[Show abstract][Hide abstract] ABSTRACT: Given the high lifetime prevalence rates of bipolar disorder and comorbid substance use disorders (SUDs), the aim of the study was to examine the effect of a remitted SUD on the future course of bipolar I disorder in patients taking part in a clinical trial. Patients with bipolar I disorder were enrolled in a larger study examining the effects of pharmacotherapy plus family interventions. These patients were recruited during an acute mood episode and their mood symptoms and substance abuse were assessed longitudinally for up to 28 months. Patients with a remitted SUD showed a poorer acute treatment response, a longer time to remission of their acute mood episode, and a greater percentage of time with subthreshold but clinically significant depression and manic symptoms over follow-up compared to those without this comorbidity pattern. Subsequent substance abuse during follow-up could not fully account for the poorer course of illness. As remitted SUDs appear to negatively predict treatment outcome, current findings have implications for both clinical trials of bipolar patients as well as clinical practice.
Psychiatry Research 08/2008; 160(1):63-71. · 2.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
There were few differences overall, although the differences that we did find were primarily limited to somatic symptoms, and particularly appetite and weight disturbance.
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.
Psychological Medicine 07/2008; 39(4):591-601. · 5.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To date, few prospective studies of life events and bipolar disorder are available, and even fewer have separately examined the role of life events in depression and mania. The goal of this study was to prospectively examine the role of negative and goal-attainment life events as predictors of the course of bipolar disorder. One hundred twenty-five individuals with bipolar I disorder were interviewed monthly for an average of 27 months. Negative and goal-attainment life events were assessed with the Life Events and Difficulties Schedule. Changes in symptoms were evaluated using the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Scale. The clearest results were obtained for goal-attainment life events, which predicted increases in manic symptoms over time. Negative life events predicted increases in depressive symptoms within regression models but were not predictive within multilevel modeling of changes in depressive symptoms. Given different patterns for goal attainment and negative life events, it appears important to consider specific forms of life events in models of bipolar disorder.
Journal of Abnormal Psychology 06/2008; 117(2):268-77. · 4.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: Increased understanding of the treatment goals of depressed patients may lead to improved treatments and assist researchers and program evaluators in choosing clinically relevant outcome measures. To characterize patients' depression treatment goals, we interviewed hospitalized depressed patients about their treatment goals. Common responses included improving relationships, decreasing sadness or anxiety, and finding a job or improving job performance. On a written questionnaire, patients also ranked decreasing suicidal thoughts highly. These results suggest that for many severely depressed individuals, primary treatment goals include improvements in social and occupational functioning in addition to symptomatic improvement.
The Journal of nervous and mental disease 04/2008; 196(3):217-22. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is a clear need for psychosocial treatments to supplement pharmacotherapy for bipolar disorder. In this study, the efficacy of 2 forms of adjunctive family intervention were compared to pharmacotherapy alone. In addition to evaluating overall differences between treatments, a chief goal was to examine whether family impairment levels moderated the effects of family intervention on outcome.
Ninety-two patients diagnosed with bipolar I disorder (according to DSM-III-R) were randomly assigned to receive (1) pharmaco-therapy alone, (2) family therapy + pharmacotherapy, or (3) multi-family psychoeducational group + pharmacotherapy. Treatments and assessments continued for up to 28 months. Primary outcome measures were number of episodes per year and percentage of time symptomatic throughout the entire follow-up period. The study was conducted from September 1992 through March 1999.
No significant main effects were found for treatment condition. Thus, for the total sample, the addition of a family intervention did not improve outcome. However, there were significant treatment condition by family impairment interactions (p < .05). In patients from families with high levels of impairment, the addition of a family intervention (family therapy or psycho-educational group) resulted in a significantly improved course of illness, particularly the number of depressive episodes (p < .01) and proportion of time spent in a depressive episode (p < .01). These effects were relatively large (Cohen d = 0.7-1.0), with patients receiving either family intervention having roughly half the number of depressive episodes and amount of time spent depressed as those receiving pharmaco-therapy alone. In contrast, for patients from low-impairment families, the addition of a family intervention did not improve course of illness.
Our findings build on previous literature suggesting the importance of treatment matching within the mood disorders and suggest that the utility of adding family interventions for bipolar patients and their families may depend upon the family's level of impairment.
The Journal of Clinical Psychiatry 03/2008; 69(5):732-40. · 5.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories.
One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3-, 6-, 12-, and 18-month follow-up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis.
Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single attempters and nonattempters.
Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.
[Show abstract][Hide abstract] ABSTRACT: Research has shown both childhood physical and sexual abuse to be associated with later suicide attempts, although some studies have not supported these findings. However, few studies have investigated differences in physical and sexual abuse histories among single and multiple suicide attempters. The goals of the current study were two-fold: (a) to replicate previous findings of associations between childhood sexual and physical abuse and suicide attempts, and (b) to explore differences in reports of childhood physical and sexual abuse among single and multiple suicide attempters. While our results supported the findings that individuals with a history of suicide attempts are more likely to report histories of childhood physical and sexual abuse, we did not find a difference in reported abuse between single and multiple suicide attempters. Implications of these findings, as well as implications for future research, are discussed.
Suicide and Life-Threatening Behavior 09/2007; 37(4):467-74. · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study is a randomized, double-blind, placebo-controlled clinical trial examining the effects of an intensive cognitive-behavioral mood management treatment (CBTD) and of bupropion, both singularly and in combination, on smoking cessation in adult smokers. As an extension of our previous work, we planned to examine the synergistic effects of CBTD and bupropion on smoking cessation outcomes in general and among smokers with depression vulnerability factors. Participants were 524 smokers (47.5% female, M (age) = 44.27 years) who were randomized to one of four 12-week treatments: (a) standard, cognitive-behavioral smoking cessation treatment (ST) plus bupropion (BUP), (b) ST plus placebo (PLAC), (c) standard cessation treatment combined with cognitive-behavioral treatment for depression (CBTD) plus BUP, and (d) CBTD plus PLAC. Follow-up assessments were conducted 2, 6, and 12 months after treatment, and self-reported abstinence was verified biochemically. Consistent with previous studies, bupropion, in comparison with placebo, resulted in better smoking outcomes in both intensive group treatments. Adding CBTD to standard intensive group treatment did not result in improved smoking cessation outcomes. In addition, neither CBTD nor bupropion, either alone or in combination, was differentially effective for smokers with single-past-episode major depressive disorder (MDD), recurrent MDD, or elevated depressive symptoms. However, findings with regard to recurrent MDD and elevated depressive symptoms should be interpreted with caution given the low rate of recurrent MDD and the low level of depressive symptoms in our sample. An a priori test of treatment effects in smokers with these depression vulnerability factors is warranted in future clinical trials.
Nicotine & Tobacco Research 08/2007; 9(7):721-30. · 2.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Repeated experiences with major depressive disorder (MDD) may strengthen associations between negative thinking and dysphoria, rendering negative cognition more accessible and pronounced with each episode. According to cognitive theory, greater negative cognition should lead to a more protracted episode of depression. In this study of 121 adults with MDD, number of previous episodes was associated with slower change in depression across inpatient and outpatient treatment. Further, although pretreatment negative cognition and pretreatment family impairment both uniquely predicted slower change in depressive symptoms, only negative cognition mediated the association between depression history and depression change. Findings suggest that repeated MDD episodes are specifically associated with increased negative cognition, which in turn contributes to a more pernicious course of symptom change during treatment for depression.
Journal of Consulting and Clinical Psychology 07/2007; 75(3):422-31. · 4.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Depressed breastfeeding women may have concerns about taking antidepressant medications due to fears regarding infant exposure. We examined the clinical records of 73 breastfeeding women who sought depression treatment, to identify characteristics of those who took antidepressants. Compared to women who were not treated with pharmacotherapy, breastfeeding patients who took antidepressants had more severe symptoms, greater functional impairment, more extensive psychiatric histories, and were less likely to be involved in a committed relationship. No differences were found in age, race, or education.
Depression and Anxiety 05/2007; 25(10):888-91. · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous research is inconsistent regarding the significance of mood-incongruent psychotic symptoms in relation to the severity and course of bipolar disorder. In the present study, bipolar I patients were assessed at index hospitalization using standardized symptom measures and followed up to 28 months. We contrasted the symptomatic course in patients experiencing mood-congruent versus mood-incongruent psychotic symptoms. Results revealed that patients spent an average of 29% of the time during follow-up in a mood episode, but only 5% of the time with psychotic symptoms. Few differences were found at the index hospitalization and no differences were found on any longitudinal course variables between mood-congruence subtypes. Although experiencing high levels of psychosis at baseline, both subtypes improved considerably following hospitalization, and psychotic symptom levels remained relatively stable. Current results suggest that when provided efficacious treatment, mood-incongruent psychotic mania does not predict a worse symptomatic course of illness.
[Show abstract][Hide abstract] ABSTRACT: The short allele in a variable repeat sequence of the promoter region of the serotonin transporter gene (5-HTTLPR) has been associated with stronger activation in brain regions critical for processing emotional stimuli. The authors examined whether variants of the 5-HTTLPR promoter polymorphism were also associated with individual differences in attentional biases for emotional stimuli. Words related to anxious and dysphoric emotional states were presented to psychiatric inpatients in a standard dot-probe reaction time task. Compared with participants with two long alleles, carriers of the short 5-HTTLPR allele exhibited a stronger attentional bias for anxious word stimuli. No genetic group difference was observed for dysphoric word stimuli. Findings from this preliminary study highlight the potential for integrating genetic and cognitive models of psychopathology.
Journal of Abnormal Psychology 03/2007; 116(1):208-12. · 4.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A randomized, placebo-controlled trial has yet to be completed in patients with psychological nonepileptic seizures (NES). Treatment publications for NES are limited to class III trials and class IV reports. Little is written on the methodology of treatment trials in NES. The authors describe the procedures and limitations of such a trial to inform future NES treatment trials, based on their prospective, open-label pharmacological, feasibility trial. The authors review the recruitment, enrollment, completion of surveys, compliance, and follow-up of patients with NES. The majority of patients who enrolled, readily completed surveys and took the medication during the trial. Twelve patients were screened, eight enrolled, and six completed the trial. The authors discuss the use of outcomes and the various symptoms scales in the trial. A comprehensive neuropsychiatric initial assessment and assessing cognitive, emotional, behavioral, and psychosocial measures are important for monitoring the outcomes in NES treatment RCTs.
Journal of Neuropsychiatry 02/2007; 19(4):391-8. · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Psychotic depression is a relatively prevalent mood disorder associated with greater symptom severity, a poorer course of illness and higher levels of functional impairment compared with nonpsychotic depression. Separate lines of investigation suggest that various forms of cognitive-behavioral therapy are efficacious for treating severe forms of nonpsychotic depression as well as primary psychotic disorders. However, there currently are no empirically supported psychotherapies specifically designed for treating psychotic depression.
We review the efficacy of current somatic treatments for the disorder and discuss the limited data to date on potentially useful psychotherapeutic approaches. In particular, we describe the clinical improvement observed in a subgroup of hospitalized patients with psychotic depression treated with Acceptance and Commitment Therapy as part of a larger clinical trial.
Pilot results demonstrated that Acceptance and Commitment Therapy was associated with clinically significant reductions in acute symptom severity and impairment compared with treatment as usual.
The findings suggest that patients with psychotic depression can benefit from psychotherapy. Clinical and research recommendations in this area are presented.
Psychotherapy and Psychosomatics 02/2007; 76(5):271-7. · 9.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is growing evidence that a functional polymorphism in the serotonin transporter gene (5-HTTLPR) moderates the impact of negative life events (e.g., childhood abuse) on the development of depression. However, it is unclear whether the gene x environment interaction predicts suicide attempts specifically. In addition, previous studies have not examined different forms of childhood abuse separately. In the current study, we found that 5-HTTLPR genotype moderated the link between childhood physical and sexual, but not emotional, abuse and adult psychiatric inpatients' histories of suicide attempts.
Suicide and Life-Threatening Behavior 01/2007; 36(6):687-93. · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Journal of Consulting and Clinical Psychology 01/2007; 74(6):1192-202. · 4.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine if a telephone support behavioral intervention improves depressive symptoms among HIV positive outpatients, we enrolled 177 persons with Beck Depression Inventory (BDI) scores scores of >/=10. Participants were randomized to receive up to 12 scheduled psycho-educational calls over 6 months or to an assessment-only control condition. Co-enrolled informal caregivers of HIV patients received the same telephone intervention in parallel. Among the 160 (90.4%) participants who were re-interviewed at 6 months, 56% were male, and 41% were Caucasian, with a mean baseline BDI score of 22.7. Overall, participants' mean BDI scores improved 5.3 points from baseline, but intervention group differences on depression outcomes including 50% or greater reduction in BDI scores and depression remission were not statistically significant. In the full cohort, men were significantly more likely to improve than women. We conclude that a psycho-educational telephone support intervention did not reduce depressive symptoms for HIV patients more than an assessment-only control condition.
AIDS and Behavior 01/2007; 11(1):15-23. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous research suggests that psychotic major depression (PMD) is associated with greater illness severity and functional impairment as well as poorer treatment response to antidepressants and psychotherapies compared with nonpsychotic major depression. Although patients with PMD exhibit a number of neurobiological abnormalities, little research has been conducted to date on possible psychological factors that are related to illness in this depression subtype. In the current study, baseline data were pooled from 2 clinical trials in which depressed patients (n = 235) were recruited during a psychiatric hospitalization for an acute episode. Twelve percent (n = 28) of this treatment-seeking sample met criteria for PMD and showed elevated levels of depression severity and dysfunctional beliefs compared with individuals with nonpsychotic major depression. However, even after controlling for depression severity and other relevant baseline variables, only a measure of common dysfunctional beliefs differentiated those with vs those without psychotic features. Furthermore, higher levels of depressive cognitions were related to poorer psychosocial functioning and suicidality in PMD patients. Results suggest that elevated levels of common negative cognitions in depressed patients may be associated with the presence of more severe psychotic symptoms. Adapted cognitive-behavioral treatments may be useful for treating patients with PMD specifically.