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Background.- Interpersonal difficulties and stressful life events are important etiological factors in (recurrence of) depression. This study examines whether stressful life events mediate the influence of problems in nonverbal communication on recurrence of depression.Methods.- We registered nonverbal expressions of involvement from videotaped behavior of 101 remitted outpatients and their interviewers. During a 2-year follow-up, We assessed stressful life events and recurrence of depression.Results.- The less congruent the levels of nonverbal involvement behavior of participants and interviewers, the higher the incidence of stressful life events, and -via these - the risk of recurrence.Limitations.- Nonverbal behavior was measured in an experimental setting.Conclusions.- The results suggest that lack of nonverbal congruence during social interaction contributes to the occurrence of stressful life events, which in turn may trigger depression. (c) 2006 Elsevier B.V All rights reserved.

This study examines the association between cortisol secretion and fear perception in remitted patients to identify mechanisms underlying risk for recurrence of depression. We hypothesized that the stronger the association between cortisol secretion and fear perception in persons with remitted depression, the more recurrence would be experienced. We also investigated whether high levels of cortisol and fear perception per se predict more recurrence. These effects were assumed to be stronger in women than in men. In a prospective design, we investigated 77 outpatients with remitted depression and related the association between their 24-hour urinary free cortisol secretion and fear perception (from ambiguous faces and from vocal expressions) to recurrence of depression within 2 years. We applied Cox regression models, partial correlations, and Fisher z tests. In 21 patients, depression recurred. Irrespective the channel of perception (eye or ear), the interaction between fear perception and cortisol secretion was significantly related to recurrence of depression. Patients high or low on both variables are more at risk. This increased risk was also reflected by a significant association between cortisol secretion and facial fear perception, but only among subjects who experienced recurrence. A trend in the same direction was found for vocal fear perception. Fear perception and cortisol secretion per se did not predict recurrence. No gender differences were found. The association between cortisol secretion and fear perception (probably indicative for altered fear circuits in the brain) constitutes a mechanism underlying risk for recurrence of depression.

High neuroticism and low extraversion are related to depression and its recurrence. We investigated whether nonverbal involvement behavior during social interaction is one of the factors via which these relations are effectuated. We measured nonverbal expressions of involvement from videotaped behavior of remitted depressed outpatients (n =101) and their conversation partners, and assessed self-reported neuroticism and extraversion scores. During a 2-year follow-up, we assessed the recurrence of depression. Twenty-eight participants (27.7%) experienced a recurrent episode. Time to recurrence was predicted by neuroticism and extraversion, and also by the degree of association between levels of nonverbal involvement behavior of conversation partners. The behavioral effect did not explain the personality effect. Neuroticism moderated the behavioral effect. The results point to the independent relevance of personality and nonverbal behavior in the long-term course of depressive disorder. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Background: The risk of recurrence in depressive disorder is high and increases with the number of episodes. We investigated whether individuals with a history of recurrent depression deviate from individuals with a single episode, as regards risk-related variables in 3 different domains of depression research.Methods: Participants were 102 outpatients with major depressive disorder remitted from an episode (60 recurrent, 42 nonrecurrent). We assessed the perception of emotions from vocal stimuli, 24-h urinary free cortisol, and neuroticism.Results: The recurrent group had higher cortisol levels than the nonrecurrent group, and recurrent women also had a more negative perception than nonrecurrent women. These results were independent of each other, and could also not be accounted for by neuroticism or residual symptoms. Gender differences were found in all 3 domains.Limitations: The cross-sectional design limits the possibility to draw conclusions on the causality of the observed effects.Conclusions: Remitted outpatients with recurrent depression deviate from remitted outpatients with single episode depression as regards physiology and social cognition, in a way that may increase their risk of the development of subsequent episodes. The results may have implications for prophylactic treatment strategies. (c) 2005 Elsevier B.V. All rights reserved.

The Scale for Interpersonal Behaviour (SIB), a multidimensional self-report measure of difficulty and distress in state assertiveness, was psychometrically evaluated in a large sample comprising 1242 unselected psychiatric inpatients. In addition to an overall measure of assertion, the SIB contains four factorially-derived dimensions: (I) negative assertion, (II) expression of and dealing with personal limitations, (III) initiating assertiveness, and (IV) positive assertion. The factors were originally interpreted in data of 703 members of a society for phobic individuals. Evidence is presented on the factorial constancy of the SIB measuring constructs across samples, biological sex, age, and educational level. Outstanding internal consistency figures are also given. Construct validity is established in a subset of the inpatients in relation to the Assertion Self-Statement Test-Revised. Both descriptive and specialized norms are presented for psychiatric inpatients. (C) 2004 Elsevier Ltd. All rights reserved.

Background: The Seasonal Pattern Assessment Questionnaire (SPAQ) is a frequently used screening instrument in the research on Seasonal Affective Disorder (SAD). Nevertheless, studies on its reliability and validity are relatively scarce. In the present study the reliability and the contrast validity of the SPAQ are investigated. Methods: SAD patients, selected by means of a clinical interview, non-seasonal depressed out-patients, non-depressed out-patients, and a control group, are contrasted to estimate the discriminating power of the SPAQ. Also, the reliability and factor structure of the seasonality and the climate subscales are investigated. To study food intake the Seasonal Food Preference Questionnaire (SFPQ) was developed. Results: The SAD criterion of the SPAQ shows good specificity (94%), but a low sensitivity (44%). Discriminant analysis shows sufficient ability to classify subjects (81% correctly classified), The Global Seasonality Scale has a good internal consistency. It consists of two factors, a psychological factor and a food factor. The SFPQ is sensitive for carbohydrate intake by SAD patients. Limitations: Most SAD patients had received treatment and completed the SPAQ while they were not depressed, which may have influenced the sensitivity. Conclusions: The SPAQ is not sensitive enough to be considered a diagnostic instrument for SAD. Nevertheless, it is accurate enough to be used as a screenings instrument. The only false positives were found in the depressive group. The accuracy of prevalence Figs. can be improved by completion of the SPAQ in the summer months, combined with the completion of a depression scale. (C) 2003 Elsevier B.V. All rights reserved.

The vulnerability-accumulation (or scarring) hypothesis postulates that the experience of depression induces a lasting increase in vulnerability, and through this raises the risk of recurrence. We examined the validity of the vulnerability-accumulation model for depressive episodes in later life. The sample comprised 26 elderly persons who had remitted from a depressive episode and 96 control respondents who were all selected from the participants of a large community survey among persons aged 57 years or more. Several psychosocial vulnerability indicators were assessed premorbidity, during the depressive episode and after remission. High levels of psychological distress, low life satisfaction, chronic somatic diseases, high neuroticism, and low scores on extraversion, mastery, and self-efficacy appeared to be predictors of depression in this sample. During the depressive episode, psychological distress was higher and life satisfaction, physical, role, and social functioning, as well as feelings of self-efficacy lower than before the episode. Physical and role functioning, cognitive function, and self-efficacy were lower after remission compared to premorbid levels, but (other) personality indices bad not changed after remission compared to premorbid levels. Furthermore, we failed to find differences between first and recurrent episodes. Support for the vulnerability-accumulation model was limited at the most. Although psychosocial scarring may occur in the elderly, our findings tentatively suggest that this accumulation does not manifest itself in major vulnerability indicators such as neuroticism. (C) 2003 Wiley-Liss, Inc.

The authors investigated the association of premorbidly-assessed disability and neuroticism with the onset of late-life depression in 86 depressed and 72 randomly selected control persons, originating front a 1993 Dutch community, study, of elderly, people, Compared with elderly people with average levels of disability, and neuroticism, people with low, levels were significantly less likely, to develop a depressive disorder High scorers, on the other hand, did not differ significantly,front the average group. Furthermore, the data tend to suggest that the increased risk for depression associated with disability was larger for patients with higher levels of neuroticism.

Background: A change in number and/or activity of natural killer cells has repeatedly been reported in depressive illness. Much less attention has yet been given to the subgroup of natural killer cells that are positive for the T-cell marker CD3 (NK–T cells). These cells possibly have important immunoregulatory properties. Methods: We compared number and percentage of NK–T cells (defined as CD3 + and CD16 + and/or CD56 + by two-color flow cytometry) in the peripheral blood of control subjects and two groups of elderly depressive subjects using or not using antidepressive drugs. Results: The number and percentage of NK–T cells were strongly elevated in elderly depressive subjects not using antidepressive drugs, as compared with control subjects and elderly depressive subjects using antidepressive drugs. Conclusions: Depressive illness in a geriatric population is associated with a substantial increase of NK–T cells. This increase was absent in a depressive group using antidepressive drugs.

Background: Coordination of nonverbal behaviour during interactions is a prerequisite for satisfactory relationships. Lack of coordination may form a risk factor for depression. The 'vulnerability-accumulation hypothesis' assumes that vulnerability to recurrence of depression will increase with increasing experience of depressive episodes. Therefore it is expected that interviewers and patients remitted from a recurrent episode of depression would reach less coordination during a clinical interview compared to interviewers and patients remitted from a first Lifetime episode. Moreover, we assumed that prior severity of depression modifies this reciprocal coordination process. Methods: During discharge interviews, interviewers were videotaped in interaction with remitted patients with unipolar major depression recurrent depression (REC); n = 28; first episode (SEP); n = 22. Durations and frequencies of nonverbal involvement behaviour was registered during the first 15 min. Involvement of the patients consisted of gesticulating, looking at the interviewer, and general head movements; yes nodding and hm, hm, yes, yes reflected involvement of the interviewer. Coordination between patients and interviewers was analyzed per S-min epochs and defined as 'attunement': the absolute difference between patients' and interviewers' involvement. Averaged attunement, its time course and variability (presumably reflecting control of the attunement process) were assessed. Results: The time course of nonverbal attunement differed between the REC and SEP condition. A larger variability of attunement was found in patients remitted from a relatively severely depressed episode, compared to patients remitted from a seven first life time episode. No other significant differences were found. Conclusions: Partial support was found for the notion that nonverbal vulnerability accumulates in depression and that the severity of prior depression modifies this process. (C) 2000 Elsevier Science B.V. All rights reserved.

Excessive support seeking and lack of receiving social support have been associated with depression onset and unfavorable course of depression. It has been assumed that social support is effected by observable behaviors that express involvement. Twenty-five patients with major depression were studied during a social interaction with their partner and a similar interaction, with a stranger, matched on the sex and age of the partner. We anticipated that (1) partners would display less involvement behaviors to the depressed patients than would strangers and that (2) lack of involvement would predict an unfavorable course of depression, as assessed for depression remission within 6 months of admission. The social interactions, conducted at admission, were videotaped and the behaviors were assessed by ethological methods. The frequency and duration of behavioral elements were associated on the basis of statistical criteria into behavioral factors. Certain factors were supposed to express (lack of) involvement during an interaction. In the patient-partner interaction it was found that both participants displayed lower levels of involvement as compared to the patient-stranger interaction. The patients' low involvement was reflected by less Speech, less Eagerness (yes-nodding and no-shaking), less Speaking Effort (head movements, looking and gesturing during speech) and more Active Listening (intense touching of one's own body and head movements during listening). The partners' low involvement was also expressed by less Speech and more Active Listening, together with less Encouragement (yes-nodding and 'um-hum'-ing during listening). In addition, the partners displayed less Speech to patients who did not remit within 6 months, whereas patients and strangers behaviors were not related to depression remission. These findings supported our anticipations and the findings are related back to data on social support, involvement and to previous human ethological studies on depression.

Within the framework of interpersonal theories on depression, it was postulated 1) that an anxiety-related mood-congruent bias with respect to the perception of facial expressions could be demonstrated in clinically depressed patients; 2) that the perception of negative facial emotions would be associated with co-occurring anxiety levels rather than with depression, and 3) that the putative anxiety-related bias would predict the subsequent course of depression. Such relationships would support the possible causal role of negative biases for the persistence of depression.Thirty-nine depressed patients (thirty-six patients met the criteria for major depression, two had a dysthymic disorder and one patient suffered from a cyclothymic disorder) were studied. The patients judged schematic faces with respect to the emotions they express (fear, happiness, anger, sadness, disgust, surprise, rejection and invitation) at admission (TO), and after 6 (T1) and 30 (T2) weeks. Severity of depression (BDI) and anxiety (SCL-90) were assessed at these three points.We found considerable support for the first 2 hypotheses: a) The perception of negative emotions was related to anxiety but not to depression (at T0 this association was significant and at T1 and T2 tendencies were found); b) When the level of depression was controlled for, significant relationships remained (emerged) between anxiety and the perception of negative emotions at each of the three different time points; c) Anxiety and perception of negative emotions covaried within subjects when large changes in depression/anxiety were involved, i.e. after 30 weeks. This relationship disappeared when depression change was partialled out. The third hypothesis was not confirmed: The perception of negative emotions did not predict the course of depression.Although a direct relationship with depression persistence and a negative bias in the perception of interaction-relevant stimuli (i.e. facial emotions) in anxious depressed patients could not be found, the existence of such anxiety-related negative bias forms indirect evidence for the notion that this negative bias may mediate rejective attitudes of others towards depressives and consequently may contribute to an unfavourable course of depression. (C) 1997 Elsevier Science B.V.

It was hypothesized that pre-treatment activation plays a role in the response to light therapy in Seasonal Affective Disorder (SAD). In 55 SAD patients (DSMIII-R) energetic and tense activation was assessed before light therapy via self-rating (AD-ACL) and voice sound characteristics (mean pitch and variation in pitch). These variables were studied in relation to the ''acute'' response to 4 days of light therapy (30 min, 10 000 lux) and to a ''late'' response (11 (10) days after light therapy had stopped). Acute response was defined as the percent change in 3 times daily self-rated depressed mood (AMS) with respect to the average of 4 baseline days. ''Late'' response was defined as the percent change in HRSD or AMS scores between baseline and 11 (10) days after light therapy. It was found that patients having high pitched voices with small variation in this pitch benefitted more from light therapy than the patients with low pitch and large variation in pitch levels. This effect was only significant after the first day of light exposure. No other significant relations were found between baseline activation and acute or late responses to light therapy. Hence, light therapy seems to give extra comfort in ''tense'' patients, who become rapid responders to light therapy. (C) 1997 Elsevier Science B.V.

Nonverbal support seeking behavior of 11 mildly depressed patients was studied in relation to the nonverbal support giving behavior of a female interviewer. The patients were interviewed for 20 minutes during which the interviewer gave high and low nonverbal support for 10 minutes in a cross-over design. Different behavioral elements of the patients and of the interviewer were pooled into behavioral factors. Support seeking behavior (Speaking Effort) was significantly higher when high nonverbal support giving behavior (Encouragement) was displayed (p = .05). Also, a positive relationship between Encouragement and patients' Speech was observed (p = .04). The causal relationship between depressed patients' nonverbal support seeking behavior and an interviewer's nonverbal support giving behavior underscores an interpersonal approach of depression.

BackgroundSixty-eight patients with seasonal affective disorder participated in a 10 000-lux light treatment study in which two questions were addressed: do response rates differ when the light is applied at different times of the day and does short-term rank ordering of morning and evening light influence response rates?MethodThree groups of patients received a 4-day light treatment: (I) in the morning (8.00–8.30 a.m., n = 14), (II) in the afternoon (1.00–1.30 p.m., n = 15) or (III) in the evening (8.00–8.30 p.m., n = 12). Two additional groups of patients received two days of morning light treatment followed by two days of evening light (IV, n = 13) or vice versa (V, n = 14).ResultsResponse rates for groups I, II and III were 69, 57 and 80% respectively, with no significant differences between them. Response rates for groups IV and V were 67 and 50% respectively; this difference was not significant and these percentages did not differ significantly from those of groups I and III.ConclusionsThe results indicate that the timing of light treatment is not critical and that short-term rank ordering of morning and evening light does not influence therapeutic outcome.

The judgement of healthy subject rating the emotional expressions of a set of schematic drawn faces is validated (study 1) to examine the relationship between mood (depressed/elated) and judgement of emotional expressions of these faces (study 2).Study 1: 30 healthy subjects judged 12 faces with respect to the emotions they express (fear, happiness, anger, sadness, disgust, surprise, rejection and invitation). It was found that a particular face could reflect various emotions. All eigth emotions were reflected in the set of faces and the emotions were consensually judged. Moreover, gender differences in judgement could be established.Study 2: In a cross-over design, 24 healthy subjects judged the faces after listening to depressing or elating music. The faces were subdivided in six 'ambiguous' faces (i.e., expressing similar amounts of positive and negative emotions) and six 'clear' faces (i.e., faces showing a preponderance of positive or negative emotions). In addition, these two types of faces were distinguished with respect to the intensity of emotions they express.11 subjects who showed substantial differences in experienced depression after listening to the music were selected for further analysis. It was found that, when feeling more depressed, the subjects perceived more rejection/sadness in ambiguous faces (displaying less intensive emotions) and less invitation/happiness in dear faces. In addition, subjects saw more fear in clear faces that express less intensive emotions. Hence, results show a depression-related negative bias in the perception of facial displays.

Recently it was hypothesized that the antidepressant response to total sleep deprivation (SD) results from a disinhibition process induced by the increase of tiredness in the course of SD. In the present study, the role of tiredness in the antidepressant response to SD is further investigated, Seventy-two depressed patients scored subjective tiredness and depressed mood three times daily (in the morning afternoon, and evening) on the days preceding and following SD. It was found that averaged tiredness on the day prior to SD was related to the SD response, when the severity of depression prior to SD had been held statistically constant. Also, when both severity of depression and diurnal variation of mood prior to SD were partialed out, tiredness showed a positive correlation with the SD response: patients who reported a relatively low degree of tiredness on the day preceding SD improved by SD. This result suggests that tiredness has an influence on SD effects, and that this influence is independent from that of the severity of depression, The findings are in accordance with current ideas on the role of tiredness as a mediating factor in the induction of the therapeutic effects of SD.

The course of 39 depressed in-patients' daily mood was recorded by means of frequent self-ratings during their entire stay (in total 3718 days). The frequency of diurnal variations largely varies between subjects without clear dichotomy in 'diurnal' and 'non-diurnal' subjects and the occurrence of diurnal variations is rather irregular. Mood variability measures rather than average daily mood improvement correlate with the response to sleep deprivation. These observations do not support theories of chronobiological rhythm disturbances in depression. It is argued that depressed subjects largely vary in susceptibility to stimuli. Signals generated by the biological clock or by processes related to the sleep-wake cycle are considered examples of such stimuli.

The role of cognitive sensitivity to light in the development of seasonal affective disorder (SAD, winter type) was studied by comparing 29 SAD patients during remission with 29 non-depressed controls matched by sex and age, and by relating measures for cognitive sensitivity of remitted SAD patients to the onset of a depressive episode during the following autumn/winter. To ensure that only cognitive processes were involved, the subjects were exposed to symbolic light. Thr;ee schematic drawings of ambiguous faces expressing different emotions were embedded in light or dark backgrounds for tl;is purpose. The subjects rated the various facial expressions with respect to the degree of elation-sadness, rejection-invitation, and activation-sleepiness. SAD patients saw larger differences in activation between faces embedded in light and dark backgrounds than controls, perceiving less activation in faces with dark backgrounds. Furthermore, the larger the difference that SAD patients saw in invitation between faces with light and dark backgrounds, the earlier they became depressed in the subsequent autumn/winter. Only the SAD patients who became depressed early (before December 21) differed from controls in the perception of invitation. Results are interpreted within the framework of psychological theories on the development of depression and suggest that altered cognitive sensitivity of SAD patients to light plays a role in the development of depressive episodes.

The administration of light at the development of the first signs of a winter depression appears to prevent it from developing into a full-blown depression. Not a single patient from a group of 16 treated this way became severely depressed during the remaining part of the winter season, whereas 5 out of 11 from the non-treated control group did.

Patients with seasonal affective disorder were randomly assigned to treatment with light in the morning (9.00-12.00 a.m.; n = 16; ML) or evening (6.00-9.00 p.m.; n = 11; EL). An intensive 24-day assessment procedure revealed the same response rates: 57% for ML, 50% for EL. During the rest of the winter season a relatively low relapse rate of 54% was found. No differences between ML and EL were found in the time course of depressed mood or fatigue. A significant negative correlation was found between diurnal variation during baseline and therapeutic response: the larger the diurnal variation the less the response, indicating a potential negative predictive value for this symptom. There were no significant correlations between baseline fatigue or hypersomnia and response.

Observed behaviour of a psychiatrist interacting with severely depressed patients during an interview was related to the course of depression during hospitalization. The behavioural structure of such interaction could be described by 6 factors for the patients and 7 factors for the psychiatrist. The study focuses on the psychiatrist's behaviour.The severity of depression and the level of the behaviour factors were assessed just after admission (drug-free) and 10 weeks later. Patients were divided a posteriori into non-improved patients (N = 13) and improved patients (N = 18). The psychiatrist displayed low levels of 'active-listening' (intensive body touching and other hand movements during listening) and showed a tendency to more 'encouragement' by use of remarks such as hm, yes, and head-nodding) in his interaction with patients who did not improve. These factors did not change over time, suggesting that they may play a role in the maintenance of depression. They are supposed to express involvement, and probably indicate psychiatrist's giving support to the support-seeking patients. At the same time the psychiatrist exhibited an aversive response to the non-improved patients, by showing higher frequencies of looking away during his encouragement. The results provide support for interactional theories on depression and illustrate the possible value of an ethological approach in the study of interactional processes.

This study examined whether the interaction of severely depressed patients and a psychiatrist was related to the course of depression during hospitalization. Interactional processes were defined on the basis of directly observed behaviour displayed during an interview and by the use of ethological methods. The behavioural structure of the interaction could be described by five factors. The severity of depression and the level of the behaviour factors were assessed just after admission (at baseline) and 10 weeks later. Patients were divided a posteriori into non-improved patients (N = 13) and improved patients (N = 18). Patients who did not improve displayed more 'speaking-effort' (looking, gesticulating, head movements during speech) and less 'active-listening' (head movements and intensive body touching during listening to the psychiatrist) than those who did improve. These factors increased over time in the improved patients but not in the non-improved patients suggesting that they may play a role in the maintenance of depression. The study illustrates the possible value of an ethological approach in the study of interactional processes.

The interaction of 61 severely depressed hospitalized patients and a psychiatrist was studied during a clinical interview. Interactional processes were defined by the use of ethological methods. Various observed behaviors were clustered on the basis of statistical criteria, yielding behavior factors of the patients and of the psychiatrist. The present paper deals with the organization of the psychiatrist's behavior and the interrelatedness of the patients' and the psychiatrist's behavior.Analysis of the behavior of the psychiatrist revealed seven factors: restlessness-1 (head, leg movements, object touching), restlessness-2 (body touching, head movements), speech (speech, gesticulating, yes and no movements), active listening (intensive body touching and hand movements), turn-taking (leg movements and gesticulating during listening), encouragement (back-channel behavior and yes-nodding), and change-looking (looking and head movements). Within the constraints of studying interactions which are bidirectional, it was found that restlessness-2, speech, encouragement and active listening of the psychiatrist could be 'predicted' from observed behavior of the patients (multiple regression model). The psychiatrist's behavior was related both to the severity of depression and to observed behavior not directly associated with severity. The psychiatrist's behavior was more strongly related to that of the more severely depressed patients than to that of the less severely depressed patients. These results contribute to an understanding of the behaviors displayed and elicited by depressed patients during a first encounter with a stranger.

The administration of light at the development of the first signs of a winter depression appears to prevent it from developing into a full-blown depression. No patient from a group of 10 treated in this way developed any signs of depression during the rest of the winter season, while five of seven patients from a control group became depressed and needed treatment during the winter season.

The possibility that the clinical response to total sleep deprivation (TSD) is mediated by dimensions of arousal was investigated in a group of 16 depressed patients. Self-reports of activation, stress, and mood were assessed 3 days before, during, and 2 days after TSD. Urinary cortisol excretion and responses to the dexamethasone suppression test (DST) were also measured. TSD increased cortisol excretion in depressed patients and advanced the time of the maximal excretion of cortisol. No such changes have been reported for normal subjects. Neither the increased excretion nor the time shift was related to the mood response to TSD. The DST results were also unrelated to this response. Indications that the mood response to TSD may be mediated by dimensions of arousal are the significant relationships between this response and the responses of subjective stress and activation to TSD. The TSD-induced cortisol increase was not related to the subjective arousal response to TSD. The increased cortisol excretion itself could be predicted by the averaged baseline levels of subjective stress: the lower the stress levels before TSD, the larger the cortisol response to TSD.

The mechanism underlying improvement after total sleep deprivation (TSD) was studied in 14 major depressed patients. The suggestions that (1) circadian processes and/or (2) dimensions of arousal may play a role in the response to TSD were investigated. Diurnal variation of depressed mood and of mood- and arousal-related vocal parameters was studied in relation to the effect of TSD on depressed mood and vocal parameters. During 3 baseline days, during TSD and 2 days after TSD vocal parameters and depressed mood were assessed 6 and 3 times daily respectively. The mean fundamental frequency (frequency of vocal fold vibration, F0) (presumably reflecting aspects of arousal) as well as the range of the F0 (proposed to reflect sadness) showed a clear circadian pattern with a peak at about 4.00 p.m. TSD affected the circadian organization of the mean F0 and advanced the peak of the curve. After one night of subsequent sleep this effect disappeared. In addition, improvement after TSD coincided with an increase of the mean F0. The diurnal variation of mood before TSD predicted the mood response to TSD, whereas diurnal variation of vocal parameters did not. Moreover, circadian changes in vocal parameters were not related to changes in depressed mood. These findings suggest that the diurnal variations in mood and vocal parameters are regulated by different mechanisms. Data support the presumption that circadian as well as arousal processes are involved in the mood response to TSD. Circadian changes in vocal parameters due to TSD are not likely to reflect changes in the biological clock.

Twenty-three patients with a major depressive disorder were deprived of a night's sleep twice weekly, one week staying up in the dimly lit living room of the ward (less than 60 lux), and one week in a brightly lit room (greater than 2000 lux). Immediate, but transient beneficial effects of sleep deprivation were observed primarily in eight patients (the 'responders'). The immediate effects did not differ greatly for the two conditions, indicating that exposure to light at night is an implausible explanation for the antidepressant effects of total sleep deprivation. There was some evidence that the bright light condition led to a more prolonged improvement of the responders.

Since the description of SAD the prevalence of this disorder has been of particular interest. The more so, because early studies, indicated the correctness of the on theoretical grounds - expected interaction between latitude and prevalence rate of SAD. More eleborate prevalence studies, mainly in the USA indeed showed a positive correlation between prevalence rate and latitude. In Europe, only few studies have appeared. Although the results of most of these studies are preliminary and research-methods and criteria vary across studies, tentative conclusions are that the prevalence rates in Europe are considerably lower than in the USA, but that there is a similar trend in the direction of an increase of prevalence at higher latitudes.8"10 In the present study, the prevalence of SAD in the Netherlands is investigated.

Unequivocal results demonstrating a causal relationship between a disturbance in circadian rhythms and depression have not yet been reported (reviews). However, acute mood changes, such as the antidepressive effect of sleep deprivation, diurnal variations of mood and their interrelationship, are commonly put forward as evidence of the importance of circadian dysregulations in affective disorders. The purpose of the present study is to obtain more insight in the mechanisms underlying these mood changes. The results will be discussed in the context of a recently postulated non-chronobiological explanation.Earlier studies have suggested that the relationship between diurnal variation of mood and the response to total sleep deprivation (TSD) is clear and unambiguous: improvement of mood during the day prior to TSD (a positive diurnal variation) is followed by a positive response (mood improvement) to TSD, while no improvement or deterioration of mood during the day prior to TSD (a negative diurnal variation) may result in no, or even a negative, TSD response (for references see Van den Hoofdakker). However, these conclusions were based on the results from cross-sectional studies, comparing single TSD effects across individuals. Comparison of sleep deprivation effects within individuals, however, revealed that the course of mood during the day prior to TSD is irrelevant for the TSD response. Accordingly, a favourable response to TSD appeared to be related to the patient's propensity to show diurnal mood variations per se, irrespective of their direction.

Although depression and immune changes in elderly subjects constitute a considerable health risk, mechanisms underlying the association between depression and immune function are unclear. The question of whether personality and social support can explain the variation in immune function during depression was addressed in 21 elderly depressive and 23 control subjects. The following variables were studied: neuroticism, extraversion, received social support, depression-related immune parameters [i.e. numbers of lymphocytes, lymphocyte subsets CD3+, CD8+, natural killer-like T cells (NKT), CD4/CD8 ratio, and interleukin-6 (Il-6)]. We found that neuroticism reduced the association between depression and Il-6 (from 62 to 22.4%) and between depression and CD3+ (from 27.6 to 21.6%), and was also directly related to Il-6 (i.e. adjusted for age and depression). Social support reduced the association between depression and NKT cells from 25 to 18%, while it was also directly related to NKT cells. Extraversion, adjusted for age and depression, was negatively related to CD4/CD8 ratio. Subjects with high extraversion and high social support had more NKT cells. We concluded that changes in immune function during depression can partly be explained by neuroticism and received social support, whereas immune function is also directly related to these psychosocial variables. Neuroticism may exert its contribution to the risk for depression partly via Il-6 production. (C) 2004 Elsevier Ireland Ltd. All rights reserved.

Fifty-one remitted depressed inpatients and their interviewers were observed during a conversation. We investigated whether non-verbal behavioral elements indicative of involvement displayed by the remitted patients and/or their interviewers were predictive of depressive symptoms 6 months later. Involvement behavior of the patients appeared to be related to future complaints; the lower the level of involvement displayed, the more unfavorable the outcome. We interpret these results with reference to concepts of social support. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

Several studies have found that cortisol hypersecretion may occur in severely depressed patients who are characterized by melancholic features. On the other hand, illness chronicity seems to be related to low, rather than high, cortisol levels. This study aims to trace factors associated with 24-h urinary free cortisol levels in a sample of 23 elderly persons with major or minor depression and 21 non-depressed control subjects. Depressive episodes were subdivided according to severity and chronicity (i.e. length and recurrence). None of the depressed persons showed unusually high 24-h cortisol levels, and cortisol excretion was not elevated as compared with that in the control group, regardless of subtype of depression. The results suggest, however, that hyposecretion of cortisol may be a feature of chronic depressive episodes, especially in males. (C) 2001 Elsevier Science Ireland Ltd. All rights reserved.

Background: Various studies support the notion that early onset depression and late onset depression have different etiological pathways. Late onset depression has been found to be a heterogeneous group. This study attempts to divide the late onset group in two subgroups with different aetiology and find evidence for the vascular depression hypothesis. Methods: Subjects were 132 depressed elderly persons from the general population, general practitioners and mental health care outpatient clinics. Sixty-four had early-onset depression (

Background: Associations between different types of depression with clinical characteristics and putative vulnerability factors from several domains (health, disability, personality, familial psychopathology) were studied in a sample of elderly subjects, in order to find arguments that support or discard the notion of discontinuity in correlates of depression. Methods: Subjects were 183 depressed elderly persons from the general population, general practitioners and mental health care outpatient clinics, and a random elderly control group (n =74). Depression was subdivided into symptomatic (n = 45), DSM-IV minor (n = 73), and DSM-IV major (n = 65) depression. The groups were compared with respect to a variety of variables from different domains. Results: Most variables showed a marked difference between the control group and the depressive groups, and smaller or no differences between depressive subtypes. Limitations: The data were collected cross-sectionally. Conclusions: With a few notable exceptions, all subtypes of depression were significantly different from the control group, while differences between depressive subtypes were generally smaller. Depressive subtypes showed no discontinuum with respect to the associated variables. Similar associations in different subtypes of depression may indicate common vulnerability factors. (C) 2000 Elsevier Science B.V. All rights reserved.

We proposed that a negative bias in the perception of facial expressions would affect the way in which deficient coping and interpersonal functioning influenced the risk of persistent depression. Furthermore, we hypothesised that cognitions, coping strategies, and interpersonal functioning would be more likely to contribute to the prediction of outcome of depression among women than among men. At admission, 60 in-patients with major depression judged 12 schematic faces with respect to the emotions that they expressed (fear, happiness, anger, sadness, disgust, surprise, rejection and invitation). In addition, difficulty in assertiveness and social distress, and coping strategies for dealing with stressful events were measured with self-report questionnaires. At admission and 6 weeks later, the severity of depression was evaluated with the Beck Depression Inventory. Women who were inclined to perceive high levels of negative emotions from facial expressions and who reported high levels of social distress at admission were less likely to be improved after 6 weeks. Among women, these high levels of perception of negative emotions and high levels of social distress tended to predict the persistence of depression independently. A propensity to perceive negative facial expressions may underlie the unfavourable course of depression, especially among women.

Background: Research has shown that cognitive and interpersonal processes play significant roles in depression development and maintenance. Depressed patients judgments of emotions displayed in facial expressions, as well as those of their partners, allow for better understanding of these processes. Methods: In this study, twenty major depression outpatients, their partners and control persons (matched on the sex and age of the partner) judged facial expressions as to the emotions they felt were portrayed, at the patients outpatient admission. It was expected that the patients would judge the facial expression more negatively and less positively than their partners and that the partners would judge more negatively and less positively than the controls. Results: It was found that while both the patients and partners judged less positive emotions than the controls, the patients and partners did not judge the expressions differently. A trend in the same direction was found between the three groups as to judgment of negative emotions. Conclusion: These findings are related back to interpersonal and cognitive theories of depression. Limitation: A limitation of this study was the somewhat small patient population available for study. Clinical Relevance: This study helps to shed light on the similarity between interpersonal and cognitive processes of depressed patients and their partners. (C) 1998 Elsevier Science B.V.

Deficits ill the decoding of facial emotional expressions may play a role in the persistence of depression. In a prospective longitudinal study, 33 depressed outpatients (30 major depression, 2 dysthymia, and 1 cyclothymic disorder) judged schematic faces with respect to the emotions they expressed (fear, happiness, anger, sadness, disgust, surprise, rejection, and invitation) at admission (T-0) and again 6 and 30 weeks later. Severity of depression (BDI) was assessed at these three times. Those patients who perceived less sadness, rejection, or anger in faces at T-0 were less likely to show a favorable course of depression after 6 weeks (sadness, anger) or after 30 weeks (sadness, rejection, anger). These relationships could not be ascribed to initial levels of depression, age, or gender. The perception of sadness and rejection did not change over time, and therefore may have trait-like qualities. Depression appears to be more persistent in the subgroup that is hyposensitive to (negative) facial signals.

Seasonal affective disorder (SAD), winter type, is characterized by the occurrence of depression in autumn/winter, followed by a complete recovery in spring/summer. In SAD patients, some atyp- ical symptoms are highly characteristic, such as hypersomnia, carbohydrate craving, weight gain, fatigue, and loss of social inter- actions (Rosenthal et ai 1984). The repeated occurrence of symp- toms during successive winters is one of the diagnostic criteria, l~lot every SAD patient becomes depressed every year, however. In prospective studies it was found that 70,4% of the SAD diagnosed subjects who were followed from a symptom-free moment at the end of September, became depressed during the following winter (Meesters et al 1991; 1993a), In a previous study it was found that severe winter depression can be prevented by light treatment administered at the first signs of an emerging winter depression, that is, the moment subjects reported complaints of slight depression (Meesters et al 1991; 1993a). In the present study, the question was raised whether light exposure given at the beginning of the winter season, when sub- jeers are still free of symptoms, could be successful in preventing the development of a winter depressmn during the rest of the season. Such a ueatment, which might prevent depression alto- gether, would be highly advantageous

The relationship between diurnal variation of mood and the clinical response to total sleep deprivation (TSD) was investigated in 43 depressed patients. The question asked was whether the propensity to produce diurnal variations of mood or the actual mood course on the day before TSD determines the clinical response to TSD. Patients rated their mood three times daily during an experimental period of 56 days. The frequency as well as the amplitude of daily mood changes were assessed during this period. For each patient six TSDs were scheduled: two after days with a positive mood course, two after a negative mood course, and two after days without a diurnal change of mood. This strategy allowed comparisons of TSD responses within patients. Moreover, longitudinally and retrospectively assessed diurnal variation were compared with each other. It was found that patients vary largely in the occurrence of diurnal variations of mood. The propensity to produce diurnal variations either in terms of frequency or amplitude was positively correlated with the response to TSD. Within patients no differences were found in responses to TSDs applied after days with diurnal variations (positive or negative) or without diurnal variations. A second aim was to get more insight into the mechanism relating diurnal variations of mood and the TSD response. Therefore, the interrelatedness of various measures of diurnal variations, such as amplitudes and frequencies of positive or negative diurnal mood changes, was studied, as well as the relationships of these variables with TSD responses. On the basis of the strong interrelatedness it is suggested that they all reflect the same underlying mechanism, to be symbolized by an oscillator, producing positive daily fluctuations of mood.

Drug-induced improvement of depression may be mediated by changes in sleep physiology. The aim of this study was to relate changes in sleep polygraphic variables to clinical state during treatment with citalopram, a highly specific serotonin uptake inhibitor. Sixteen patients took part. The study was single-blind and uncontrolled. A 1-week wash-out period was followed by 1 week of placebo administration, a medication period of 5 weeks, and a 1-week placebo period. For the entire group a significant decrease of rapid eye movement sleep (REMS) and a significant lengthening of REMS latency were observed initially as well as at the end of treatment. No changes in sleep continuity were found, but non-REMS stage 2 (percentage) was significantly increased. On the basis of clinical change, as expressed by the scores of the Hamilton Rating Scale for Depression, at the end of the citalopram treatment the patient group was split in two halves: eight less and eight more improved patients. The groups did not differ with respect to any sleep polygraphic variable.

In view of the opposing theories regarding the arousing or de-arousing action of total sleep deprivation (TSD) in producing antidepressant effects, 23 patients with a major depressive disorder were deprived of a night’s sleep twice weekly for two weeks, and self-rated their condition 38 times using von Zerssen’s scale for depression and, concurrently, Thayer’s Activation Deactivation Adjective Check List (AD ACL). Transient relief of depression after TSD, indicated by eight patients, was mimicked by their AD ACL scores, which revealed the same underlying factors as were found in Thayer’s studies. TSD appears to be simultaneously arousing (giving more energy) and de-arousing (leading to less tension), while this response takes place against a background of increased tiredness/sleepiness. It is argued that TSD sets off a psychological disinhibition process on the basis of cerebral fatigue; in particular the prefrontal (orbital?) areas of the cerebral cortex may be implicated, possibly in relation to a dampening down of subcortical arousal systems.

It is hypothesized that in depressed patients diurnal variation in mood (DV) is a daily recurring phenomenon, which fails to achieve expression on all days (showing a random distribution of DVs). From this perspective a meta-analysis was performed on the raw data of earlier presented studies. The effect of total sleep deprivation (TSD) on mood was examined in 14 so-called prototypical patients, showing on three successive days either positive DVs (feeling better in the evening) or inverse DVs. It was hypothesized that under baseline conditions mood follows a monotonous course with switching points at 7 AM and 11 PM and that during the TSD night the 7-AM switch took place earlier. The position of this switch was calculated, assuming that (1) before the switch the curve ran parallel to the nightly baseline curves, and (2) after the switch the curve showed a monotonous change parallel to the daily baseline curves. The best fit between predicted and measured depression after TSD was found for a switch at 3 AM, varying the switching point during the TSD night with hourly intervals. The characteristics based on prototypical patients contributed significantly to the prediction of the morning and the afternoon depression levels after TSD in a group of 53 patients (prototypical and nonprototypical).

In 61 drug-free depressed patients, relationships were studied between observed behaviors and measures of common clinical concepts of activation. The behaviors were observed during a clinical interview and analyzed with ethological methods. Activation was assessed by means of self-ratings (Thayer, AD-ACL) and global judgment (Hamilton, retardation, agitation). Various aspects of patients' speaking and listening behaviors were recorded and analyzed, such as looking, head movements, yes-nodding and no-shaking, leg movements, gesturing, and body and object touching. A factor analysis was applied, enabling grouping of behaviors without using a priori concepts. Five factors reflected different aspects of a conversation: restlessness (leg and hand movements), speech, active listening (head movements and intensive body touching, during listening), speaking effort (looking, gesticulating, head movements, during speaking), and eagerness (yes-nodding and no-shaking). Significant positive relationships were found between the speech factor, the speaking effort factor and the restlessness factor on the one hand, and activation on the other. The eagerness factor was related negatively with activation. The results give insight into the organization of behavior during an interview, and show how this is related to clinical concepts of activation.