Jack D. Maser

Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse.

BACKGROUND The study tested whether level of recovery from major depressive episodes (MDEs) predicts duration of recovery in unipolar major depressive disorder (MDD) patients. METHODS MDD patients seeking treatment at five academic centers were followed naturalistically for 10 years or longer. Patients were divided on the basis of intake MDE recovery into residual depressive symptoms (SSD; N=82) and asymptomatic (N=155) recovery groups. They were compared on time to first episode relapse/recurrence, antidepressant medication, and comorbid mental disorders. Recovery level was also compared to prior history of recurrent MDEs ( > 4 lifetime episodes) as a predictor of relapse/recurrence. RESULTS Residual SSD compared to asymptomatic recovery patients relapsed to their next MDE > 3 times faster (median=68 vs. 23 weeks) and to any depressive episode > 5 times faster (median=33 vs. 184 weeks). Residual SSD recovery status was significantly associated with early episode relapse (OR=3.65) and was stronger than history of recurrent MDEs (OR=1.64). Rapid relapse in the SSD group could not be attributed to higher comorbidity or lower antidepressant treatment. LIMITATIONS Although inter-rater agreement on weekly depressive symptom ratings was very high (ICC > 0.88), some error may exist in assigning recovery levels. Antidepressant treatments were recorded, but were not controlled. CONCLUSIONS MDE recovery is a powerful predictor of time to episode relapse/recurrence. Residual SSD recovery is associated with very rapid episode relapse which supports the idea that SSD is an active state of illness. Asymptomatic recovery is associated with prolonged delay in episode recurrence. These findings of this present study have important implications for the goals of treatment of MDD and for defining true MDE recovery.

The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders?

BACKGROUND The present analyses were designed to compare the clinical characteristics and long-term episode course of Bipolar-I and Bipolar-II patients in order to help clarify the relationship between these disorders and to test the bipolar spectrum hypothesis. METHODS The patient sample consisted of 135 definite RDC Bipolar-I (BP-I) and 71 definite RDC Bipolar-II patients who entered the NIMH Collaborative Depression Study (CDS) between 1978 and 1981; and were followed systematically for up to 20 years. Groups were compared on demographic and clinical characteristics at intake, and lifetime comorbidity of anxiety and substance use disorders. Subsets of patients were compared on the number and type of affective episodes and the duration of inter-episode well intervals observed during a 10-year period following their resolution of the intake affective episode. RESULTS BP-I and BP-II had similar demographic characteristics and ages of onset of their first affective episode. Both disorders had more lifetime comorbid substance abuse disorders than the general population. BP-II had a significantly higher lifetime prevalence of anxiety disorders in general, and social and simple phobias in particular, compared to BP-I. Intake episodes of BP-I were significantly more acutely severe. BP-II patietns had a substantially more chronic course, with significantly more major and minor depressive episodes and shorter inter-episode well intervals. BP-II patients were prescribed somatic treatment a substantially lower percentage of time during and between affective episodes. LIMITATIONS BP-I patients with severe manic course are less likely to be retained in long-term follow-up, whereas the reverse might be true for BP-II patients who are significantly more prone to depression (i.e., patients with less inclination to depression and with good prognosis may have dropped out in greater proportions); this could increase the gap in long term course characteristics between the two samples. The greater chronicity of BP-II may be due, in part, to the fact that the patients were prescribed somatic treatments substantially less often both during and between affective episodes. CONCLUSIONS The variety in severity of the affective episodes shows that bipolar disorders, similar to unipolar disorders, are expressed longitudinally during their course as a dimensional illness. The similarities of the clinical phenotypes of BP-I and BP-II, suggest that BP-I and BP-II are likely to exist in a disease spectrum. They are, however, sufficiently distinct in terms of long-term course (i.e., BP-I with more severe episodes, and BP-II more chronic with a predominantly depressive course), that they are best classified as two separate subtypes in the official classification systems.

Residual Symptom Recovery From Major Affective Episodes in Bipolar Disorders and Rapid Episode Relapse/Recurrence

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.

Alcoholism and drug abuse in three groups — bipolar I, unipolars and their acquaintances

OBJECTIVE Previous work has shown that manic-depressive illness and alcohol abuse are linked. This study further explores the relationship of alcohol and drug abuse in bipolar I patients and unipolar depressives and a comparison group obtained through the acquaintance method. METHOD Diagnosis was accomplished according to Research Diagnostic Criteria (RDC): controls = 469; bipolars = 277; unipolar depressives = 678. Systematic data were gathered using the SADS on lifetime and current drug abuse and alcoholism. Both patients and comparison subjects were then followed prospectively for 10 years. First degree family members were interviewed using the RDC family history method. RESULTS The group of bipolar patients and the group of unipolar patients had higher rates of drug and alcohol abuse than the comparison group when primary and secondary affective disorder patients were combined. However, primary unipolar patients did not have higher rates of alcohol or drug abuse than the comparison group. In contrast, primary bipolar patients had higher rates of alcoholism, stimulant abuse, and ever having abused a drug than the primary unipolar group and the control group. In an evaluation of the bipolar patients, drug abusers were significantly younger at intake and had a significantly younger age of onset of bipolar disorder. There was a significant increase in family history of mania or schizoaffective mania in the drug-abusing bipolar patients as compared to the non-abusing bipolar patients. LIMITATION As in all adult samples of patients with affective illness, the chronology of alcohol and substance problems vis-à-vis the onset of illness was determined retrospectively. CONCLUSIONS (1) Alcoholism and drug abuse are more frequent in bipolar than unipolar patients. (2) The drug abuse of bipolar patients tends toward the abuse of stimulant drugs. (3) In a bipolar patient, familial diathesis for mania is significantly associated with the abuse of alcohol and drugs. (4) More provocatively, these findings suggest the hypothesis of a common familial-genetic diathesis for a subtype of bipolar I, alcohol and stimulant abuse. CLINICAL IMPLICATIONS The present analyses, coupled with two previous ones from the CDS, suggest that drug abuse may precipitate an earlier onset of bipolar I disorder in those who already have a familial predisposition for mania. Furthermore, in dually diagnosed patients with manic-depressive and alcohol/stimulant abuse history, mood stabilization of the bipolar disorder represents a rational approach to control concurrent alcohol and drug problems, and should be studied in systematic controlled trials.

International use and attitudes toward DSM-III and DSM-III--R: Growing consensus in psychiatric classification.

: A survey of the uses and attitudes of 146 mental health professionals, primarily psychiatrists and psychologists, in 42 countries (not including the United States) toward the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and its revision (DSM-III-R; American Psychiatric Association, 1980,1987) is reported. The results revealed wide-spread endorsement of the multiaxial system, theoretical neutrality, descriptive symptom criteria forming discrete categories, and the placement of personality disorders on a separate axis. We report that the DSM-III and DSM-III-R are more widely used around the world than the International Classification of Diseases for teaching, research, and clinical practice. Opinions about various dimensions of the DSMs usefulness and shortcomings are presented.

The Spectrum Model: A More Coherent Approach to the Complexity of Psychiatric Symptomatology

The current tools used to define and diagnose mental disorders, including the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, have added specificity to the psychiatric nomenclature. However, their stereotypic rigidity in classification has resulted in the failure to identify the full range of potentially debilitating psychiatric symptoms with which patients may present. A spectrum model of psychopathology is more adept at recognizing the subclinical or threshold symptomatology that may occur concomitantly with core psychiatric disorders. The authors discuss the development of a spectrum approach to the diagnosis of mental disorders, which offers the potential to improve treatment selection and therapeutic outcomes .

Panic-agoraphobic spectrum: reliability and validity of assessment instruments

DSM IV is a simple, reliable diagnostic system with many advantages. However, DSM diagnostic criteria may not provide sufficient characterization of clinically significant symptoms. We have undertaken a project to assess an array (spectrum) of clinical features associated with different DSM Disorders. The purpose of this paper is to report on reliability of assessment instruments for Panic-Agoraphobic Spectrum (PAS), to document convergent validity of PAS symptom groupings, and to confirm the relationship between PAS and DSM IV Panic Disorder (PD). We studied 22 normal controls and 95 outpatients who met criteria for Panic Disorder with and without lifetime Major Depression, and Major Depression or Obsessive Compulsive Disorder without lifetime Panic Disorder. Assessment instruments had excellent reliability and there was good concordance between interview and self-report formats. PAS scores were highest in subjects with PD, followed by outpatients without PD, and were lowest in normal controls. PAS scores varied among PD patients, and a subgroup of patients without PD scored high on PAS. We conclude that PAS can be reliably assessed, and that it describes a valid, coherent constellation of features associated with DSM IV Panic Disorder, but providing additional important clinical information.

The likelihood of recurrence in bipolar affective disorder: the importance of episode recency

These analyses used a high-intensity follow-up of of patients with bipolar affective disorder to describe the immediate and long-term risks for recurrence and the importance of sustained recovery to those risks. At the baseline evaluation, all patients were in episodes of Research Diagnostic Criteria major depressive disorder, mania or schizoaffective disorder (excluding the mainly schizophrenic subtype); those who were depressed at intake had a history of mania or schizoaffective mania. Raters re-evaluated these patients at 6-month intervals for 5 years and annually for the remainder of a 10-year follow-up. The following report describes relapse risks for the 186 patients observed to recover from their index episodes. Survival analyses quantified the likelihood of relapse over time, beginning after symptom-free periods of 4 months and 1, 2 and 3 years. Further survival analyses used treatment status as a censoring variable to estimate the eventual likelihood of recurrence among those who reported sustained compliance with lithium prophylaxis; the prophylaxis group remained under observation until they relapsed, were lost to follow-up or ceased taking lithium. Progressively longer symptom-free periods were clearly associated with lower relapse risks over the subsequent 4 years. Thereafter, however, this effect dissipitated. 7 years after recovery, the cumulative likelihood of recurrence was four in five for all bipolar patients and two in three for those whose index episode had been followed by at least 3 years without symptoms. Even with sustained lithium prophylaxis, the likelihood of at least one recurrence exceeded 70% within 5 years of recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Personality traits in subjects with bipolar I disorder in remission

This study compared the personality traits of subjects with bipolar I disorder in remission to the personality traits of subjects with no history of any mental illness. Subjects were assessed as part of a prospective, multicenter, naturalistic study of mood disorders. Diagnoses were rendered according to Research Diagnostic Criteria, through use of the Schedule for Affective Disorders and Schizophrenia - Lifetime Version. A total of 30 euthymic bipolar I subjects were compared to 974 never-ill subjects on 17 personality scales selected for their relevance to mood disorders. The subjects with bipolar I disorder in remission had more aberrant scores on 6 of the 17 personality measures, including Emotional Stability, Objectivity, Neuroticism, Ego Resiliency, Ego Control, and Hysterical Factor. These findings indicate that patients with bipolar I disorder in remission have personality traits that differ from those of normal controls.

A multidimensional spectrum approach to post-traumatic stress disorder: comparison between the Structured Clinical Interview for Trauma and Loss Spectrum (SCI-TALS) and the Self-Report instrument (TALS-SR)

Dimensional approaches to psychiatric disorders have shown an increased relevance in the ongoing debate for the forthcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In line with previously validated instruments for the assessment of different mood, anxiety, eating and psychotic spectra, we tested the validity and reliability of a newly developed Structured Clinical Interview for Trauma and Loss Spectrum (SCI-TALS). The instrument is based on a multidimensional approach to post-traumatic stress spectrum that includes a range of threatening or frightening experiences, as well as a variety of potentially significant losses, to which an individual can be exposed. Furthermore, it explores the spectrum of the peritraumatic reactions and post-traumatic symptoms that may ensue from either type of life events, targeting soft signs and subthreshold conditions, as well as temperamental and personality traits that may constitute risk factors for the development of the disorder. The aim of the present study is to describe the reliability of the self-report version of the SCI-TALS: the TALS-SR. Thirty patients with PTSD and thirty healthy control subjects were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Half of the patients and controls received the TALS-SR first and the SCI-TALS after 15 days; for the other half of the sample, the order of administration was reversed. Agreement between the self-report and the interview formats was substantial. Intraclass correlation coefficients ranged from 0.934 to 0.994, always exceeding the threshold of 0.90. Our findings provide substantial support for the reliability of the TALS-SR questionnaire.