Daniel N. Klein

The 16-Item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression

The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbachs alpha =.86), the IDS-SR(30) (Cronbachs alpha =.92), and the HAM-D(24) (Cronbachs alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.

Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma

Major depressive disorder is associated with considerable morbidity, disability, and risk for suicide. Treatments for depression most commonly include antidepressants, psychotherapy, or the combination. Little is known about predictors of treatment response for depression. In this study, 681 patients with chronic forms of major depression were treated with an antidepressant (nefazodone), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or the combination. Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. Our results suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma.

Natural course of adolescent major depressive disorder: I. Continuity into young adulthood.

OBJECTIVE To examine the course of adolescent major depressive disorder (MDD) by comparing rates of mood and non-mood disorders between age 19 and 24 years in participants with a history of adolescent MDD versus participants with adolescent adjustment disorder with depressed mood, nonaffective disorder, and no disorder. METHOD Participants from a large community sample who had been interviewed twice during adolescence completed a third interview assessing Axis I psychopathology and antisocial and borderline personality disorders after their 24th birthday: 261 participants with MDD, 73 with adjustment disorder, 133 with nonaffective disorder, and 272 with no disorder through age 18. RESULTS MDD in young adulthood was significantly more common in the adolescent MDD group than the nonaffective and no disorder groups (average annual rate of MDD = 9.0%, 5.6%, and 3.7%, respectively). Adolescents with MDD also had a high rate of nonaffective disorders in young adulthood (annual nonaffective disorder rate = 6.6%) but did not differ from adolescents with nonaffective disorder (7.2%). Prevalence rates of dysthymia and bipolar disorder were low (< 1%). Adolescents with adjustment disorder exhibited similar rates of MDD and nonaffective disorders in young adulthood as adolescents with MDD. CONCLUSIONS This study documents the significant continuity of MDD from adolescence to young adulthood. Public health implications of the findings are discussed.

A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: a conceptual framework and five validation studies.

In an attempt to study predisposition to bipolar manic-depressive disorder, we developed a behavioral paradigm to identify persons at risk for various forms of the disorder. We provide a theoretical discussion for denning bipolar disorder within the broader framework of common human diseases and then employ this framework to derive dimensions of bipolar disorder that define its distinctness from the normal phenotype. These dimensions (behavioral and nonbehavioral features of disorder) are operationalized in the form of a self-report inventory which estimates the probability that an individual is at risk. Five external validation studies using nontest criteria are presented, including interview, roommate, family history, clinical characteristics, and longitudinal mood rating investigations. Results indicate that the inventory serves as a promising first-stage case identification procedure for bipolar disorder when employed in a research context.

Personality and Depression: Explanatory Models and Review of the Evidence

Understanding the association between personality and depression has implications for elucidating etiology and comorbidity, identifying at-risk individuals, and tailoring treatment. We discuss seven major models that have been proposed to explain the relation between personality and depression, and we review key methodological issues, including study design, the heterogeneity of mood disorders, and the assessment of personality. We then selectively review the extensive empirical literature on the role of personality traits in depression in adults and children. Current evidence suggests that depression is linked to traits such as neuroticism/negative emotionality, extraversion/positive emotionality, and conscientiousness. Moreover, personality characteristics appear to contribute to the onset and course of depression through a variety of pathways. Implications for prevention and prediction of treatment response are discussed, as well as specific considerations to guide future research on the relation between personality and depression.

Toward Guidelines for Evidence-Based Assessment of Depression in Children and Adolescents.

We aim to provide a starting point toward the development of an evidence-based assessment of depression in children and adolescents. We begin by discussing issues relevant to the diagnosis and classification of child and adolescent depression. Next, we review the prevalence, selected clinical correlates, course, and treatment of juvenile depression. Along with some general considerations in assessment, we discuss specific approaches to assessing depression in youth (i.e., interviews, rating scales) and briefly summarize evidence on the reliability and validity of a few selected instruments. In addition, we touch on the assessment of several other constructs that are important in a comprehensive evaluation of depression (i.e., social functioning, life stress, and family history of psychopathology). Last, we highlight areas in which further research is necessary and conclude with some broad recommendations for clinical practice given the current state of the knowledge.

Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

Does psychosocial functioning improve independent of depressive symptoms? A comparison of nefazodone, psychotherapy, and their combination.

BACKGROUND Although it is known that antidepressant treatment improves psychosocial functioning, whether such changes occur independent of depressive symptoms is not known. This study compared efficacy of nefazodone, psychotherapy, and their combination in improving psychosocial functioning in chronically depressed outpatients. METHODS Patients with chronic forms of major depressive disorder were randomized to 12 weeks of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combined nefazodone/CBASP. Psychosocial assessments measured overall psychosocial functioning, work functioning, interpersonal functioning, and general health. RESULTS Relative to community norms, patients with chronic major depression evidenced substantially impaired psychosocial functioning at baseline. Combined treatment produced significantly greater psychosocial improvement than either CBASP alone or nefazodone alone on all primary measures. Combined treatment remained superior to nefazodone on primary measures of work, social, and overall functioning, and superior to CBASP on social functioning when depressive symptoms were controlled. Unlike the two groups receiving nefazodone, CBASP alones effect on psychosocial function was relatively independent of symptom change. Psychosocial functioning improved more slowly than depressive symptoms, and moderate psychosocial impairments remained at end point. CONCLUSIONS Combined treatment had greater effect than either monotherapy. Change in depressive symptoms did not fully explain psychosocial improvement. Moderate residual psychosocial impairment remained, suggesting the need for continuation/maintenance treatment.

The prevalence and co-morbidity of subthreshold psychiatric conditions.

BACKGROUND In previous studies of subthreshold conditions, co-morbidity has been largely ignored. The purpose was to examine rates of co-morbidity among subthreshold disorders and between subthreshold and full-syndrome disorders for the major non-psychotic classes of disorders from DSM-IV. METHOD Participants came from the Oregon Adolescent Depression Project (mean age=16.6 years; females=52.1%). On the basis of a diagnostic interview (K-SADS), participants were assigned to eight subthreshold disorders (MDD, bipolar, eating, anxiety, alcohol use, substance use, conduct, ADHD). RESULTS Of the 1704 adolescents in the analyses, 52.5% had at least one subthreshood disorder. Of those, 40.0% had also experienced a co-morbid subthreshold condition, and 29.9% of those had a second co-morbid subthreshold condition. Of those with a subthreshold, 36.4% also had a full syndrome. The subthreshold forms of externalizing disorders were co-morbid with each other. As expected, subthreshold anxiety was co-morbid with subthreshold MDD but subthreshold anxiety was also co-morbid with subthreshold alcohol, conduct, and ADHD. The pattern of co-morbidities was nearly identical for males and females. CONCLUSIONS The hypotheses that externalizing disorders would be co-morbid with other externalizing disorders and that internalizing disorders would be co-morbid with other internalizing disorders was partially supported. Co-morbidities between subthreshold disorders and between subthreshold disorders and full syndrome should impact future research and clinical practice. The assessment of subthreshold disorders needs to include the assessment of other subthreshold and full-syndrome conditions.

Age of onset in chronic major depression: relation to demographic and clinical variables, family history, and treatment response

BACKGROUND The clinical and etiological significance of the early-late onset distinction in chronic major depressive disorder was explored. METHOD Subjects were 289 outpatients with DSM-III-R chronic major depression drawn from a multi-site study comparing the efficacy of sertraline and imipramine in the acute and long-term treatment of chronic depression. Patients received comprehensive evaluations using semi-structured interviews and rating scales. RESULTS Early-onset chronic major depression was associated with a longer index major depressive episode and higher rates of recurrent major depressive episodes, comorbid personality disorders, lifetime substance use disorders, depressive personality traits, and a history of psychiatric hospitalization. In addition, more early-onset patients tended to have a family history of mood disorders. The early-late onset distinction was not associated with differences in symptom severity, functional impairment, or treatment response. LIMITATIONS Family members were not interviewed directly; there were a large number of statistical comparisons; and interrater reliability of the assessments was not evaluated. CONCLUSIONS Early-onset chronic major depression has a more malignant course and is associated with greater comorbidity than late-onset chronic major depression.