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This study sought to evaluate the relationship of obesity to demographic and clinical characteristics and treatment outcome in a group of 175 patients with bipolar I disorder who were treated for an acute affective episode and followed through a period of maintenance treatment.Data were from participants entering the Maintenance Therapies for Bipolar Disorder protocol between 1991 and 2000. Analyses focused on differences in baseline demographic and clinical characteristics and in treatment outcomes between obese and nonobese patients.A total of 35.4% of the patients met criteria for obesity. Significant differences between the obese and nonobese patients were observed for years of education, numbers of previous depressive and manic episodes, baseline scores on the Hamilton Rating Scale for Depression, and durations of the acute episode. A Kaplan-Meier survival analysis indicated a significantly shorter time to recurrence during the maintenance phase among obese patients. The number of patients experiencing a depressive recurrence was significantly higher in the obese than in the nonobese group.Obesity is correlated with a poorer outcome in patients with bipolar I disorder. Preventing and treating obesity in bipolar disorder patients could decrease the morbidity and mortality related to physical illness, enhance psychological well-being, and possibly improve the course of bipolar illness. Weight-control interventions specifically designed for patients with bipolar illness should be developed, tested, and integrated into the routine care provided for these patients.

Lifetime rates of suicide attempts among patients with bipolar I disorder were compared to rates during a 2-year period of intensive treatment with pharmacotherapy and with one of two adjunctive psychosocial interventions.Subjects entered the study during an acute mood episode. Subjects were treated with primarily lithium pharmacotherapy and with either psychotherapy specific to bipolar disorder, which included help in regularizing daily routines, or nonspecific, intensive clinical management involving regular visits with empathic clinicians. Data on prior suicide attempts were obtained retrospectively from interviews with the NIMH-Life-Chart method. Data on suicide attempts during the clinical trial were collected systematically throughout the protocol.The rate of suicide attempts was 1.05 per 100 person-months before patients entered the trial. Patients experienced a threefold reduction in the rate of suicide attempts during the acute treatment phase (until the patient achieved stabilization, defined by completion of 4 weeks during which the patient had a mean score ofor =7 on the 17-item Hamilton Depression Rating Scale andor =7 on the Bech-Rafaelsen Mania Scale) and a 17.5-fold reduction during maintenance treatment. Poisson loglinear regression analysis modeling the relationship between the observed rates and the three protocol stages (pretreatment, acute, and maintenance) showed that the reductions were significant in the acute and maintenance phases, compared with the pretreatment phase. No patient with one or more suicide attempts before entering the trial attempted suicide during the protocol.A treatment program in a maximally supportive clinical environment can significantly reduce suicidal behavior in high-risk patients with bipolar I disorder.

The authors provide a detailed clinical description of minor depression: its symptoms, level of disability, stability, and relationship to patient and family history of major depressive disorder.Rigorous criteria for minor depression, including functional disability, were used to identify 226 individuals for a three-phase treatment study. This report presents data obtained on that study group during the first study phase, a 4-week placebo lead-in period.One hundred sixty-two subjects (72% of the initial study group) remained in the study for 4 weeks and continued to meet criteria for minor depression. Minor depression in these subjects was primarily characterized by mood and cognitive symptoms, not the classical neurovegetative signs and symptoms of depression. Approximately one-third of the subjects with minor depression had a past history of major depressive disorder, and nearly half had a family history of unipolar depressive disorder; however, neither factor affected the severity or quality of minor depressive symptoms.These data suggest that 1) minor depression is not evanescent; 2) minor depression is characterized by mood and cognitive symptoms rather than neurovegetative symptoms; 3) minor depression may occur either independently of a lifetime history of major depressive disorder or as a stage of illness in the course of recurrent unipolar depressive disorder; and 4) depressive disorders should be conceptualized as a continuum of severity.

The Committee on Research on Psychiatric Treatments of the American Psychiatric Association identified treatment of major depression during pregnancy as a priority area for improvement in clinical management. The goal of this article was to assist physicians in optimizing treatment plans for childbearing women.The authors' work group developed a decision-making model designed to structure the information delivered to pregnant women in the context of the risk-benefit discussion. Perspectives of forensic and decision-making experts were incorporated.The model directs the psychiatrist to structure the problem through diagnostic formulation and identification of treatment options for depression. Reproductive toxicity in five domains (intrauterine fetal death, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity) is reviewed for the potential somatic treatments. The illness (depression) also is characterized by symptoms of somatic dysregulation that compromise health during pregnancy. The patient actively participates and provides her evaluation of the acceptability of the various treatments and outcomes. Her capacity to participate in this process provides evidence of competence to consent. Included in the decision-making process are the patient's significant others and obstetrical physician. The process is ongoing, with the need for incorporation of additional data as the pregnancy and treatment response progress.The conceptual model provides structure to a process that is frequently stressful for both patients and psychiatrists. By applying the model, clinicians will ensure that critical aspects of the risk-benefit discussion are included in their care of pregnant women.

This study compared the long-term efficacy of two fixed plasma levels of nortriptyline in preventing or delaying recurrence of major depression in elderly patients and in minimizing residual depressive symptoms and somatic complaints.The authors randomly assigned 41 elderly patients with histories of recurrent major depression to 3-year, double-blind maintenance pharmacotherapy using nortriptyline, with controlled plasma concentrations of 80-120 ng/ml versus 40-60 ng/ml. The authors compared times to, and rates of, recurrence of major depression. They also compared frequencies of side effects, noncompliance episodes, and subsyndromal symptomatic flare-ups.Major depressive episodes recurred for six (29%) of 21 subjects in the 80-120-ng/ml condition and eight (40%) of 20 subjects in the 40-60-ng/ml condition, a nonsignificant difference. Most recurrences took place in the first year of maintenance treatment. Hamilton depression scores in the subsyndromal range (higher than either 10 or 7) occurred significantly more often at 40-60 ng/ml, while constipation occurred significantly more often at 80-120 ng/ml. The proportions of patients reporting missed doses did not differ.Maintenance pharmacotherapy with nortriptyline at 80-120 ng/ml is associated with fewer residual depressive symptoms, that is, a less variable long-term response, than pharmacotherapy at 40-60 ng/ml, but constipation is more frequent and there is no difference in recurrence of syndromal major depressive episodes. Treatment at 80-120 ng/ml may be preferable, because of fewer residual symptoms and less variability of response, as long as side effect burden can be managed successfully.

Objective: This study was conducted to identify which elderly patients with remitted recurrent major depression remain well with maintenance interpersonal psychotherapy after discontinuation of active antidepressant medication (nortriptyline). Method: The authors examined outcomes of maintenance therapy over 1 year for 47 elderly patients who were randomly assigned to monthly maintenance interpersonal psychotherapy with placebo (N=19) or to placebo and a supportive medication clinic without interpersonal psychotherapy (N=28). A Kaplan-Meier survival analysis was performed on the basis of treatment assignment and subjective sleep quality assessed by the Pittsburgh Sleep Quality Index, on which good subjective sleep quality is indicated by a score of 5 or lower. Results: Nine (90%) of 10 patients reporting good subjective sleep quality (by 1 month into continuation treatment) remained well for at least 1 year when treated with monthly maintenance interpersonal psychotherapy, versus five (31%) of 16 patients with good sleep quality assigned to a medication clinic, three (33%) of nine patients with impaired sleep quality treated with maintenance interpersonal psychotherapy, and two (17%) of 12 patients with impaired sleep quality assigned to a medication clinic. Conclusions: Recovery of good subjective sleep quality by early continuation treatment is useful in identifying which remitted elderly depressed patients will remain well with monthly maintenance interpersonal psychotherapy, following discontinuation of antidepressant medication, and which patients may be more vulnerable to recurrence of major depressive episodes in the absence of antidepressant medication. (Am J Psychiatry 1997; 154:958‐962)

Objective: The authors tested the hypothesis that patients whose episodes of major depression evidenced more neurobiological disturbance would be less responsive to psychotherapy. Method: The study subjects were outpatients who were given a diagnosis of recurrent major depressive disorder (unipolar or bipolar II), according to the Research Diagnostic Criteria, following an interview with the Schedule for Affective Disorders and Schizophrenia. They were classified into a group with normal sleep profiles (N=50) and a group with abnormal sleep profiles (N=41) on the basis of a validated index score derived from three EEG sleep variables monitored for 2 nights: sleep efficiency, REM latency, and REM density. The groups’ responses to short-term interpersonal psychotherapy were compared by means of chi-square tests and life table and random effects model analyses. Responses to the addition of pharmacotherapy for subjects who did not respond to interpersonal psychotherapy were also compared. Results: The patients with abnormal sleep profiles had significantly poorer clinical outcomes with respect to symptom ratings, attrition rates, and remission rates than the patients with more normal sleep profiles. Seventy-five percent of the patients who did not respond to interpersonal psychotherapy had remissions during subsequent pharmacotherapy. Conclusions: These findings help to define further a neurobiological “boundary” that may limit response to psychotherapy in depression. An abnormal sleep profile may reflect a more marked disturbance of CNS arousal that warrants pharmacotherapy. (Am J Psychiatry 1997; 154:502‐509)

Objective : The authors compared response rates, the temporal course of response to acute treatment, and relapse rates during continuation treatment of elderly and midlife patients with recurrent major depression. Method : They analyzed results from two separate controlled studies of maintenance therapies for recurrent major depression, in which 148 elderly patients (mean age=67.9 years) and 214 midlife patients (mean age=38.5 years) were treated in open acute and continuation therapy with a combination of interpersonal psychotherapy and a tricyclic antidepressant (nortriptyline for the elderly, imipramine for the midlife patients). in an intent-to-treat analysis, remission rates during acute treatment and relapse rates during continuation treatment were examined. Random regression analysis of weekly Hamilton depression scale ratings was used to compare the temporal course of response. Results : During acute-phase therapy, 78.4% (N=116) of the elderly patients and 69.6% (N=149) ofthe midlife patients had remissions. The midlife patients had a faster reduction of Hamilton depression ratings. Following stabilization, 15.5% of the elderly patients and 6. 7% of the midlife patients relapsed. Ultimately, 66.2% of the late-life patients and 57.0% of the midlife patients recovered fully. Conclusions : Older patients appear to benefit as much as, but perhaps more slowly than, midlife patients from treatment of major depression. Continuation treatment should be vigorous and closely monitored, given the apparently higher relapse rates among the elderly. These conclusions should be viewed as preliminary because of the post hoc nature of the analysis reported here.

Objective: This study sought to determine whether a set of symptoms interpreted as cornplicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Method: Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation ofphysiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects’ spouses, and follow-up data were collected from 56 of the subjects I 8 months after the baseline assessments. Candidate items for assessing complicated griefcame from a variety ofscales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the BriefSymptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. Results: A principal-components analysis conducted on intake data (N=82) revealed a complicated grieffactor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated griefscores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. Conclusions: The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment. (Am J Psychiatry 1995; 152:22-30)

OBJECTIVE: Psychosocial interventions are effective adjuncts to pharmacotherapy in delaying recurrences of bipolar disorder; however, to date their effects on life functioning have been given little attention. In a randomized trial, the authors examined the impact of intensive psychosocial treatment plus pharmacotherapy on the functional outcomes of patients with bipolar disorder over the 9 months following a depressive episode. METHOD: Participants were 152 depressed outpatients with bipolar I or bipolar II disorder in the multisite Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. All patients received pharmacotherapy. Eighty-four patients were randomly assigned to intensive psychosocial intervention (30 sessions over 9 months of interpersonal and social rhythm therapy, cognitive behavior therapy [CBT], or family-focused therapy), and 68 patients were randomly assigned to collaborative care (a 3-session psychoeducational treatment). Independent evaluators rated the four subscales of the Longitudinal Interval Follow-Up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT) (relationships, satisfaction with activities, work/role functioning, and recreational activities) through structured interviews given at baseline and every 3 months over a 9-month period. RESULTS: Patients in intensive psychotherapy had better total functioning, relationship functioning, and life satisfaction scores over 9 months than patients in collaborative care, even after pretreatment functioning and concurrent depression scores were covaried. No effects of psychosocial intervention were observed on work/role functioning or recreation scores during this 9-month period. CONCLUSIONS: Intensive psychosocial treatment enhances relationship functioning and life satisfaction among patients with bipolar disorder. Alternate interventions focused on the specific cognitive deficits of individuals with bipolar disorder may be necessary to enhance vocational functioning after a depressive episode.

Nocturnal penile tumescence recordings were performed in 10 men with major depression and 10 age-matched healthy control subjects to evaluate the possibility that clinical disturbances in sexual interest and activity often reported by depressed persons are associated with objective changes in sexual neurophysiology. Depressed men had significantly reduced minutes of tumescence time, a finding that was not attributable to alterations in sleep efficiency or REM sleep time. Three depressed men had baseline tumescence profiles suggestive of "organogenic" impotence, which improved after recovery. The authors discuss the implications of such findings for clinical practice and future research.

Assessment of 29 couples seeking marital therapy and 25 seeking sexual therapy at the same institution permitted the delineation of two distinct profiles. Although the two groups were similar in the degree of their sexual and marital difficulties and in demographic characteristics, the relationships of the sex therapy couples were generally characterized by satisfaction and affection, whereas those of the marital therapy couples were often antagonistic. In addition, the sex therapy couples tended to be less conservative and more thoughtful in their approach to life and their problems.

Personality assessments of 119 treatment-responsive patients with recurrent unipolar depression revealed that nearly half of the patients (48%) showed some personality disturbance. The most common personality features were avoidant (30.4%), compulsive (18.6%), and dependent (15.7%). Factor analyses of personality data in this homogeneous population yielded results that were consistent with previous factor analytic studies of personality features and clinical descriptions of depressed patients. Most notably, a discriminant function analysis using personality variables alone was able to distinguish (with 65% accuracy) between patients who responded normally to treatment and those who responded more slowly.

The authors compared responses of 16 couples, in which one partner had a diagnosis of remitted bipolar illness, to a lengthy self-report questionnaire (KDS-15) designed to assess many aspects of marital adjustment with those of 16 matched nonpatient couples. The bipolar patient-well spouse couples had marital adjustments closely resembling those of the nonpatient couples; three of four global ratings of satisfaction failed to discriminate between the two groups. Perceptions of the courtship, first year of marriage, and the degree to which the marriage had met expectations were also similar for both groups.

The authors examined 52 women with recurrent depression to determine the differences between women with and without histories of pregnancy-related affective episodes. The women with histories of such episodes (N = 24) had been significantly younger at illness onset, were more severely depressed at baseline, and tended to show less emotional stability. The EEG-recorded sleep of the women with pregnancy-related affective episodes was distinguished by longer REM sleep time and more REM activity, differences accounted for almost entirely by the women with histories of only postpartum episodes.