Category: Depression

Major depression affects as many as 16% of reproductive-aged women in the U.S. Yet pregnant women have a higher rate of undiagnosed depression than nonpregnant women, according to a study published in Journal of Women's Health, a peer-reviewed publication from Mary Ann Liebert, Inc., publishers.

Jean Ko, PhD and coauthors from the Centers for Disease Control and Prevention (CDC), Atlanta, GA, found that more than 1 in 10 women ages 18-44 years had a major depressive event during the previous year — representing about 1.2 million U.S. women — but more than half of those women did not receive a diagnosis of depression and nearly half did not receive any mental health treatment. The article "Depression and Treatment among U.S. Pregnant and Nonpregnant Women of Reproductive Age, 2005-2009," further reports that disparities in receiving a diagnosis and treatment were associated with younger age, belonging to a racial/ethnic minority, and insurance status.

The accompanying Editorial entitled "Depression: Is Pregnancy Protective?" by Jennifer Payne, MD, Johns Hopkins School of Medicine, Baltimore, MD, explores the ongoing challenges in the adequate diagnosis and treatment of major depression, the additional factors that come into play during pregnancy, and the implications of the Ko et al. study results.

"As health care providers, we simply must do a better job at diagnosing depression and referring women for mental health treatment. Reproductive health care visits provide an opportune time to address this ," says Susan G. Kornstein, MD, Editor-in-Chief of Journal of Women's Health, Executive Director of the Virginia Commonwealth University Institute for Women's Health, Richmond, VA, and President of the Academy of Women's Health.

Researchers at Emory University have found that a medication that inhibits inflammation may offer new hope for people with difficult-to-treat depression.

The study was published Sept. 3 in the online version of Archives of General Psychiatry.

"Inflammation is the body's natural response to infection or wounding, says Andrew H. Miller, MD, senior author for the study and professor of Psychiatry and Behavioral Sciences at Emory University School of Medicine. "However when prolonged or excessive, inflammation can damage many parts of the body, including the brain."

Prior studies have suggested that depressed people with evidence of high inflammation are less likely to respond to traditional treatments for the disorder, including anti-depressant medications and psychotherapy. This study was designed to see whether blocking inflammation would be a useful treatment for either a wide range of people with difficult-to-treat depression or only those with high levels of inflammation.

The study employed infliximab, one of the new biologic drugs used to treat autoimmune and inflammatory diseases such as rheumatoid arthritis and inflammatory bowel disease. A biologic drug copies the effects of substances naturally made by the body's immune system. In this case, the drug was an antibody that blocks tumor necrosis factor (TNF), a key molecule in inflammation that has been shown to be elevated in some depressed individuals.

Study participants all had major depression and were moderately resistant to conventional antidepressant treatment. Each participant was assigned either to infliximab or to a non-active placebo treatment.

When investigators looked at the results for the group as a whole, no significant differences were found in the improvement of depression symptoms between the drug and placebo groups. However, when the subjects with high inflammation were examined separately, they exhibited a much better response to infliximab than to placebo.

Inflammation in this study was measured using a simple blood test that is readily available in most clinics and hospitals and measures C-reactive protein or CRP. The higher the CRP, the higher the inflammation, and the higher the likelihood of responding to the drug.

"The prediction of an antidepressant response using a simple blood test is one of the holy grails in psychiatry," says Miller. "This is especially important because the blood test not only measured what we think is at the root cause of depression in these patients, but also is the target of the drug."

"This is the first successful application of a biologic therapy to depression," adds Charles L. Raison, MD, first author of the study. "The study opens the door to a host of new approaches that target the immune system to treat psychiatric diseases." Raison, formerly at Emory, is now associate professor in the Department of Psychiatry at the University of Arizona College of Medicine — Tucson.

Non-pain-related factors — including previous use of pain medications, high perceived risk of addiction, and symptoms of depression — increase the risk of continuing to use strong pain-relieving drugs several months after surgery, reports a study in the September issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

"Each of these factors was a better predictor of prolonged opioid use than postoperative pain duration or severity," according to the new research, led by Dr Ian Carroll of Stanford University.

Non-Pain Factors Predict Long-Term Opioid Use after Surgery

The researchers analyzed factors associated with long-term use of strong pain medications in 109 patients undergoing various types of surgery (breast cancer surgery, chest surgery, or joint replacement). Before their operation, the patients were evaluated for a number of factors potentially affecting use of pain medications.

After surgery, the patients underwent regular assessment of their use of opioid medications — morphine and related drugs. The goal was to identify preoperative factors that predicted continued use of opioids several months after surgery.

Five months postoperatively, six percent of patients still had a prescription for opioid drugs. Three factors were independently related to long-term opioid use, after adjustment for other factors. Patients who took opioids for pain relief before surgery — whether prescribed or otherwise — were 73 percent more likely to be still using these medications at follow-up.

Long-term opioid use was also higher for patients who, before surgery, rated themselves at increased risk of becoming addicted. For each one-point increase on a four-point scale of perceived addiction risk, the risk of long-term opioid use increased by 53 percent. Patients with symptoms of depression were also at increased risk: a 42 percent increase for every ten points on a standard scale (the Beck Depression Inventory).

These risk factors were better predictors of long-term opioid use than the severity or duration of pain after surgery. The same three factors were significant regardless of the type of surgery the patient had.

"As patients recover from surgery, they face an ongoing choice either to continue taking prescribed opioids or to stop opioids and undertake non-opioid pain treatment," Dr Carroll and colleagues explain. But few studies have looked at the factors influencing continued use of strong pain medications after surgery. In patients with chronic pain, opioid use is more related to psychological distress and substance abuse than to pain intensity.

The new study finds that long-term opioid use is also linked to non-pain-related factors in patients undergoing surgery. The researchers point out that, if there six percent rate of long-term opioid use applied to the average 17.6 million patients undergoing surgery each year, there would be 1.1 million new opioid users in the population each year.

Use of prescription opioid drugs has increased rapidly in recent years, including both legitimate use for pain treatment and drug diversion and recreational use. Dr Carroll and coauthors emphasize that some of the long-term opioid use in their study could have been legitimate — but the findings raise concerns about the "disconnect" between the non-pain-related risk factors and the reason (pain relief) the drugs are prescribed. The researchers call for further research to clarify the relationship been the three risk factors and the development of opioid abuse and addiction.

 Chronic stress, prompted by major life stressors and type A personality traits, is linked to a high risk of stroke, finds research published online in the Journal of Neurology Neurosurgery and Psychiatry.

Chronic stress, manifested as physical and/or mental symptoms in response to stressors lasting longer than 6 months has been linked to a heightened risk of heart disease. But its impact on the risk of stroke has not been clear.

The research team base their findings on150 adults, with an average age of 54, who had been admitted to one stroke unit, and 300 randomly selected healthy people of a similar age who lived in the same neighbourhood.

Levels of chronic stress were assessed using the combined quantitative scores of four validated scales, looking at major life events; symptoms, such as anxiety and depression; general wellbeing; and behaviour patterns indicative of type A personality (ERCTA scale).

Type A behaviours include hostility, aggression, impatience and a quick temper. A score of 24 or higher on the ERCTA scale is considered to be indicative of a type A personality.

Participants were also assessed for known biological risk factors for stroke, including diabetes, high blood pressure, high cholesterol, any history of heart rhythm abnormalities, and daytime sleepiness.

And they were quizzed on their lifestyle, including their caffeine, alcohol and energy drink intake, as well as whether they smoked, had a partner, and a job.

The results showed that several factors were independently associated with a heightened risk of stroke.

Compared with the healthy comparison group, the risk of a stroke was almost four times higher among those who had experienced a major life event in the previous year.

A high score on the ERCTA scale more than doubled stroke risk, as did a current or previous history of smoking, and intake of two or more energy drinks a day.

And those with heart rhythm disturbances were more than three times as likely to have a stroke while those with a high daytime sleepiness score almost tripled their risk. And being a man boosted the risk nine-fold.

But when all the factors were assessed together, the risk of a stroke was associated with a stressful life and type A behaviours. And this held true, irrespective of other risk factors, including gender and an unhealthy lifestyle.

Workers who perceive their jobs aren't secure are more likely to rate themselves in poor health and have increased symptoms of anxiety and depression, reports the September Journal of Occupational and Environmental Medicine, official publication of the American College of Occupational and Environmental Medicine (ACOEM).

Sarah A. Burgard, PhD, and colleagues of University of Michigan, Ann Arbor, analyzed data on about 440 working-aged adults living in southeast Michigan in 2009-10. The analysis was part of a larger study to assess the impact of the recent economic recession and ongoing recovery on the lives of workers in the Detroit area, which was hit particularly hard by the "Great Recession."

Nearly 18 percent of workers perceived their job was insecure — they felt it was at least "fairly likely" that they would lose their job or be laid off within the next year. Workers with job insecurity rated their health lower than workers who perceived their jobs as more secure — they were nearly three times more likely to rate their health as fair to poor.

Workers with job insecurity were nearly four times more likely to report symptoms of anxiety attacks, and close to seven times more likely to have symptoms suggesting minor or major depression. These effects were significant after adjustment for other characteristics.

The study adds to previous research linking job insecurity to poorer health. This could have a major impact on population health in the wake of the recent economic recession — especially with the "jobless recovery" and continued high unemployment rates.

"The study provides some of the first available evidence on the extent and distribution of perceived job insecurity and its association with health in the wake of the Great Recession," Dr Burgard and coauthors write. They call for interventions targeting the large number of people who may be suffering the mental and physical health effects of job worries. Especially with the slow recovery, they add, "perceptions of job insecurity may persist for some time."

Expectant mothers who learn from prenatal diagnosis that they are carrying a fetus with a congenital heart defect (CHD) commonly suffer post-traumatic stress, depression and anxiety. However, a healthy relationship with one's partner and positive coping mechanisms can reduce this intense stress, according to new research from the Cardiac Center of The Children's Hospital of Philadelphia.

The study is published in the September 2012 issue of The Journal of Pediatrics.

"Receiving the news of carrying a fetus with a CHD is a stressful event which can potentially influence a mother's anxiety level," said study leader Jack Rychik, M.D., medical director of the Fetal Heart Program in the Cardiac Center at The Children's Hospital of Philadelphia. "Prenatal diagnosis is helpful in that it gives parents time to learn about the defect, review treatment options, plan for necessary interventions and consider their options. While this is intrinsically a stressful time for parents, there has previously been little research on the details of this stress and ways to buffer it."

The researchers surveyed 59 pregnant mothers, ranging in gestational age from 17 to 31.5 weeks, who were recruited by nurse coordinators at either the initial visit to the Fetal Heart Program or a follow-up visit, then followed throughout the rest of their gestation. Participants intended to continue the pregnancy, and to plan for follow-up with the Fetal Heart Program. All were carrying fetuses with serious CHD requiring neonatal evaluation and postnatal surgical or catheter-based intervention within the first six months of life.

Using psychological evaluation tools and self-report instruments, the study team measured traumatic stress, depression and anxiety among the mothers. The researchers also measured partner satisfaction and collected demographic data.

More than 39 percent of the women experienced clinically important traumatic stress, 22 percent experienced depression, and 31 percent experienced state anxiety. Lower partner satisfaction and lower income were both associated with higher levels of depression, anxiety and traumatic stress. When the researchers controlled for partner satisfaction and income, they found denial to be most important factor contributing to depression.

"Prenatal diagnosis of CHD is a traumatic event for many pregnant women. In our study we found that a substantial proportion of mothers exhibited evidence for traumatic stress, with nearly 40 percent exceeding clinical cut-off points for post-traumatic stress disorder," said Guy S. Diamond, Ph.D., a psychologist at The Children's Hospital of Philadelphia who participated in this study.

"While individual coping skills are important, partner satisfaction may better predict a more resilient response to the stress of prenatal CHD," Diamond added. We have identified 'denial' as an important contributor to depression and that on-going counseling sessions should focus on this risk factor."

"This study is the beginning, and more research needs to be done to ensure we are giving mothers the very best multidisciplinary care. In one way, the families are fortunate to know in advance that their baby has a CHD and in another way given more stress with that knowledge. In the future, optimal management strategies to improve outcomes for both mom and fetus will include stress reduction techniques, which should accompany the diagnosis of CHD prior to birth," added Rychik.

Dr. Rychik's co-authors are Denise D. Donaghue, RN, MSN; Suzanne Levy, Ph.D.; Clara Fajardo, MS; Jill Combs, RN, MSN; Xuemei Zhang, MS; Anita Szwast, M.D., and Guy S. Diamond, Ph.D., all from The Children's Hospital of Philadelphia.

Dr. Rychik is supported in part by the Robert and Dolores Harrington Endowed Chair in Pediatric Cardiology.

 Heart defects are the most common form of congenital malformations affecting newborns. Infants who were prenatally diagnosed with congenital heart disease (CHD) are more stable and have better outcomes than infants who were diagnosed after birth. Diagnosing CHD in a fetus also allows mothers to educate themselves on heart malformations, consider their options, and potentially plan for intervention or surgery after birth. However, a new study scheduled for publication in The Journal of Pediatrics finds that, along with these benefits, maternal posttraumatic stress, depression, and anxiety are common after prenatal diagnosis of CHD.

The prenatal diagnosis of CHD is a stressful event for parents, which can affect mood and anxiety. Maternal stress has been linked to fetal disturbances in the hypothalamic-adrenal-pituitary system, poor intrauterine growth, preterm birth, and newborns who are small for gestational age (associated with childhood attention and learning difficulties, anxiety, and depression). Therefore, healthy partner relationships and positive coping mechanisms are important for pregnant women to successfully deal with stress. Jack Rychik, MD, at the Fetal Heart Program at The Cardiac Center at The Children's Hospital of Philadelphia, states, "Our study supports the notion that maternal psychological support is an important intervention that may someday accompany prenatal diagnosis of CHD, in order to potentially improve outcomes for both fetus and mother."

Dr. Rychik and colleagues from The Children's Hospital of Philadelphia assessed women whose fetus had been diagnosed with serious CHD, requiring newborn assessment and cardiac surgery or catheterization within 6 months after birth. Two to four weeks after initial diagnosis, 59 pregnant women were given self-reporting surveys to assess their perceived posttraumatic stress, anxiety, depression, coping responses, and couples/partner adjustment. The authors found that depression and anxiety were higher for the pregnant women whose fetus had been diagnosed with CHD and partner satisfaction was lower, compared with women with healthy pregnancies.

Twenty-two percent of the women in the study had depression, 31% had anxiety, and 39% had traumatic stress. Low income was associated with increased maternal depression. Low partner satisfaction was associated with increased maternal depression and anxiety. Denial was associated with increased maternal depression, anxiety, and traumatic stress, regardless of partner satisfaction or income. Alternatively, increased acceptance was associated with decreased maternal depression.

Women may grieve the loss of a "normal" pregnancy by going through the various stages of grief (denial, guilt, anger, bargaining, and potentially acceptance). Health care providers should incorporate a strategy of maternal stress reduction through the promotion of coping skills after diagnosis of a fetus with CHD and throughout the pregnancy. Although maternal coping is important, partner satisfaction may be a better "buffer" for the stress of prenatal CHD. Brief couples therapy also may be beneficial to the pregnant women and their partners.

The process of grieving can be compared to the workings of a pinball machine, where mourners' movement between different stages of grief such as shock and depression may be unpredictable, according to authors writing in September's issue of Mental Health Practice journal.

Margaret Baier of Baylor University, Waco, Texas and Ruth Buechsel of Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas, say they are not trying to suggest grief is a game or downplay the experience, but that the metaphor can help people understand that grieving is not a linear process.

As on a pinball machine, there are triggers which can prolong or even restart the process. For the mourner these could be the anniversary of a death or a special event they used to share with their loved one. This model can be used in therapy by healthcare professionals to help people understand that their responses are normal. It may also be adaptable to help those coping with separation, divorce, loss of employment or financial loss, say the authors.

They identify numerous models and factors for understanding grief in the literature as helpful in predicting coping and adjustment in bereavement. However, they say, many of the models are misinterpreted as linear. Grieving patients often speak of feeling as though they are 'bouncing' from one stage to another, which elicited the image of a pinball.

They say their model contains elements of the seminal work by Kubler-Ross (1969) but illustrates the process in a way that helps bereaved people see and understand their emotional processes, which helps them normalise and move through the experience of grief. This normalisation may help people to relax and better process grief, make sense of a seemingly chaotic experience, and be prepared when grief is triggered by other events or prolonged, as in the process of complicated grief.

Glucocorticoids, a group of hormones that includes cortisol, are considered stress hormones because their levels increase following stress. When their relationship to stress was first identified, it was shown that the release of cortisol prepared the body to cope with the physical demands of stress. Subsequently, high levels of cortisol were linked to depression and other stress-related disorders, giving rise to the hypothesis that high levels of cortisol on a long-term basis may impair the psychological capacity to cope with stress.

For this reason, drugs such as mifepristone that block glucocorticoid activity, called glucocorticoid receptor antagonists, have been tested as treatments for depression. But other recent data suggest that, in animal models and in humans, elevating glucocorticoid levels may reduce the development of posttraumatic stress disorder or PTSD.

This hypothesis is now supported by a new study in Biological Psychiatry. Using an animal model of PTSD, Rajnish Rao and colleagues demonstrate that elevated levels of glucocorticoids at the time of acute stress confers protection against anxiety-like behavior and the delayed enhancing effect of stress on synaptic connectivity in the basolateral amygdala.

"It seems, increasingly, that the 'trauma' in posttraumatic stress disorder is the impact of stress on brain structure and function," commented Dr. John Krystal, Editor of Biological Psychiatry. "The study by Rao and colleagues provides evidence that glucocorticoids may have protective effects in their animal model that prevent from these changes in synaptic connectivity, potentially shedding light on protective effects of glucocorticoids described in relation to PTSD."

Senior author Prof. Sumantra Chattarji from the National Centre for Biological Sciences in Bangalore, India, explained the reasoning behind their work: "First, this work was inspired by a puzzle — counterintuitive clinical reports — that individuals having lower levels of cortisol are more susceptible to developing PTSD and that cortisol treatment in turn reduces the cardinal symptoms of PTSD. Second, using a rodent model of acute stress, we were not only able to capture the essence of these clinical reports, but also identify a possible cellular mechanism in the amygdala, the emotional hub of the brain."

Their results are consistent with clinical reports on the protective effects of glucocorticoids against the development of PTSD symptoms triggered by traumatic stress.

Two successive manipulations, both of which elevate corticosterone levels by themselves, together reset the number of synapses in the amygdala and restored anxiety behavior to normal levels in rats. Strikingly, these high and low numbers of synapses in the amygdala appear to be reliable predictors of high and low anxiety states respectively.

"With the increasing costs and suffering associated with PTSD victims, it is our hope that basic research of the kind reported in this study will help in developing new therapeutic strategies against this debilitating disorder," concluded Chattarji.

Post-stroke depression is a major issue affecting approximately 33% of stroke survivors. A new study published in the current issue of Archives of Physical Medicine and Rehabilitation reports that the level to which survivors are uncertain about the outcome of their illness is strongly linked to depression. The relationship is more pronounced for men than for women.

"Male stroke survivors in the US who subscribe to traditional health-related beliefs may be accustomed to, and value highly, being in control of their health," says lead investigator Michael J. McCarthy, PhD, of the University of Cincinnati College of Health Sciences School of Social Work. "For these individuals, loss of control due to infirmity caused by stroke could be perceived as a loss of power and prestige. These losses, in turn, may result in more distress and greater depressive syndromes."

Thirty-six survivors (16 female, 20 male) who had experienced their first stroke within the preceding 36 months participated in the study. Survivors' depressive symptoms and ability to perform activities of daily living, such as bathing and cutting food with a knife and fork, were measured. The degree to which survivors were experiencing health ambiguity, or uncertainty about the outcomes of their illness, was evaluated by their agreement with statements such as "I don't know what's wrong with me," and "I have a lot of questions without answers."

Investigators found health ambiguity was significantly associated with greater depression for both sexes, and the association was stronger for male survivors than for females. "These findings suggest that reducing health ambiguity through proactive communication with patients and family members may be an effective approach for reducing survivor distress and, ultimately, for improving rehabilitation outcomes, Dr. McCarthy says. "The also reinforce the importance of rehabilitation professionals acknowledging that health-related beliefs can have a tangible impact on patient outcomes."

Dr. McCarthy notes that there was a wide variability in time since diagnosis in the study, and patients were likely at different points in recovery with respect to health ambiguity and depressive syndromes. The small sample size and lack of sample diversity may limit the generalizability of the findings to the broader stroke population. "Future research, with more socioeconomically diverse samples, should examine how gender-based health-related beliefs affect survivor outcomes, and explore the factors that protect female stroke survivors from the harmful effects of health ambiguity," he concludes.