Improved methods of assessment and research design have established a robust and causal association between stressful life events and major depressive episodes. The chapter reviews these developments briefly and attempts to identify gaps in the field and new directions in recent research. There are notable shortcomings in several important topics: measurement and evaluation of chronic stress and depression; exploration of potentially different processes of stress and depression associated with first-onset versus recurrent episodes; possible gender differences in exposure and reactivity to stressors; testing kindling/sensitization processes; longitudinal tests of diathesis-stress models; and understanding biological stress processes associated with naturally occurring stress and depressive outcomes. There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time-including effects of childhood and lifetime stress exposure on later reactivity to stress.

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Stress and Depression

At diagnosis, 59 breast cancer patients reported on their overall optimism about life; 1 day presurgery, 10 days postsurgery, and at 3-, 6-, and 12-month follow-ups, they reported their recent coping responses and distress levels. Optimism related inversely to distress at each point, even controlling for prior distress. Acceptance, positive reframing, and use of religion were the most common coping reactions; denial and behavioral disengagement were the least common reactions. Acceptance and the use of humor prospectively predicted lower distress; denial and disengagement predicted more distress. Path analyses suggested that several coping reactions played mediating roles in the effect of optimism on distress. Discussion centers on the role of various coping reactions in the process of adjustment, the mechanisms by which dispositional optimism versus pessimism appears to operate, third variable issues, and applied implications.

How coping mediates the effect of optimism on distress : a study of women with early stage breast cancer

Advances in the conceptualization and measurement of life stress in the past 2 decades raise several questions concerning traditional diathesis— stress theories of psychopathology. First, comprehensive measures of life stress force investigators to become more precise about the particular stressful circumstances hypothesized to interact with diatheses. Second, the influence of the diathesis on a person's life is typically ignored, which results in several types of possible bias in the assessment of life stress. Finally, information is available on diatheses and stress for specific disorders to provide a foundation for more empirically based hypotheses about diathesis—stress interactions. This possibility is outlined for depression. Such an approach provides the basis for developing broader, yet more specific, frameworks for investigating diathesis—stress theories of psychopathology in general and of depression in particular.

Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders.

OBJECTIVE: Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. METHOD: Following admission to a university psychiatric hospital, 347 consecutive patients who were 14–72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psycho...

https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.2.181

Toward a clinical model of suicidal behavior in psychiatric patients.

Importance Cannabis and cannabinoid drugs are widely used to treat disease or alleviate symptoms, but their efficacy for specific indications is not clear. Objective To conduct a systematic review of the benefits and adverse events (AEs) of cannabinoids. Data Sources Twenty-eight databases from inception to April 2015. Study Selection Randomized clinical trials of cannabinoids for the following indications: nausea and vomiting due to chemotherapy, appetite stimulation in HIV/AIDS, chronic pain, spasticity due to multiple sclerosis or paraplegia, depression, anxiety disorder, sleep disorder, psychosis, glaucoma, or Tourette syndrome. Data Extraction and Synthesis Study quality was assessed using the Cochrane risk of bias tool. All review stages were conducted independently by 2 reviewers. Where possible, data were pooled using random-effects meta-analysis. Main Outcomes and Measures Patient-relevant/disease-specific outcomes, activities of daily living, quality of life, global impression of change, and AEs. Results A total of 79 trials (6462 participants) were included; 4 were judged at low risk of bias. Most trials showed improvement in symptoms associated with cannabinoids but these associations did not reach statistical significance in all trials. Compared with placebo, cannabinoids were associated with a greater average number of patients showing a complete nausea and vomiting response (47% vs 20%; odds ratio [OR], 3.82 [95% CI, 1.55-9.42]; 3 trials), reduction in pain (37% vs 31%; OR, 1.41 [95% CI, 0.99-2.00]; 8 trials), a greater average reduction in numerical rating scale pain assessment (on a 0-10-point scale; weighted mean difference [WMD], −0.46 [95% CI, −0.80 to −0.11]; 6 trials), and average reduction in the Ashworth spasticity scale (WMD, −0.12 [95% CI, −0.24 to 0.01]; 5 trials). There was an increased risk of short-term AEs with cannabinoids, including serious AEs. Common AEs included dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination. Conclusions and Relevance There was moderate-quality evidence to support the use of cannabinoids for the treatment of chronic pain and spasticity. There was low-quality evidence suggesting that cannabinoids were associated with improvements in nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders, and Tourette syndrome. Cannabinoids were associated with an increased risk of short-term AEs.

/pdf/cannabinoids-for-medical-use-a-systematic-review-and-meta-2sf620jl57.pdf

Cannabinoids for Medical Use: A Systematic Review and Meta-analysis.

OBJECTIVE: The authors sought to determine the efficacy and acceptability of lithium for relapse prevention in bipolar disorder. METHOD: A systematic review and meta-analysis of randomized controlled trials comparing lithium with placebo in the long-term treatment of bipolar disorders was conducted. Data were obtained from searching the registers of the Cochrane Collaboration; reviewing reference lists, journals, and conference abstracts; and contacting authors, experts, and pharmaceutical companies. Outcomes investigated included risk of relapse (manic, depressive, and total) as well as risk of specific adverse effects and total withdrawal rates. RESULTS: Five randomized controlled trials (770 participants) were included. Lithium was more effective than placebo in preventing all relapses (random effects relative risk=0.65, 95% CI=0.50 to 0.84) and manic relapses (relative risk=0.62, 95% CI=0.40 to 0.95). The protective effect of lithium on depressive relapses was smaller and was less robust (relative ris...

https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/appi.ajp.161.2.217

Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials.

The authors administered a questionnaire to 41 women who had had mastectomies to investigate aspects of the procedure itself, pre- and postmastectomy adjustment, effects on sexual relationships, and the influence of age. Although most women reported good overall adjustment, there were strong indications of psychological suffering (suicidal ideation, increased use of alcohol and tranquilizers, etc.). Psychological intervention may be called for in many cases, and age, support systems, and premorbid functioning may be indicators of the amount and type of intervention needed. Counseling is particularly important before surgery, since this was viewed as the period of maximum stress by most women. Further research with larger, more random samples and postsurgical control groups is indicated to determine more precisely the factors related to adjustment to mastectomy.

Psychosocial Aspects of Mastectomy: II. The Man's Perspective

The authors examined the impact of life stress on the course of bipolar disorder over a 2-year period in a group of 61 outpatients. The patients were followed prospectively with ongoing assessments of stressful life events, symptoms, levels of maintenance medication, and compliance with treatment regimens. As predicted, survival analyses indicated a significant association between life events and relapse or recurrence of the disorder. These effects could not be explained by differences in levels of medication or compliance. Further research is recommended to examine which specific subgroups of bipolar patients are most susceptible to stress.

Life events and the course of bipolar disorder.

Followed samples of unipolar and bipolar patients for a 6-month period, with independent assessment of symptoms and life events. Patients were initially categorized into subtypes using Beck's Sociotropy/Autonomy Scale, with the prediction that onset or exacerbation of symptoms, as well as more total symptoms, would occur for sociotropic individuals experiencing more negative interpersonal events than achievement events, and for autonomous-achievement patients experiencing more achievement events than interpersonal events. Results were confirmed for unipolars, indicating that the course of disorder was associated with the occurrence of personally meaningful life events, but not for bipolars. Further research is recommended to examine whether the effect is equally robust for both subtypes of unipolars, whether longer study duration may be required for bipolars, and whether a cognitive self-schema mechanism may account for the specific vulnerability to a subset of stressful events.

Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders.

Clinical psychiatry has focused almost entirely on the psychopathology of the affective disorders The authors studied responses of 61 patients (35 bipolar 26 unipolar) to questions about perceived short- and long-term benefits (increased sensitivity, sexuality, productivity, creativity, and social outgoingness) they attributed to their affective illness Bipolar patients strongly indicated positive experiences associated with manic-depressive illness; few unipolar patients perceived their disorder in such a way Significant sex differences emerged in the attributions made by bipolar patients

Kay Jamison

Papers

Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials.

Psychosocial Aspects of Mastectomy: II. The Man's Perspective

Life events and the course of bipolar disorder.

Sociotropy/autonomy and vulnerability to specific life events in patients with unipolar depression and bipolar disorders.

Clouds and silver linings: positive experiences associated with primary affective disorders.