Elena Ezquiaga

Psychosocial predictors of outcome in major depression: a prospective 12-month study

This study examined the relationship between clinical and psychosocial variables and unipolar major depression outcome. Ninety ambulatory patients, with an index phase duration of less than 6 months, were followed-up for 12 months. Two measures of outcome were used: persistence of severe or partial symptomatology. Sixty percent of the patients were asymptomatic (HDRS < 8), 24% improved but not totally and 17% persisted with severe symptomatology (HDRS> 18). Personality disorder, recurrent depression, low self-esteem and low satisfaction with social support were associated to non-full remission. Personality disorder and low satisfaction with social support were associated to non-improvement. This work underlines the need during treatment to take into account personality and social variables.

Psychosocial factors and episode number in depression

We studied the relationship between 2 types of psychosocial factors, life events and chronic stress, and the numerical order of the depressive episodes. The population studied consisted of 97 subjects suffering from major depressive disorder and 65 controls. Life events occurred with the first 2 depressive episodes with significantly higher frequency than with later episodes or with the control group. Patients in the third or later episode had no more life events than controls. No significant differences were apparent in the incidence of chronic stress in the different depressive episodes of the patient group or in the comparison of this group with controls. No second order interaction between life events and chronic stress was found.

Time spent with symptoms in a cohort of bipolar disorder outpatients in Spain: A prospective, 18-month follow-up study

OBJECTIVE Most research on the symptomatic burden in bipolar disorder has included patients enrolled exclusively from tertiary centers, and only a few studies have analyzed factors related to it. We investigated the proportion of time and the proportion of visits with symptoms in a cohort of bipolar outpatients followed-up for 18 months, as well as the associated variables. METHODS 296 DSM-IV-TR bipolar outpatients were included in a naturalistic longitudinal follow-up study, with quarterly assessment. Euthymia was defined by a Hamilton Depression Rating Scale score <7 and Young Mania Rating Scale score <5. Depressive episode, by a HDRS score of >17, hypomanic episode by a YMRS score of 10-20, and manic episode by a YMRS score >20. Sub-syndromal symptoms required scores of 7-17 in HDRS and 5-10 in YMRS. Based on a detailed recall of affective symptoms in the time between interviews, time in episode was also determined. RESULTS Patients were symptomatic for one third of the follow-up, and also one third of the visits. They spent three times more days depressed than manic or hypomanic. More prior affective episodes were related both to more time symptomatic and more visits with symptoms. LIMITATIONS Some of the data were collected retrospectively. Treatment was naturalistic. CONCLUSIONS In a bipolar outpatient cohort from Spain, time with symptoms was shorter than previously found in tertiary care settings. In accordance with other longitudinal studies, those patients spent much more time depressed than manic.

Clinical and psychosocial factors associated with the outcome of unipolar major depression: a one year prospective study

BACKGROUND The role of psychosocial and clinical variables in the prediction of major depression is controversial. In a previous paper, we obtained a one-year predictive multivariate model of non-remission for major depression, based on the presence of a personality disorder, a low self-esteem and a low satisfaction with social support. OBJECTIVES To evaluate more in depth both personality disorders and psychosocial variables as predictors of outcome. METHODS A prospective study on 57 consecutive outpatients with major depressive episodes were followed-up monthly during one year. Clinical and psychosocial variables were registered, including personality (DSM-IV criteria and IPDE structured interview), previous quality of life, self-esteem, social support and dyadic adjustment. Remission was defined as a HDS score less than 8. Univariate and multivariate (logistic regression) analyses were applied. RESULTS 68% of the patients reached remission at 12 months. Personality disorder (diagnosed clinically but not according to IPDE), and previous quality of life were the variables more consistently associated to remission at 12 months. Among follow-up variables, remission at 3 months was strongly associated with remission. CONCLUSIONS Our findings confirm the importance of the clinical diagnosis of personality disorder in the major depression outcome. However, more studies are needed to clarify the divergence between clinical and structured interview guided diagnosis. With the exception of quality of life, psychosocial variables had a weak and non consistent relationship with outcome.

Subthreshold symptoms and time to relapse/recurrence in a community cohort of bipolar disorder outpatients.

BACKGROUND Researchers have previously found that persistent subthreshold symptoms increase the risk and shorten the time until an affective relapse in bipolar disorder (BD) patients. Research has mainly focused on patients from tertiary Care Centers in USA. We tested the hypothesis that even in a different setting, BD outpatients with subsyndromal affective symptoms would re.turn to a subsequent major affective episode significantly faster than completely asymptomatic at baseline. Secondarily, we analysed other variables related to time and risk to relapse. METHODS A community cohort of BD outpatients from Madrid (Spain) followed-up in a systematic prospective follow-up protocol for up to five years were evaluated. Patients in clinical euthymia at baseline were included and evaluated quarterly. RESULTS Initially, 225 patients were included in the survival analysis. Of them, according to predefined psychometric criteria, 163 were in euthymia (72.4%) and 62 (27.6%) suffered subsyndromal symptoms. Median follow-up was 157.6 weeks (95% CI, 78.14 to 111); 57.3% of patients experienced at least one affective episode during their follow-up. Median survival time to first affective episode was 109 weeks for patients in euthymia at baseline, versus 35 weeks for those with subsyndromal symptoms (p<0.0001). Psychosocial stress (p=0.003; HR 2.20; 95% CI 1.31-3.68) and the affective mood baseline state, subsyndromal vs. euthymic (p=0.046; HR 1.74; 95%CI 1.009-3.020), were related to time to first affective episode. LIMITATIONS Naturalistic study, some of the data collected were necessarily retrospective. CONCLUSIONS In Spanish non-tertiary psychiatric outpatients, subsyndromal BD symptoms and psychosocial stress at baseline predict earlier episode relapse/recurrence.

Usefulness of the Spanish version of the mood disorder questionnaire for screening bipolar disorder in routine clinical practice in outpatients with major depression

BackgroundAccording to some studies, almost 40% of depressive patients – half of them previously undetected – are diagnosed of bipolar II disorder when systematically assessed for hypomania. Thus, instruments for bipolar disorder screening are needed. The Mood Disorder Questionnaire (MDQ) is a self-reported questionnaire validated in Spanish in stable patients with a previously known diagnosis. The purpose of this study is to evaluate in the daily clinical practice the usefulness of the Spanish version of the MDQ in depressive patients.MethodsPatients (n = 87) meeting DSM-IV-TR criteria for a major depressive episode, not previously known as bipolar were included. The affective module of the Structured Clinical Interview (SCID) was used as gold standard.ResultsMDQ screened 24.1% of depressive patients as bipolar, vs. 12.6% according to SCID. For a cut-off point score of 7 positive answers, sensitivity was 72.7% (95% CI = 63.3 – 82.1) and specificity 82.9% (95% CI = 74.9–90.9). Likelihood ratio of positive and negative tests were 4,252 y 0,329 respectively.LimitationsThe small sample size reduced the power of the study to 62%.ConclusionSensitivity and specificity of the MDQ were high for screening bipolar disorder in patients with major depression, and similar to the figures obtained in stable patients. This study confirms that MDQ is a useful instrument in the daily clinical assessment of depressive patients.

Understanding Bipolar Disorder in Late Life Clinical and Treatment Correlates of a Sample of Elderly Outpatients

AbstractThe aim of this study was to examine the demographic, clinical, and treatment correlates of bipolar disorder (BD) in outpatients 65 years or older and to compare patients with BD subtype I (BD-I) versus BD subtype II (BD-II) and patients with early onset (EO; ⩽50 years old) versus late onset (LO; >50 years old) of the illness. Sixty-nine consecutive outpatients with BD were included. Diagnosis was delayed for a mean of 14.1 years, significantly longer in patients with EO (18.6 years) than with LO (3.3 years). Mild to moderate depressive symptoms were detected in 29% of the patients. The patients were receiving a mean of 3 different psychotropic medications. Antidepressantswere more frequently prescribed to patients with BD-II than to patients with BD-I (75.80% vs. 48.60%) and to patients with EO (71.7%) than to LO (35.3%). Geriatric BD has similar clinical characteristics with those of younger ages, and these do not seem to greatly differ with subtype or age of onset.

Syndromal and Subsyndromal Illness Status and Five-Year Morbidity Using Criteria of the International Society for Bipolar Disorders Compared to Alternative Criteria

Background: Subsyndromal symptoms have been recognized as relevant in the course and outcome of bipolar disorder (BD) patients. Nevertheless, their definition and cutoff points on current depression and mania scales are uncertain. The recently defined International Society for Bipolar Disorders (ISBD) operational criteria for the assessment of the course and outcome of bipolar illness have never been tested until now. Methods: A naturalistic longitudinal follow-up study of up to 5 years included a cohort of 317 DSM-IV-TR BD outpatients. For the first time, we assessed the proportion of visits in different affective states using the ISBD criteria. Secondarily, we compared the results with those obtained applying other cutoff points. Results: Patients were symptomatic in 39.1% (95% CI 35.3–42.9) of the visits. Subsyndromal symptoms, primarily subsyndromal depression, were present in 15.9% of patients (95% CI 13.4–18.4). No significant differences were found between bipolar I patients and bipolar II patients. There were differences in the total percentage of visits in euthymia depending on the cutoff points (p < 0.05). Conclusions: Applying ISBD criteria, bipolar patients have significant clinical morbidity and are often symptomatic, both with threshold symptoms and with subthreshold symptoms, especially with depression. The chosen cutoff points modify the apparent results. Limitations: The cutoff points used have not been validated. Psychopharmacologic treatments were naturalistic.

Retraso diagnostico y diferencias por sexo y subtipo clinico en una cohorte de pacientes ambulatorios con trastorno bipolar

INTRODUCTION We describe the clinical and sociodemographic features at baseline of a cohort of bipolar patients included in a prospective study. METHODS A total of 296 consecutive outpatients with bipolar disorder were recruited. Diagnosis relied on clinical judgment according to DSM-IV-TR criteria and the semi-structured MINI Interview. Retrospective data on the course of the disease and cross-sectional data on social adaptation (Social Adaptation Adjustment Self-Assessment Scale (SASS) and affective symptoms were collected. Affective symptomatology (euthymia, subsyndromal symptoms and episodes) was studied according to clinical criteria and the Hamilton Depression and Young rating scales. Differences between type I and II bipolar patients and between men and women were analyzed. RESULTS The mean age was 48.8 years (95% CI 47.2-50.4); 56.8% were women and 43.2% were men. A total of 65.2% had a diagnosis of type I bipolar disorder and 23.3% of type II; 49.8% of the sample were euthymic, 32.7% had subsyndromal symptoms and 17.5% had had an affective episode. Diagnostic delay was 9.3 years (95% CI 8.2-10.3). In patients with type II bipolar disorder, the mean age (54.4 years; 95% CI 50.9-57.9 vs. 47.7 years; 95% CI 45.8-49.7, p=0.007), age at onset of illness (35.7 years; 95% CI 31.8-39.7 vs. 29.8 years; 95% CI 28-31.6, p=0.008) and age at diagnosis (47.7 years; 95% CI 44-51.3 vs. 37.9; 95% CI 35.9-39.8, p<0.0001) were higher than in patients with type I bipolar disorder. Manic polarity in the initial episode and psychotic episodes were more frequent in men, while depressive episodes and hypothyroidism were more frequent in women. CONCLUSIONS Our results confirm data published in our environment on sociodemographic and clinical variables but diagnostic delay in our study was longer. Compared with American samples, age at onset and at diagnosis were higher in our sample but comorbidity was much lower.

Depressive symptoms in early- and late-onset older bipolar patients compared with younger ones

The aim of this study was to determine clinical and outcome differences between older bipolar patients with early onset (EO) and late onset (LO) of the illness and between younger and EO older patients with a bipolar disorder under long‐term treatment in an outpatient clinical setting.