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Letter to the Editor   |    
Childhood Trauma and Depression
ROBERT D. LEVITAN, M.D., M.Sc., F.R.C.P.C.; SAGAR V. PARIKH, M.D., F.R.C.P.C.
Am J Psychiatry 2003;160:1188-1188. doi:10.1176/appi.ajp.160.6.1188

To the Editor: We reviewed with great interest the recent article by Kate L. Harkness, Ph.D., and Scott M. Monroe, Ph.D. (1), demonstrating a strong link between early childhood trauma and endogenous depression, in contrast to prior work linking early adversity with nonendogenous subtypes of depression (2). However, we are skeptical of these new findings in view of critical exclusions in their data collection, including a lack of consideration of atypical depression and overly narrow inclusion criteria.

Atypical depression, by definition, is characterized by mood reactivity, hypersomnia, and increased eating, in contrast to the lack of mood reactivity, insomnia, and loss of appetite seen in endogenous depression. Subjects with atypical depression thus provide a natural comparison group for linking particular vulnerability factors with endogenous depressive subtypes. Using this latter approach in a community-based sample of 653 individuals with major depression, we previously demonstrated a significant association between early childhood physical and/or sexual abuse and atypical but not endogenous symptoms of depression (3). Biological studies also point to a mechanistic link between atypical depression and severe trauma. More specifically, low baseline cortisol levels and hypersensitivity to low doses of dexamethasone have been found in both posttraumatic stress disorder (4) and atypical depression (5, 6), consistent with a hypothalamic-pituitary-adrenal (HPA) axis that is hyperregulated. In contrast, a large body of work has demonstrated hypercortisolemia and resistance to dexamethasone in endogenous depression, consistent with a stress response that is chronically overactivated and hyporegulated (7). This further suggests that severe trauma is more closely linked with atypical than endogenous depressive symptoms.

Given these links between atypicality and early trauma, the sampling procedure of Drs. Harkness and Monroe becomes problematic in that individuals with chronic depression and many with a "comorbid exclusionary diagnosis" were excluded from consideration in their study. Chronicity and comorbidity are hallmarks of atypical depression (810) and are themselves associated with early trauma; thus, elimination of subjects with these characteristics establishes a significant sampling bias.

Another issue relates to the cross-sectional nature of their study, in that many patients with recurrent depression have a fluctuation of neurovegetative symptoms over time; i.e., they may appear endogenously depressed at one point in time, while exhibiting atypical symptoms at other times (11). This is not a trivial point in that we have previously reported that depressed individuals with this fluctuating course have particularly high rates of severe childhood abuse (3). We speculate that several individuals labeled endogenous in the current study would have been designated as fluctuating had this been a consideration, further diluting the authors’ ability to find a putative link between early trauma and nonendogenous symptoms.

In sum, it may be that in a heterogeneous group of individuals with major depression, particularly high rates of trauma will be found in those with atypical symptoms, while in a more homogeneous group with nonchronic illness without certain comorbidities, a link with endogenous symptoms will emerge. This is an important consideration in designing and interpreting research linking early trauma with particular depressive subtypes.

Harkness KL, Monroe SM: Childhood adversity and the endogenous versus nonendogenous distinction in women with major depression. Am J Psychiatry  2002; 159:387-393
[PubMed]
[CrossRef]
 
Parker G, Gladstone G, Wilhelm K, Mitchell P, Hadzi-Pavlovic D, Austin MP: Dysfunctional parenting: over-representation in non-melancholic depression and capacity of such specificity to refine sub-typing depression measures. Psychiatry Res  1997; 73:57-71
[PubMed]
[CrossRef]
 
Levitan RD, Parikh SV, Lesage AD, Hegadoren KM, Adams M, Kennedy SH, Goering PN: Major depression in individuals with a history of childhood physical or sexual abuse: relationship to neurovegetative features, mania, and gender. Am J Psychiatry  1998; 155:1746-1752
[PubMed]
 
Yehuda R: Biology of posttraumatic stress disorder. J Clin Psychiatry 2001; 62(suppl 17):41-46
 
Anisman H, Ravindran AV, Griffiths J, Merali Z: Endocrine and cytokine correlates of major depression and dysthymia with typical or atypical features. Mol Psychiatry  1999; 4:182-188
[PubMed]
[CrossRef]
 
Levitan RD, Vaccarino FJ, Brown GM, Kennedy SH: Low-dose dexamethasone challenge in women with atypical major depression: pilot study. J Psychiatry Neurosci  2002; 27:47-51
[PubMed]
 
Gold PW, Chrousos GP: Organization of the stress system and its deregulation in melancholic and atypical depression: high vs low CRH/NE states. Mol Psychiatry  2002; 7:254-275
[PubMed]
[CrossRef]
 
Horwath E, Johnson J, Weissman MM, Hornig CD: The validity of major depression with atypical features based on a community study. J Affect Disord  1992; 26:117-125
[PubMed]
[CrossRef]
 
Stewart JW, McGrath PJ, Rabkin JG, Quitkin FM: Atypical depression: a valid clinical entity? Psychiatr Clin North Am  1993; 16:479-495
[PubMed]
 
Posternak MA, Zimmerman M: Partial validation of the atypical features subtype of major depressive disorder. Arch Gen Psychiatry 2002: 59:70-76
 
Levitan RD, Lesage A, Parikh SV, Goering P, Kennedy SH: Reversed neurovegetative symptoms of depression: a community study of Ontario. Am J Psychiatry  1997; 154:934-940
[PubMed]
 
+

References

Harkness KL, Monroe SM: Childhood adversity and the endogenous versus nonendogenous distinction in women with major depression. Am J Psychiatry  2002; 159:387-393
[PubMed]
[CrossRef]
 
Parker G, Gladstone G, Wilhelm K, Mitchell P, Hadzi-Pavlovic D, Austin MP: Dysfunctional parenting: over-representation in non-melancholic depression and capacity of such specificity to refine sub-typing depression measures. Psychiatry Res  1997; 73:57-71
[PubMed]
[CrossRef]
 
Levitan RD, Parikh SV, Lesage AD, Hegadoren KM, Adams M, Kennedy SH, Goering PN: Major depression in individuals with a history of childhood physical or sexual abuse: relationship to neurovegetative features, mania, and gender. Am J Psychiatry  1998; 155:1746-1752
[PubMed]
 
Yehuda R: Biology of posttraumatic stress disorder. J Clin Psychiatry 2001; 62(suppl 17):41-46
 
Anisman H, Ravindran AV, Griffiths J, Merali Z: Endocrine and cytokine correlates of major depression and dysthymia with typical or atypical features. Mol Psychiatry  1999; 4:182-188
[PubMed]
[CrossRef]
 
Levitan RD, Vaccarino FJ, Brown GM, Kennedy SH: Low-dose dexamethasone challenge in women with atypical major depression: pilot study. J Psychiatry Neurosci  2002; 27:47-51
[PubMed]
 
Gold PW, Chrousos GP: Organization of the stress system and its deregulation in melancholic and atypical depression: high vs low CRH/NE states. Mol Psychiatry  2002; 7:254-275
[PubMed]
[CrossRef]
 
Horwath E, Johnson J, Weissman MM, Hornig CD: The validity of major depression with atypical features based on a community study. J Affect Disord  1992; 26:117-125
[PubMed]
[CrossRef]
 
Stewart JW, McGrath PJ, Rabkin JG, Quitkin FM: Atypical depression: a valid clinical entity? Psychiatr Clin North Am  1993; 16:479-495
[PubMed]
 
Posternak MA, Zimmerman M: Partial validation of the atypical features subtype of major depressive disorder. Arch Gen Psychiatry 2002: 59:70-76
 
Levitan RD, Lesage A, Parikh SV, Goering P, Kennedy SH: Reversed neurovegetative symptoms of depression: a community study of Ontario. Am J Psychiatry  1997; 154:934-940
[PubMed]
 
+
+

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