Lauren M. Weinstock

Neuroticism as a common feature of the depressive and anxiety disorders: a test of the revised integrative hierarchical model in a national sample.

The revised integrative hierarchical model of depression and anxiety (S. Mineka, D. Watson, & L. A. Clark, 1998) proposes that high levels of neuroticism are shared between the depressive and anxiety disorders. This perspective was evaluated with data from the National Comorbidity Survey (N = 5,847), a population-based community sample. Analyses were based on both a broadband (i.e., diagnostic class) and a narrowband (i.e., specific disorder) approach. Results supported the model insofar as high neuroticism was shared across the depressive and anxiety disorders and was particularly elevated in people with comorbid depression and anxiety. Results are discussed in terms of their implications for understanding the association between personality and the depressive and anxiety disorders in a community sample and for the revised integrative hierarchical perspective.

Use of item response theory to understand differential functioning of DSM-IV major depression symptoms by race, ethnicity and gender

BACKGROUND Psychological literature and clinical lore suggest that there may be systematic differences in how various demographic groups experience depressive symptoms, particularly somatic symptoms. The aim of the current study was to use methods based on item response theory (IRT) to examine whether, when equating for levels of depression symptom severity, there are demographic differences in the likelihood of reporting DSM-IV depression symptoms. METHOD We conducted a secondary analysis of a subset (n=13 753) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset, which includes a large epidemiological sample of English-speaking Americans. We compared data from women and men, Hispanics and non-Hispanic Whites, African Americans and Whites, Asian Americans and Whites, and American Indians and Whites. RESULTS There were few differences overall, although the differences that we did find were primarily limited to somatic symptoms, and particularly appetite and weight disturbance. CONCLUSIONS For the most part, individuals responded similarly to the criteria used to diagnose major depression across gender and across English-speaking racial and ethnic groups in the USA.

Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up

BACKGROUND The aim of this study was to examine prospective predictors of suicide events, defined as suicide attempts or emergency interventions to reduce suicide risk, in 119 adolescents admitted to an in-patient psychiatric unit for suicidal behaviors and followed naturalistically for 6 months. Method Structured diagnostic interviews and self-report instruments were administered to adolescent participants and their parent(s) to assess demographic variables, history of suicidal behavior, psychiatric disorders, family environment and personality/temperament. RESULTS Baseline variables that significantly predicted time to a suicide event during follow-up were Black race, high suicidal ideation in the past month, post-traumatic stress disorder (PTSD), childhood sexual abuse (CSA), borderline personality disorder (BPD), low scores on positive affectivity, and high scores on aggression. In a multivariate Cox regression analysis, only Black race, CSA, positive affect intensity and high aggression scores remained significant. CONCLUSIONS Our findings suggest the following for adolescent populations: (1) in a very high-risk population, risk factors for future attempts may be more difficult to ascertain and some established risk factors (e.g. past suicide attempt) may not distinguish as well; and (2) cross-cutting constructs (e.g. affective and behavioral dysregulation) that underlie multiple psychiatric disorders may be stronger predictors of recurrent suicide events than psychiatric diagnoses. Our finding with respect to positive affect intensity is novel and may have practical implications for the assessment and treatment of adolescent suicide attempters.

Improving Treatment Adherence in Bipolar Disorder A Review of Current Psychosocial Treatment Efficacy and Recommendations for Future Treatment Development

Treatment adherence is a frequent problem in bipolar disorder, with research showing that more than 60% of bipolar patients are at least partially nonadherent to medications. Treatment nonadherence is consistently predictive of a number of negative outcomes in bipolar samples, and the discontinuation of mood stabilizers places these patients at high risk for relapse. Several types of adjunctive treatment (family, psychoeducational, cognitive-behavioral) have been investigated for improving symptoms and functioning in bipolar patients with some success. To date, less attention has been paid to developing treatments specifically to promote treatment adherence to and engagement with pharmacological as well as behavioral treatments in patients with bipolar disorder. First, we review the effects of adjunctive interventions specifically on treatment adherence outcomes in 14 published clinical trials. Based on this empirical knowledge base, we present a preliminary description of the treatment strategies that appear most promising for improving adherence. The article also provides research recommendations for developing more effective interventions for the purpose of improving bipolar treatment adherence. Finally, special treatment considerations, including the potential impact of comorbid substance abuse and bipolar depression, are discussed.

Family functioning and mood disorders : A comparison between patients with major depressive disorder and bipolar I disorder

Within a sample of patients with major depressive disorder (MDD; n = 121) and bipolar affective disorder (BPAD; n = 69), the authors examined (a) diagnostic differences in family functioning at acute episode, (b) diagnostic differences in family functioning at episode recovery, (c) within-group changes in family functioning from acute episode to recovery, and (d) whether within-group changes from acute episode to recovery varied by diagnosis. Using a multidimensional model, the authors evaluated interviewer, patient, and family ratings. Overall, patients with MDD and BPAD evidenced similar levels of family impairment at acute episode and recovery. Generally, patients in both groups experienced improvement in family functioning over time, yet mean scores at recovery continued to range from fair to poor. Although certain specific differences emerged, diagnostic groups appeared to be more similar than different in level and pattern of family functioning.

Differential item functioning of DSM-IV depressive symptoms in individuals with a history of mania versus those without : an item response theory analysis

OBJECTIVES Although major depression is characteristic of both bipolar disorder and major depressive disorder, there is disagreement as to whether there are distinct features of depression that differentiate these two conditions. The primary aim of this study was to use methods based in item response theory to evaluate differences in DSM-IV depression symptom endorsement in an epidemiological sample of individuals with a history of mania (i.e., bipolar depression) versus those without (i.e., unipolar depression). METHODS Clinical interview data were drawn from a subsample (n = 13,058) of individuals with bipolar or unipolar depression who had participated in the National Epidemiologic Survey on Alcohol and Related Conditions. Using these data, a two-parameter item response model was used to estimate differential item functioning of DSM-IV depressive symptoms between these two groups. RESULTS Differences in severity parameter estimates revealed that suicidal ideation and psychomotor disturbance were more likely to be endorsed across most levels of depression severity in bipolar versus unipolar depression. Differences in discrimination parameter estimates revealed that fatigue was significantly less discriminating in bipolar versus unipolar depression. CONCLUSIONS Equating for level of depression symptom severity, study results revealed that suicidal ideation and psychomotor disturbance are endorsed more frequently in bipolar versus unipolar depression. Study data also suggested that fatigue may be endorsed more frequently in unipolar relative to bipolar samples at moderate (versus low or high) levels of depression symptom severity.

Functional impairment as a predictor of short-term symptom course in bipolar I disorder.

OBJECTIVES Most prior research has focused on functional impairment as a consequence, rather than a predictor, of mood symptoms in bipolar disorder (BD). Yet the majority of this research has been cross-sectional, thus limiting conclusions regarding directionality of effects. Indeed, just as functional impairment may represent an important outcome of BD, it may also serve as a risk factor for future affective symptoms or episodes. Thus, the primary aim of this study was to evaluate functional impairment as a predictor of mood symptoms in BD. METHODS Ninety-two patients with bipolar I disorder, recruited from hospital settings, were administered the Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, and UCLA Social Attainment Survey (SAS) at baseline and at four-month follow-up. RESULTS Overall, patients evidenced a moderate level of functional impairment at both time points. Whereas baseline functional impairment was not associated with subsequent manic symptoms, baseline functional impairment was significantly predictive of depressive symptom levels at four-month follow-up. When individual SAS subscales were evaluated, impaired romantic relationship functioning and activity involvement were each significantly predictive of subsequent depressive symptoms, whereas baseline peer functioning was not. CONCLUSIONS The study results suggest that functional impairment may be predictive of subsequent depressive, but not manic, symptoms over a relatively short-term follow-up period. Future studies that evaluate illness course over longer follow-up periods would be useful to further clarify the potential bidirectional relationship between depression and functional impairment in BD.

Rumination and Excessive Reassurance-Seeking in Depression: A Cognitive-Interpersonal Integration

The purpose of this study was to conduct a preliminary investigation into the cross-sectional associations between depression, rumination, and excessive reassurance-seeking. Guided by conceptual linkages between these variables, ruminative response style was examined as both a potential moderator and as a potential mediator of the association between depressive symptoms and excessive reassurance-seeking in a sample of undergraduate students (N=244). Results from this investigation suggest that rumination mediates, but does not moderate, the association between depression and excessive reassurance-seeking. Findings are discussed within the context of integrating cognitive and interpersonal perspectives within the study of depression.

Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder

OBJECTIVE The aim of the current study was to evaluate family functioning, social support, and functional impairment as predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder. This study builds upon the extant literature by evaluating these putative psychosocial risk factors simultaneously to determine whether they account for unique variance in clinical outcomes. METHOD Patients (N = 92) were recruited from hospital settings during an acute mood episode to participate in pharmacologic or combined family and pharmacologic interventions. The Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, Family Assessment Device, Interpersonal Support Evaluation List, and UCLA Social Attainment Survey were administered at acute phase treatment completion and again at 1-year follow-up. Controlling for mood symptom severity at acute phase treatment completion, multiple regression analyses were used to examine longitudinal associations between the psychosocial variables and subsequent depressive and manic symptoms. RESULTS None of the aforementioned psychosocial variables predicted manic symptomatology, and social support alone emerged as a unique predictor of depression at the 1-year follow-up. Effects of social support were moderated by recovery status, such that the strength of association between social support and subsequent depression was stronger for those who had not fully recovered during the acute phase of treatment than for those who had. CONCLUSIONS Low levels of social support at acute phase treatment completion, especially in concert with residual symptomatology, may place individuals with bipolar I disorder at risk for subsequent depressive symptoms. These data suggest that maintenance therapies focused on improving level of social support might be especially important to consider in the management of bipolar depression, and add to a growing literature focused on unique vs shared effects of psychosocial risk factors for poor illness course in bipolar disorder.

Medication burden in bipolar disorder: A chart review of patients at psychiatric hospital admission

Individuals with bipolar disorder (BD) often receive complex polypharmacy regimens as part of treatment, yet few studies have sought to evaluate patient characteristics associated with this high medication burden. This retrospective chart review study examined rates of complex polypharmacy (i.e., ≥4 psychotropic medications), patterns of psychotropic medication use, and their demographic and clinical correlates in a naturalistic sample of adults with bipolar I disorder (BDI; N=230) presenting for psychiatric hospital admission. Using a computer algorithm, a hospital administrator extracted relevant demographic, clinical, and community treatment information for analysis. Patients reported taking an average of 3.31 (S.D.=1.46) psychotropic medications, and 5.94 (S.D.=3.78) total medications at intake. Overall, 82 (36%) met criteria for complex polypharmacy. Those receiving complex polypharmacy were significantly more likely to be female, to be depressed, to have a comorbid anxiety disorder, and to have a history of suicide attempt. Women were significantly more likely than men to be prescribed antidepressants, benzodiazepines, and stimulants, even after controlling for mood episode polarity. Study data highlight the high medication burden experienced by patients with BD, especially those who are acutely symptomatic. Data also highlight the particularly high medication burden experienced by women with BD; a burden not fully accounted for by depression.