▪ Abstract This chapter reviews recent research on the relationship between stressful life experiences and depression. A distinction is made between aggregate studies of overall stress effects and focused studies of particular events and difficulties. A distinction is also made between effects of life stress on first onset of depression and on the subsequent course of depression. Although the available evidence suggests that acute stressful life events can lead to the recurrence of episodes of major depression, a series of methodological problems compromise our ability to make clear causal inferences about the effects of life events on first onset of major depression or about the effects of chronic stress on either onset or recurrence of depression. The main problems of this sort are discussed, and recommendations made for ways of addressing these problems in future studies.

The effects of stressful life events on depression.

Objective. —To examine the impact of common mental illness on functional disability and the cross-cultural consistency of this relationship while controlling for physical illness. A secondary objective was to determine the level of disability associated with specific psychiatric disorders. Design. —A cross-sectional sample selected by two-stage sampling. Setting. —Primary health care facilities in 14 countries covering most major cultures and languages. Patients. —A total of 25916 consecutive attenders of these facilities were screened for psychopathology using the General Health Questionnaire (96% response). Screened patients were sampled from the General Health Questionnaire score strata for the second-stage Composite International Diagnostic Interview administered to 5447 patients (62% response). Main Outcome Measures. —Patient-reported physical disability, number of disability days, and interviewer-rated occupational role functioning. Results. —After controlling for physical disease severity, psychopathology was consistently associated with increased disability. Physical disease severity was an independent, although weaker, contributor to disability. A dose-response relationship was found between severity of mental illness and disability. Disability was most prominent among patients with major depression, panic disorder, generalized anxiety, and neurasthenia; disorder-specific differences were modest after controlling for psychiatric comorbidity. Results were consistent across disability measures and across centers. Conclusions. —The consistent relationship of psychopathology and disability indicates the compelling personal and socioeconomic impact of common mental illnesses across cultures. This suggests the importance of impairments of higher-order human capacities (eg, emotion, motivation, and cognition) as determinants of functional disability. (JAMA. 1994;272:1741-1748)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=383978&pdfFileName=jama_272_22_028.pdf

Common Mental Disorders and Disability Across Cultures: Results From the WHO Collaborative Study on Psychological Problems in General Health Care

The empirical case for the common factors in therapy: Quantitative findings.

Epidemiology of depression in primary care.

Generalized anxiety disorder is a relatively new clinical entity and current understanding of this syndrome lacks a solid research base. However, useful generalizations can be derived from earlier studies of anxiety neurosis and other previously defined anxiety syndromes. Most persons with GAD are seen by primary care physicians, but recognizing these patients may be difficult. In the primary care setting they often present with physical complaints suggesting a specific organ system disease. Depression and substance abuse may be presenting problems in patients with primary GAD. Primary care physicians are usually able to provide appropriate care for generalized anxiety disorder patients. By keeping in mind the cognitive, behavioral, affective, and physiologic aspects of the syndrome, they can appropriately address the specific therapeutic needs of individual patients. The nature of the doctor-patient relationship in primary care favors the development of therapeutic trust that is important for effective management of GAD. Drug therapy is a useful adjunct in the treatment of many patients with GAD. However, the use of drugs as the sole therapeutic modality is seldom appropriate.

Generalized anxiety disorder.

One hundred patients, selected to be representative of those attending general practitioners with non-psychotic psychiatric disorders were followed up for one year. Standard assessments of mental state, personality, social stresses and supports were carried out for each patient at the outset and after a year. The outcome for this cohort determined both by the level of psychiatric morbidity at interview after one year and by the pattern of the psychiatric morbidity during the year has been analysed with reference to the assessment measures. Discriminant function analysis indicates that the initial estimate of the severity of the psychiatric morbidity and a rating of the quality of the social life at the time of follow-up are the only factors that significantly predict the psychiatric state after one year. Social measures also predict a pattern of illness characterized by a rapid recovery after the initial assessment. Patients who reported continuous psychiatric morbidity during the year were older, physically ill and very likely to have received psychotropic drugs. Receipt of this medication during the year was associated with initial assessments of abnormality of personality, older age, and a diagnosis of depression. The findings of this study are seen to support a triaxial assessment and classification of non-psychotic psychiatric disorders, with symptoms, personality and social state being rated independently.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291700052855

E. Belsey

Papers

The twelve-month outcome of patients with neurotic illness in general practice

The background, design and use of a short interview to assess social stress and support in research and clinical settings.