Jules Angst

Mortality of patients with mood disorders: follow-up over 34–38 years

BACKGROUND All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes. The reported rates by gender, disorder type and treatment are more variable. METHODS Hospitalised affective disordered patients (n=406) were followed prospectively for 22 years or more. Later, mortality was assessed for 99% of them at which time 76% had died. RESULTS Standardised Mortality Rates (observed deaths/expected deaths) for patients were elevated especially for suicide and circulatory disorders in both men and women. Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men. Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs. In all groups long term medication treatment with antidepressants alone or with a neuroleptic, or with lithium in combination with antidepressants and/or neuroleptics significantly lowered suicide rates even though the treated were more severely ill. Although at the age of onset the suicide rates were most elevated, from ages 30 to 70 the rates were remarkably constant despite the different courses of illness. LIMITATIONS The patients were identified as inpatients and followed prospectively. The treatments were uncontrolled and are not quantifiable but were documented during the follow-up. CONCLUSIONS Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders. Unipolars have higher suicide rates than bipolar Is or IIs. Long term medication treatment lowers the suicide rates, despite the fact that it was the more severely ill who were treated.

The emerging epidemiology of hypomania and bipolar II disorder

The literature on the lifetime prevalence of the bipolar spectrum suggests rates of 3-6.5%. The Zurich cohort study identified a prevalence rate up to age 35 of 5.5% of DSM-IV hypomania/mania and a further 2.8% for brief hypomania (recurrent and lasting 1-3 days). The validity of DSM-IV hypomania and brief hypomania was demonstrated by a family history of mood disorders, a history of suicide attempts and treatment for depression. Comorbidity with anxiety disorders and substance abuse was found equally in both subtypes of hypomania. The study suggests that recurrent brief hypomania belongs to the bipolar spectrum. The findings should be verified on larger national cohorts in other epidemiological and clinical studies.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Epidemiology of depression

Review of the published literature produces 1-year prevalence rates for major depressive disorder DSM-III between 2.6 and 6.2%, for dysthymia between 2.3 and 3.7%, bipolar disorder 1.0–1.7%. Data from the prospective Zurich Study with four interviews over 10 years give relatively high 10-year prevalence rates for subjects from age 20 to 30 (14.4% major depression, 10.5% recurrent brief depression, 0.9% dysthymia, 3.3% bipolar disorder, 1.3% hypomania). On average, 49% of all these cases received treatment for affective disorder, resulting in a weighted treatment prevalence rate of the population of 11.6% (18% for females and 5% for males). It has to be assumed that lifetime prevalence rates based on recall may greatly underestimate true morbidity.

The Zurich study

SummaryThe longitudinal study of a cohort of 591 men and women aged 20 and 21 years respectively at outset, and 23/24 years at a subsequent investigation, was analyzed for the manifestation of depressive syndromes. The syndromes were grouped according to their duration: 1 week once or twice per year (group B),1 week three or more times per year (C), 2 weeks (D), 4 weeks (E) and 3 months (F). Prevalence rates are given over 1 month, 3 months and 1 year, subdivided by sex. Unexpected identical prevalence rates are found for both sexes up to 3 months. Over 1 year, the ratio shifts to favor the women.Setting out from the hypothesis of a continuum of depressive mood from normal to pathological, groups B to E were examined with respect to the prevailing symptomatology (assessed with an interview and a self-rating questionnaire, the SCL-90R). We found no relevant qualitative differences, only a trend of somatic symptoms becoming more prominent along with increasing duration of episode. Symptomatology thus does not point to further classification. Other criteria, such as subjective impairment, social impairment, illness behavior, discussing depressive mood with parents/friends/employer, treatment, all favor the assumption of a continuum of depressive syndromes from normal to pathological.

Gender differences in depression: Epidemiological findings from the European DEPRES I and II studies

Abstract.Background: While there is ample evidence that the prevalence rates for major depressive disorder (MDD) in the general population are higher in women than in men, there is little data on gender differences as regard to symptoms, causal attribution, help-seeking, coping, or the consequences of depression. Method: The large DEPRES Study dataset covering representative population samples of six European countries (wave I: 38,434 men and 40,024 women; wave II: 563 men and 1321 women treated for depression) was analyzed for gender differences. Results: In wave I marked gender differences were found in the six-month prevalence rate for major depression but less so for minor depression; the gender differences for major depression persisted across all age groups. Even after stratification by clinically significant impairment and paid employment status, men reported fewer symptoms than women; as a consequence, men reached the diagnostic threshold less often. In wave II there were clear gender differences in causal attribution and in coping. Men coped by increasing their sports activity and consumption of alcohol and women through emotional release and religion. Women felt the effects of depression in their quality of sleep and general health, whereas men felt it more in their ability to work. Limitations: The second wave of the study comprises treated depressives only and may be less representative than the first wave.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 1: acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

The Comorbidity of Alcoholism With Anxiety and Depressive Disorders in Four Geographic Communities

The comorbidity of alcoholism with anxiety and depressive disorders was examined in four epidemiologic investigations from diverse geographic sites. Despite variability in lifetime prevalence rates for these disorders, there was strong cross-site consistency in the magnitude and specific patterns of comorbidity. Individuals with alcohol abuse or dependence generally experienced a twofold to threefold increased risk of anxiety and depressive disorders. Phobic conditions typically preceded the onset of alcoholism, but no systematic pattern was observed for panic or depressive disorders. Considerable heterogeneity was also observed concerning the impact of comorbid conditions on symptoms of the index disorder. While the presence of comorbid anxiety or depressive disorders was consistently associated with moderate increases in the symptoms of alcohol abuse or dependence, alcoholism was associated with large increases in the number of depressive symptoms and little or no increase in phobic symptoms. The findings are discussed in terms of the self-medication hypothesis and the etiologic heterogeneity of these forms of comorbidity in the general population.

Metabolic hyperfrontality and psychopathology in the ketamine model of psychosis using positron emission tomography (PET) and [18F]fluorodeoxyglucose (FDG)

To date, the ketamine/PCP model of psychosis has been proposed to be one of the best pharmacological models to mimic schizophrenic psychosis in healthy volunteers, since ketamine can induce both positive and negative symptoms of schizophrenia. At subanesthetic doses, ketamine has been reported to primarily block N-methyl-D-aspartate (NMDA) receptor complex giving support to a glutamate deficiency hypothesis in schizophrenia. Positron emission tomography was used to study ketamine-induced psychotic symptom formation in relation to cerebral metabolic alterations in healthy volunteers. Our study shows that NMDA receptor blockade results in a hyperfrontal metabolic pattern. Increased metabolic activity in the frontomedial and anterior cingulate cortex correlated positively with psychotic symptom formation, in particular with ego pathology. Analysis of correlations between syndrome scores and metabolic rate of glucose (CMRglu) or metabolic gradients (ratios) revealed that each psychopathological syndrome was associated with a number of metabolic alterations in cortical and subcortical brain regions, suggesting that not a single brain region, but distributed neuronal networks are involved in acute psychotic symptom formation.

The Course of Affective Disorders

A representative sample of 95 hospitalized bipolar manic-depressive patients was followed up from 1959 to 1975. The mean age of the group at the time of this study was 61 years. It was observed that female bipolar patients demonstrate depression much more frequently than mania, while male patients show a symmetric distribution of both manic and depressive syndromes. The longitudinal occurrence of syndromes remains more or less constant; for instance, individual patients do not tend to go into depression with increasing age. The study shows that even after three episodes 29% of all bipolar patients would still have been misdiagnosed as unipolar depression.