This article was downloaded by: [Southern Illinois University] On: 02 January 2015, At: 01:36 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Association Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzch20
Depressed College Students and Tricyclic Antldepressant Therapy Ben Maurice Brown M.D. a
a b
Mental Health Section, Student Health Service, University of Arizona , Tucson, Arizona, 85724, USA
b
Department of Psychiatry , University of Arizona School of Medicine , USA Published online: 07 Apr 2011.
To cite this article: Ben Maurice Brown M.D. (1978) Depressed College Students and Tricyclic Antldepressant Therapy, Journal of American College Health Association, 27:2, 79-83, DOI: 10.1080/01644300.1978.10392830 To link to this article: http://dx.doi.org/10.1080/01644300.1978.10392830
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Depressed Cgllege Students and Tricyclic Antiaepressant Therapy* BEN MAURICE BROWN, M.D.t University
o f Arizona
Downloaded by [Southern Illinois University] at 01:36 02 January 2015
Abstract Charts of all outpatients (n = 267) seen during three consecutive months of 1977 by a university student mental health clinic were retrospectively reviewed for reports o f depression. Over one-fourth of university students (n = 76) seen during this period were noted to present with significant symptoms and signs o f depression. Charts of depressed patients were further analyzed for distribution by final diagnostic category, demographic data, and treatment outcome results. The majority of depressed patients were diagnosed as depressive neurosis while the second most common diagnosis was adjustment reaction. A significant proportion of patients with a final diagnosis of depressive neurosis had initially been diagnosed as adjustment reaction. Vegetativesigns of depression were infrequently noted in patients with adjustment reaction. These patients were usually treated with psychotherapy alone and showed symptomatic improvement in one-ha1f o f cases. Vegetative signs, especially sleep disturbance, were noted in one-ha1f o f patients with depressive neurosis. These patients were often treated with tricyclic antidepresants plus psychotherapy, which resulted in significantly greater improvement in both dysphoria and vegetative signs than treatment with psychotherapy only. Treatment outcomes for depressed patients thought to have concomitant character disorders were uniformly poor. Thus, depressed college students in the present study represented several distinct diagnostic groups, of which patients with depressive neurosis showed optimal treatment outcomes following tricyclic antidepressant therapy. Introduction A common complaint in university students, depression i s noted frequently by students themselves as well as peers and health care providers. A recent survey’ indicated that threefourths of 158 college sophomores reported a t least mild depression during their freshman year while 40% reported moderate to severe depression. Psychotherapists in university health services often describe depression in students in terms of a symptomatic reaction to 1 0 ~ s . ~Such reactive depressions, which technically merit a diagnosis of adjustment reaction, are frequently treated with brief supportive psychotherapy aimed a t providing emotional support, bolstering existing coping mechanisms, expanding adaptive skills, and strengtheningsocial support networks. While such a treatment approach appears suitable for treating reactive depressions, it has been noted that a number of depressed students do not respond favorably to treatment with psychotherapy alone.3 At the same time, a variety of studies done on middle-aged inpatients4b and outpatient^^^^^ have supported the benefits of tricyclic antidepressants in the treatment of severe depression. Furthermore, three controlled studies11-13 have recently reported the effectiveness of tricyclics in inducing remissions and preventing recurrence of depressive symptoms in neurotically depressed outpatients in their mid-30s to mid-50s. It has remained unclear however, what proportion of depressed university students might represent reactive versus neurotic depressions and what benefits
*Presented before the Section on Me,ntal Health at the Fifty-Sixth Annual Meeting, American College Health Association, New Orleans, Louisiana, March 30, 1978 ?Staff psychiatrist, Mental Health Section, Student Health Service, University o f Arizona, Tucson, Arizona 85724; Lecturer, Department of Psychiatry, University o f Arizona School o f Medicine VOL. 27, OCTOBER 1978
tricyclic antidepressants might offer in treating this young popuI ation. Methods Setting The Mental Health Section (MHS) of the Student Health Service (SHS) a t the University of Arizona serves primarily as an outpatient clinic fof the 30,000 undergraduate, graduate, and professional students a t the university. Patients are seen by the multidisciplinary MHS staff o f two psychiatrists, two psychologists, one social worker, and three half-time trainees. Treatment usually involves brief to intermediate length weekly individual psychotherapy, frequently includes medications, and occasionally includes other modalities such as group psychotherapy, hypnotherapy, and biofeedback. For every outpatient session, a problem-oriented chart entry14 i s made by the therapist utilizing the S.O.A.P. format (Subjective, Objective, Assessment, Plan) and including a DSM-IIi5 diagnosis under Assessment. Data The data for the current study were obtained from a retrospective chart review of all 267 outpatients seen in the MHS from January 1 to March 31, 1977. Charts reporting a primary presenting complaint of depression were examined for final diagnoses during the three-month study period. Of students presenting with depression, those who returned for treatment after their initial visit provided the data for the follow-up study. The follow-up study on charts of depressed patients seen for two or more visits focused on providing two kinds of data: demographic and clinical data and treatment outcome data. Demographic and clinica! data included: 79
Downloaded by [Southern Illinois University] at 01:36 02 January 2015
COLLEGE HEALTH
distribution by final diagnosis, age and sex incidence of vegetative signs of depression incidence of change from initial to final diagnosis incidence of treatment approach selected by diagnostic group 5) number of psychotherapy visits by diagnostic group Treatment outcomes for the target disturbances o f dysphoric mood were then separated by diagnostic category. For each of the two largest diagnostic categories in the followup study (depressive neurosis and adjustment reaction) remissions in dysphoria were compared for two treatment approaches: corn bined treatment (i.e., tricyclic antidepressants plus psychotherapy) versus psychotherapy alone. For the two remaining small diagnostic groups in the follow-up study, multiple diagnoses (depressive neurosis plus substance abuse or plus personatity disorder) and other diagnoses (manic depressive illness, depressed, and schizoaffective schizophrenia) treatment outcomes of dysphoria were also tabulated. Chart data were then examined for reports of three classes of vegetative signs of depression:
1) sleep disturbances, including early morning awakening, difficulty falling asleep and hypersomnia 2) appetite disturbances, including anorexia or hyperphagia with weight change 3) kinetic disturbances] including motor retardation or agitation Charts reporting vegetative signs were then examined for reports of improvement and all charts reporting vegetative signs without noting subsequent improvement were tabulated as not improved. Treatment outcomes for vegetative signs were then separated by diagnostic category. For the one diagnostic category (depressive neurosis) with frequently presentingvegetative signs, remissions in vegetative signs were compared for the two treatment approaches: combined treatment versus psychotherapy alone. Jreatm ent Procedures Depressed students treated with psychotherapy alone were usually seen in individual therapy from 3 to 30 visits and in a few instances received small quantities of benzodiazepines for intermittent use. Patients treated with tricyclics plus psychotherapy were generally seen for 3 to 30 visits in weekly individual therapy and were prescribed at least 50mg of tricyclics (usually 75 to 200 mg. Amitriptyline or Imipramine) on a daily basis for a minimum of seven consecutive days. Shortterm individual psychotherapy (six visits or less) was usually supportive in orientation while intermediate to long-term therapy (7 to 50 visits) relied upon both insight-oriented and supportive techniques. A few patients in both groups were simultaneously treated in group psychoterapy. Results
Demographic and Clinical Data Depression was a common presenting symptom noted on the charts of 28% of the 267 university students seen in the MHS during the study period. For all students presenting with depression, depressive neurosis was the most common final diagnosis. The second most common final diagnosis for depressed students was adjustment reaction although this diagnosis was used for the majority of all students presenting for treatment in the. MHS during the study. Multiple diagnoses and other diagnoses were used relatively infrequently. (See Table 1). Thus, the majority of (85%) of depressed students seen fell into two diagnostic groups, depressive neurosis and adjustment reaction. 80
Table 1 DISTRIBUTION OF DEPRESSED PATIENTS BY F I N A L DIAGNOSIS
Diagnostic Category
Patients Presenting
Patients Followed
37 27
31 18
4 2
3 2
1 1 2 1 -
1 1
1. Depressive neurosis (300.4) 2. Adjustment reaction (307.2,307.3) Multiple diagnoses 3. Depressive neurosis + substance abuse 4. Depressive neurosis + personality disorder Other Diagnoses 5. Manic-depressive illness, depressed (296.2) 6. Schizoaffective Schizophrenia (295.74) 7. Manic-depressive illness, circular (296.3) 8. Cyclothymlc personality (301 . l )
-
75
56
Of 75 students initially presentihg with depression, threefourths were for follow-up. A higher proportion of students with depressive neurosis were seen in follow-up treatment than patients with adjustment reaction, among whom adolescents returned least frequently. The great majority of depressed students not seen in follow-up did not follow their therapist’s recommendation for follow-up while a small majority were initially referred to other agencies. Depressed students followed in the current study were predominantly young adults in their 20s (median age 25). Relatively few adolescent or patients over 30 were included in the study. More than two-thirds of the depressed students seen were female. (See Table 2). Table 2 SEX A N D AGE OF DEPRESSED PATIENTS FOLLOWED n Male ---
Female
Mean Age Median t S.D. Age
2
11 (35%) 20 (65%) 4 (22%) 14 (78%) 1 (20%) 4 (80%) 1 (50%) 1(50%)
27.2 f 9.3 25.8 f 5.1 29.0 i 11.9 2 6 . 0 i 1.4
24.5 24.5 26.0 26.0
56
17 (30%) 39 (70%)
26.9
25.0
Depressive Neurosis Adjustment Reaction Multiple diagnoses Other diagnoses
31 18
Overall
5
f 8.2
Symptoms of depression, (i.e., dysphoric mood) appeared, by definition, in all depressed students; whereas vegetative signs of depression were noted in varying proportions for different diagnostic groups. For patients with deprssive neurosis, more than one-half exhibited vegetative signs, most commonly sleep disturbance, while appetite and kinetic disturbances were much less common. Relatively few depressed students with adjustment reaction and none o f the depressed students with multiple diagnoses showed vegetative signs. (See Table 3.) Patients with depressive neurosis reported a significantly higher incidence of vegetative signs than patients with adjustment reaction (n=49, X2=5.85, p .05).
Journal of American College Health Association Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzch20
Depressed College Students and Tricyclic Antldepressant Therapy Ben Maurice Brown M.D. a
a b
Mental Health Section, Student Health Service, University of Arizona , Tucson, Arizona, 85724, USA
b
Department of Psychiatry , University of Arizona School of Medicine , USA Published online: 07 Apr 2011.
To cite this article: Ben Maurice Brown M.D. (1978) Depressed College Students and Tricyclic Antldepressant Therapy, Journal of American College Health Association, 27:2, 79-83, DOI: 10.1080/01644300.1978.10392830 To link to this article: http://dx.doi.org/10.1080/01644300.1978.10392830
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Depressed Cgllege Students and Tricyclic Antiaepressant Therapy* BEN MAURICE BROWN, M.D.t University
o f Arizona
Downloaded by [Southern Illinois University] at 01:36 02 January 2015
Abstract Charts of all outpatients (n = 267) seen during three consecutive months of 1977 by a university student mental health clinic were retrospectively reviewed for reports o f depression. Over one-fourth of university students (n = 76) seen during this period were noted to present with significant symptoms and signs o f depression. Charts of depressed patients were further analyzed for distribution by final diagnostic category, demographic data, and treatment outcome results. The majority of depressed patients were diagnosed as depressive neurosis while the second most common diagnosis was adjustment reaction. A significant proportion of patients with a final diagnosis of depressive neurosis had initially been diagnosed as adjustment reaction. Vegetativesigns of depression were infrequently noted in patients with adjustment reaction. These patients were usually treated with psychotherapy alone and showed symptomatic improvement in one-ha1f o f cases. Vegetative signs, especially sleep disturbance, were noted in one-ha1f o f patients with depressive neurosis. These patients were often treated with tricyclic antidepresants plus psychotherapy, which resulted in significantly greater improvement in both dysphoria and vegetative signs than treatment with psychotherapy only. Treatment outcomes for depressed patients thought to have concomitant character disorders were uniformly poor. Thus, depressed college students in the present study represented several distinct diagnostic groups, of which patients with depressive neurosis showed optimal treatment outcomes following tricyclic antidepressant therapy. Introduction A common complaint in university students, depression i s noted frequently by students themselves as well as peers and health care providers. A recent survey’ indicated that threefourths of 158 college sophomores reported a t least mild depression during their freshman year while 40% reported moderate to severe depression. Psychotherapists in university health services often describe depression in students in terms of a symptomatic reaction to 1 0 ~ s . ~Such reactive depressions, which technically merit a diagnosis of adjustment reaction, are frequently treated with brief supportive psychotherapy aimed a t providing emotional support, bolstering existing coping mechanisms, expanding adaptive skills, and strengtheningsocial support networks. While such a treatment approach appears suitable for treating reactive depressions, it has been noted that a number of depressed students do not respond favorably to treatment with psychotherapy alone.3 At the same time, a variety of studies done on middle-aged inpatients4b and outpatient^^^^^ have supported the benefits of tricyclic antidepressants in the treatment of severe depression. Furthermore, three controlled studies11-13 have recently reported the effectiveness of tricyclics in inducing remissions and preventing recurrence of depressive symptoms in neurotically depressed outpatients in their mid-30s to mid-50s. It has remained unclear however, what proportion of depressed university students might represent reactive versus neurotic depressions and what benefits
*Presented before the Section on Me,ntal Health at the Fifty-Sixth Annual Meeting, American College Health Association, New Orleans, Louisiana, March 30, 1978 ?Staff psychiatrist, Mental Health Section, Student Health Service, University o f Arizona, Tucson, Arizona 85724; Lecturer, Department of Psychiatry, University o f Arizona School o f Medicine VOL. 27, OCTOBER 1978
tricyclic antidepressants might offer in treating this young popuI ation. Methods Setting The Mental Health Section (MHS) of the Student Health Service (SHS) a t the University of Arizona serves primarily as an outpatient clinic fof the 30,000 undergraduate, graduate, and professional students a t the university. Patients are seen by the multidisciplinary MHS staff o f two psychiatrists, two psychologists, one social worker, and three half-time trainees. Treatment usually involves brief to intermediate length weekly individual psychotherapy, frequently includes medications, and occasionally includes other modalities such as group psychotherapy, hypnotherapy, and biofeedback. For every outpatient session, a problem-oriented chart entry14 i s made by the therapist utilizing the S.O.A.P. format (Subjective, Objective, Assessment, Plan) and including a DSM-IIi5 diagnosis under Assessment. Data The data for the current study were obtained from a retrospective chart review of all 267 outpatients seen in the MHS from January 1 to March 31, 1977. Charts reporting a primary presenting complaint of depression were examined for final diagnoses during the three-month study period. Of students presenting with depression, those who returned for treatment after their initial visit provided the data for the follow-up study. The follow-up study on charts of depressed patients seen for two or more visits focused on providing two kinds of data: demographic and clinical data and treatment outcome data. Demographic and clinica! data included: 79
Downloaded by [Southern Illinois University] at 01:36 02 January 2015
COLLEGE HEALTH
distribution by final diagnosis, age and sex incidence of vegetative signs of depression incidence of change from initial to final diagnosis incidence of treatment approach selected by diagnostic group 5) number of psychotherapy visits by diagnostic group Treatment outcomes for the target disturbances o f dysphoric mood were then separated by diagnostic category. For each of the two largest diagnostic categories in the followup study (depressive neurosis and adjustment reaction) remissions in dysphoria were compared for two treatment approaches: corn bined treatment (i.e., tricyclic antidepressants plus psychotherapy) versus psychotherapy alone. For the two remaining small diagnostic groups in the follow-up study, multiple diagnoses (depressive neurosis plus substance abuse or plus personatity disorder) and other diagnoses (manic depressive illness, depressed, and schizoaffective schizophrenia) treatment outcomes of dysphoria were also tabulated. Chart data were then examined for reports of three classes of vegetative signs of depression:
1) sleep disturbances, including early morning awakening, difficulty falling asleep and hypersomnia 2) appetite disturbances, including anorexia or hyperphagia with weight change 3) kinetic disturbances] including motor retardation or agitation Charts reporting vegetative signs were then examined for reports of improvement and all charts reporting vegetative signs without noting subsequent improvement were tabulated as not improved. Treatment outcomes for vegetative signs were then separated by diagnostic category. For the one diagnostic category (depressive neurosis) with frequently presentingvegetative signs, remissions in vegetative signs were compared for the two treatment approaches: combined treatment versus psychotherapy alone. Jreatm ent Procedures Depressed students treated with psychotherapy alone were usually seen in individual therapy from 3 to 30 visits and in a few instances received small quantities of benzodiazepines for intermittent use. Patients treated with tricyclics plus psychotherapy were generally seen for 3 to 30 visits in weekly individual therapy and were prescribed at least 50mg of tricyclics (usually 75 to 200 mg. Amitriptyline or Imipramine) on a daily basis for a minimum of seven consecutive days. Shortterm individual psychotherapy (six visits or less) was usually supportive in orientation while intermediate to long-term therapy (7 to 50 visits) relied upon both insight-oriented and supportive techniques. A few patients in both groups were simultaneously treated in group psychoterapy. Results
Demographic and Clinical Data Depression was a common presenting symptom noted on the charts of 28% of the 267 university students seen in the MHS during the study period. For all students presenting with depression, depressive neurosis was the most common final diagnosis. The second most common final diagnosis for depressed students was adjustment reaction although this diagnosis was used for the majority of all students presenting for treatment in the. MHS during the study. Multiple diagnoses and other diagnoses were used relatively infrequently. (See Table 1). Thus, the majority of (85%) of depressed students seen fell into two diagnostic groups, depressive neurosis and adjustment reaction. 80
Table 1 DISTRIBUTION OF DEPRESSED PATIENTS BY F I N A L DIAGNOSIS
Diagnostic Category
Patients Presenting
Patients Followed
37 27
31 18
4 2
3 2
1 1 2 1 -
1 1
1. Depressive neurosis (300.4) 2. Adjustment reaction (307.2,307.3) Multiple diagnoses 3. Depressive neurosis + substance abuse 4. Depressive neurosis + personality disorder Other Diagnoses 5. Manic-depressive illness, depressed (296.2) 6. Schizoaffective Schizophrenia (295.74) 7. Manic-depressive illness, circular (296.3) 8. Cyclothymlc personality (301 . l )
-
75
56
Of 75 students initially presentihg with depression, threefourths were for follow-up. A higher proportion of students with depressive neurosis were seen in follow-up treatment than patients with adjustment reaction, among whom adolescents returned least frequently. The great majority of depressed students not seen in follow-up did not follow their therapist’s recommendation for follow-up while a small majority were initially referred to other agencies. Depressed students followed in the current study were predominantly young adults in their 20s (median age 25). Relatively few adolescent or patients over 30 were included in the study. More than two-thirds of the depressed students seen were female. (See Table 2). Table 2 SEX A N D AGE OF DEPRESSED PATIENTS FOLLOWED n Male ---
Female
Mean Age Median t S.D. Age
2
11 (35%) 20 (65%) 4 (22%) 14 (78%) 1 (20%) 4 (80%) 1 (50%) 1(50%)
27.2 f 9.3 25.8 f 5.1 29.0 i 11.9 2 6 . 0 i 1.4
24.5 24.5 26.0 26.0
56
17 (30%) 39 (70%)
26.9
25.0
Depressive Neurosis Adjustment Reaction Multiple diagnoses Other diagnoses
31 18
Overall
5
f 8.2
Symptoms of depression, (i.e., dysphoric mood) appeared, by definition, in all depressed students; whereas vegetative signs of depression were noted in varying proportions for different diagnostic groups. For patients with deprssive neurosis, more than one-half exhibited vegetative signs, most commonly sleep disturbance, while appetite and kinetic disturbances were much less common. Relatively few depressed students with adjustment reaction and none o f the depressed students with multiple diagnoses showed vegetative signs. (See Table 3.) Patients with depressive neurosis reported a significantly higher incidence of vegetative signs than patients with adjustment reaction (n=49, X2=5.85, p .05).
