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Psychosocial stressors and the prognosis of major depression: a test of Axis IV

  • S. E. Gilman (a1) (a2) (a3), N.-H. Trinh (a3) (a4), J. W. Smoller (a2) (a3) (a4), M. Fava (a3) (a4), J. M. Murphy (a2) (a3) (a4) and J. Breslau (a5)...



Axis IV is for reporting ‘psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders’. No studies have examined the prognostic value of Axis IV in DSM-IV.


We analyzed data from 2497 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with major depressive episode (MDE). We hypothesized that psychosocial stressors predict a poor prognosis of MDE. Secondarily, we hypothesized that psychosocial stressors predict a poor prognosis of anxiety and substance use disorders. Stressors were defined according to DSM-IV's taxonomy, and empirically using latent class analysis (LCA).


Primary support group problems, occupational problems and childhood adversity increased the risks of depressive episodes and suicidal ideation by 20–30%. Associations of the empirically derived classes of stressors with depression were larger in magnitude. Economic stressors conferred a 1.5-fold increase in risk for a depressive episode [95% confidence interval (CI) 1.2–1.9]; financial and interpersonal instability conferred a 1.3-fold increased risk of recurrent depression (95% CI 1.1–1.6). These two classes of stressors also predicted the recurrence of anxiety and substance use disorders. Stressors were not related to suicidal ideation independent from depression severity.


Psychosocial and environmental problems are associated with the prognosis of MDE and other Axis I disorders. Although DSM-IV's taxonomy of stressors stands to be improved, these results provide empirical support for the prognostic value of Axis IV. Future work is needed to determine the reliability of Axis IV assessments in clinical practice, and the usefulness of this information to improving the clinical course of mental disorders.


Corresponding author

*Address for correspondence: S. E. Gilman, Sc.D., Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. (Email:


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