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Palliative Care: An Opportunity for Mental Health Professionals
Harvey Max Chochinov
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In Review
Structured Interview Assessment of Symptoms and Concerns in Palliative Care
Keith G Wilson, Ian D Graham, Raymond A Viola, Susan Chater, Barbara J de Faye, Lynda A Weaver, Julie A Lachance
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Palliative Care for Families: Remembering the Hidden Patients
Linda J Kristjanson, Samar Aoun
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Psychotherapeutic Interventions at the End of Life: A Focus on Meaning and Spirituality
William Breitbart, Christopher Gibson, Shannon R Poppito, Amy Berg
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Review Paper
Prevalence Studies of Substance-Related Disorders: A Systematic Review of the Literature
Julian M Somers, Elliot M Goldner, Paul Waraich, Lorena Hsu
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Original Research
Stress and Psychological Impact on SARS Patients During the Outbreak
Siew E Chua, Vinci Cheung, Grainne M McAlonan, Charlton Cheung, Josephine WS Wong, Erik PT Cheung, Marco TY Chan, Teresa KW Wong, Khai M Choy, Chung M Chu, Peter WH Lee, Kenneth WT Tsang
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Brief Communication
Psychological Effects of the SARS Outbreak in Hong Kong on High-Risk Health Care Workers
Siew E Chua, Vinci Cheung, Charlton Cheung, Grainne M McAlonan, Josephine WS Wong, Erik PT Cheung, Marco TY Chan, Michael MC Wong, Siu W Tang, Khai M Choy, Meng K Wong, Chung M Chu, Kenneth WT Tsang
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Schizophrenia: The Quest for a Minimum Sense of Identity to Ward Off Delusional Disorder
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Diabetes, Tardive Dyskinesia, Parkinsonism, and Akathisia in Schizophrenia: A Retrospective Study Applying 1998 Diabetes Health Care Guidelines to Antipsychotic Use
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The Psychosocial Effects of Being Quarantined Following Exposure to SARS: A Qualitative Study of Toronto Health Care Workers
Emma Robertson, Karen Hershenfield, Sherry Lynn Grace, Donna Eileen Stewart
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Hard Times and Good Friends: Negative Life Events and Social Support in Patients With Seasonal and Nonseasonal Depression
Erin E Michalak, Edwin M Tam, Chinnapalli V Manjunath, Lakshmi N Yatham, Anthony J Levitt, Robert D Levitan, Raymond W Lam
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Letters to the Editor
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Combined Transcranial Magnetic Stimulation and Right Unilateral Electroconvulsive Therapy in Patients With Treatment-Refractory Depression

Re: Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets

Reply: Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets

Quetiapine in the Management of Psychosis Secondary to Huntington's Disease: A Case Report

Ziprasidone-Induced Lupus Erythematosus

Lorazepam-Induced Prolongation of the QT Interval in a Patient With Schizoaffective Disorder and Complete AV Block

Brief Communication

Hard Times and Good Friends: Negative Life Events and Social Support in Patients With Seasonal and Nonseasonal Depression

Erin E Michalak, PhD¹, Edwin M Tam, MD², Chinnapalli V Manjunath, MD³, Lakshmi N Yatham, MD⁴, Anthony J Levitt, MB⁵, Robert D Levitan, MD⁶, Raymond W Lam, MD⁴

A significant body of research has now accumulated concerning the relation between negative life events (NLEs), social support (SS), and major depressive disorder (MDD). Although the etiologic model is complex, increased incidence of NLEs and decreased SS are generally acknowledged to be psychosocial risk factors for depression (1–4). However, relatively little research has examined the relation between these risk factors and winter depression, or seasonal affective disorder (SAD) (5). We recently reported an association between psychosocial risk factors (in particular, increased NLEs, decreased SS, female sex, and being non- native to residential area) and increased seasonality (that is, seasonal changes in mood and behaviour as measured by a commonly used screening tool for SAD) in a primary care population in the UK (6). Another recent longitudinal study has also described an association between poor perceived SS and earlier onset of depressive symptoms in patients with SAD (7). This emerging body of research emphasizes the importance of studying psychosocial factors, as well as biological factors, in relation to SAD. The present study expands these findings by further examining the relation between NLEs, SS, and depression in a different population, namely, outpatients with seasonal and nonseasonal recurrent MDD.

Aims

We had 2 aims: to assess whether increased NLEs and decreased SS are associated with diagnosed SAD in addition to reported seasonality and to compare levels of NLEs and SS between patients with seasonal and nonseasonal recurrent depression. We hypothesized that, first, the relation between NLEs, SS, and SAD would be similar to that which we observed in our previous research in patients high in seasonality, and second, no significant between-group differences would emerge in either number of NLEs experienced or in severity of SS shortfall, indicating that these psychosocial risk factors are associated with both seasonal and nonseasonal depression.

Materials and Methods

Participants
The study was conducted in a mood disorders centre at a university teaching hospital. Participants were 26 patients with seasonal MDD and 66 patients with nonseasonal recurrent MDD. The seasonal depression group consisted of patients recruited at one arm (in Vancouver, British Columbia) of an ongoing, multicentre trial of light therapy vs medication. Participants were recruited via regional advertising campaigns and physician referrals. The sample met criteria for MDD with a seasonal (winter) pattern as determined by structured interview (Structured Clinical Interview for DSM-IV) modified with criteria for a seasonal pattern. The nonseasonal depression group comprised outpatients with a primary diagnosis of recurrent MDD referred to the Mood Disorders Centre. The study was approved by the Human Ethics Committee of the University of British Columbia. After we completely described the study to all participants, we obtained written informed consent.

Instruments
Participants completed 2 self-report instruments at baseline (between October and December 2002). We assessed Recent NLEs using the List of Threatening Experiences (LTE), a brief questionnaire that examines incidence of 12 categories of NLE over the previous 6 months (8). The LTE assesses life stressors involving moderate or long-term threat, such as illness or injury, death of a close friend or relative, unemployment, financial loss, and loss of important relationships. The questionnaire shows acceptable levels of reliability (9) and has been shown to be associated with increased risk for depression (10).

We assessed perceived SS using the Medical Outcomes Study (MOS) Social Support Survey (SSS), a 19-item questionnaire that examines 4 domains of SS (that is, emotional- informational, tangible, affectionate, and positive social interaction) and provides an overall functional SS index, where higher scores (range 0 to 100) indicate better social support (11). To assess depression severity, we also administered the Beck Depression Inventory II (BDI II) (12) at baseline.

Statistics
All data are presented as mean (SD) scores. We analyzed demographic and diagnostic data using t tests and chi-square tests (with Fisher’s exact test in place of chi-square where expected proportions were small). We derived a single total score for the LTE by summing the number of NLEs experienced in the previous 6 months; mean scores were compared via t tests. Summary scores were calculated for the 4 domains of the SSS and linearly transformed to a 0-to-100 scale. We used t tests with Bonferroni corrections to make between- group comparisons. All calculations were undertaken with SPSS version 10 (13).

Results

The seasonal depression group comprised 14 women and 12 men with a mean age of 40.1 years (SD 12.4). The nonseasonal depression group comprised 46 women and 20 men with a mean age of 38.1 years (SD 11.8). The 2 groups did not differ significantly in the demographic variables of sex, age, and marital or occupational status. Baseline BDI scores were significantly higher in the nonseasonal group (mean 34.0, SD 10.9 vs mean 25.2, SD 12.2; t₈₄ = 3.1, P = 0.003).

The mean number of NLEs in the seasonal and nonseasonal groups was 1.8 (SD 2.0) and 2.3 (SD 2.1), respectively (not significant). The number of NLEs reported by men and women did not differ significantly overall (mean 2.0, SD 2.1 in men; mean 2.2, SD 2.0 in women), nor did they differ significantly in the seasonal (mean 1.4, SD 2.1 in men vs mean 2.1, SD 1.9 in women) and nonseasonal group (mean 2.3, SD 2.2 in men vs mean 2.3, SD 2.1 in women). Perceived levels of SS were impaired in both groups, compared with other patient populations, but no significant between-group differences were apparent in the 4 domains of the SSS or in the overall SS index score (Table 1).

Discussion

In a previous study (6) of psychosocial factors and seasonality in a community sample, we used a multivariate model and observed that 4 variables (that is, having experienced more NLEs, having low levels of SS, being a woman, and being nonnative to residential area) were associated with increased reported seasonality (as determined by the “global seasonality” score of the Seasonal Pattern Assessment Questionnaire [SPAQ]; 14). However, only female sex was found to predict being diagnosed with SAD according to DSM-IV criteria. In the present study, we examined whether a similar association exists between NLEs, SS, and SAD in outpatients diagnosed with winter depression. We also questioned whether number of life events experienced and quality of SS were different in a comparison sample of patients with recurrent MDD.

Patients with SAD reported having experienced approximately 2 (mean 1.8, SD 2.0) major NLEs in the previous 6 months. In comparison, previous studies using the LTE questionnaire reported figures of 0.84 (SD 1.04) in college students (15) and 1.45 (SD 1.44) in a sample of 399 European patients diagnosed with MDD according to DSM-IV criteria (Odd Dalgard, personal communication of data obtained from the Outcomes of Depression International Network [ODIN] project; 16,17). Patients diagnosed with recurrent non- seasonal depression reported a similar (mean 2.3, SD 2.1) number of life events. These results replicate the results of earlier work that also showed no difference in reported NLEs in primary care patients with seasonal or nonseasonal depression (18). However, the results should be interpreted with some caution, because the life events instrument used here does not apportion differential weights to different types of life events. Moreover, it was administered at different time points in the 2 patient populations (specifically, during the 6 months prior to an episode of depression in the seasonal group and during an episode of depression in the nonseasonal group). The results of the present study also indicated that patients with seasonal and nonseasonal depression have similarly impaired SS networks. Mean SSS index scores were 52.9 (SD 24.1) and 56.7 (SD 25.1), respectively, for the 2 groups, compared with 70.1 (SD 24.2) reported in the MOS study of patients with chronic medical conditions (that is, hypertension, diabetes, coronary heart disease, and depression) (11).

The results of the present study provide further evidence of a relation between SAD, increased NLEs, and decreased SS. Further, patients with SAD appear to experience similar numbers of NLEs and impairments in their SS networks equivalent to those experienced by patients with nonseasonal recurrent depression. It is generally accepted that a causal relation exists between NLEs and nonseasonal depression (19). However, the relation between NLEs and SAD is more challenging to explain, particularly in regard to the question of whether increased incidence of NLEs is a cause, consequence, or correlate of SAD. The current findings are particularly interesting, given that the DSM-IV definition of SAD excludes recurrent depressions attributable to predictable seasonal stressors, such as regular winter unemployment. These data suggest that, notwithstanding this exclusionary criterion, random, nonseasonal stressors may play a role in SAD, much as they do in other mood disorders. It may be that such random stressors, occurring at all times of the year, establish subclinical changes that prime light-sensitive individuals to have full blown depressions later, at their most vulnerable time. Alternatively, a lack of coping resources, both internal (for example, having low self-esteem) and external (for example, having poor SS, also observed in the present study), may predispose individuals to develop depression. Recent research conducted by McCarthy and colleagues (20) in the UK is directly relevant to the present study. In a prospective study of 45 patients diagnosed with SAD, the authors found that both low perceived levels of SS and poor self-esteem (measured in the summer) were significantly related to faster onset of depressive symptoms during the winter months. Poor SS was also related to quicker onset of anxiety symptoms. A key task remaining for future research will be to determine whether these psychosocial variables have an effect on, or indeed are affected by, treatment interventions for SAD.

Funding and Support

Dr Michalak is supported by a Canadian Institutes of Health Research–Wyeth Ayerst Canada Postdoctoral Research Fellowship. This study was supported in part by a research grant from the Canadian Institutes of Health Research (CIHR MCT-38150).

References

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2. Paykel ES, Dowlatshahi, D. Life events and mental disorder. In: Fisher S, Reason J, editors. Handbook of life stress, cognition and health. Chichester (UK): John Wiley; 1988.

3. Paykel ES. Life events, social support and depression. Acta Psychiatr Scand Suppl 1994;377:50–8.

4. Brugha TS. Depression undertreatment: lost cohorts, lost opportunities? Psychol Med 1995;25(1):3–6.

5. Rosenthal NE, Sack DA, Gillin JC, Lewy AJ, Goodwin FK, Davenport Y, and others. Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry 1984;41:72–80.

6. Michalak EE, Wilkinson C, Hood K, Dowrick C. Seasonal affective disorder, negative life events and social support: evidence of an association in a community sample. Br J Psychiatry 2003;182:434–8.

7. McCarthy E, Tarrier N, Gregg L. The nature and timing of seasonal affective symptoms and the influence of self-esteem and social support: a longitudinal prospective study. Psychol Med 2002;32:1425–34.

8. Brugha T, Bebbington P, Tennant C, Hurry J. The list of threatening experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychol Med 1985;15:189–94.

9. Brugha TS, Cragg D. The list of threatening experiences: the reliability and validity of a brief life events questionnaire. Acta Psychiatr Scand 1990;82:77–81.

10. Brugha TS, Conroy R. Categories of depression: reported life events in a controlled design. Br J Psychiatry 1985;147:641–6.

11. Sherbourne CD, Stewart AL. The MOS Social Support Survey. Soc Sci Med 1991;32:705–14.

12. Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories IA and II in psychiatric outpatients. J Pers Assess 1996;67:588–97.

13. SPSS Inc. SPSS for Windows. Version 10.1.0. Chicago (IL): SPSS Inc; 2000.

14. Rosenthal NE, Bradt GH, Wehr TA. Seasonal Pattern Assessment Questionnaire. Bethesda (MD): National Institutes of Mental Health; 1987.

15. Clark DA, Oates T. Daily hassles, major and minor life events, and their interaction with sociotropy and autonomy. Behav Res Ther 1995;33:819–23.

16. Ayuso-Mateos JL, Vazquez-Barquero JL, Dowrick C, Lehtinen V, Dalgard OS, Casey P, and others. Depressive disorders in Europe: prevalence figures from the ODIN study. Br J Psychiatry 2001;179:308–16.

17. Dowrick C, Casey P, Dalgard O, Hosman C, Lehtinen V, Vazquez-Barquero JL, and others. Outcomes of Depression International Network (ODIN). Background, methods and field trials. ODIN Group. Br J Psychiatry 1998;172:359–63.

18. Michalak EE, Wilkinson C, Hood K, Dowrick C. Seasonal and nonseasonal depression: how do they differ? Symptom profile, clinical and family history in a general population sample. J Affect Disord 2002;69:185–92.

19. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 1999;156:837–41.

20. McCarthy E, Tarrier N, Gregg L. The nature and timing of seasonal affective symptoms and the influence of self-esteem and social support: a longitudinal prospective study. Psychol Med 2002;32:1425–34.

Author(s)

Manuscript received June 2003, revised, and accepted September 2003.

1. Research Associate, Department of Psychiatry, University of British Columbia; UBC Hospital, VCHA, Vancouver, British Columbia.

2. Clinical Associate Professor, Department of Psychiatry, University of British Columbia; UBC Hospital, VCHA, Vancouver, British Columbia.

3. Clinical Instructor, Department of Psychiatry, University of British Columbia; UBC Hospital, VCHA, Vancouver, British Columbia.

4. Professor, Department of Psychiatry, University of British Columbia; UBC Hospital, VCHA, Vancouver, British Columbia.

5. Professor, Department of Psychiatry, University of Toronto; Sunnybrook Health Sciences Centre, Toronto.

6. Professor, Department of Psychiatry, University of Toronto; Centre for Addictions and Mental Health, Clarke Division, Toronto.

Address for correspondence: Dr Erin E Michalak, Division of Clinical Neuroscience, Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver BC V6T 2A1

e-mail: emichala@interchange.ubc.ca

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