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Is the distinction between situational and nonsituational primary depression valid?
Is the Distinction Between Situational and Nonsituational Primary Depression Valid? Michael
J. Garvey, Gary D. Tollefson,
Dan Mungas,
and Norman
Hoffmann
ABSTRACT Fifty-one patients with situational major depression were compared to 75 nonsituational depressives, using multiple clinical variables. Very few differences were found between the two groups for the 75 tested variables. The study data is most consistent with the postulate that the division of depressives into situational and nonsituational categories may not be valid.
S
ubstantial clinical interest and emphasis is placed on whether a depressed patient has experienced a stressful life event prior to a depressive episode. Many clinicians believe situational depressives differ from nonsituational depressives in meaningful ways and should thus be viewed differently.’ The notion exists that nonsituational depressives are “biological”, whereas situational depressions result from various “nonbiological” mechanisms. If situational depressives are basically different from nonsituational depressives, then it would be expected that fundamental differences between the two groups would result from comparisons of clinically relevant variables. To test this hypothesis we compared situational to nonsituational depressives on a variety of parameters, including depressive symptomatology, longitudinal course of illness, family history, and personality traits. MATERIALS AND METHODS Study patients were selected from consecutive referrals to a psychiatric outpatient clinic. Referral sources included community physicians, patient self-referrals, and a community hospital inpatient unit, emergency room and consultation service. Patients meeting Research Diagnostic Criteria (RDC) for major depressive disorder were given a structured interview. Patients were excluded if they met RDC criteria for a primary nonaffective psychiatric disorder. Included in a structured interview were clinical variables from the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SAD%L), severity of depression ratings from the Hamilton Rating Scale for Depression (HRSD), RDC depressive subtype diagnosis, ratings of 26 individual symptoms of depression, longitudinal psychiatric history, and family history. The data was analyzed using two different definitions for dichotomizing the study sample into situational and nonsituational depressives. The more rigorous definition of situational was that of the RDC which states” the episode almost certainly would not have developed at that time, in the absence of the external events.” The less restrictive definition (probable situational depression) included depressive episodes in which a stressful life event was equivocal either in its temporal relationship to the depression onset or the amount of disruption it appeared to have on the patient’s life. Both definitions used an upper time limit of twelve months predepression during which the event must have taken place. Situational depressives were compared to nonsituational depressives using 75 variables of illness obtained from the index interview. Chi square analyses were used for categorical variables and analyses of variance for continuous variables.
From the Department of Psychiatry, University of California, Davis Sacramento, CA: and the Department of Psychiatry, University of Minnesota at St. Paul Ramsey Medical Center St. Paul, MN. Address reprint requests to Michael J. Garvey. M.D.. Department of Psychiatry, 640 Jackson Street, St. Paul, MN 55101. @ 1984 by Grune & Stratton, Inc. 0010-440X/84/2503-0015$01.00/0
372
Comprehensive Psychiatry, Vol. 25, No. 3, (May/June)
1984
373
SITUATIONAL DEPRESSION
RESULTS One hundred and twenty-six patients met study criteria. Seventy-five percent were women and 75% were unipolar. Thirty-six (29%) of the sample patients met the more stringent RDC definition for situational depression, and 15 (12%) patients met the less stringent definition of probable situational depression, resulting in a combined total of 51 (40%) patients. The temporal relationship of the stressful event to the depression onset was relatively close even when the less stringent definition of situational depression was used. In 42 of these 51 patients (82%), the stressful event occurred less than three months before the depression onset. The event-depression interval was greater than six months for only one patient. Table 1 lists the precipitating events by general categories. If muliple events occurred during the predepression period, only the most serious event is listed. The definite situational depressives were compared to the nonsituational depressives using the study variables previously described. Only three of the tested variables were significant at the .05 level and none of these reached a significance level of .Ol. Differences included a greater number of nonsituational depressives experiencing recurrent depressions (64% vs 42%; P < .03) and more nonsituational depressives complaining of loss of libido during the index depression (64% vs 4OG; P C: .04). As a group, nonsituational depressives had shorter remissions prior to index depression (26 k 34 months vs 65 & 104: P < .03). Similar findings resulted when the probable and definite situational depressives were combined and compared to the nonsituational depressives. Examples of the notable similarities between nonsituational and RDC situational depressives included baseline HRSD (17 + 6 vs 17 3: 6), age of first depression (28 + 14 vs 30 + 13), proportion of females (72% vs 82%), number of suicide attempts (0.5 f 1 vs 0.5 & l), and number of patients with depressed first degree relatives (40% vs 32%). Finding nearly identical percentages of RDC endogenous depression (47’; vs 44%) in the two groups, suggests situational primary depression is not less “biological” than nonsituational primary depression.
DISCUSSION The percentage of patients diagnosed situational depression (29% for definite and 40% for definite and probable) for our study sample is similar to that reported by others using RDC subtyping criteria. One investigation found 48% of 8 1 outpatient Table 1. Categorization of Predepression Stressful Life Events
Separation from Significant Other Death of Significant Other Medical Problems in Significant Other Patient Physical Injuries Job Problems Miscellaneous (i.e., moving, family conflict, financial worry)
Definite Situational Depres-
Probable and Definite Situational Depres-
sion N = 36
sion N = 51
16 5 5 4 1 5
21 6 5 4 4 11
374
GARVEY
ET AL
depressives met RDC situational criteria* and a separate study using RDC reported 50% of 90 inpatient depressives were situationally depressed.3 Our most striking finding is the lack of substantive differences between situational and nonsituational depressives. Only three variables were significant at the .Ol < P < .05 level. Since 75 variables were tested, these low level differences could represent chance findings. This possibility is supported by the lack of apparent connection between the three “positive” variables. It must be emphasized that patients with non-affective primary psychiatric diagnosis were excluded. Perhaps differences between situational and nonsituational depression would emerge, if patients with depressions secondary to other psychiatric disorders such as alcohol abuse, somatiform disorders, anxiety disorders, etc., were included. Our study does not control for the random occurrence of stressful life events. It might be argued that if we could have separated out those situational depressives whose stressful life event was a random occurrence from those situational depressives whose stress was casually related to the depression onset, that then we could have found differences between “real” situational depressives and the other depressives. A recent review” of the relationship of life events to depression illustrates the difficulty in clearly establishing a relationship between life events and depression “real” situational depressions from those in onset let alone trying to distinguish which a stressful life event was merely a random happening. Perhaps the clearest example of depressions likely “caused” by a life event are those following the death of a spouse. A review of this topic suggests a causal relationship does exist between spousal death and depression.5 Most of the studies reviewed used apparently healthy subjects for controls. It is not possible from these studies to be certain whether the bereaved subjects who experienced depression would have differed from nonsituationally depressed controls. Examination of the reported clinical features of the bereaved depressives suggests more similarities than differences to nonsituational depressives6 Death of a significant other was a relatively uncommon predepression event in our study group (Table 1). However, difficulty with a living significant other was the major stressful life event in over one-half of those patients diagnosed as situationally depressed. Other events such as job problems, moving, financial problems, were relatively infrequently implicated as major stressors leading to the depressive episode. Our data would be consistent with the hypothesis that while primary depressive disorders may be triggered by either endogenous or exogenous mechanisms, once precipitated the depression involves similar neurophysiological dysfunctions and hence produces similar clinical phenomenon, e.g., acute symptomatology, longitudinal course, family history. A recent review outlines how diverse depressives pathogenetic mechanism may interact with each other and with neurophysiological functions in ways that result in a depressive syndrome that is similar in spite of markedly different etiologies.’ ACKNOWLEDGMENTS This investigation was supported in part by NIMH Research Grants No. MH 29689 and MH 33250 and by the St. Paul Ramsey Hospital Medical Education and Research Foundation. The authors wish to thank Judy Barclift for her secretarial assistance.
SITUATIONAL
375
DEPRESSION
REFERENCES 1. Comstock BS: Outpatient management of depressive disorders, in Fann WE fed): Phenomenology and Treatment of Depression. New York, Spectrum Publications, 3255328. 1977 2. Prusoff BA, Weissman MM, Klerman GL. et al: Research diagnostic criteria subtypes of depression. Arch Gen Psychiatr 37:796-801, 1980 3. Klerman GL, Endicott J, Spitzer R, et al: Neurotic depression: a systematic analysis of multiple criteria and meanings. Am J Psychiatr 136:57-61, 1979 4. Lloyd C: Life events and depressive disorder reviewed. Arch Gen Psychiatr 37541~ 548, 1980 5. Clayton PJ: The sequelae and nonsequelae of conjugal bereavement. Am J Psychiatr 136:1530-1534, 1979 6. Clayton PJ: The mortality and morbidity in the first year of widowhood. Arch Gen Psychiatr 3017477750, 1974 7. Akiskal HS, McKinney WT: Overview of recent research in depression. Arch Gen Psychiatr 32285-305, 1975
J. Garvey, Gary D. Tollefson,
Dan Mungas,
and Norman
Hoffmann
ABSTRACT Fifty-one patients with situational major depression were compared to 75 nonsituational depressives, using multiple clinical variables. Very few differences were found between the two groups for the 75 tested variables. The study data is most consistent with the postulate that the division of depressives into situational and nonsituational categories may not be valid.
S
ubstantial clinical interest and emphasis is placed on whether a depressed patient has experienced a stressful life event prior to a depressive episode. Many clinicians believe situational depressives differ from nonsituational depressives in meaningful ways and should thus be viewed differently.’ The notion exists that nonsituational depressives are “biological”, whereas situational depressions result from various “nonbiological” mechanisms. If situational depressives are basically different from nonsituational depressives, then it would be expected that fundamental differences between the two groups would result from comparisons of clinically relevant variables. To test this hypothesis we compared situational to nonsituational depressives on a variety of parameters, including depressive symptomatology, longitudinal course of illness, family history, and personality traits. MATERIALS AND METHODS Study patients were selected from consecutive referrals to a psychiatric outpatient clinic. Referral sources included community physicians, patient self-referrals, and a community hospital inpatient unit, emergency room and consultation service. Patients meeting Research Diagnostic Criteria (RDC) for major depressive disorder were given a structured interview. Patients were excluded if they met RDC criteria for a primary nonaffective psychiatric disorder. Included in a structured interview were clinical variables from the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SAD%L), severity of depression ratings from the Hamilton Rating Scale for Depression (HRSD), RDC depressive subtype diagnosis, ratings of 26 individual symptoms of depression, longitudinal psychiatric history, and family history. The data was analyzed using two different definitions for dichotomizing the study sample into situational and nonsituational depressives. The more rigorous definition of situational was that of the RDC which states” the episode almost certainly would not have developed at that time, in the absence of the external events.” The less restrictive definition (probable situational depression) included depressive episodes in which a stressful life event was equivocal either in its temporal relationship to the depression onset or the amount of disruption it appeared to have on the patient’s life. Both definitions used an upper time limit of twelve months predepression during which the event must have taken place. Situational depressives were compared to nonsituational depressives using 75 variables of illness obtained from the index interview. Chi square analyses were used for categorical variables and analyses of variance for continuous variables.
From the Department of Psychiatry, University of California, Davis Sacramento, CA: and the Department of Psychiatry, University of Minnesota at St. Paul Ramsey Medical Center St. Paul, MN. Address reprint requests to Michael J. Garvey. M.D.. Department of Psychiatry, 640 Jackson Street, St. Paul, MN 55101. @ 1984 by Grune & Stratton, Inc. 0010-440X/84/2503-0015$01.00/0
372
Comprehensive Psychiatry, Vol. 25, No. 3, (May/June)
1984
373
SITUATIONAL DEPRESSION
RESULTS One hundred and twenty-six patients met study criteria. Seventy-five percent were women and 75% were unipolar. Thirty-six (29%) of the sample patients met the more stringent RDC definition for situational depression, and 15 (12%) patients met the less stringent definition of probable situational depression, resulting in a combined total of 51 (40%) patients. The temporal relationship of the stressful event to the depression onset was relatively close even when the less stringent definition of situational depression was used. In 42 of these 51 patients (82%), the stressful event occurred less than three months before the depression onset. The event-depression interval was greater than six months for only one patient. Table 1 lists the precipitating events by general categories. If muliple events occurred during the predepression period, only the most serious event is listed. The definite situational depressives were compared to the nonsituational depressives using the study variables previously described. Only three of the tested variables were significant at the .05 level and none of these reached a significance level of .Ol. Differences included a greater number of nonsituational depressives experiencing recurrent depressions (64% vs 42%; P < .03) and more nonsituational depressives complaining of loss of libido during the index depression (64% vs 4OG; P C: .04). As a group, nonsituational depressives had shorter remissions prior to index depression (26 k 34 months vs 65 & 104: P < .03). Similar findings resulted when the probable and definite situational depressives were combined and compared to the nonsituational depressives. Examples of the notable similarities between nonsituational and RDC situational depressives included baseline HRSD (17 + 6 vs 17 3: 6), age of first depression (28 + 14 vs 30 + 13), proportion of females (72% vs 82%), number of suicide attempts (0.5 f 1 vs 0.5 & l), and number of patients with depressed first degree relatives (40% vs 32%). Finding nearly identical percentages of RDC endogenous depression (47’; vs 44%) in the two groups, suggests situational primary depression is not less “biological” than nonsituational primary depression.
DISCUSSION The percentage of patients diagnosed situational depression (29% for definite and 40% for definite and probable) for our study sample is similar to that reported by others using RDC subtyping criteria. One investigation found 48% of 8 1 outpatient Table 1. Categorization of Predepression Stressful Life Events
Separation from Significant Other Death of Significant Other Medical Problems in Significant Other Patient Physical Injuries Job Problems Miscellaneous (i.e., moving, family conflict, financial worry)
Definite Situational Depres-
Probable and Definite Situational Depres-
sion N = 36
sion N = 51
16 5 5 4 1 5
21 6 5 4 4 11
374
GARVEY
ET AL
depressives met RDC situational criteria* and a separate study using RDC reported 50% of 90 inpatient depressives were situationally depressed.3 Our most striking finding is the lack of substantive differences between situational and nonsituational depressives. Only three variables were significant at the .Ol < P < .05 level. Since 75 variables were tested, these low level differences could represent chance findings. This possibility is supported by the lack of apparent connection between the three “positive” variables. It must be emphasized that patients with non-affective primary psychiatric diagnosis were excluded. Perhaps differences between situational and nonsituational depression would emerge, if patients with depressions secondary to other psychiatric disorders such as alcohol abuse, somatiform disorders, anxiety disorders, etc., were included. Our study does not control for the random occurrence of stressful life events. It might be argued that if we could have separated out those situational depressives whose stressful life event was a random occurrence from those situational depressives whose stress was casually related to the depression onset, that then we could have found differences between “real” situational depressives and the other depressives. A recent review” of the relationship of life events to depression illustrates the difficulty in clearly establishing a relationship between life events and depression “real” situational depressions from those in onset let alone trying to distinguish which a stressful life event was merely a random happening. Perhaps the clearest example of depressions likely “caused” by a life event are those following the death of a spouse. A review of this topic suggests a causal relationship does exist between spousal death and depression.5 Most of the studies reviewed used apparently healthy subjects for controls. It is not possible from these studies to be certain whether the bereaved subjects who experienced depression would have differed from nonsituationally depressed controls. Examination of the reported clinical features of the bereaved depressives suggests more similarities than differences to nonsituational depressives6 Death of a significant other was a relatively uncommon predepression event in our study group (Table 1). However, difficulty with a living significant other was the major stressful life event in over one-half of those patients diagnosed as situationally depressed. Other events such as job problems, moving, financial problems, were relatively infrequently implicated as major stressors leading to the depressive episode. Our data would be consistent with the hypothesis that while primary depressive disorders may be triggered by either endogenous or exogenous mechanisms, once precipitated the depression involves similar neurophysiological dysfunctions and hence produces similar clinical phenomenon, e.g., acute symptomatology, longitudinal course, family history. A recent review outlines how diverse depressives pathogenetic mechanism may interact with each other and with neurophysiological functions in ways that result in a depressive syndrome that is similar in spite of markedly different etiologies.’ ACKNOWLEDGMENTS This investigation was supported in part by NIMH Research Grants No. MH 29689 and MH 33250 and by the St. Paul Ramsey Hospital Medical Education and Research Foundation. The authors wish to thank Judy Barclift for her secretarial assistance.
SITUATIONAL
375
DEPRESSION
REFERENCES 1. Comstock BS: Outpatient management of depressive disorders, in Fann WE fed): Phenomenology and Treatment of Depression. New York, Spectrum Publications, 3255328. 1977 2. Prusoff BA, Weissman MM, Klerman GL. et al: Research diagnostic criteria subtypes of depression. Arch Gen Psychiatr 37:796-801, 1980 3. Klerman GL, Endicott J, Spitzer R, et al: Neurotic depression: a systematic analysis of multiple criteria and meanings. Am J Psychiatr 136:57-61, 1979 4. Lloyd C: Life events and depressive disorder reviewed. Arch Gen Psychiatr 37541~ 548, 1980 5. Clayton PJ: The sequelae and nonsequelae of conjugal bereavement. Am J Psychiatr 136:1530-1534, 1979 6. Clayton PJ: The mortality and morbidity in the first year of widowhood. Arch Gen Psychiatr 3017477750, 1974 7. Akiskal HS, McKinney WT: Overview of recent research in depression. Arch Gen Psychiatr 32285-305, 1975