Download patterns of depressive symptoms in three groups of depressed adults

Issues in Mental Health Nursing, 21:711– 720, 2000
Copyright ° c 2000 Taylor & Francis
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PATTERNS OF DEPRESSIVE SYMPTOMS IN
THREE GROUPS OF DEPRESSED ADULTS
Jaclene A. Zauszniewski, PhD, RNC
Muayyad Ahmad, PhD, RN
Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio, USA
This study examined patterns of depressive symptoms
experienced by acutely depressed inpatients, previously
hospitalized depressed outpatients, and depressed
outpatients who had never been hospitalized for depression.
The groups’ symptom proŽ les were compared to determine
whether the 21 major depressive symptoms measured by the
Beck Depression Inventory were similar or different for the
three groups. The groups differed signiŽ cantly on Ž ve
depressive symptoms that are classiŽ ed as affective/
cognitive symptoms (sadness, guilt, self-blame,
indecisiveness, suicidal ideas) and one that is considered a
somatic/vegetative symptom of depression (anorexia). Thus,
commonly used diagnostic criteria may not re ect the full
range or temporal patterning of symptoms experienced by
depressed persons at varying levels of acuity or severity and
in different treatment settings.
The National Institute of Mental Health estimates that clinical depression affects approximately 17.6 million Americans each year (Thobaben,
1998 ). The diagnosis is commonly based on the criteria set forth in
the Diagnostic and Statistica l Manual of Mental Disorders (DSM-IV;
American Psychiatric Association, 1994 ):
The essential feature of a major depressive episode is a period of at least 2
weeks during which there is either depressive mood or the loss of interest
or pleasure in nearly all activities. The individual must also experience
at least four additional symptoms drawn from a list that includes change
Address correspondenc e to Jaclene Zauszniewski, Bolton School of Nursing, Case Western
Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106 – 4904. E-mail: [email protected]
711
712
J. A. Zauszniewski and M. Ahmad
in appetite or weight, sleep, and psychomotor activity; decreased energy;
feelings of worthlessness or guilt; difŽ culty thinking, concentrating, or
making decisions; or recurrent thoughts of death or suicidal ideation,
plans, or attempts (p. 320).
Despite these criteria, there continues to be a lack of consensus by
mental health professionals on the diagnosis of clinical depression (Beck
& Koenig, 1996; Endicott, 1984; Kathol, Mutgi, Williams, Clamon, &
Noyes, 1990 ). This lack of consensus is complicated by the large range
of symptoms that may be related to depression (Weissman et al., 1996 ),
the inconsisten t expression of depressive symptoms, and the possible
temporal patterning of symptoms during the course of depression (Beck
& Koenig, 1996 ). While current diagnostic measures assume that the
symptoms experienced by depressed persons are consistent and have
a stable clinical course (Klerman & Weissman, 1989 ), some evidence
suggests that there is a temporal patterning in the expression of depressive symptoms over the course of depressive illness (Mottram, Hamer,
Williams, & Wilson, 1996; Walker, 1997 ). However, no studies have
examined such patterning in persons diagnosed with a major depressive
episode.
This study examined patterns of depressive symptoms in three groups
of clinically depressed adults: acutely depressed inpatients, previously
hospitalized outpatients, and depressed outpatients who had never been
hospitalized for the treatment of depression. The goal was to determine
whether there are similarities or differences in the expression of depressive symptoms in three groups representing different levels of severity
of depression, different treatment settings, and different treatment plans.
METHOD
Design and Sample
This secondary analysis used data from two cross-sectional comparative studies of health-seeking resources for three groups of adults currently being treated for clinical depression: inpatients, previously hospitalized outpatients , and outpatients who had never been hospitalized
for depression (Zauszniewski, 1992, 1994, 1995 ). The inpatients were
recruited from the psychiatric units of three large teaching hospitals, and
the outpatients were drawn from outpatient clinics, community mental
health centers, and private practices. Mental health care providers such
as psychiatric nurses, psychologists , psychiatrists, and social workers
Patterns of Symptoms in Depressed Adults
713
identiŽ ed the subjects. To be included in the studies, patients had to be
adults (age 21 – 65 ) who were being treated for clinical depression and
met DSM-IV criteria for major depression, bipolar disorder (depressed
phase ), or dysthymia when treatment was initiated. Persons diagnosed
with coexisting physical illness, organic mental disorder (e.g., dementia, neurological deŽ cit ), or thought disorder (e.g., schizophrenia ) were
excluded from the study. Subjects could be male or female and of any
racial/ethnic origin.
Instruments
Data on demographic characteristics, including age, gender, educational level, and annual income were collected using an open-ended
questionnaire.
Depressive symptoms were measured by the 21-item Beck Depression Inventory (BDI), which was developed by Beck, Ward, Mendelson,
Mock, and Erbaugh (1961 ) to measure the subjective experience of depression (Steer, Beck, Riskind, & Brown, 1987 ). The BDI is clinically
useful for determining severity of depression, though it was never intended as a diagnostic measure (Katz, Shaw, Vallis, & Kaiser, 1995 ). It
assesses a range of depressive symptoms that extend beyond diagnostic
criteria (McDowell, Kristjansson, & Newell, 1996; Steer & Beck, 1996 ).
The 21 BDI items have been classiŽ ed in two broad dimensions: affective/cognitive and somatic/vegetative (Cavanaugh, Clark, & Gibbons,
1983 ). The affective and cognitive symptoms measured are sadness,
pessimism, sense of failure, anhedonia, guilt, sense of punishment, selfhate, self-blame, suicidal ideas, crying, irritability, social withdrawal,
and indecisiveness . The somatic and vegetative symptoms measured are
body image change, work inhibition , insomnia, fatigue, anorexia, weight
loss, somatic preoccupation, and loss of libido.
Each item consists of four self-evaluative statements scored 0 to 3,
with higher scores indicating greater depression. Responses are added
to yield a total score that may range from 0 to 63 (Beck et al., 1961 ).
The suggested BDI cut off scores are 0– 9, normal; 10 – 18, mild depression; 19– 29, moderate depression; and greater than 30, severe depression (Kendall, Hollon, Hammen, & Ingram, 1987 ). In psychiatric
populations , the internal consistency of the BDI has ranged from .76 – .95
(Beck, Steer, & Garbin, 1988 ). Cronbach’s alpha for the BDI in this study
was .91. SigniŽ cant correlations with other rating scales of depression,
including the Hamilton Rating Scale of Depression (HRSD ), the Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D ),
714
J. A. Zauszniewski and M. Ahmad
and the Zung Self-Rating Depression Scale (SDS ), have indicated construct validity of the BDI (Beck, Steer, & Garbin, 1988 ).
Procedure
Subjects participated in face-to-face structured interviews during
which the demographic questionnair e and BDI were completed. The
interviews were conducted in a quiet room or ofŽ ce, and sufŽ cient time
for completion of the questionnaire s without interruption was assured.
The subjects received compensation upon completion of the interview.
RESULTS
This study compared three groups of depressed adults (inpatients,
previously hospitalize d outpatients, and never hospitalize d outpatients )
on 21 major depressive symptoms to determine whether patterns of
symptoms could be identiŽ ed. Preliminary analysis to evaluate the assumptions for multivariate analysis of variance (MANOVA ) revealed
no gross violations of the assumptions of normality, linearity, and homogeneity of the variance covariance matrices. There were no missing
data.
There were 189 subjects in the study, with 63 in each of the three
groups. The three groups were matched on gender and age within 3 years.
The average age was 38 years, and there were 24 men and 39 women
in each group. The average number of years of education was 13 and
the average annual income was $21,376. One-way analysis of variance
(ANOVA ) indicated that the groups did not differ signiŽ cantly on education or annual income. Only African-American and Caucasian persons
participated in the study, and chi square analysis showed that the three
groups were comparable on race.
One-way ANOVA was also used to determine whether the three
groups differed in severity of depression. Although the difference was
expected to be pronounced, it was only marginally signiŽ cant ( F = 2.95,
df = 2,186, p = .055 ). The acutely depressed inpatients had the highest average mean score ( M = 26.44 ) on the Beck Depression Inventory,
indicating the most severe depression. The mean scores for the previously hospitalize d and never hospitalized groups were 21.59 and 23.32,
respectively.
MANOVA was used to examine the differences between the three
groups on the 21 symptoms of depression simultaneousl y, taking into
account the intercorrelation s that existed among the symptoms. Two statistical values of F were computed to test the group differences. Wilks’s
715
Patterns of Symptoms in Depressed Adults
TABLE 1. Univariate Means, F Scores, and
SigniŽ cance Levels of Each of the 21 Depressive
Symptoms in the Three Groups of Depressed Adults
Symptom
Present
Past
Never
Sadness
Pessimism
Failure
Anhedonia
Guilt
Punished
Self-hate
Self-blame
Suicidal
Crying
Irritability
Withdrawn
Indecision
Body image
Inhibition
Insomnia
Fatigue
Anorexia
Weight loss
Somatic
Libido loss
1.43
1.27
1.40
1.40
1.24
0.97
1.46
1.54
1.14
1.35
1.03
1.30
1.52
0.92
1.29
1.21
1.40
1.21
1.11
0.83
1.44
1.03
0.98
1.13
1.29
0.79
1.19
1.16
1.14
0.70
1.16
1.19
1.06
1.03
0.82
1.22
0.95
1.25
0.71
0.79
0.79
1.16
1.11
0.95
1.10
1.37
1.00
1.49
1.22
1.32
0.62
1.13
1.27
1.19
1.14
1.10
1.29
0.98
1.33
0.84
0.76
0.89
1.22
¤
p < .05. ¤ ¤ p < .01. ¤
¤ ¤
F
3.16¤
2.24
1.97
0.26
3.38¤
2.88
2.07
3.77¤
8.99¤
0.86
1.46
1.10
5.30¤
1.22
0.14
1.54
0.49
4.26¤
1.79
0.19
1.11
¤ ¤
¤
p < .001.
lambda was equal to 1.89 (df = 21,166, p = .001 ). Pillai’s criterion,
which is more robust, was equal to 1.76 (df = 21, 166, p = .003 ). Despite slightly different results, the Wilks’s lambda and Pillai’s criterion
led to the same conclusion: The three groups of depressed adults had
different proŽ les of depressive symptoms. The univariate F statistics
were examined to determine which depressive symptoms differed signiŽ cantly among the three groups. Table 1 displays the univariate means,
F scores, and signiŽ cance levels for each of the 21 depressive symptoms
in the three groups of depressed adults.
The groups differed signiŽ cantly on Ž ve depressive symptoms classiŽ ed as affective/cognitive symptoms (sadness, guilt, self-blame, indecisiveness, and suicidal ideas ) and one symptom classiŽ ed as a somatic/
vegetative symptom of depression (anorexia ). Figures 1 and 2 compare
the proŽ les of the three groups on line graphs for the affective/cognitive
and somatic/vegetative symptoms.
716
FIGURE 1. Affective and cognitive symptoms measured by the BDI.
717
FIGURE 2. Somatic and vegetative symptoms measured by the BDI.
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J. A. Zauszniewski and M. Ahmad
As both Ž gures show, on 12 of the 21 BDI symptoms, the depressed
inpatients had the highest mean scores, followed by the never hospitalized outpatients, and then the previously hospitalize d outpatients . As
expected, the depressed inpatients, who were most severely depressed,
reported experiencing those 12 symptoms with greater intensity than
the two outpatient groups. However, the depressed inpatients, on average, had the lowest scores on irritability and feeling punished. Thus,
depressed outpatients appeared to experience more irritability and feelings of being punished than inpatients.
DISCUSSION
This secondary analysis of data from depressed inpatients and outpatients found trends toward differences in 12 depressive symptoms
of adults who had different levels of acuity or severity of depression
and were in different treatment settings. As would be expected, the
acutely depressed inpatients had the highest mean scores on each of
these 12 symptoms; that is, they experienced the symptoms more intensely than depressed outpatients. However, the depressed outpatients
who had never been hospitalized for depression reported experiencing
these symptoms more intensely than previously hospitalize d depressed
outpatients.
Six speciŽ c depressive symptoms signiŽ cantly differentiated the
groups: sadness, guilt, self-blame, indecisiveness , suicidal ideas, and
anorexia. Interestingly, these six symptoms re ected only four of the
nine criteria for clinical depression deŽ ned by the DSM-IV—sad or irritable mood, feelings of worthlessness or guilt, inability to think or
indecisiveness, and recurrent thoughts of death. Although the DSM-IV
criteria include weight loss, they do not speciŽ cally address anorexia,
which differed by group in this study. Two additiona l symptoms of depression, irritability and feelings of being punished, were more marked
in the depressed outpatients than in the inpatients. Irritability is one of
the criteria of the DSM-IV, but feeling punished is not mentioned.
Thus, while the most commonly used psychiatric diagnostic system,
the DSM-IV, appears to capture the key symptoms of depression, depressed persons at varying levels of acuity or severity and in different
treatment settings (hospital versus community ) appear to present differing symptom proŽ les. This suggests the need to develop additional
diagnostic criteria that re ect the range of symptoms experienced by
depressed persons over the course of treatment.
The generalizabilit y of these Ž ndings is, of course, limited by convenience sampling and the use of self-report measures. Further, a
Patterns of Symptoms in Depressed Adults
719
cross-sectiona l study cannot furnish information about progress during the treatment of depression. It would be interesting to follow depressed persons who are being treated to see if symptom patterns change
over time and whether temporal patterning is related to site and type of
treatment.
The Ž nding here that previously hospitalized patients had less severe
symptoms than those treated only in the community suggests the value
of being hospitalize d for treatment of depression. Perhaps, the more
thorough assessment and closer observation of depressed persons by
mental health professionals in the hospital lead to more effective treatment than in the community. Managed care plans, however, encourage
treatment in the community rather than in the hospital. To determine
whether hospitalizatio n provides sufŽ cient beneŽ t to be cost effective in
the treatment of depression, more rigorous studies are needed to compare the effects of inpatient and outpatient care over time, taking into
account both treatment plan and length of treatment, as well as possible
temporal patterning of depressive symptoms.
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