Naomi Breslau

Comorbidity of migraine and depression Investigating potential etiology and prognosis

Background: An association between migraine and major depression has been observed in clinical and community samples. The factors that contribute to this association and their implications remain unclear. Objective: To determine the factors contributing to the association of migraine and major depression. Methods: A cohort study of persons aged 25 to 55 years with migraine (n = 496) or with other headaches of comparable severity (n = 151) and control subjects with no history of severe headaches (n = 539) randomly selected from the general community were interviewed first in 1997 and then reinterviewed in 1999. Results: Major depression at baseline predicted the first-onset migraine during the 2-year follow-up period (odds ratio [OR] = 3.4; 95% CI = 1.4, 8.7) but not other severe headaches (OR = 0.6; 95% CI = 0.1, 4.6). Migraine at baseline predicted the first-onset major depression during follow-up (OR = 5.8; 95% CI = 2.7, 12.3); the prospective association from severe headaches to major depression was not significant (OR = 2.7; 95% CI = 0.9, 8.1). Comorbid major depression did not influence the frequency of migraine attacks, their persistence, or the progression of migraine-related disability over time. Conclusions: Major depression increased the risk for migraine, and migraine increased the risk for major depression. This bidirectional association, with each disorder increasing the risk for first onset of the other, was not observed in relation to other severe headaches. With respect to other severe headaches, there was no increased risk associated with pre-existing major depression, although the possibility of an influence in the reverse direction (i.e., from severe headaches to depression) cannot be securely ruled out.

The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation

BACKGROUND The DSM-IV two-part definition of posttraumatic stress disorder (PTSD) widened the variety of stressors (A1) and added a subjective component (A2). The effects of the revised stressor criterion on estimates of exposure and PTSD in a community sample are evaluated. METHODS A representative sample of 2181 persons in southeast Michigan were interviewed about lifetime history of traumatic events and PTSD. The evaluation of the revised two-part definition is based on a randomly selected sample of events that represents the total pool of traumatic events experienced in the community. RESULTS The enlarged definition of stressors in A1 increased the total number of events that can be used to diagnose PTSD by 59%. The majority of A1 events (76.6%) involved the emotional response in A2. Females were more likely than males to endorse A2 (adjusted odds ratio = 2.66; 95% confidence interval 1.92, 3.71). Of all PTSD cases resulting from the representative sample of events, 38% were attributable to the expansion of qualifying events in A1. The identification of exposures that lead to PTSD were not improved materially by A2 however, events that did not involve A2 rarely resulted in PTSD. CONCLUSIONS Compared to previous definitions, the wider variety of stressors in A1 markedly increased the number of events experienced in the community that can be used to diagnose PTSD. Furthermore, A2 might be useful as a separate criterion, an acute response necessary for the emergence of PTSD, and might serve as an early screen for identifying a subset of recently exposed persons at virtually no risk for PTSD. The utility of A2 as a screen must be tested prospectively.

Migraine and Major Depression: A Longitudinal Study

SYNOPSIS

Depressive symptoms, major depression, and generalized anxiety: A comparison of self-reports on CES-D and results from diagnostic interviews.

This study evaluates the validity of the Center for Epidemiologic Studies Depression Scale (CES-D) by comparing it to DSM-III diagnoses of major depression and generalized anxiety, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS). Data were gathered on a sample of 310 mothers of children with chronic disabilities. The utility of the CES-D for detecting major depression was approximately equal to its utility for detecting generalized anxiety. Multivariate analysis revealed that the unique association of CES-D with current depression was equal to its association with current generalized anxiety and that the two disorders had additive effects on CES-D. The analysis did not identify any individual CES-D symptom as specific to either disorder. The findings, therefore, do not support the notion that the CES-D measures depression specifically.

Posttraumatic stress disorder. The stressor criterion.

Posttraumatic stress disorder (PTSD) was officially introduced into psychiatric nomenclature in 1980, when it was incorporated into DSM-III. There is as yet little empirical research on the validity of the diagnosis/Literature on disasters, civilian and wartime, and on more ordinary stressful life events does not support the view that extreme stressors form a discrete class of stressors in terms of the probability of psychiatric sequelae or the distinctive nature of subsequent psychopathology. Extraordinary stressors are like more ordinary stressful events with respect to their complex differential effects upon individuals. Personal characteristics and the nature of the social environment modify the likelihood and form of the response of individuals to all types of stressors.

Headache types and panic disorder Directionality and specificity

Objective: To examine the relationship of migraine and other severe headaches with panic disorder. Methods: Representative samples of persons with migraine, non-migrainous severe headaches, and controls with no history of severe headaches, identified by a telephone survey, were interviewed in person, using a standardized psychiatric interview. Cox proportional hazards models with time-dependent covariates were used to examine the relationship of headaches with first-onset panic disorder and vice versa. Results: Lifetime prevalence of panic disorder was significantly higher in persons with migraine and in persons with other severe headaches, compared with controls. Migraine and other severe headaches were associated with an increased risk for first onset of panic disorder (hazards ratios = 3.55 and 5.75). Panic disorder was associated with an increased risk for first onset of migraine and for first onset of other severe headaches, although the influences in this direction were lower (hazards ratios = 2.10 and 1.85). Conclusions: Comorbidity of panic disorder is not specific to migraine and applies also to other severe headaches. The influence is primarily from headaches to panic disorders, with a weaker influence in the reverse direction. The bidirectional associations, despite the difference in the strength of the associations, suggest that shared environmental or genetic factors might be involved in the comorbidity of panic disorder with migraine and other severe headaches.

Continuity of Care in a University-Based Practice.

Effects of changes in a pediatric practice--expansion of the number of pediatricians and incorporation into a university hospital setting--on continuity of care and utilization were examined by means of a longitudinal study of a sample of 63 families. Continuity of care was measured by the following index: the number of visits with own physician divided by the total number of pediatric visits per year. Although continuity of well-child visits remained unchanged at the university setting, the continuity of sick visits declined markedly. An increased use of doctor visits for illness care was observed; its relationship with the decline in continuity is analyzed and discussed. While continuity is inherent in a small partnership practice, it is not so in a larger medical organization, particularly when involvement in patient care is part time. In such an organization, deliberate arrangements that enable patients with acute needs to receive care from their own doctors are needed.

Psychiatric disorder in children with physical disabilities.

Psychiatric disorder in 304 children with four congenital conditions was compared with that of 360 normal children and across conditions, three that involve the brain and one that does not. Children with physical disability were at increased risk for psychiatric disturbance. Those with conditions involving the brain had greater psychopathology than children with cystic fibrosis. Severity of physical disability had little effect on psychopathology. The risk of psychiatric disturbance in children with conditions involving the brain varied directly with level of mental retardation. In addition, brain involvement conferred a risk of social isolation independent of mental retardation. The unique feature of severe psychopathology secondary to physical disorder was marked social isolation accompanied by a low level of aggressive behavior outside the home.

Alcohol disorders in young adulthood : Effects of transitions into adult roles

Using data gathered prospectively, the authors examined whether transitions in two major adult social roles, marriage and parenthood, influence the risk of developing (1) DSM-III-R alcohol disorder and (2) symptoms of alcohol disorder. Additionally, the potential impact of these transitions on persistence of alcohol disorder was examined. In the study, 1,007 members (21 to 30 years old) of a large health maintenance organization located in southeast Michigan were interviewed initially in 1989, 979 of whom were reinterviewed in 1992. Incidence of alcohol disorder symptoms was significantly higher among those who remained single (RR = 2.1) or became divorced (RR = 6.0) during the follow-up period, compared to those getting or staying married. Those who were never parents through the follow-up were also at increased risk (RR = 2.5), relative to those who became parents for the first time. Similar results were obtained for the incidence and persistence of an alcohol disorder. Transitions into adult roles, such as marriage and parenthood, appear to reduce the risk of developing alcohol disorder or related symptoms in young adulthood. These transitions also reduce the likelihood that an existing alcohol disorder will persist.

Psychological disturbance in children with physical disabilities: continuity and change in a 5-year follow-up.

This study measures continuity in behavioral disturbance over a 5-year period among 255 children with physical disabilities who were 6 to 18 years old at first assessment. The pattern of the results differed from that reported previously for a sample of the general population of children. Disabled children showed little stability in aggression, an area in which stability over time had been consistently reported for the general child population. Furthermore, important differences were observed between children with cystic fibrosis and children with cerebral palsy, myelodysplasia, or multiple physical handicaps, all conditions involving brain abnormality. Children with cystic fibrosis followed the trend toward better adjustment seen among the general population of children. In contrast, among children with conditions involving the brain, the majority of those who had been classified as psychologically severely impaired remained at this level of impairment 5 years later. In two behavioral domains, Mentation Problems and Isolation, children with conditions involving the brain maintained, on the average, the same markedly high score they had initially. Among children with physical conditions involving the brain, Mentation Problems and Isolation signify persistent problems that do not subside as the children mature.