Jonathan P. Stange

Impact of substance use disorders on recovery from episodes of depression in bipolar disorder patients: prospective data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

OBJECTIVE Bipolar disorder is highly comorbid with substance use disorders, and this comorbidity may be associated with a more severe course of illness, but the impact of comorbid substance abuse on recovery from major depressive episodes in these patients has not been adequately examined. The authors hypothesized that comorbid drug and alcohol use disorders would be associated with longer time to recovery in patients with bipolar disorder. METHOD Subjects (N=3,750) with bipolar I or bipolar II disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were followed prospectively for up to 2 years. Prospectively observed depressive episodes were identified for this analysis. Subjects with a past or current drug or alcohol use disorder were compared with those with no history of drug or alcohol use disorders on time to recovery from depression and time until switch to a manic, hypomanic, or mixed episode. RESULTS During follow up, 2,154 subjects developed a new-onset major depressive episode; of these, 457 subjects switched to a manic, hypomanic, or mixed episode prior to recovery. Past or current substance use disorder did not predict time to recovery from a depressive episode relative to no substance use comorbidity. However, those with current or past substance use disorder were more likely to experience switch from depression directly to a manic, hypomanic, or mixed state. CONCLUSIONS Current or past substance use disorders were not associated with longer time to recovery from depression but may contribute to greater risk of switch into manic, mixed, or hypomanic states. The mechanism conferring this increased risk merits further study.

Cognitive vulnerabilities and depression versus other psychopathology symptoms and diagnoses in early adolescence.

We examined the concurrent associations between multiple cognitive vulnerabilities to depression featured in hopelessness theory, Becks theory, and response styles theory and depressive symptoms and diagnoses in a sample of early adolescents. We also examined the specificity of these cognitive vulnerabilities to depression versus anxiety and externalizing psychopathology, controlling for co-occurring symptoms and diagnoses. Male and female, Caucasian and African American, 12- to 13-year-old adolescents were assessed in a cross-sectional design. Cognitive vulnerabilities of hopelessness, inferential style, rumination, and self-referent information processing were assessed with self-reports and behavioral tasks. Symptoms and diagnoses of depressive, anxiety, and externalizing disorders were assessed with self-report questionnaires and diagnostic interviews. Hopelessness exhibited the greatest specificity to depressive symptoms and diagnoses, whereas negative inferential styles, rumination, and negative self-referent information processing were associated with both depressive and anxiety symptoms and diagnoses and, in some cases, with externalizing disorders. Consistent with cognitive theories of depression, hopelessness, negative inferential styles, rumination, and negative self-referent information processing were associated with depressive symptoms and diagnoses. However, with the exception of hopelessness, most of the remaining cognitive vulnerabilities were not specific to depression. With further maturation of our sample, these cognitive vulnerabilities may become more specific to depression as cognitive styles further develop and consolidate, the rates of depression increase, and individuals’ presentations of psychopathology become more differentiated.

Mindfulness-Based Cognitive Therapy for Bipolar Disorder: Effects on Cognitive Functioning

Bipolar disorder is associated with impairments in cognition, including difficulties in executive functioning, even when patients are euthymic (neither depressed nor manic). The purpose of this study was to assess changes in self-reported cognitive functioning in patients with bipolar disorder who participated in an open pilot trial of mindfulness-based cognitive therapy (MBCT). Following MBCT, patients reported significant improvements in executive functioning, memory, and ability to initiate and complete tasks, as measured by the Behavior Rating Inventory of Executive Function (BRIEF) and the Frontal Systems Behavior Scale (FrSBe). Changes in cognitive functioning were correlated with increases in mindful, nonjudgmental observance and awareness of thoughts, feelings, and sensations, and were not associated with decreases in depression. Improvements tended to diminish after termination of treatment, but some improvements, particularly those in executive functioning, persisted after 3 months. These results provide preliminary evidence that MBCT may be a treatment option that can be used as an adjunct to medication to improve cognitive functioning in bipolar disorder. (Journal of Psychiatric Practice 2011;17:410–419)

Emotional Maltreatment, Peer Victimization, and Depressive versus Anxiety Symptoms During Adolescence: Hopelessness as a Mediator

Extensive comorbidity between depression and anxiety has driven research to identify unique and shared risk factors. This study prospectively examined the specificity of three interpersonal stressors (emotional abuse, emotional neglect, and relationally oriented peer victimization) as predictors of depressive versus anxiety symptoms in a racially diverse community sample of adolescents. We expanded on past research by examining hopelessness as a mediator of the relationships between these interpersonal stressors and symptoms. Participants included 225 adolescents (55% African American; 59% female; M age = 12.84 years) who completed measures at baseline (Time 1) and two follow-up assessments (Times 2 and 3). Symptoms of depression and anxiety (social, physical, total) were assessed at Time 1 and Time 3, whereas intervening emotional maltreatment, peer victimization, and hopelessness were assessed at Time 2. Hierarchical linear regressions indicated that emotional abuse was a nonspecific predictor of increases in both depressive symptoms and symptoms of social, physical, and total anxiety, whereas relationally oriented peer victimization predicted depressive symptoms specifically. Emotional neglect did not predict increases in depressive or anxiety symptoms. In addition, hopelessness mediated the relationships between emotional abuse and increases in symptoms of depression and social anxiety. These findings suggest that emotional abuse and relationally oriented peer victimization are interpersonal stressors that are relevant to the development of internalizing symptoms in adolescence and that hopelessness may be one mechanism through which emotional abuse contributes to an increased risk of depression and social anxiety.

Pubertal timing and vulnerabilities to depression in early adolescence: differential pathways to depressive symptoms by sex.

Although research implicates pubertal processes in the emergence of the sex difference in depression during adolescence, few studies have examined how cognitive and affective vulnerabilities influence the effect of pubertal timing on depressive symptoms. The current study prospectively examined whether early pubertal timing predicted increases in depressive symptoms among adolescents with more negative cognitive styles and lower emotional clarity, and whether this risk was specific to adolescent girls. In a diverse sample of 318 adolescents, early pubertal timing predicted increases in depressive symptoms among adolescent boys and girls with more negative cognitive styles and adolescent girls with poor emotional clarity. These findings suggest that earlier pubertal maturation may heighten the risk of depression for adolescents with pre-existing vulnerabilities to depression, and that early maturing adolescent girls with lower levels of emotional clarity may be particularly vulnerable to depressive symptoms, representing one pathway through which the sex difference in depression may emerge.

Stress and the Development of Cognitive Vulnerabilities to Depression Explain Sex Differences in Depressive Symptoms During Adolescence

Although cognitive vulnerabilities to depression have received considerable empirical support, little research has evaluated the differential development of cognitive vulnerabilities in adolescent girls and boys. The current study examined the role of stressful life events, as well as sex differences in reactivity and exposure to stress, in the development of negative cognitive style and rumination in a multiwave study of 382 adolescents. Path analyses indicated that interpersonal dependent stress predicted higher prospective levels of negative cognitive styles and rumination. In addition, girls’ greater exposure to interpersonal dependent stress explained their higher levels of rumination, which accounted for higher levels of depressive symptoms in girls than in boys. These findings suggest that interpersonal dependent stress is a significant risk factor for the formation of cognitive vulnerabilities to depression during adolescence, and that the sex difference in depressive symptoms may result from girls’ greater exposure to interpersonal dependent stress and ruminative response style.

Development of an Integrated Psychosocial Treatment to Address the Medical Burden Associated with Bipolar Disorder

We developed an integrated psychosocial treatment for bipolar disorder to decrease the disproportionate medical burden associated with this illness. Three treatment modules, Nutrition/weight loss, Exercise, and Wellness Treatment (NEW Tx) were administered in twelve 60-minute group sessions over 14 weeks. After the first group (N=4) had completed the treatment, it was revised, and then a second group (N=6) completed the revised treatment. Participants completed all of the study assessments and attended 82% of the sessions. Both groups added over 100 minutes of weekly exercise to their baseline duration. Participants in the second group showed improvements in their quality of life, depressive symptoms, and weight. It appears that NEW Tx may be a feasible intervention with promising pilot data for reducing the medical burden in bipolar disorder, but future research is needed to further evaluate the efficacy of NEW Tx.

Emotion regulation characteristics and cognitive vulnerabilities interact to predict depressive symptoms in individuals at risk for bipolar disorder: A prospective behavioural high-risk study

Recent work has identified behavioural approach system (BAS) sensitivity as a risk factor for the first onset and recurrence of mood episodes in bipolar disorder, but little work has evaluated risk factors for depression in individuals at risk for, but without a history of, bipolar disorder. The present study evaluated cognitive styles and the emotion-regulatory characteristics of emotional clarity and ruminative brooding as prospective predictors of depressive symptoms in individuals with high versus moderate BAS sensitivity. Three separate regressions indicated that the associations between dysfunctional attitudes, self-criticism, and neediness with prospective increases in depressive symptoms were moderated by emotional clarity and brooding. Whereas brooding interacted with these cognitive styles to exacerbate their impact on depressive symptoms, emotional clarity buffered against their negative impact. These interactions were specific to high-BAS individuals for dysfunctional attitudes, but were found across the full sample for self-criticism and neediness. These results indicate that emotion-regulatory characteristics and cognitive styles may work in conjunction to confer risk for and resilience against depression, and that some of these relationships may be specific to individuals at risk for bipolar disorder.

Kindling of Life Stress in Bipolar Disorder: Comparison of Sensitization and Autonomy Models

Research on life stress in bipolar disorder largely fails to account for the possibility of a dynamic relationship between psychosocial stress and episode initiation. The kindling hypothesis (Post, 1992) states that over the course of recurrent affective disorders, there is a weakening temporal relationship between major life stress and episode initiation that could reflect either a progressive sensitization or progressive autonomy to life stress. The present study involved a comprehensive and precise examination of the kindling hypothesis in 102 participants with bipolar II disorder that allowed for a direct comparison of sensitization and autonomy models. Polarity-specific tests were conducted across the continuum of event severity with respect to impact and frequency of life events. Hypotheses were polarity- and event-valence specific and were based on the stress sensitization model. Results were only partially consistent with the sensitization model: Individuals with more prior mood episodes had an increased frequency of minor negative events before depression and of minor positive events before hypomania. However, the number of past episodes did not moderate relationships between life events and time until prospective onset of mood episodes. These results are more consistent with a sensitization than an autonomy model, but several predictions of the sensitization model were not supported. Methodological strengths, limitations, and implications are discussed regarding putative changes in stress reactivity that may occur with repeated exposure to mood episodes in bipolar II disorder.

Overgeneral Autobiographical Memory, Emotional Maltreatment, and Depressive Symptoms in Adolescence: Evidence of a Cognitive Vulnerability-Stress Interaction.

Overgeneral autobiographical memory (OGM) is associated with depression and may confer risk for the development of depressed mood, but few longitudinal studies have evaluated OGM as a predictor of depressive symptoms in early adolescence, particularly in the context of environmental stressors. We investigated whether OGM and emotional maltreatment would interact to predict prospective increases in depressive symptoms in early adolescents and whether these effects differed by race. Among 174 seventh-graders, OGM and familial emotional abuse interacted to predict depressive symptoms eight months later, controlling for initial depressive symptoms. Specifically, emotional abuse predicted increases in depressive symptoms among Caucasian adolescents with more OGM, but not among those with less OGM. This association was not significant for African American adolescents. These results provide support for a cognitive vulnerability-stress relationship between OGM and emotional abuse in early adolescence and suggest that these mechanisms of risk for depression may be specific to Caucasian adolescents.