Journal ofAffective Disorders, 23 (1991) 35-41 0 1991 Elsevier Science Publishers B.V. All rights reserved ADONIS 016503279100118D
35 0165-0327/91/$03.50
JAD 00831
Life satisfaction and psychosocial functioning in chronic depression: effect of acute treatment with antidepressants Vito Agosti
‘, Jonathan
W. Stewart
’ New York State Psychiatric Institute and ’ Department
2 and Fredric
of Psychiatry,
Columbia
M. Quitkin
2
Uniuersity, New York, NI: U.S.A.
(Received 23 January 1991) (Revision received 30 May 1991) (Accepted 6 June 1991)
Summary Social functioning was evaluated in 61 chronically depressed adults with early onset. Patients were treated for 6 weeks in a double-blind trial of phenelzine, imipramine, L-deprenyl, or placebo and functioning was reassessed. The posttreatment social functioning of patients who received drug treatment was superior to the placebo group in the following areas: work functioning, house functioning, relationship with relatives, sex frequency and life satisfaction. These results suggest that psychosocial impairment in some chronic depressives may be a sequaela of depression, rather than a global manifestation of characterological pathology.
Key words:
Chronic
depression;
Social functioning;
Introduction The dissatisfying lives and impaired psychosocial functioning of adults with early onset chronic depression have been attributed to deeply ingrained characterological disturbancess (Blanck and Blanck, 1974; Kernberg, 1988; Bemporad, 1983). Though Bemporad (1983) and Kernberg (1988) have recommended long-term psychoanalytic psychotherapy as the treatment of choice for
Address for correspondence: Vito Agosti, M.S.W., New York State Psychiatric Institute, 722 West 168th Street, Box 35, New York, NY 10032, U.S.A.
Antidepressants
these patients, controlled studies supporting the efficacy of this recommendation have not been reported. In contrast, there have been a series of studies demonstrating that antidepressant medications are relatively effective in reducing symptoms of chronic depressives. Akiskal et al. (1980) observed, in an uncontrolled study, that a subgroup of early onset chronic depressives with ‘stable’ personality traits had a favorable response to antidepressant medications. Stewart et al. (1989) and Kocsis et al. (19881, in short-term controlled studies, found that antidepressant medications were superior to placebo. In a long-term medication discontinuation pilot study, Harrison et al.
36
(1986) found that 80% of patients who were maintained on antidepressant medication remained euthymic, in contrast to 0% among those who were switched to pIacebo. Though many psychoanalysts concede that medication is an effective treatment for reducing the vegetative depression symptoms of the ‘depressive personality’, some seriously question whether symptomatic treatment alone can alter ‘strong inhibitions [which] prevent them from finding meaning or enjoyment in life’ (Arieti and Bemporad, 1978). The impoverished quality of life of chronic depressives has been described in the literature (Bemporad, 1983; Weissman and Klerman, 1977; Akiskal et al., 1980). Psychosocial functioning scales are putative measures of the quality of life, measuring interpersonal, work, and recreational functioning (Markowitz et al., 1989). Studies by Stewart et al. (1988) and Kocsis et al. (1988b) reported a significant improvement in Social Adjustment Scale (SAS) (Weissman et al., 1976) scores of chronic depressed patients after acute antidepressant medication treatment. Similar changes were not seen in the placebo-treated group. The purpose of this study was to determine whether the doctor-rated Longitudinal Interval Life Scale (LIFE) (Keller et al., 1987) would replicate earlier findings of improved social adjustment, assessed by the patient-rated SAS, among chronic depressives who received antidepressant medications. Methods Subjects The subjects were physically healthy, nonmelancholic chronically depressed outpatients (29 men, 32 women) with a mean age of 35 (k8.9). All had graduated from high school. Fifty-seven percent were single (n = 35), 23% married (n = 14), and 19.6% divorced or separated (n = 12). Mean Hamilton Rating Scale of Depression (HAM-D) (Hamilton, 1960) score was 14.2 ( f 3.7). Scores on this scale may not adequately reflect the degree of psychopathology in our sample, since the reversed vegetative symptoms oversleeping and overeating are not rated by the HAM-D.
DSM-III (American Psychiatric Association, 1980) diagnoses included: dysthymic disorder (31%, n = 191, major depression, without melancholia (25%, n = 151 and major depression superimposed on dysthymic disorder (44%, n = 27). Study entrance requirements were a DSM-III depressive disorder and mood reactivity (i.e., significant lifting of mood in response to positive environmental events). Following baseline evaluation, patients were treated with single-blind placebo for l-2 weeks, those who were still depressed were randomly assigned to 6 weeks of treatment with increasing doses of one of four agents in a double-blind design. Dosage ranged from 60 to 90 mg/day of phenelzine, 200 to 300 mg/day of imipramine, 40 mg/day of L-deprenyl, and four to six placebo pills. At baseline 26.2% (n = 16) were assigned to imipramine, 16.4% (n = 10) to phenelzine, 37.7% (n = 23) to placebo, and 19.7% (n = 12) to I.-deprenyl. The uneven distribution among treatments is due to the disproportionate frequencies of patients we had collected LIFE data on, rather than a skewed randomization process. Due to administrative errors, we did not have LIFE data on all patients at week 6. Clinical outcome was determined by the treating psychiatrist on the basis of Clinical Global Improvement (CGI) (McGlashan, 1973) scale scores. A score of 1 or 2 (very much or much improved) defined positive response. All other ratings defined non-response. Responders did not differ significantly from non-responders with regard to diagnosis, baseline HAM-D scores, sex, age, education, or marital status. In order to focus specifically on chronically depressed patients, we chose the subgroup of 61 patients who had an onset prior to age 21 and were rated prospectively by an experienced clinician as depressed either most or virtually all of the time throughout adulthood. Rating scales Global ratings of severity and change were made weekly on the CGI scale and the HAM-D. All patients were assessed for the presense of psychiatric disorders according to DSM-III. Chronicity was evaluated by a clinician prior to treatment. Initial histories were scored on a 4-
37
point scale to rate the proportion of affective symptomatology during the patient’s adult life: 1, mostly well; 2, depressed about half the time; 3, depressed most of the time; or 4, virtually always depressed. This was considered to be an ordinal scale. The LIFE is a semi-structured interview which tracks episodes of psychiatric illness. The instrument measures both psychosocial functioning and psychopathology over time. The LIFE was modified in our study. The section measuring psychopathology was not utilized because we were already using other psychopathology rating scales. The portion of the LIFE which we used assessed psychosocial functioning during the past week in five areas: employment, house work, interpersonal relationships, sexual functioning, life satisfaction and recreational activity. The LIFE was administered to the patient by the treating psy-
TABLE
Data analysis The five item choices measuring sexual satisfaction were collapsed into two categories, i.e., good vs. poor (having sex and being satisfied = good; not having sex, satisfied or dissatisfied, and having sex, fairly or poorly satisfied = poor). The four drug groups were combined to enhance statistical power. Outcome LIFE measures for treatment groups, and diagnostic subgroups, were compared by analysis of covariance, using the pretreatment scores as covariates. All tests were two-tailed. In order to give a concrete sense of the rate of improvement, LIFE item scores were dichotomized. McNemar’s test (with Yate’s cor-
1
LIFE SCORES
Hours worked
OF PATIENTS
’
Work functioning Household
functioning
Relationship spouse Relationship children Relationship relatives Friendships
with with with
Sex frequency Life satisfaction Recreation
chiatrist at baseline and after 6 weeks of doubleblind treatment. High scores indicate impairment and/or dissatisfaction, low scores indicate high levels of functioning or satisfaction.
WHO
RECEIVED
ANTIDEPRESSANTS
OR PLACEBO
FOR 6 WEEKS
Pretreatment unadjusted means (SD) a
Posttreatment unadjusted means (SD)
Drug (n = 38)
Placebo (n = 23)
Drug
Placebo
30.8 (21.X) n = 27 2.7 (1.2) n = 23 2.x (1.1) n = 30 3.0 (1.0) n = 13 2.x (0.9X) n=ll 2.7 (0.85) n = 37 3.0 (0.94) n = 3X 3.2 (1.1) n = 37 3.3 (1.0) n = 3X 3.0 (0.85) n = 3X
32.6 (15.7) n = I6 2.6 (1.5) n= 14 2.9 (1.0) n = 22 3.2 (1.3) n=9 3.1 (1.2) n=X 2.9 (1.2) 12= 21 2.x (0.99) n = 23 2.9 (1.1) n = 20 3.2 (1.0) n = 21 2.9 (0.79) n = 20
2X.2 (19.9)
37.7 (19.5)
1.X (1.4)
2.6 (1.3)
2.3 (1.2)
2.9 (1 .O)
2.5 (1.3)
3.3
2.0 (1.0,
3.0 (1.0)
2.2 (1.1)
2.9 (1.2)
2.3 (1.1)
2.3 (1.1)
2.X (1.3)
3.0 (1.0)
2.6 (1.3)
3.0 (1.0)
2.4 (1.2)
2.6 (1.1)
Drugs vs. placebo
df=l
“ There were no significant pretreatment differences between drug and placebo. h Sample size differs for individual items since not all items apply to individual married).
patients
(I .2I
(e.g., only a portion
F = 2.2 P=NS Fz6.1 P = 0.02 F = 4.2 P = 0.05 F = 0.30 P=NS F = 0.14 P=NS F = 4.0 P = 0.04 F=O.ll P=NS F = 4.3 P = 0.04 F=4.1 P = 0.05 F = 0.40 P = NS
of our sample
is
38 TABLE
2
RELATIONSHIP BETWEEN TREATMENT STATUS AND WEEK 6 LIFE SCORES
rection) was applied to these dichotomized to test for significant changes in LIFE between baseline and posttreatment.
RESPONSE
ANCOVA F
TABLE
Results P-value
0.008
Work hours Work functioning Household functioning Relationship with spouse Relationship with children Relationship with relatives Friendships Sex frequency Life satisfaction Recreation
scores scores
24.9 30.6 14.5 16.1 9.9 1.2 6.3 32.9 9.4
The mean pretreatment (*SD) HAM-D score was 14.4 (3.9) for the drug group and 13.9 (3.1) for placebo (t = 0.51, df= 60, P = NS). Mean ages for drug and placebo groups were 35.8 (9.3) and 34.5 (8.9) respectively (t = 0.54, df= 60, P = NS). After controlling for pre-treatment LIFE scores, using ANCOVA, the analysis revealed that the week 6 LIFE scores of the drug group
NS
0.000 0.000 0.001 0.001 0.003 0.009 0.02 0.000 0.003
3
CATEGORICAL
COMPARISONS
Baseline
OF LIFE SCORES
NON-RESPONDERS
Week 6 Non-responders
TO DRUG
Reponders
Non-responders
P
P
0 (0) 44 (4)
0.004
NS
13 (1) 13 (1)
13 (1) 61 (5)
0.02
NS
0 (0) 100 (6)
NS
NS
NS
NS
0.07
NS
Good
Poor
Good
Poor
C/r(N)
SC(N)
S(N)
(%c)N
(6) (9)
0 (0) 0 (0)
44 (4) 12 (1)
44(11) 40 (10)
4 (1) 12 (3)
40 60
AND RESPONDERS Comparison
Responders
Work functioning Good Poor House functioning Good Poor Closeness to spouse Good Poor Closeness to children Good Poor Closeness to relatives Good Poor Friendships Good Poor Sex satisfaction Good Poor Life satisfaction Good Poor Recreation Good Poor
BETWEEN
57 43
(4) (3)
0 (0) 0 (0)
0 (0) 0 (0)
28 12
(2) (5)
0 (0) 0 (0)
25 (1) 0 (0)
25 50
44 (12) 26 (7)
4 (1) 26 (3)
IS (2) 23 (3)
54
21 (6) 47 (13)
25 (7)
29
(4)
21 (3) 13 (6)
0.007
NS
52 (14) 3 (1)
19 (5) 26 (7)
77 (10) 0 (0)
0 (0) 13 (3)
NS
NS
18 (5) 46 (13)
36 (0) 0 (0)
21 (3) 0 (0)
0 (0) 70 (11)
0.000
NS
18 (5) 46 (13)
4 (1) 32 (9)
14 (2) 22 (3)
14 (2) so (7)
0.001
NS
7 (2)
7 (1)
(1) (2)
8 (1) (7)
39
were significantly superior to placebo in the following areas: work functioning, house functioning, relationship to relatives, sex frequency and life satisfaction (see Table 1). Work hours, recreational functioning, relationships with children, spouse, and friends did not demonstrate a differential treatment effect. LIFE scores at week 6 were significantly related to response status, after controlling for pretreatment LIFE scores by ANCOVA (see Table 2). To clarify how much functioning improved in a more tangible manner, LIFE scores were dichotomized by collapsing the very good and good functioning/ satisfaction responses into a single category, (‘good’), and mild, moderate or severe impairment into a ‘poor’ category. As can be seen in Table 3, there was a significant improvement from baseline in work functioning, house functioning, friendships, life satisfaction and recreational activity among those who responded to drug treatment. Drug non-responders did not improve in any category. TABLE
Discussion This study demonstrated that antidepressants were superior to placebo in improving functioning at work, house chores, relationship with relatives, sex frequency, sexual satisfaction, recreational activities and life satisfaction.
4
COMPARISON
OF LIFE SCORE
CHANGES
BY DIAGNOSTIC
Drugs baseline
Hours
The LIFE scores of patients with major depression and dysthymic disorder (DSM-III) who were assigned to drug treatment were compared. Because the sample was too small to validly test for differences among three diagnostic groups, patients who met criteria for major depression and dysthymic disorder were combined with patients who had major depression only. The week 6 LIFE scores of patients with major depression underwent a significant improvement from baseline in work functioning, friendships, sex frequency, life satisfaction and recreational activity. Patients with dysthymic disorder did not manifest a significant improvement in any area (see Table 4).
worked
Household Closeness Spouse
functioning
Baseline
vs. week 6
Dysthymic (n = 17) Means (SD)
Major Means (SD)
Dysthymic Means (SD)
Major P
Dysthymic P
28.2 (22.9)
32.5 (21.1)
27.3 (18.2)
NS
NS
2.9 (1.3) n=15 2.9 (1.1) n=21
34.7 (19.0) n = 15 2.3 (1.1) rl= 12 2.6 (0.93) n = 14
3.0 (1.0) n=9 2.7 (2.0) n=9 2.7 (0.90) n = 25 3.0 (1.1) n = 26 3.4 (1.0) n = 25 3.5 (0.91) n = 26 3.3 (0.78) n = 26
3.6 (1.1) n=5 3.0 (1.0) n=3 2.6 (0.80) n= 17 2.6 (0.61) n= 17 2.6 (1.3) n = 16 2.7 (1.2) n= 17 2.5 (0.94) n= 17
2.1
(1.6)
2.1
(1.3)
0.003
NS
2.4
(1.2)
2.5
(1.2)
NS
NS
2.3
(1.5)
3.0
(1.0)
NS
NS
1.9
(1.1)
2.3
(0.58)
NS
NS
2.2
(1.1)
2.2
(1.0)
NS
NS
2.3
(1.1)
2.1
(0.99)
0.007
NS
2.9
(1.3)
2.4
(1.3)
0.02
NS
2.8
(1.3)
2.5
(1.3)
0.002
NS
2.3
(1.2)
2.6
(0.93)
0.000
NS
to:
Children Relatives Friendships Sex frequency Life satisfaction Recreation
Drugs week 6
Major (n = 26) Means (SD) n = 16
Work functioning
CATEGORY
40
The improvements in psychosocial adaptation were most evident among week 6 responders to drug: 60% of the responders who began with ‘poor’ work functioning improved to ‘good’ functioning; there were corresponding changes in household functioning (40%), friendships (47%), life satisfaction (46%) and recreational activity (46%) (Table 3). A proportion of drug responders were rated as having ‘poor’ functioning both at baseline and at week 6 in the following areas: household functioning (120/o), closeness to relatives (26%), friendships (25%), sexual satisfaction (26%), and recreation (32%). Thus, a small proportion of drug responders continued to manifest some residual impairment in psychosocial functioning. One interpretation of this finding is that 6 weeks may not constitute a sufficient time period for some patients to significantly improve some aspects of functioning. Another possibility is that some patients may need psychosocial therapy to enhance functioning. Though drug-treated patients with major deprcssion showed a marked improvement in functioning, dysthymics did not. The relatively low number of subjects in the latter subgroup limits the statistical validity of this finding. The most recent documentation of the degree of social morbidity associated with depression is in a large national study conducted by Wells et al. (1989), who found that the functioning of outpatients with dcpressivc disorders was as impaired as that of those with chronic medical conditions. The clinical implication of this report and others (Stewart et al., 1988; Kocsis et al., 1988) is that antidepressant medications not only alleviate symptoms in some patients; they also improve some aspects of role functioning and overall well-being, even in chronic depressives with an early onset. Thus, pharmacotherapy not only reduced depressive symptoms among chronically depressed individuals but also improved their functioning and contentment with life. These results suggest that psychosocial impairment in some of these patients may be a sequela of depression, rather than a global manifestation of characterological pathology. This study is similar to the reports of Kocsjs et al. (1988) and Stewart et al. (1988) which inter-
preted improvements in SAS scores as demonstrating improved psychosocial functioning in chronic depression. (The patients in this report are drawn from the same clinic that the Stewart et al. (1988) study was drawn from, but they are a separate cohort.) The LIFE, unlike the SAS, is a clinician-rated instrument, which assesses patients’ psychosocial functioning and life satisfaction. We were unable to locate literature on LIFE scores for normal controls. Thus, we could not compare how well our responders did vis-a-vis mentally healthy controls. A comparison of the adjusted posttreatment SAS scores of Stewart et al.‘s (1988) drugand placebo-treated chronic depressives with Weissman et al.‘s (1978) community control group revealed that the drug group scores remained superior to imipramine (t = 11.7, P = O.OOO), phenelzine (t = 7.0, P = 0.000) and placebo (t = 14.9, P = 0.000). A data analysis of Kocsis et al.‘s (1988) sample also found that Weissman’s control group had higher levels of social functioning than imipramine (t = 3.3, P = 0.001) and placebo (t = 8.9, P = 0.000) groups. However, the time of these studies may be too brief (6 weeks) to expect that functioning would match that of a community control group. A limitation of this study is that the majority of LIFE items, except for measures regarding work hours and sex frequency, are subjective assessments and therefore may not be valid measures of actual functioning. An advantage of using a clinician-rated instrument is that it increases the degree of objective assessment. However, future studies need to utilize significant others at baseline and posttreatment to assess the validity of patient self-reports. This study does not imply that medication treatment is the only effective treatment of impaired social functioning among chronic depressives. The addition of psychotherapy specifically aimed at improving psychosocial functioning, c.g., interpersonal psychotherapy, has been recommended as an adjunctive treatment in patients who manifest residual impairment in role functioning after benefiting from antidepressant medications (Weissman et al., 1981).
41
References Akiskal, H.S., Rosenthal, T.L., Haykal, R.F., et al. (1980) Characterological depressions: clinical sleep EEG findings separating ‘subaffective dysthymias’ from ‘character spectrum disorders’. Arch. Gen. Psychiatry 37, 777-783. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. American Psychiatric Association, Washington, DC. Arieti, S. and Bemporad, J., (1978) Severe and Mild Depression. Basic Books, New York, NY, p. 290. Bemporad, J. (19831 Psychotherapy of the depressive character. In: M.B. Cantor and M.L. Glucksman (Eds.), Affect: Psychoanalytic Theory and Practice, pp. 185-209. Blanck, G. and Blanck, R. (1974) Ego Psychology: Theory and Practice. Columbia University Press, New York, NY, p. 256. Hamilton, M.A. (1960) A rating scale for depression. J. Neurol. Neurosurg. Psychiatry, 23, 56-62. Harrison, W., Rabkin, L., Stewart, J.S., et al. (1986) Phenelzine for chronic depression: a study of continuation treatment. J. Clin. Psychiatry 47, 346-349. Keller, M.B., Lavori, P.W., Friedman, B., et al.. (1987) The longitudinal interval follow-up evaluation. Arch. Gen. Psychiatry 44, 540-548. Kernberg, 0. (1988) Clinical dimensions of masochism. J. Am. Psychoanal. Ass. 36, 1005-1029. Kocsis, J.H., Frances, A.J., Carlyle, V., et al.. (1988a) Imipramine treatment for chronic depression. Arch. Gen. Psychiatry 45, 253-257. Kocsis, J.H., Frances, A.J., Voss, C., Mason, B.J. and Sweeney, J. (1988b) Imipramine and socio-vocational adjustment in chronic depression. Am. J. Psychiatry 145, 997-999.
Markowitz, J.S.. Weissman, M.M., Ouellette, R. et al. (1989) Quality of life in panic disorder. Arch. Gen. Psychiatry 46, 984-992. McGlashan, T. (Ed.) (197.3) The Documentation of Clinical Psychotropic Drug Trials. NIMH, Rockville, MD. Stewart, J.W., Quitkin, F.M., McGrath, P.J. et al. (1988) Social functioning in chronic depression: effect of six weeks of antidepressant treatment. Psychiatr. Res. 25, 213-222. Stewart, J.W., McGrath, P.J., Quitkin, F.M. et al. (1989) Relevance of DSM-III depressive subtype and chronicity of antidepressant efficacy in atypical depression. Arch. Gen. Psychiatry 46, 1080-1087. Weissman, M.M. and Bothwell, S. (19761 Assessment of social adjustment by patient self-report. Arch. Gen. Psychiatry 33, 1111. Weissman, M.M., and Klerman, G.L. (1977) The chronic depressive in the community - unrecognized and undertreated. Comp. Psychiatry 18, 523. Weissman, M.M., Prusoff, B.A., Thompson, W.D., et al. (1978) Social adjustment by self-report in a community sample and in psychiatric outpatients. J. Nerv. Ment. Disord. 166, 766-771. Weissman, M.M., Klerman, G.L., Paykel, E.S., et al. (1981) Depressed outpatients: results one year after treatment with drugs and/or interpersonal psychotherapy. Arch. Gen. Psychiatry 38, 51-55. Wells, K.B., Stewart, A., Hays, R., et al. (1989) The functioning and well-being of depressed patients: results from the Medical Outcomes study. J. Am. Med. Ass. 262, 914-919.
35 0165-0327/91/$03.50
JAD 00831
Life satisfaction and psychosocial functioning in chronic depression: effect of acute treatment with antidepressants Vito Agosti
‘, Jonathan
W. Stewart
’ New York State Psychiatric Institute and ’ Department
2 and Fredric
of Psychiatry,
Columbia
M. Quitkin
2
Uniuersity, New York, NI: U.S.A.
(Received 23 January 1991) (Revision received 30 May 1991) (Accepted 6 June 1991)
Summary Social functioning was evaluated in 61 chronically depressed adults with early onset. Patients were treated for 6 weeks in a double-blind trial of phenelzine, imipramine, L-deprenyl, or placebo and functioning was reassessed. The posttreatment social functioning of patients who received drug treatment was superior to the placebo group in the following areas: work functioning, house functioning, relationship with relatives, sex frequency and life satisfaction. These results suggest that psychosocial impairment in some chronic depressives may be a sequaela of depression, rather than a global manifestation of characterological pathology.
Key words:
Chronic
depression;
Social functioning;
Introduction The dissatisfying lives and impaired psychosocial functioning of adults with early onset chronic depression have been attributed to deeply ingrained characterological disturbancess (Blanck and Blanck, 1974; Kernberg, 1988; Bemporad, 1983). Though Bemporad (1983) and Kernberg (1988) have recommended long-term psychoanalytic psychotherapy as the treatment of choice for
Address for correspondence: Vito Agosti, M.S.W., New York State Psychiatric Institute, 722 West 168th Street, Box 35, New York, NY 10032, U.S.A.
Antidepressants
these patients, controlled studies supporting the efficacy of this recommendation have not been reported. In contrast, there have been a series of studies demonstrating that antidepressant medications are relatively effective in reducing symptoms of chronic depressives. Akiskal et al. (1980) observed, in an uncontrolled study, that a subgroup of early onset chronic depressives with ‘stable’ personality traits had a favorable response to antidepressant medications. Stewart et al. (1989) and Kocsis et al. (19881, in short-term controlled studies, found that antidepressant medications were superior to placebo. In a long-term medication discontinuation pilot study, Harrison et al.
36
(1986) found that 80% of patients who were maintained on antidepressant medication remained euthymic, in contrast to 0% among those who were switched to pIacebo. Though many psychoanalysts concede that medication is an effective treatment for reducing the vegetative depression symptoms of the ‘depressive personality’, some seriously question whether symptomatic treatment alone can alter ‘strong inhibitions [which] prevent them from finding meaning or enjoyment in life’ (Arieti and Bemporad, 1978). The impoverished quality of life of chronic depressives has been described in the literature (Bemporad, 1983; Weissman and Klerman, 1977; Akiskal et al., 1980). Psychosocial functioning scales are putative measures of the quality of life, measuring interpersonal, work, and recreational functioning (Markowitz et al., 1989). Studies by Stewart et al. (1988) and Kocsis et al. (1988b) reported a significant improvement in Social Adjustment Scale (SAS) (Weissman et al., 1976) scores of chronic depressed patients after acute antidepressant medication treatment. Similar changes were not seen in the placebo-treated group. The purpose of this study was to determine whether the doctor-rated Longitudinal Interval Life Scale (LIFE) (Keller et al., 1987) would replicate earlier findings of improved social adjustment, assessed by the patient-rated SAS, among chronic depressives who received antidepressant medications. Methods Subjects The subjects were physically healthy, nonmelancholic chronically depressed outpatients (29 men, 32 women) with a mean age of 35 (k8.9). All had graduated from high school. Fifty-seven percent were single (n = 35), 23% married (n = 14), and 19.6% divorced or separated (n = 12). Mean Hamilton Rating Scale of Depression (HAM-D) (Hamilton, 1960) score was 14.2 ( f 3.7). Scores on this scale may not adequately reflect the degree of psychopathology in our sample, since the reversed vegetative symptoms oversleeping and overeating are not rated by the HAM-D.
DSM-III (American Psychiatric Association, 1980) diagnoses included: dysthymic disorder (31%, n = 191, major depression, without melancholia (25%, n = 151 and major depression superimposed on dysthymic disorder (44%, n = 27). Study entrance requirements were a DSM-III depressive disorder and mood reactivity (i.e., significant lifting of mood in response to positive environmental events). Following baseline evaluation, patients were treated with single-blind placebo for l-2 weeks, those who were still depressed were randomly assigned to 6 weeks of treatment with increasing doses of one of four agents in a double-blind design. Dosage ranged from 60 to 90 mg/day of phenelzine, 200 to 300 mg/day of imipramine, 40 mg/day of L-deprenyl, and four to six placebo pills. At baseline 26.2% (n = 16) were assigned to imipramine, 16.4% (n = 10) to phenelzine, 37.7% (n = 23) to placebo, and 19.7% (n = 12) to I.-deprenyl. The uneven distribution among treatments is due to the disproportionate frequencies of patients we had collected LIFE data on, rather than a skewed randomization process. Due to administrative errors, we did not have LIFE data on all patients at week 6. Clinical outcome was determined by the treating psychiatrist on the basis of Clinical Global Improvement (CGI) (McGlashan, 1973) scale scores. A score of 1 or 2 (very much or much improved) defined positive response. All other ratings defined non-response. Responders did not differ significantly from non-responders with regard to diagnosis, baseline HAM-D scores, sex, age, education, or marital status. In order to focus specifically on chronically depressed patients, we chose the subgroup of 61 patients who had an onset prior to age 21 and were rated prospectively by an experienced clinician as depressed either most or virtually all of the time throughout adulthood. Rating scales Global ratings of severity and change were made weekly on the CGI scale and the HAM-D. All patients were assessed for the presense of psychiatric disorders according to DSM-III. Chronicity was evaluated by a clinician prior to treatment. Initial histories were scored on a 4-
37
point scale to rate the proportion of affective symptomatology during the patient’s adult life: 1, mostly well; 2, depressed about half the time; 3, depressed most of the time; or 4, virtually always depressed. This was considered to be an ordinal scale. The LIFE is a semi-structured interview which tracks episodes of psychiatric illness. The instrument measures both psychosocial functioning and psychopathology over time. The LIFE was modified in our study. The section measuring psychopathology was not utilized because we were already using other psychopathology rating scales. The portion of the LIFE which we used assessed psychosocial functioning during the past week in five areas: employment, house work, interpersonal relationships, sexual functioning, life satisfaction and recreational activity. The LIFE was administered to the patient by the treating psy-
TABLE
Data analysis The five item choices measuring sexual satisfaction were collapsed into two categories, i.e., good vs. poor (having sex and being satisfied = good; not having sex, satisfied or dissatisfied, and having sex, fairly or poorly satisfied = poor). The four drug groups were combined to enhance statistical power. Outcome LIFE measures for treatment groups, and diagnostic subgroups, were compared by analysis of covariance, using the pretreatment scores as covariates. All tests were two-tailed. In order to give a concrete sense of the rate of improvement, LIFE item scores were dichotomized. McNemar’s test (with Yate’s cor-
1
LIFE SCORES
Hours worked
OF PATIENTS
’
Work functioning Household
functioning
Relationship spouse Relationship children Relationship relatives Friendships
with with with
Sex frequency Life satisfaction Recreation
chiatrist at baseline and after 6 weeks of doubleblind treatment. High scores indicate impairment and/or dissatisfaction, low scores indicate high levels of functioning or satisfaction.
WHO
RECEIVED
ANTIDEPRESSANTS
OR PLACEBO
FOR 6 WEEKS
Pretreatment unadjusted means (SD) a
Posttreatment unadjusted means (SD)
Drug (n = 38)
Placebo (n = 23)
Drug
Placebo
30.8 (21.X) n = 27 2.7 (1.2) n = 23 2.x (1.1) n = 30 3.0 (1.0) n = 13 2.x (0.9X) n=ll 2.7 (0.85) n = 37 3.0 (0.94) n = 3X 3.2 (1.1) n = 37 3.3 (1.0) n = 3X 3.0 (0.85) n = 3X
32.6 (15.7) n = I6 2.6 (1.5) n= 14 2.9 (1.0) n = 22 3.2 (1.3) n=9 3.1 (1.2) n=X 2.9 (1.2) 12= 21 2.x (0.99) n = 23 2.9 (1.1) n = 20 3.2 (1.0) n = 21 2.9 (0.79) n = 20
2X.2 (19.9)
37.7 (19.5)
1.X (1.4)
2.6 (1.3)
2.3 (1.2)
2.9 (1 .O)
2.5 (1.3)
3.3
2.0 (1.0,
3.0 (1.0)
2.2 (1.1)
2.9 (1.2)
2.3 (1.1)
2.3 (1.1)
2.X (1.3)
3.0 (1.0)
2.6 (1.3)
3.0 (1.0)
2.4 (1.2)
2.6 (1.1)
Drugs vs. placebo
df=l
“ There were no significant pretreatment differences between drug and placebo. h Sample size differs for individual items since not all items apply to individual married).
patients
(I .2I
(e.g., only a portion
F = 2.2 P=NS Fz6.1 P = 0.02 F = 4.2 P = 0.05 F = 0.30 P=NS F = 0.14 P=NS F = 4.0 P = 0.04 F=O.ll P=NS F = 4.3 P = 0.04 F=4.1 P = 0.05 F = 0.40 P = NS
of our sample
is
38 TABLE
2
RELATIONSHIP BETWEEN TREATMENT STATUS AND WEEK 6 LIFE SCORES
rection) was applied to these dichotomized to test for significant changes in LIFE between baseline and posttreatment.
RESPONSE
ANCOVA F
TABLE
Results P-value
0.008
Work hours Work functioning Household functioning Relationship with spouse Relationship with children Relationship with relatives Friendships Sex frequency Life satisfaction Recreation
scores scores
24.9 30.6 14.5 16.1 9.9 1.2 6.3 32.9 9.4
The mean pretreatment (*SD) HAM-D score was 14.4 (3.9) for the drug group and 13.9 (3.1) for placebo (t = 0.51, df= 60, P = NS). Mean ages for drug and placebo groups were 35.8 (9.3) and 34.5 (8.9) respectively (t = 0.54, df= 60, P = NS). After controlling for pre-treatment LIFE scores, using ANCOVA, the analysis revealed that the week 6 LIFE scores of the drug group
NS
0.000 0.000 0.001 0.001 0.003 0.009 0.02 0.000 0.003
3
CATEGORICAL
COMPARISONS
Baseline
OF LIFE SCORES
NON-RESPONDERS
Week 6 Non-responders
TO DRUG
Reponders
Non-responders
P
P
0 (0) 44 (4)
0.004
NS
13 (1) 13 (1)
13 (1) 61 (5)
0.02
NS
0 (0) 100 (6)
NS
NS
NS
NS
0.07
NS
Good
Poor
Good
Poor
C/r(N)
SC(N)
S(N)
(%c)N
(6) (9)
0 (0) 0 (0)
44 (4) 12 (1)
44(11) 40 (10)
4 (1) 12 (3)
40 60
AND RESPONDERS Comparison
Responders
Work functioning Good Poor House functioning Good Poor Closeness to spouse Good Poor Closeness to children Good Poor Closeness to relatives Good Poor Friendships Good Poor Sex satisfaction Good Poor Life satisfaction Good Poor Recreation Good Poor
BETWEEN
57 43
(4) (3)
0 (0) 0 (0)
0 (0) 0 (0)
28 12
(2) (5)
0 (0) 0 (0)
25 (1) 0 (0)
25 50
44 (12) 26 (7)
4 (1) 26 (3)
IS (2) 23 (3)
54
21 (6) 47 (13)
25 (7)
29
(4)
21 (3) 13 (6)
0.007
NS
52 (14) 3 (1)
19 (5) 26 (7)
77 (10) 0 (0)
0 (0) 13 (3)
NS
NS
18 (5) 46 (13)
36 (0) 0 (0)
21 (3) 0 (0)
0 (0) 70 (11)
0.000
NS
18 (5) 46 (13)
4 (1) 32 (9)
14 (2) 22 (3)
14 (2) so (7)
0.001
NS
7 (2)
7 (1)
(1) (2)
8 (1) (7)
39
were significantly superior to placebo in the following areas: work functioning, house functioning, relationship to relatives, sex frequency and life satisfaction (see Table 1). Work hours, recreational functioning, relationships with children, spouse, and friends did not demonstrate a differential treatment effect. LIFE scores at week 6 were significantly related to response status, after controlling for pretreatment LIFE scores by ANCOVA (see Table 2). To clarify how much functioning improved in a more tangible manner, LIFE scores were dichotomized by collapsing the very good and good functioning/ satisfaction responses into a single category, (‘good’), and mild, moderate or severe impairment into a ‘poor’ category. As can be seen in Table 3, there was a significant improvement from baseline in work functioning, house functioning, friendships, life satisfaction and recreational activity among those who responded to drug treatment. Drug non-responders did not improve in any category. TABLE
Discussion This study demonstrated that antidepressants were superior to placebo in improving functioning at work, house chores, relationship with relatives, sex frequency, sexual satisfaction, recreational activities and life satisfaction.
4
COMPARISON
OF LIFE SCORE
CHANGES
BY DIAGNOSTIC
Drugs baseline
Hours
The LIFE scores of patients with major depression and dysthymic disorder (DSM-III) who were assigned to drug treatment were compared. Because the sample was too small to validly test for differences among three diagnostic groups, patients who met criteria for major depression and dysthymic disorder were combined with patients who had major depression only. The week 6 LIFE scores of patients with major depression underwent a significant improvement from baseline in work functioning, friendships, sex frequency, life satisfaction and recreational activity. Patients with dysthymic disorder did not manifest a significant improvement in any area (see Table 4).
worked
Household Closeness Spouse
functioning
Baseline
vs. week 6
Dysthymic (n = 17) Means (SD)
Major Means (SD)
Dysthymic Means (SD)
Major P
Dysthymic P
28.2 (22.9)
32.5 (21.1)
27.3 (18.2)
NS
NS
2.9 (1.3) n=15 2.9 (1.1) n=21
34.7 (19.0) n = 15 2.3 (1.1) rl= 12 2.6 (0.93) n = 14
3.0 (1.0) n=9 2.7 (2.0) n=9 2.7 (0.90) n = 25 3.0 (1.1) n = 26 3.4 (1.0) n = 25 3.5 (0.91) n = 26 3.3 (0.78) n = 26
3.6 (1.1) n=5 3.0 (1.0) n=3 2.6 (0.80) n= 17 2.6 (0.61) n= 17 2.6 (1.3) n = 16 2.7 (1.2) n= 17 2.5 (0.94) n= 17
2.1
(1.6)
2.1
(1.3)
0.003
NS
2.4
(1.2)
2.5
(1.2)
NS
NS
2.3
(1.5)
3.0
(1.0)
NS
NS
1.9
(1.1)
2.3
(0.58)
NS
NS
2.2
(1.1)
2.2
(1.0)
NS
NS
2.3
(1.1)
2.1
(0.99)
0.007
NS
2.9
(1.3)
2.4
(1.3)
0.02
NS
2.8
(1.3)
2.5
(1.3)
0.002
NS
2.3
(1.2)
2.6
(0.93)
0.000
NS
to:
Children Relatives Friendships Sex frequency Life satisfaction Recreation
Drugs week 6
Major (n = 26) Means (SD) n = 16
Work functioning
CATEGORY
40
The improvements in psychosocial adaptation were most evident among week 6 responders to drug: 60% of the responders who began with ‘poor’ work functioning improved to ‘good’ functioning; there were corresponding changes in household functioning (40%), friendships (47%), life satisfaction (46%) and recreational activity (46%) (Table 3). A proportion of drug responders were rated as having ‘poor’ functioning both at baseline and at week 6 in the following areas: household functioning (120/o), closeness to relatives (26%), friendships (25%), sexual satisfaction (26%), and recreation (32%). Thus, a small proportion of drug responders continued to manifest some residual impairment in psychosocial functioning. One interpretation of this finding is that 6 weeks may not constitute a sufficient time period for some patients to significantly improve some aspects of functioning. Another possibility is that some patients may need psychosocial therapy to enhance functioning. Though drug-treated patients with major deprcssion showed a marked improvement in functioning, dysthymics did not. The relatively low number of subjects in the latter subgroup limits the statistical validity of this finding. The most recent documentation of the degree of social morbidity associated with depression is in a large national study conducted by Wells et al. (1989), who found that the functioning of outpatients with dcpressivc disorders was as impaired as that of those with chronic medical conditions. The clinical implication of this report and others (Stewart et al., 1988; Kocsis et al., 1988) is that antidepressant medications not only alleviate symptoms in some patients; they also improve some aspects of role functioning and overall well-being, even in chronic depressives with an early onset. Thus, pharmacotherapy not only reduced depressive symptoms among chronically depressed individuals but also improved their functioning and contentment with life. These results suggest that psychosocial impairment in some of these patients may be a sequela of depression, rather than a global manifestation of characterological pathology. This study is similar to the reports of Kocsjs et al. (1988) and Stewart et al. (1988) which inter-
preted improvements in SAS scores as demonstrating improved psychosocial functioning in chronic depression. (The patients in this report are drawn from the same clinic that the Stewart et al. (1988) study was drawn from, but they are a separate cohort.) The LIFE, unlike the SAS, is a clinician-rated instrument, which assesses patients’ psychosocial functioning and life satisfaction. We were unable to locate literature on LIFE scores for normal controls. Thus, we could not compare how well our responders did vis-a-vis mentally healthy controls. A comparison of the adjusted posttreatment SAS scores of Stewart et al.‘s (1988) drugand placebo-treated chronic depressives with Weissman et al.‘s (1978) community control group revealed that the drug group scores remained superior to imipramine (t = 11.7, P = O.OOO), phenelzine (t = 7.0, P = 0.000) and placebo (t = 14.9, P = 0.000). A data analysis of Kocsis et al.‘s (1988) sample also found that Weissman’s control group had higher levels of social functioning than imipramine (t = 3.3, P = 0.001) and placebo (t = 8.9, P = 0.000) groups. However, the time of these studies may be too brief (6 weeks) to expect that functioning would match that of a community control group. A limitation of this study is that the majority of LIFE items, except for measures regarding work hours and sex frequency, are subjective assessments and therefore may not be valid measures of actual functioning. An advantage of using a clinician-rated instrument is that it increases the degree of objective assessment. However, future studies need to utilize significant others at baseline and posttreatment to assess the validity of patient self-reports. This study does not imply that medication treatment is the only effective treatment of impaired social functioning among chronic depressives. The addition of psychotherapy specifically aimed at improving psychosocial functioning, c.g., interpersonal psychotherapy, has been recommended as an adjunctive treatment in patients who manifest residual impairment in role functioning after benefiting from antidepressant medications (Weissman et al., 1981).
41
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