Subtypes of major depression: latent class analysis in depressed Han Chinese women
Y. LiSteven H. AggenS. ShiJingfang GaoYuting LiMing TaoK. ZhangX. WangC. GaoLijun YangYihan LiK. LiJianyou ShiG. WangLiu LiJun ZhangDU BiaoGuoqing JiangJianhua ShenZ. ZhangLiang WeiJing SunJian HuT. LiuX. WangGuixi MiaoHui MengY. LiCheng HuYanhui LiGuoping HuangG. LiBaowei HaHong DengQing MeiHui ZhongShuping GaoHong SangY. ZhangXiang FangJessica YuDonglin YangT. LiuY. ChenXiaojuan HongW. WuG. ChenMin CaiYan SongJiyang PanJicheng DongR. PanW. ZhangZ. ShenZ. LiuDanhua GuX. WangXin LiuQianyu ZhangJonathan FlintKenneth S. Kendler
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Abstract:
Background. Despite substantial research, uncertainty remains about the clinical and etiological heterogeneity of major depression (MD). Can meaningful and valid subtypes be identified and would they be stable cross-culturally? Method. Symptoms at their lifetime worst depressive episode were assessed at structured psychiatric interview in 6008 women of Han Chinese descent, age ⩾30 years, with recurrent DSM-IV MD. Latent class analysis (LCA) was performed in Mplus. Results. Using the nine DSM-IV MD symptomatic A criteria, the 14 disaggregated DSM-IV criteria and all independently assessed depressive symptoms ( n = 27), the best LCA model identified respectively three, four and six classes. A severe and non-suicidal class was seen in all solutions, as was a mild/moderate subtype. An atypical class emerged once bidirectional neurovegetative symptoms were included. The non-suicidal class demonstrated low levels of worthlessness/guilt and hopelessness. Patterns of co-morbidity, family history, personality, environmental precipitants, recurrence and body mass index (BMI) differed meaningfully across subtypes, with the atypical class standing out as particularly distinct. Conclusions. MD is a clinically complex syndrome with several detectable subtypes with distinct clinical and demographic correlates. Three subtypes were most consistently identified in our analyses: severe, atypical and non-suicidal. Severe and atypical MD have been identified in multiple prior studies in samples of European ethnicity. Our non-suicidal subtype, with low levels of guilt and hopelessness, may represent a pathoplastic variant reflecting Chinese cultural influences.Keywords:
Atypical depression
Depression
Etiology
Major depressive episode
Article Abstract Objective: Although studies have linked childhood trauma to depression resembling the atypical subtype, a majority of these studies did not use DSM-IV criteria for atypical features nor assess trauma both before and after depression onset. This study examined the relationship between atypical depression and lifetime trauma with the hypothesis that atypically depressed patients would report a higher number of trauma exposures than nonatypically depressed patients. Method: Raters blind to depressive subtype investigated trauma history by reviewing the Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) posttraumatic stress disorder modules and social history sections in charts of depressed outpatients who had participated in treatment studies between 1985 and 2010. Rates of trauma both before and after depression onset were compared for 292 depressed patients with and without DSM-IV-defined atypical features using χ2 tests and binary logistic regressions. This chart review was conducted from 2009 to 2011. Results: Lifetime trauma was reported significantly more often by depressed patients with atypical features than by those without (P < .001). Patients with atypical features reported significantly more traumatic experiences both prior to (P = .012) and following (P = .015) depression onset. When sex and age at onset or duration of depression were used as covariates, depressive subtype was a significant predictor of reported trauma both prior to (P = .028) and following (P = .011) depression onset. Conclusions: These results suggest that a relationship exists between atypical depression and lifetime trauma that may be more complex than the etiologic pathways outlined in prior research. Rather, trauma and atypical depression may be interrelated throughout life. J Clin Psychiatry 2013;74(5):500-506 © Copyright 2013 Physicians Postgraduate Press, Inc. Submitted: April 27, 2012; accepted December 19, 2012(doi:10.4088/JCP.12m07870). Corresponding author: Amy C. Withers, MA, 1051 Riverside Drive #3300, New York, NY 10032 (amywithers267@gmail.com).
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Purpose of review The current status of atypical depression is reviewed, with reference to articles published between 1 July 2002 and 1 September 2003. To clarify several current issues, background information is also reviewed. Recent findings New developments include partial validation of a division of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-IV) atypical depression into subtypes, emerging evidence of hypopituitary function in atypical depression (versus hyperpituitary function in melancholia), and an update of the prospective Zurich epidemiological study. A potential role for chromium picolinate in treating atypical depression has been described. Summary Important new data on the course and hypothalamic-pituitary-adrenal function of atypical depression have become available.
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Melancholic depression
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• One hundred ninety-four nonmelancholic depressed outpatients with features of atypical depression took part in a 6-week randomized trial of imipramine hydrochloride, phenelzine sulfate, and placebo. Their courses of illness were also rated for chronicity. Significantly more patients responded to phenelzine (71%) than to imipramine (48%), which benefited significantly more patients than placebo (26%). Both chronicity andDMS-IIIdiagnosis predicted response on several outcome measures. For example, patients with dysthymic disorder responded better to treatment than did those with major depression, suggesting that dysthymic disorder can be treated with medication. Placebo response correlated inversely with chronicity, regardless ofDMS-IIIdiagnosis. Atypical depression and longitudinal course of illness may add to the usefulness of DMS-III depressive diagnosis as a predictor of antidepressant response.
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Atypical depression
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Hypomania
Bipolar II disorder
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One hundred nineteen patients who met specific criteria for atypical depression completed six weeks of double-blind, randomly assigned treatment with phenelzine sulfate, imipramine hydrochloride, or placebo. The overall response rates were 71% with phenelzine, 50% with imipramine, and 28% with placebo. Phenelzine was widely superior to placebo and also showed superiority to imipramine. Phenelzine superiority appeared even greater after an additional six-week continuation phase. Imipramine was only moderately effective in this atypical depressive sample. Unexpectedly, the superiority of either phenelzine or imipramine to placebo was largely confined to patients in subsets of the study sample who were prospectively judged to also have a history of spontaneous panic attacks and/or show hysteroid dysphoric features. This is consonant with some but not other recent findings and requires replication. Overall, the concept of atypical depression as a subtype that is preferentially responsive to monoamine oxidase inhibitors is supported.
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Objective: A comparison of psychiatric, psychological and somatic characteristics in specified subgroups of major depressive episodes (MDE). Method: In a stratified community sample of young adults investigated prospectively from age 20/21 to 40/41, we defined four MDE subgroups: i) DSM‐IV melancholia or atypical depression (the ‘combined group’), ii) pure melancholia, iii) pure atypical depression, and iv) unspecified MDE. Results: The cumulative incidence rates of the four groups were 4.1%, 7.1%, 3.5% and 8.2% respectively. Women were over‐represented in the combined and atypically depressed group. In 56 of 117 (47.9%) cases, melancholia was longitudinally associated with atypical MDE ( n = 84) (OR = 11.9). Conclusion: Melancholic MDE was more severe than atypical MDE although the two groups shared many characteristics. The longitudinal overlap of melancholia with atypical depression in almost half of all cases calls for comparative analyses of combined, pure and unspecified MDE.
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Depressed patients with atypical features have an earlier onset of depression, a more chronic course of illness, several distinctive biological and familial features, and a different treatment response than those without atypical features. The efficacy and tolerability of selective serotonin reuptake inhibitors (SSRIs) have not been fully evaluated in depression with atypical features. This report evaluates data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study to determine whether depressed outpatients with and without atypical features respond differently to the SSRI citalopram. Treatment-seeking participants with non-psychotic major depressive disorder were recruited from primary- and psychiatric-care settings. The presence/absence of atypical features was approximated using baseline ratings on the 30-item Inventory of Depressive Symptomatology – Clinician-rated. Following baseline assessments, participants received citalopram up to 60 mg/d for up to 14 wk. Baseline sociodemographic and clinical characteristics, and treatment outcomes, were compared between participants with and without atypical features. Of the 2876 evaluable STAR*D participants, 541 (19%) had atypical features. Participants with atypical features were significantly more likely to be female, younger, unemployed, have greater physical impairment, a younger age of depression onset, a longer index episode, greater depressive severity, and more concurrent anxiety diagnoses. Those with atypical features had significantly lower remission rates, although this difference was no longer present after adjustment for baseline differences. Depressed patients with atypical features are less likely to remit with citalopram than those without atypical features. This finding is probably due to differences in baseline characteristics other than atypical symptom features.
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