work functioning at the follow-up assessment. All associations remained significant after controlling for concurrent symptom levels. LIMITATIONS The findings need to be confirmed in larger samples with longer follow-up periods. A more comprehensive assessment of functional impairment is also warranted. CONCLUSIONS The findings suggest that a persistent affective dysregulation between episodes of BD may be an important predictor of depression and functional impairment. Monitoring daily affect during inter-episode periods could allow for a more timely application of interventions that aim to prevent or reduce depressive symptoms and improve functioning for individuals with BD.

The prediction of study‐emergent suicidal ideation in bipolar disorder: a pilot study using ecological momentary assessment data

OBJECTIVES Bipolar disorder is associated with idiosyncratic precursors of clinically important states such as suicidal ideation. Ecological momentary assessment (EMA) - high frequency data collection in a subjects usual environment - provides the potential for development of temporal, individualized prediction of risk states. The present study tested the ability of EMA data to predict individual symptom change in clinician-rated suicidal ideation. METHODS Thirty-five adults diagnosed with inter-episode bipolar disorder completed daily measures of affect in their home environments using diaries administered over an eight-week assessment timeline. Suicidal ideation was assessed monthly at in-person visits using the Inventory of Depressive Symptomatology-Clinician Rated. We used a novel application of functional linear models (FLMs) to generate prospective predictions of suicidal ideation at in-person clinician assessments based on intensively sampled trajectories of daily affect. RESULTS Eight instances of suicidal ideation scores > 0 were recorded during the study period on six participants. Utilizing trajectories of negative and positive affect, cross-validated predictions attained 88% sensitivity with 95% specificity for elevated suicidal ideation one week prior to in-person clinician assessment. This model strongly outperformed prediction models using cross-sectional data obtained at study visits alone. CONCLUSIONS Utilizing EMA data with FLM prediction models substantially increases the accuracy of prediction of study-emergent suicidal ideation. Prediction algorithms employing intensively sampled longitudinal EMA data could sensitively detect the warning signs of suicidal ideation to facilitate improved suicide risk assessment and the timely delivery of preventative interventions.

Social support and social strain in inter-episode bipolar disorder.

Eidelman P, Gershon A, Kaplan K, McGlinchey E, Harvey AG. Social support and social strain in inter‐episode bipolar disorder. 
Bipolar Disord 2012: 14: 628–640.

Daily Actigraphy Profiles Distinguish Depressive and Interepisode States in Bipolar Disorder

Disruptions in activity are core features of mood states in bipolar disorder (BD). In this study, we sought to identify activity patterns that discriminate between mood states in BD. Locomotor activity was collected by using actigraphy for 6 weeks in participants with interepisode BD Type I (n = 37) or participants with no lifetime mood disorders (n = 39). The 24-hr activity pattern of each participant-day was characterized and within-person differences in activity patterns were examined across mood states. Results showed that among participants with BD, depressive days are distinguished from other mood states by an overall lower activity level and a pattern of later activity onset, a midday elevation of activity, and low evening activity. No distinct within-person activity patterns were found for hypomanic/manic days. Given that activity can be monitored noninvasively for extended time periods, activity pattern identification may be leveraged to detect mood states in BD, thereby providing more immediate delivery of care.

Chronic stressors and trauma: prospective influences on the course of bipolar disorder.

BACKGROUND Exposure to life stress is known to adversely impact the course of bipolar disorder. Few studies have disentangled the effects of multiple types of stressors on the longitudinal course of bipolar I disorder. This study examines whether severity of chronic stressors and exposure to trauma are prospectively associated with course of illness among bipolar patients. METHOD One hundred and thirty-one participants diagnosed with bipolar I disorder were recruited through treatment centers, support groups and community advertisements. Severity of chronic stressors and exposure to trauma were assessed at study entry with in-person interviews using the Bedford College Life Event and Difficulty Schedule (LEDS). Course of illness was assessed by monthly interviews conducted over the course of 24 months (over 3000 assessments). RESULTS Trauma exposure was related to more severe interpersonal chronic stressors. Multiple regression models provided evidence that severity of overall chronic stressors predicted depressive but not manic symptoms, accounting for 7.5% of explained variance. CONCLUSIONS Overall chronic stressors seem to be an important determinant of depressive symptoms within bipolar disorder, highlighting the importance of studying multiple forms of life stress.

The Influence of Trauma, Life Events, and Social Relationships on Bipolar Depression

A growing body of research suggests that the social environment exerts a powerful influence on the course of bipolar depression. This article reviews longitudinal research to suggest that trauma, negative life events, social support deficits, and family difficulties are common and predict a more severe course of depression when present among those diagnosed with bipolar disorder. The triggers of bipolar depression overlap with those documented for unipolar depression, suggesting that many of the treatment targets for unipolar depression may be applicable for bipolar depression.

Subjective versus objective evening chronotypes in bipolar disorder

BACKGROUND Disturbed sleep timing is common in bipolar disorder (BD). However, most research is based upon self-reports. We examined relationships between subjective versus objective assessments of sleep timing in BD patients versus controls. METHODS We studied 61 individuals with bipolar I or II disorder and 61 healthy controls. Structured clinical interviews assessed psychiatric diagnoses, and clinician-administered scales assessed current mood symptom severity. For subjective chronotype, we used the Composite Scale of Morningness (CSM) questionnaire, using original and modified (1, ¾, ⅔, and ½ SD below mean CSM score) thresholds to define evening chronotype. Objective chronotype was calculated as the percentage of nights (50%, 66.7%, 75%, or 90% of all nights) with sleep interval midpoints at or before (non-evening chronotype) vs. after (evening chronotype) 04:15:00 (4:15:00a.m.), based on 25-50 days of continuous actigraph data. RESULTS BD participants and controls differed significantly with respect to CSM mean scores and CSM evening chronotypes using modified, but not original, thresholds. Groups also differed significantly with respect to chronotype based on sleep interval midpoint means, and based on the threshold of 75% of sleep intervals with midpoints after 04:15:00. Subjective and objective chronotypes correlated significantly with one another. Twenty-one consecutive intervals were needed to yield an evening chronotype classification match of ≥ 95% with that made using the 75% of sleep intervals threshold. LIMITATIONS Limited sample size/generalizability. CONCLUSIONS Subjective and objective chronotype measurements were correlated with one another in participants with BD. Using population-specific thresholds, participants with BD had a later chronotype than controls.