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Psychological and physiological effects of caring for patients with treatment-resistant depression

Published online by Cambridge University Press:  17 January 2012

L. J. Rane ,
A. Fekadu ,
A. S. Papadopoulos ,
S. C. Wooderson ,
L. Poon ,
K. Markopoulou  and
A. J. Cleare
L. J. Rane*
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
A. Fekadu
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
A. S. Papadopoulos
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
S. C. Wooderson
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
L. Poon
Affiliation:
The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
K. Markopoulou
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
A. J. Cleare
Affiliation:
Section of Neurobiology of Mood Disorders, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK The National Affective Disorder Unit, South London and Maudsley NHS Foundation Trust, UK
*
*Address for correspondence: L. J. Rane, B.A., M.R.C.Psych., Section of Neurobiology of Mood Disorders (PO 74), Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, 103 Denmark Hill, London SE5 8AZ, UK. (Email: [email protected])
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Abstract

Background

Carers of patients with psychiatric disorders show high levels of anxiety and depression, possibly mediated through disruption of the hypothalamo–pituitary–adrenal (HPA) axis. Among carers of patients with treatment-resistant depression (TRD), we set out to determine the psychological and physiological (HPA axis) consequences of caring, and the association of these consequences with long-term outcome in patients.

Method

Thirty-five informal carers of patients with severe TRD requiring in-patient treatment were recruited and compared with 23 controls. HPA-axis activity was assessed by measuring post-awaking salivary cortisol. The Involvement Evaluation Questionnaire (IEQ) and the General Health Questionnaire-12 (GHQ-12) were administered to measure carer burden and psychiatric caseness respectively. Independent t tests were used to compare differences between carers and controls and a linear regression model was used to determine the association of post-awakening cortisol with carer status while controlling for confounding variables. Data on long-term patient outcome (12 to 83 months), measured using the Hamilton Depression Rating Scale (HAMD), were also obtained and linear regression was used to determine the association between cortisol output in carers and remission status in patients.

Results

Carers experienced high carer burden and high psychiatric caseness. Carers showed reduced cortisol output after awakening, calculated as the area under the curve with respect to ground (AUCg), which remained significant after controlling for potential confounders. In a linear regression model, non-remission in patients was associated with reduced cortisol output in carers.

Conclusions

Caring for patients with TRD is associated with adverse psychological and physiological changes suggesting hypocortisolism post-awakening. These changes are associated with poor patient outcome.

Keywords

CortisolcarerdepressionHPA axisoutcome
Type
Original Articles
Information
Psychological Medicine , Volume 42 , Issue 9 , September 2012 , pp. 1825 - 1833
Copyright
Copyright © Cambridge University Press 2012

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References

Bauer, ME, Vedhara, K, Perks, P, Wilcock, GK, Lightman, SL, Shanks, N (2000). Chronic stress in caregivers of dementia patients is associated with reduced lymphocyte sensitivity to glucocorticoids. Journal of Neuroimmunology 103, 84–92.CrossRefGoogle ScholarPubMed
Chakrabarti, S, Kulhara, P, Verma, SK (1992). Extent and determinants of burden among families of patients with affective disorders. Acta Psychiatrica Scandinavica 86, 247–252.CrossRefGoogle ScholarPubMed
Chida, Y, Steptoe, A (2009). Cortisol awakening response and psychosocial factors: a systematic review and meta-analysis. Biological Psychiatry 80, 265–278.Google Scholar
Clow, A, Thorn, L, Evans, P, Hucklebridge, F (2004). The awakening cortisol response: methodological issues and significance. Stress 7, 29–37.CrossRefGoogle ScholarPubMed
Dalgard, OS, Dowrick, C, Lehtinen, V, Vazquez-Barquero, JL, Casey, P, Wilkinson, G, Ayuso-Mateos, JL, Page, H, Dunn, G (2006). Negative life events, social support and gender difference in depression: a multinational community survey with data from the ODIN study. Social Psychiatry and Psychiatric Epidemiology 41, 444–451.CrossRefGoogle ScholarPubMed
Da Roza Davis, JM, Cowen, PJ (2001). Biochemical stress of caring. Psychological Medicine 31, 1475–1478.CrossRefGoogle ScholarPubMed
de Vugt, ME, Nicolson, NA, Aalten, P, Lousberg, R, Jolle, J, Verhey, FR (2005). Behavioral problems in dementia patients and salivary cortisol patterns in caregivers. Journal of Neuropsychiatry and Clinical Neurosciences 17, 201–207.CrossRefGoogle ScholarPubMed
Dyck, DG, Short, R, Vitaliano, PP (1999). Predictors of burden and infectious illness in schizophrenia caregivers. Psychosomatic Medicine 61, 411–419.CrossRefGoogle ScholarPubMed
Emanuel, EJ, Fairclough, DL, Slutsman, J, Alpert, H, Baldwin, D, Emanuel, LL (1999). Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients. New England Journal of Medicine 341, 956–963.CrossRefGoogle ScholarPubMed
Fries, E, Dettenborn, L, Kirschbaum, C (2009 a). The cortisol awakening response (CAR): facts and future directions. International Journal of Psychophysiology 72, 67–73.CrossRefGoogle ScholarPubMed
Fries, E, Dettenborn, L, Kirschbaum, C (2009 b). The cortisol awakening response (CAR): facts and future directions. International Journal of Psychophysiology 72, 67–73.CrossRefGoogle ScholarPubMed
Fries, E, Hesse, J, Hellhammer, J, Hellhammer, DH (2005). A new view on hypocortisolism. Psychoneuroendocrinology 30, 1010–1016.CrossRefGoogle ScholarPubMed
Gallagher-Thompson, D, Shurgot, GR, Rider, K, Gray, HL, McKibbin, CL, Kraemer, HC, Sephton, SE, Thompson, LW (2006). Ethnicity, stress, and cortisol function in Hispanic and non-Hispanic white women: a preliminary study of family dementia caregivers and noncaregivers. American Journal of Geriatric Psychiatry 14, 334–342.CrossRefGoogle ScholarPubMed
Gold, PW, Chrousos, GP (2002). Organization of the stress system and its dysregulation in melancholic and atypical depression: high vs low CRH/NE states. Molecular Psychiatry 7, 254–275.CrossRefGoogle ScholarPubMed
Greden, JF (2001). The burden of disease for treatment-resistant depression. Journal of Clinical Psychiatry 62 (Suppl. 16), 26–31.Google ScholarPubMed
Hellhammer, J, Fries, E, Schweisthal, OW, Schlotz, W, Stone, AA, Hagemann, D (2007). Several daily measurements are necessary to reliably assess the cortisol rise after awakening: state and trait components. Psychoneuroendocrinology 32, 80–86.CrossRefGoogle ScholarPubMed
Jerjes, WK, Taylor, NF, Wood, PJ, Cleare, AJ (2007). Enhanced feedback sensitivity to prednisolone in chronic fatigue syndrome. Psychoneuroendocrinology 32, 192–198.CrossRefGoogle ScholarPubMed
Juruena, MF, Pariante, CM, Papadopoulos, AS, Poon, L, Lightman, S, Cleare, AJ (2009). Prednisolone suppression test in depression: prospective study of the role of HPA axis dysfunction in treatment resistance. British Journal of Psychiatry 194, 342–349.CrossRefGoogle ScholarPubMed
Kearns, NP, Cruickshank, CA, McGuigan, KJ, Riley, SA, Shaw, SP, Snaith, RP (1982). A comparison of depression rating scales. British Journal of Psychiatry 141, 45–49.Google Scholar
Kupper, N, de Geus, EJ, van den Berg, M, Kirschbaum, C, Boomsma, DI, Willemsen, G (2005). Familial influences on basal salivary cortisol in an adult population. Psychoneuroendocrinology 30, 857–868.CrossRefGoogle Scholar
Levitan, RD, Vaccarino, FJ, Brown, GM, Kennedy, SH (2002). Low-dose dexamethasone challenge in women with atypical major depression: pilot study. Journal of Psychiatry and Neuroscience 27, 47–51.Google ScholarPubMed
Magliano, L, Fiorillo, A, Malangone, C, De Rosa, C, Maj, M (2006). Patient functioning and family burden in a controlled, real-world trial of family psychoeducation for schizophrenia. Psychiatric Services 57, 1784–1789.CrossRefGoogle Scholar
Mason, JW, Wang, S, Yehuda, R, Riney, S, Charney, DS, Southwick, SM (2001). Psychogenic lowering of urinary cortisol levels linked to increased emotional numbing and a shame-depressive syndrome in combat-related posttraumatic stress disorder. Psychosomatic Medicine 63, 387–401.CrossRefGoogle Scholar
Mausbach, BT, Aschbacher, K, Patterson, TL, Ancoli-Israel, S, von Kanel, R, Mills, PJ, Dimsdale, JE, Grant, I (2006). Avoidant coping partially mediates the relationship between patient problem behaviors and depressive symptoms in spousal Alzheimer caregivers. American Journal of Geriatric Psychiatry 14, 299–306.CrossRefGoogle ScholarPubMed
Meinlschmidt, G, Heim, C (2005). Decreased cortisol awakening response after early loss experience. Psychoneuroendocrinology 30, 568–576.CrossRefGoogle ScholarPubMed
Miller, GE, Chen, E, Zhou, ES (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin 133, 25–45.CrossRefGoogle ScholarPubMed
Nemeroff, CB, Vale, WW (2005). The neurobiology of depression: inroads to treatment and new drug discovery. Journal of Clinical Psychiatry 66 (Suppl. 7), 5–13.Google ScholarPubMed
Pariante, CM, Papadopoulos, AS, Poon, L, Checkley, SA, English, J, Kerwin, RW, Lightman, S (2002). A novel prednisolone suppression test for the hypothalamic-pituitary-adrenal axis. Biological Psychiatry 51, 922–930.CrossRefGoogle ScholarPubMed
Peeters, F, Nicholson, NA, Berkhof, J (2003). Cortisol responses to daily events in major depressive disorder. Psychosomatic Medicine 65, 836–841.CrossRefGoogle ScholarPubMed
Perlick, D, Stastny, P, Mattis, S, Teresi, J (1992). Contribution of family, cognitive and clinical dimensions to long-term outcome in schizophrenia. Schizophrenia Research 6, 257–265.CrossRefGoogle ScholarPubMed
Perlick, DA, Rosenheck, RA, Clarkin, JF, Maciejewski, PK, Sirey, J, Struening, E, Link, BG (2004). Impact of family burden and affective response on clinical outcome among patients with bipolar disorder. Psychiatric Services 55, 1029–1035.CrossRefGoogle ScholarPubMed
Pruessner, JC, Hellhammer, DH, Kirschbaum, C (1999). Burnout, perceived stress, and cortisol responses to awakening. Psychosomatic Medicine 61, 197–204.Google Scholar
Pruessner, JC, Kirschbaum, C, Meinlschmid, G, Hellhammer, DH (2003). Two formulas for computation of the area under the curve represent measures of total hormone concentration versus time-dependent change. Psychoneuroendocrinology 28, 916–931.CrossRefGoogle ScholarPubMed
Putnam, F (2007). The psychobiological effects of sexual abuse: a 20-year prospective study. Paper presented at the Second International Conference on Child Abuse and Neglect, the Facts, 9–10 May, Leuven.Google Scholar
Rush, AJ, First, MB, Blacker, D (2008). Handbook of Psychiatric Measures, 2nd edn. American Psychiatric Publishing: Washington, DC.Google Scholar
Thorn, L, Hucklebridge, F, Evans, P, Clow, A (2006). Suspected non-adherence and weekend versus week day differences in the awakening cortisol response. Psychoneuroendocrinology 31, 1009–1018.CrossRefGoogle ScholarPubMed
van Wijngaarden, B, Koeter, M, Knapp, M, Tansella, M, Thornicroft, G, Vazquez-Barquero, JL, Schene, A (2009). Caring for people with depression or with schizophrenia: are the consequences different? Psychiatry Research 169, 62–69.Google Scholar
van Wijngaarden, B, Schene, AH (1997). The Involvement Evaluation Questionnaire – European Version. Amsterdam, The Netherlands: Department of Psychiatry, University of Amsterdam, 1992.Google Scholar
van Wijngaarden, B, Schene, AH, Koeter, MW (2004). Family caregiving in depression: impact on caregivers' daily life, distress, and help seeking. Journal of Affective Disorders 81, 211–222.CrossRefGoogle ScholarPubMed
Vedhara, K, Cox, NK, Wilcock, GK, Perks, P, Hunt, M, Anderson, S, Lightman, SL, Shanks, NM (1999). Chronic stress in elderly carers of dementia patients and antibody response to influenza vaccination. Lancet 353, 627–631.CrossRefGoogle ScholarPubMed
Vedhara, K, McDermott, MP, Evans, TG, Treanor, JJ, Plummer, S, Tallon, D, Cruttenden, KA, Schifitto, G (2002). Chronic stress in nonelderly caregivers: psychological, endocrine and immune implications. Journal of Psychosomatic Research 53, 1153–1161.Google Scholar
WHO (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva.Google Scholar
Wilhelm, I, Born, J, Kudielka, BM, Schlotz, W, Wust, S (2007). Is the cortisol awakening rise a response to awakening? Psychoneuroendocrinology 32, 358–366.CrossRefGoogle Scholar
Williams, JB (1988). A structured interview guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry 45, 742–747.CrossRefGoogle ScholarPubMed
Wust, S, Wolf, J, Hellhammer, DH, Federenko, I, Schommer, N, Kirschbaum, C (2000). The cortisol awakening response – normal values and confounds. Noise and Health 2, 79–88.Google ScholarPubMed