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Issues in Mental Health Nursing, 21:711– 720, 2000 Copyright ° c 2000 Taylor & Francis 0161-2840 /00 $12.00 + .00 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 pro 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 signi cantly on ve depressive symptoms that are classi 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; dif 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 identi 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 de 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 classi 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. Signi 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 of ce, and suf 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 identi 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 signi 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 signi 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 Signi 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 pro les of depressive symptoms. The univariate F statistics were examined to determine which depressive symptoms differed signi cantly among the three groups. Table 1 displays the univariate means, F scores, and signi cance levels for each of the 21 depressive symptoms in the three groups of depressed adults. The groups differed signi cantly on ve depressive symptoms classi ed as affective/cognitive symptoms (sadness, guilt, self-blame, indecisiveness, and suicidal ideas ) and one symptom classi ed as a somatic/ vegetative symptom of depression (anorexia ). Figures 1 and 2 compare the pro 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. 718 J. A. Zauszniewski and M. Ahmad As both 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 speci c depressive symptoms signi 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 de 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 speci 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 pro 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 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 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. 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