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Psychosocial stressors and the prognosis of major depression: a test of Axis IV

  • S. E. Gilman (a1) (a2) (a3), N.-H. Trinh (a3) (a4), J. W. Smoller (a2) (a3) (a4), M. Fava (a3) (a4), J. M. Murphy (a2) (a3) (a4) and J. Breslau (a5)...
Abstract
Background

Axis IV is for reporting ‘psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders’. No studies have examined the prognostic value of Axis IV in DSM-IV.

Method

We analyzed data from 2497 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with major depressive episode (MDE). We hypothesized that psychosocial stressors predict a poor prognosis of MDE. Secondarily, we hypothesized that psychosocial stressors predict a poor prognosis of anxiety and substance use disorders. Stressors were defined according to DSM-IV's taxonomy, and empirically using latent class analysis (LCA).

Results

Primary support group problems, occupational problems and childhood adversity increased the risks of depressive episodes and suicidal ideation by 20–30%. Associations of the empirically derived classes of stressors with depression were larger in magnitude. Economic stressors conferred a 1.5-fold increase in risk for a depressive episode [95% confidence interval (CI) 1.2–1.9]; financial and interpersonal instability conferred a 1.3-fold increased risk of recurrent depression (95% CI 1.1–1.6). These two classes of stressors also predicted the recurrence of anxiety and substance use disorders. Stressors were not related to suicidal ideation independent from depression severity.

Conclusions

Psychosocial and environmental problems are associated with the prognosis of MDE and other Axis I disorders. Although DSM-IV's taxonomy of stressors stands to be improved, these results provide empirical support for the prognostic value of Axis IV. Future work is needed to determine the reliability of Axis IV assessments in clinical practice, and the usefulness of this information to improving the clinical course of mental disorders.

Copyright
Corresponding author
*Address for correspondence: S. E. Gilman, Sc.D., Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. (Email: sgilman@hsph.harvard.edu)
References
Hide All
APA (2010). Classification Issues Under Discussion. American Psychiatric Association DSM-5 Development (www.dsm5.org/ProposedRevisions/Pages/ClassificationIssuesUnderDiscussion.aspx). Accessed 6 January 2011.
Benjet, C, Borges, G, Medina-Mora, ME (2010). Chronic childhood adversity and onset of psychopathology during three life stages: childhood, adolescence and adulthood. Journal of Psychiatric Research 44, 732740.
Brown, GW, Harris, TO, Kendrick, T, Chatwin, J, Craig, TK, Kelly, V, Mander, H, Ring, A, Wallace, V, Uher, R (2010). Antidepressants, social adversity and outcome of depression in general practice. Journal of Affective Disorders 121, 239246.
Clark, C, Caldwell, T, Power, C, Stansfeld, SA (2010). Does the influence of childhood adversity on psychopathology persist across the lifecourse? A 45-year prospective epidemiologic study. Annals of Epidemiology 20, 385394.
Cohen, A, Gilman, SE, Houck, PR, Szanto, K, Reynolds, CF 3rd (2009). Socioeconomic status and anxiety as predictors of antidepressant treatment response and suicidal ideation in older adults. Social Psychiatry and Psychiatric Epidemiology 44, 272277.
Cohen, A, Houck, PR, Szanto, K, Dew, MA, Gilman, SE, Reynolds, CF 3rd (2006). Social inequalities in response to antidepressant treatment in older adults. Archives of General Psychiatry 63, 5056.
D'Agostino, RB Sr., Grundy, S, Sullivan, LM, Wilson, P (2001). Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. Journal of the American Medical Association 286, 180187.
Dawson, DA, Goldstein, RB, Grant, BF (2007). Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: a 3-year follow-up. Alcoholism: Clinical and Experimental Research 31, 20362045.
Dohrenwend, BP (2006). Inventorying stressful life events as risk factors for psychopathology: toward resolution of the problem of intracategory variability. Psychological Bulletin 132, 477495.
Eaton, WW, Shao, H, Nestadt, G, Lee, HB, Bienvenu, OJ, Zandi, P (2008). Population-based study of first onset and chronicity in major depressive disorder. Archives of General Psychiatry 65, 513520.
Ezquiaga, E, Garcia, A, Pallares, T, Bravo, MF (1999). Psychosocial predictors of outcome in major depression: a prospective 12-month study. Journal of Affective Disorders 52, 209216.
Furukawa, TA, Fujita, A, Harai, H, Yoshimura, R, Kitamura, T, Takahashi, K (2008). Definitions of recovery and outcomes of major depression: results from a 10-year follow-up. Acta Psychiatrica Scandinavica 117, 3540.
Grant, BF, Dawson, D (2001). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV). National Institute on Alcohol Abuse and Alcoholism: Rockville, MD.
Grant, BF, Dawson, DA, Stinson, FS, Chou, PS, Kay, W, Pickering, R (2003). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug and Alcohol Dependence 71, 716.
Gruenberg, AM, Goldstein, RD (2003). Multiaxial assessment in the twenty-first century. In Advancing DSM: Dilemmas in Psychiatric Diagnosis(ed. Phillips, K. A., First, M. B. and Pincus, H. A.), pp. 145152. American Psychiatric Association: Washington, DC.
Hammen, C, Kim, EY, Eberhart, NK, Brennan, PA (2009). Chronic and acute stress and the prediction of major depression in women. Depression and Anxiety 26, 718723.
Hasin, DS, Goodwin, RD, Stinson, FS, Grant, BF (2005). Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of General Psychiatry 62, 10971106.
Hettema, JM, Kuhn, JW, Prescott, CA, Kendler, KS (2006). The impact of generalized anxiety disorder and stressful life events on risk for major depressive episodes. Psychological Medicine 36, 789795.
Kendler, KS, Hettema, JM, Butera, F, Gardner, CO, Prescott, CA (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Archives of General Psychiatry 60, 789796.
Kendler, KS, Karkowski, LM, Prescott, CA (1999). Causal relationship between stressful life events and the onset of major depression. American Journal of Psychiatry 156, 837841.
Kupfer, DJ, First, MB, Regier, DA (2002). A Research Agenda for DSM-V. American Psychiatric Association: Washington, DC.
Lenze, SN, Cyranowski, JM, Thompson, WK, Anderson, B, Frank, E (2008). The cumulative impact of nonsevere life events predicts depression recurrence during maintenance treatment with interpersonal psychotherapy. Journal of Consulting and Clinical Psychology 76, 979987.
McCutcheon, AL (1987). Latent Class Analysis. Sage Publications: Newbury Park.
McLaughlin, KA, Conron, KJ, Koenen, KC, Gilman, SE (2010). Childhood adversity, adult stressful life events, and risk of past-year psychiatric disorder: a test of the stress sensitization hypothesis in a population-based sample of adults. Psychological Medicine 40, 16471658.
Moncur, RA, Luthra, AS (2009). Axis IV of the DSM: origins, evolution, and utility. McMaster University Medical Journal 6, 1115.
Monroe, SM, Torres, LD, Guillaumot, J, Harkness, KL, Roberts, JE, Frank, E, Kupfer, D (2006). Life stress and the long-term treatment course of recurrent depression: III. Nonsevere life events predict recurrence for medicated patients over 3 years. Journal of Consulting and Clinical Psychology 74, 112120.
Muthén, LK, Muthén, BO (1998–2010). Mplus User's Guide. Muthén & Muthén: Los Angeles, CA.
Plapp, JM, Rey, JM, Stewart, GM, Bashir, MR, Richards, IN (1987). Ratings of psychosocial stressors in adolescence using DSM-III Axis IV criteria. Journal of the American Academy of Child and Adolescent Psychiatry 26, 8086.
Post, RM, Rubinow, DR, Ballenger, JC (1986). Conditioning and sensitisation in the longitudinal course of affective illness. British Journal of Psychiatry 149, 191201.
Regier, DA (2011). The Conceptual Evolution of DSM-5. American Psychiatric Association: Washington, DC.
Rey, JM, Plapp, JM, Stewart, GW, Richards, I, Bashir, M (1987 a). Reliability of DSM-III Axis IV. Archives of General Psychiatry 44, 9697.
Rey, JM, Stewart, GW, Plapp, JM, Bashir, MR, Richards, IN (1987 b). Sources of unreliability of DSM-III Axis IV. Australian and New Zealand Journal of Psychiatry 21, 7580.
Rey, JM, Stewart, GW, Plapp, JM, Bashir, MR, Richards, IN (1988). DSM-III axis IV revisited. American Journal of Psychiatry 145, 286292.
Ruan, WJ, Goldstein, RB, Chou, SP, Smith, SM, Saha, TD, Pickering, RP, Dawson, DA, Huang, B, Stinson, FS, Grant, BF (2008). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of new psychiatric diagnostic modules and risk factors in a general population sample. Drug and Alcohol Dependence 92, 2736.
Rutter, M, Lebovici, S, Eisenberg, L, Sneznevskij, AV, Sadoun, R, Brooke, E, Lin, TY (1969). A tri-axial classification of mental disorders in childhood. An international study. Journal of Child Psychology and Psychiatry, and Allied Disciplines 10, 4161.
Safford, SM, Alloy, LB, Abramson, LY, Crossfield, AG (2007). Negative cognitive style as a predictor of negative life events in depression-prone individuals: a test of the stress generation hypothesis. Journal of Affective Disorders 99, 147154.
Salum, GA, Polanczyk, GV, Miguel, EC, Rohde, LA (2010). Effects of childhood development on late-life mental disorders. Current Opinion in Psychiatry 23, 498503.
Schrader, G, Gordon, M, Harcourt, R (1986). The usefulness of DSM-III axis IV and axis V assessments. American Journal of Psychiatry 143, 904907.
Shrout, PE, Link, BG, Dohrenwend, BP, Skodol, AE, Stueve, A, Mirotznik, J (1989). Characterizing life events as risk factors for depression: the role of fateful loss events. Journal of Abnormal Psychology 98, 460467.
Skodol, AE (1997). Axis IV. In DSM-IV Sourcebook, pp. 409422. American Psychiatric Association: Washington, DC.
Skodol, AE, Shrout, PE (1988). Axis IV of DSM-III. American Journal of Psychiatry 145, 10461047.
Skodol, AE, Shrout, PE (1989 a). Use of DSM-III axis IV in clinical practice: rating etiologically significant stressors. American Journal of Psychiatry 146, 6166.
Skodol, AE, Shrout, PE (1989 b). Use of DSM-III Axis IV in clinical practice: rating the severity of psychosocial stressors. Psychiatry Research 30, 201211.
Slopen, N, Fitzmaurice, G, Williams, DR, Gilman, SE (2010). Poverty, food insecurity, and the behavior for childhood internalizing and externalizing disorders. Journal of the American Academy of Child and Adolescent Psychiatry 49, 444452.
Spijker, J, de Graaf, R, Bijl, RV, Beekman, AT, Ormel, J, Nolen, WA (2002). Duration of major depressive episodes in the general population: results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS). British Journal of Psychiatry 181, 208213.
Strauss, JS (1975). A comprehensive approach to psychiatric diagnosis. American Journal of Psychiatry 132, 11931197.
SUDAAN (2004). SUDAAN Language Manual, Release 9.0. Research Triangle Institute: Research Triangle Park, NC.
WHO (2007). Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65). World Health Organization (http://apps.who.int/classifications/icd10/browse/2010/en-/Z55-Z65). Accessed 25 January 2011.
Williams, JB (1985 a). The multiaxial system of DSM-III: where did it come from and where should it go? I. Its origins and critiques. Archives of General Psychiatry 42, 175180.
Williams, JB (1985 b). The multiaxial system of DSM-III: where did it come from and where should it go? II. Empirical studies, innovations, and recommendations. Archives of General Psychiatry 42, 181186.
Wilson, PW (2009). Risk scores for prediction of coronary heart disease: an update. Endocrinology and Metabolism Clinics of North America 38, 3344.
Zimmerman, M, Pfohl, B, Coryell, W, Stangl, D (1987). The prognostic validity of DSM-III axis IV in depressed inpatients. American Journal of Psychiatry 144, 102106.
Zimmerman, M, Pfohl, B, Stangl, D, Coryell, W (1985). The validity of DSM-III axis IV (severity of psychosocial stressors). American Journal of Psychiatry 142, 14371441.
Zou, G (2004). A modified poisson regression approach to prospective studies with binary data. American Journal of Epidemiology 159, 702706.
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Psychological Medicine
  • ISSN: 0033-2917
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