Depression and Guilt:  What Is The Link for Attorneys?

Attorneys with depression who work in Washington, DC may want to know:  Brain imaging research has uncovered a connection between major depressive disorder (MDD) in preschool age children and the size of their anterior insula (AI). Researchers at Washington University in St. Louis have discovered that children between the ages of three and six who are diagnosed with depression have smaller AI volumes than other children of the same age who are not depressed.  The AI is an area (visible in blue in the figure below) of the brain that has been linked to various emotions including depression and guilt processing, as well as perception, self-awareness and cognitive function. The findings are consistent with research into adult MDD and which has uncovered a relationship between insula function and structure and the appearance of the disease. 

The Beginning of the Study

The initial intent of the Preschool Depression Study was to determine if children as young as the age of three could experience clinical depression. The 10-year study examined 306 children who ranged in age from three to six years old. The children were assessed for depression and guilt annually for a period of six years. A further subgroup received magnetic resonance imaging (MRI) every 18 months between the ages of six and 13.

Of the participants in the study, 47 were diagnosed with depression during their preschool years, while 82 showed no symptoms of depression. Of those with depression, 55% exhibited signs of pathological guilt compared to only 20% of the non-depressed children who demonstrated “excessive guilt.”  Pathological guilt has been associated with clinical depression, as well as other psychiatric disorders like anxiety, bipolar disorder and obsessive-compulsive disorder. 

The Results

The discovery of a smaller right anterior insula in children diagnosed with pathological guilt provides firm evidence of a link between guilt, depression and insula size. Long-term study results further revealed that children with small AI volumes were more likely to experience repeated bouts of MDD as they got older.  The researchers – led by Andrew Belden, assistant professor of child psychiatry at Washington University School of Medicine in St. Louis, MO – say that these findings are not a complete surprise. “Because,” says Belden, “for many years now, excessive guilt has consistently been a predictor of depression and a major outcome related to being depressed.” He also goes on to state:  “Arguably, our findings would suggest that guilt early in life predicts insula shrinkage. I think the story is beginning to emerge that depression may predict changes in the brain, and these brain changes predict risk for recurrence.”

That is not to say that all children will go on to suffer major depressive episode throughout their lives. Some will never experience a repeat episode.  However, there are still others who will experience chronic depression and discerning a possible link to flag those children at as early an age as possible is invaluable.  The researchers plan to continue their study for 5 more years as the study’s subjects travel through adolescence – a high-risk period in terms of depression. Additional studies have shown that elementary and middle school students were 2.5 times more likely to experience clinical depression if they had experienced MDD in their preschool years, compared to their peers with no previous depressive episodes.  It has also been shown that adults diagnosed with depression have a smaller insula than those who have no symptoms.  So the argument that a link exists between having a small insula volume and increased evidence of MDD is clear, regardless of a patient’s age:  "We found that for children who have a very early–onset form of depression, there are changes in the structure of their brain very much in line with changes known in the adult disorder," co-investigator Joan Luby, MD, professor of psychiatry and director of the Early Emotional Development Program at Washington University School of Medicine in St. Louis, Missouri, told Medscape Medical News.

For now, however, their latest study is the first to examine changes in the anterior insula as a potential biomarker for the diagnosis of childhood MDD. It’s also important that, “clinicians should be open to the possibility that young children can experience clinical depression and that pathologic guilt is an important symptom to identify and evaluate,” states Dr. Luby. The findings set forth in this landmark study could help psychiatrists better understand the trajectory of depression throughout an individual’s life.  "The experience of these early symptoms is associated with tangible brain change, which also underscores the need to take these things seriously," she said. Early and accurate diagnosis of childhood depression is key. “That's important to know,” explains Luby, “because the question is, if this chronic and relapsing disorder arises early in life, it might be important to treat it early in life, when interventions are known to be more powerful and more effective."

The study was published online through JAMA Psychiatry, on November 12, 2014 and represents the first study of its kind suggesting that decreased AI volumes are potential physiological markers for childhood MDD.  Researchers are hopeful that this new information will not only provide more insight into identifying those individuals who may be at high risk for the recurrence of depression, but also help target at-risk individuals at a young age for earlier intervention.

Conclusion:  A smaller insula volume is linked with the presence of Major Depressive Disorder in individuals of all ages, and excessive guilt may be involved with the development of depression.  Brain scans may assist with evaluating risk of developing depression for attorneys in Washington, DC.

- Laura Wells

Belden, A., Barch, D., Oakberg, T., April, L., Harms, M., Botterton, K., & Luby, J. (2014, November 12). Anterior Insula Volume and Guilt. Retrieved November 17, 2014, from http://archpsyc.jamanetwork.com/article.aspx?articleid=1935483

Brauser, D. (2014, November 14). Guilt in Preschoolers Linked to Depression, Brain Alterations. Retrieved November 17, 2014, from http://www.medscape.com/viewarticle/834911

Washington University in St. Louis. (2014, November 12). Depression, overwhelming guilt in preschool years linked to brain changes. ScienceDaily. Retrieved November 17, 2014 from www.sciencedaily.com/releases/2014/11/141112161036.htm