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Berwian IM, Tröndle M, de Miquel C, Ziogas A, Stefanics G, Walter H, Stephan KE, Huys QJM. Emotion-Induced Frontal Alpha Asymmetry as a Candidate Predictor of Relapse After Discontinuation of Antidepressant Medication. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2024; 9:809-818. [PMID: 38735534 DOI: 10.1016/j.bpsc.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/13/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND One in 3 patients relapse after antidepressant discontinuation. Thus, the prevention of relapse after achieving remission is an important component in the long-term management of major depressive disorder. However, no clinical or other predictors are established. Frontal reactivity to sad mood as measured by functional magnetic resonance imaging has been reported to relate to relapse independently of antidepressant discontinuation and is an interesting candidate predictor. METHODS Patients (n = 56) who had remitted from a depressive episode while taking antidepressants underwent electroencephalography (EEG) recording during a sad mood induction procedure prior to gradually discontinuing their medication. Relapse was assessed over a 6-month follow-up period. Thirty five healthy control participants were also tested. Current source density of the EEG power in the alpha band (8-13 Hz) was extracted and alpha asymmetry was computed by comparing the power across 2 hemispheres at frontal electrodes (F5 and F6). RESULTS Sad mood induction was robust across all groups. Reactivity of alpha asymmetry to sad mood did not distinguish healthy control participants from patients with remitted major depressive disorder on medication. However, the 14 (25%) patients who relapsed during the follow-up period after discontinuing medication showed significantly reduced reactivity in alpha asymmetry compared with patients who remained well. This EEG signal provided predictive power (69% out-of-sample balanced accuracy and a positive predictive value of 0.75). CONCLUSIONS A simple EEG-based measure of emotional reactivity may have potential to contribute to clinical prediction models of antidepressant discontinuation. Given the very small sample size, this finding must be interpreted with caution and requires replication in a larger study.
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Affiliation(s)
- Isabel M Berwian
- Princeton Neuroscience Institute & Psychology Department, Princeton University, Princeton, New Jersey; Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland.
| | - Marius Tröndle
- Methods of Plasticity Research, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Carlota de Miquel
- Research Innovation and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain; Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - Anastasios Ziogas
- Faculty of Psychology, University Distance Suisse, Brig, Switzerland
| | - Gabor Stefanics
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Henrik Walter
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Klaas E Stephan
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland; Max Planck Institute for Metabolism Research, Cologne, Germany
| | - Quentin J M Huys
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland; Applied Computational Psychiatry Lab, Mental Health Neuroscience Department, Division of Psychiatry and Max Planck Centre for Computational Psychiatry and Ageing Research, Queen Square Institute of Neurology, University College London, London, United Kingdom; Camden and Islington NHS Foundation Trust, London, United Kingdom
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Hu Y, Xue H, Ni X, Guo Z, Fan L, Du W. Association between duration of antidepressant treatment for major depressive disorder and relapse rate after discontinuation: A meta-analysis. Psychiatry Res 2024; 337:115926. [PMID: 38733930 DOI: 10.1016/j.psychres.2024.115926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Abstract
The optimal duration of antidepressant treatment for patients with major depressive disorder to reduce the risk of relapse after discontinuation remains uncertain. Medline, Cochrane Central Register of Controlled Trials, and Embase were systematically searched for randomized controlled trials (RCTs) with a discontinuation design. A single-group summary meta-analysis was performed to calculate 6-month relapse rates after discontinuation. Meta-regression with restricted cubic splines was performed to model the non-linear relationship between treatment duration and relapse rate after discontinuation. Thirty-five RCTs were included. The relapse rate after discontinuation was approximately 34.81 % at 6 months and 45.12 % at 12 months. After controlling for covariates, the meta-analysis shows that the duration of treatment is associated with the risk of relapse after discontinuation in a non-linear curve, with a relatively higher risk of relapse observed for a duration of less than three months. There appears to be no further reduction in the risk of relapse when treatment is continued for over six months. Our results indicate the importance of at least three months of treatment to avoid the relatively high risk of relapse after discontinuation. The additional benefit of longer treatment remains to be proven.
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Affiliation(s)
- Yuhua Hu
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Hui Xue
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Xiaoyan Ni
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Zhen Guo
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Lijun Fan
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Wei Du
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China.
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Glue P, Loo C, Fam J, Lane HY, Young AH, Surman P. Extended-release ketamine tablets for treatment-resistant depression: a randomized placebo-controlled phase 2 trial. Nat Med 2024; 30:2004-2009. [PMID: 38914860 PMCID: PMC11271411 DOI: 10.1038/s41591-024-03063-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 05/08/2024] [Indexed: 06/26/2024]
Abstract
Ketamine has rapid-onset antidepressant activity in patients with treatment-resistant major depression (TRD). The safety and tolerability of racemic ketamine may be improved if given orally, as an extended-release tablet (R-107), compared with other routes of administration. In this phase 2 multicenter clinical trial, male and female adult patients with TRD and Montgomery-Asberg Depression Rating Scale (MADRS) scores ≥20 received open-label R-107 tablets 120 mg per day for 5 days and were assessed on day 8 (enrichment phase). On day 8, responders (MADRS scores ≤12 and reduction ≥50%) were randomized on a 1:1:1:1:1 basis to receive double-blind R-107 doses of 30, 60, 120 or 180 mg, or placebo, twice weekly for a further 12 weeks. Nonresponders on day 8 exited the study. The primary endpoint was least square mean change in MADRS for each active treatment compared with placebo at 13 weeks, starting with the 180 mg dose, using a fixed sequence step-down closed test procedure. Between May 2019 and August 2021, 329 individuals were screened for eligibility, 231 entered the open-label enrichment phase (days 1-8) and 168 responders were randomized to double-blind treatment. The primary objective was met; the least square mean difference of MADRS score for the 180 mg tablet group and placebo was -6.1 (95% confidence interval 1.0 to 11.16, P = 0.019) at 13 weeks. Relapse rates during double-blind treatment showed a dose response from 70.6% for placebo to 42.9% for 180 mg. Tolerability was excellent, with no changes in blood pressure, minimal reports of sedation and minimal dissociation. The most common adverse events were headache, dizziness and anxiety. During the randomized phase of the study, most patient dosing occurred at home. R-107 tablets were effective, safe and well tolerated in a patient population with TRD, enriched for initial response to R-107 tablets. ClinicalTrials.gov registration: ACTRN12618001042235 .
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Affiliation(s)
- Paul Glue
- University of Otago, Dunedin, New Zealand.
| | - Colleen Loo
- Black Dog Institute & University of New South Wales, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Johnson Fam
- National University of Singapore, Singapore, Singapore
| | - Hsien-Yuan Lane
- China Medical University, Taichung, Taiwan
- China Medical University Hospital, Taichung, Taiwan
| | - Allan H Young
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
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Kwon Y, Lauffenburger JC. Antidepressant discontinuation patterns and characteristics across sociodemographic groups in the United States. J Affect Disord 2024; 355:82-85. [PMID: 38554879 DOI: 10.1016/j.jad.2024.03.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND While antidepressants are frequently used, less is known about contemporary discontinuation patterns, especially across different sociodemographic populations. METHODS Patients 16-84 years initiating antidepressants between 2016 and 2019 within a large US health insurer were identified. The association between patient characteristics and time until antidepressant discontinuation was evaluated using adjusted Cox proportional hazard regression. RESULTS Across 1,365,576 patients, mean time to discontinuation was 168.1 days (SD: 223.6). Men were more likely to discontinue than women (HR: 0.94, 95%CI: 0.94-0.94). Younger patients (16-24 years) were more likely to discontinue than older patients. Patients who were non-White (Asian HR: 1.33, 95%CI: 1.31-1.34; Black HR: 1.27, 95%CI: 1.27-1.28; Hispanic HR: 1.34, 95%:CI 1.34-1.35), with evidence of a substance use disorder (HR: 1.31, 95%CI: 1.27-1.35), or taking tricyclic antidepressants (HR:1.26, 95%CI: 1.25-1.27) were more likely to discontinue. LIMITATIONS Information on reasons for discontinuation was not available, and wide standard deviations for the primary outcome were reported. The results may not be generalized to non-commercially insured beneficiaries. CONCLUSIONS Discontinuation is common within the first 6 months of treatment but varies across populations, highlighting patients who may benefit from potential intervention.
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Affiliation(s)
- Yoojung Kwon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, United States of America; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, United States of America
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, United States of America.
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Garakani A, Buono FD, Salehi M, Funaro MC, Klimowicz A, Sharma H, Faria CGF, Larkin K, Freire RC. Antipsychotic agents in anxiety disorders: An umbrella review. Acta Psychiatr Scand 2024; 149:295-312. [PMID: 38382649 DOI: 10.1111/acps.13669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although not approved for the treatment of anxiety disorders (except trifluoperazine) there is ongoing off-label, unapproved use of first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) for anxiety disorders. There have been systematic reviews and meta-analyses on the use of antipsychotics in anxiety disorders, most of which focused on SGAs. OBJECTIVE The specific aims of this umbrella review are to: (1) Evaluate the evidence of efficacy of FGAs and SGAs in anxiety disorders as an adjunctive treatment to traditional antidepressant treatments and other nonantipsychotic medications; (2) Compare monotherapy with antipsychotics to first-line treatments for anxiety disorders in terms of effectiveness, risks, and side effects. The review protocol is registered on PROSPERO (CRD42021237436). METHODS An initial search was undertaken to identify systematic reviews and meta-analyses from inception until 2020, with an updated search completed August 2021 and January 2023. The searches were conducted in PubMed, MEDLINE (Ovid), EMBASE (Ovid), APA PsycInfo (Ovid), CINAHL Complete (EBSCOhost), and the Cochrane Library through hand searches of references of included articles. Review quality was measured using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews) scale. RESULTS The original and updated searches yielded 1796 and 3744 articles respectively, of which 45 were eligible. After final review, 25 systematic reviews and meta-analyses were included in the analysis. Most of the systematic reviews and meta-analyses were deemed low-quality through AMSTAR-2 with only one review being deemed high-quality. In evaluating the monotherapies with antipsychotics compared with first-line treatments for anxiety disorder there was insufficient evidence due to flawed study designs (such as problems with randomization) and small sample sizes within studies. There was limited evidence suggesting efficacy of antipsychotic agents in anxiety disorders other than quetiapine in generalized anxiety disorder (GAD). CONCLUSIONS This umbrella review indicates a lack of high-quality studies of antipsychotics in anxiety disorders outside of the use of quetiapine in GAD. Although potentially effective for anxiety disorders, FGAs and SGAs may have risks and side effects that outweigh their efficacy, although there were limited data. Further long-term and larger-scale studies of antipsychotics in anxiety disorders are needed.
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Affiliation(s)
- Amir Garakani
- Department of Psychiatry and Behavioral Health, Greenwich Hospital, Greenwich, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Frank D Buono
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mona Salehi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melissa C Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Anna Klimowicz
- Department of Psychiatry, New York University Langone Health, New York, New York, USA
| | - Harshit Sharma
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Clara G F Faria
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kaitlyn Larkin
- Department of Psychology, Northern Illinois University, DeKalb, Illinois, USA
| | - Rafael C Freire
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Psychiatry and Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, Kingston, Ontario, Canada
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Duffy L, Lewis G, Marston L, Kendrick T, Kessler D, Moore M, Wiles N, Lewis G. Clinical factors associated with relapse in depression in a sample of UK primary care patients who have been on long-term antidepressant treatment. Psychol Med 2024; 54:951-961. [PMID: 37753652 DOI: 10.1017/s0033291723002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND This paper investigates whether age of onset of depression, duration of the last episode, number of episodes, and residual symptoms of depression and anxiety are associated with depression relapse in primary care patients who have been on long-term maintenance antidepressant treatment and no longer meet ICD10 criteria for depression. METHODS An observational cohort using data from ANTLER (N = 478), a double-blind placebo-controlled trial. The primary outcome was time to relapse using the retrospective CIS-R. Participants were followed for 12 months. RESULTS Primary outcome was available for 468 participants. Time to relapse in those with more than five previous episodes of depression was shorter, hazard ratio (HR) 1.84 (95% confidence interval [CI] 1.23-2.75) compared to people with two episodes; HR 1.57 (95% CI 1.01-2.43) after adjustment. The residual symptoms of depression at baseline were also associated with increased relapse: HR 1.05 (95% CI 1.01-1.09) and HR 1.06 (95% CI 1.01-1.12) in the adjusted model. There was evidence of reduced rate of relapse in older age of onset group: HR 0.86 (95% CI 0.78-0.95); HR attenuated after adjustment HR 0.91 (95% CI 0.81-1.02). There was no evidence of an association between duration of the current episode and residual anxiety symptoms with relapse. CONCLUSIONS The number of previous episodes and residual symptoms of depression were associated with increased likelihood of relapse. These factors could inform joint decision making when patients are considering tapering off maintenance antidepressant treatment or considering other treatments to prevent relapse.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Louise Marston
- Research Dept. of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Moore
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
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Gøtzsche PC, Demasi M. Interventions to help patients withdraw from depression drugs: A systematic review. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:103-116. [PMID: 37718853 DOI: 10.3233/jrs-230011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Depression drugs can be difficult to come off due to withdrawal symptoms. Gradual tapering with tapering support is needed to help patients withdraw safely. OBJECTIVE To review the withdrawal success rates, using any intervention, and the effects on relapse/recurrence rates, symptom severity, quality of life, and withdrawal symptoms. METHODS Systematic review based on PubMed and Embase searches (last search 4 October 2022) of randomised trials with one or more treatment arms aimed at helping patients withdraw from a depression drug, regardless of indication for treatment. We calculated the mean and median success rates and the risk difference of depressive relapse when discontinuing or continuing depression drugs. RESULTS We included 13 studies (2085 participants). Three compared two withdrawal interventions and ten compared drug discontinuation vs. continuation. The success rates varied hugely between the trials (9% to 80%), with a weighted mean of 47% (95% confidence interval 38% to 57%) and a median of 50% (interquartile range 29% to 65%). A meta-regression showed that the length of taper was highly predictive for the risk of relapse (P = 0.00001). All the studies we reviewed confounded withdrawal symptoms with relapse; did not use hyperbolic tapering; withdrew the depression drug too fast; and stopped it entirely when receptor occupancy was still high. CONCLUSION The true proportion of patients on depression drugs who can stop safely without relapse is likely considerably higher than the 50% we found.
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Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5. Obstet Gynecol 2023; 141:1262-1288. [PMID: 37486661 DOI: 10.1097/aog.0000000000005202] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
PURPOSE To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, "Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum" (1). TARGET POPULATION Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Kim J, Han C, Lee MS, Jeong HG, Kim JJ, Kim SH. Associations between Pharmacological Treatment Patterns during the Initial Treatment Period and the Relapse or Recurrence of Anxiety Disorders: A Nationwide Retrospective Cohort Study. Life (Basel) 2023; 13:life13051197. [PMID: 37240842 DOI: 10.3390/life13051197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Although the importance of proper pharmacological treatment for preventing the relapse/recurrence of anxiety disorders is well known, a real-world data-based study has not been conducted. We aimed to investigate the effect of the initial pharmacological patterns related to continuous treatment and the choice of medication on the relapse/recurrence of anxiety disorders. We used claim data from the Health Insurance Review and Assessment Service, South Korea, of 34,378 adults who received psychiatric medications, including antidepressants, after being newly diagnosed with anxiety disorders. We compared the relapse/recurrence rate in the patients receiving continuous pharmacological treatment with those who discontinued treatment early using Cox's proportional-hazards model. Patients receiving continuous pharmacological treatment experienced a higher risk of relapse/recurrence than those who discontinued treatment. Using three or more antidepressants during the initial treatment period decreased the risk of relapse/recurrence (adjusted hazard ratio (aHR) = 0.229 (0.204-0.256)); however, the combined use of antidepressants from the beginning of treatment increased the risk (aHR = 1.215 (1.131-1.305)). Factors other than continuous pharmacological treatment should be considered to effectively prevent the relapse/recurrence of anxiety disorders. The active use of antidepressants, including switching or adding medications based on progress and frequent follow-up visits during the acute phase, were significantly associated with a reduction in the relapse/recurrence of anxiety disorders.
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Affiliation(s)
- Junhyung Kim
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
| | - Changsu Han
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
| | - Moon-Soo Lee
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
- Department of Life Sciences, Korea University, Seoul 02841, Republic of Korea
| | - Hyun-Ghang Jeong
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
| | - Jae-Jin Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seung-Hyun Kim
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
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Lincoln TM, Sommer D, Quazzola M, Witzgall T, Schlier B. Predictors of successful discontinuation of antipsychotics and antidepressants. Psychol Med 2023; 53:3085-3095. [PMID: 34937582 PMCID: PMC10235642 DOI: 10.1017/s0033291721005146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/15/2021] [Accepted: 11/24/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND To offer support for patients who decide to discontinue antipsychotic and antidepressant medication, identifying which potentially modifiable factors correlate with discontinuation success is crucial. Here, we analyzed the predictive value of the professional support received, circumstances prior to discontinuation, a strategy of discontinuation, and use of functional and non-functional coping strategies during discontinuation on self-reported discontinuation success and on objective discontinuation. METHODS Patients who had attempted discontinuing antipsychotics (AP) and/or antidepressants (AD) during the past 5 years (n = 316) completed an online survey including questions on subjective and objective discontinuation success, sociodemographic, clinical and medication-related factors, and scales to assess the putative predictors. RESULTS A regression model with all significant predictors explained 20-30% of the variance in discontinuation success for AD and 30-40% for AP. After controlling for baseline sociodemographic, clinical and medication-related factors, the most consistent predictor of subjective discontinuation success was self-care behavior, in particular mindfulness, relaxation and making use of supportive relationships. Other predictors depended on the type of medication: For AD, good alliance with the prescribing physician predicted higher subjective success whereas gradual tapering per se was associated with lower subjective success and a lower chance of full discontinuation. In those tapering off AP, leaving time to adjust between dose reductions was associated with higher subjective success and fewer negative effects. CONCLUSIONS The findings can inform evidence-based clinical guidelines and interventions aiming to support patients during discontinuation. Further studies powered to take interactions between variables into account are needed to improve the prediction of successful discontinuation.
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Jeffery A, Bhanu C, Walters K, Wong ICK, Osborn D, Hayes JF. Association between polypharmacy and depression relapse in individuals with comorbid depression and type 2 diabetes: a UK electronic health record study. Br J Psychiatry 2023; 222:112-118. [PMID: 36451601 PMCID: PMC9929703 DOI: 10.1192/bjp.2022.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 10/14/2022] [Accepted: 10/21/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Individuals with physical comorbidities and polypharmacy may be at higher risk of depression relapse, however, they are not included in the 'high risk of relapse' group for whom longer antidepressant treatment durations are recommended. AIMS In individuals with comorbid depression and type 2 diabetes (T2DM), we aimed to investigate the association and interaction between depression relapse and (a) polypharmacy, (b) previous duration of antidepressant treatment. METHOD This was a cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) from years 2000 to 2018. We used Cox regression models with penalised B-splines to describe the association between restarting antidepressants and our two exposures. RESULTS We identified 48 001 individuals with comorbid depression and T2DM, who started and discontinued antidepressant treatment during follow-up. Within 1 year of antidepressant discontinuation, 35% of participants restarted treatment indicating depression relapse. As polypharmacy increased, the rate of restarting antidepressants increased until a maximum of 18 concurrent medications, where individuals were more than twice as likely to restart antidepressants (hazard ratio (HR) = 2.15, 95% CI 1.32-3.51). As the duration of previous antidepressant treatment increased, the rate of restarting antidepressants increased - individuals with a previous duration of ≥25 months were more than twice as likely to restart antidepressants than those who previously discontinued in <7 months (HR = 2.36, 95% CI 2.25-2.48). We found no interaction between polypharmacy and previous antidepressant duration. CONCLUSIONS Polypharmacy and longer durations of previous antidepressant treatment may be associated with depression relapse following the discontinuation of antidepressant treatment.
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Affiliation(s)
- Annie Jeffery
- Epidemiology and Applied Clinical Research Department, Division of Psychiatry, University College London (UCL), UK
| | - Cini Bhanu
- Department of Primary Care & Population Health, Institute of Epidemiology & Health, University College London (UCL), London, UK
| | - Kate Walters
- Department of Primary Care & Population Health, Institute of Epidemiology & Health, University College London (UCL), London, UK
| | - Ian C. K. Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), UK and Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - David Osborn
- Epidemiology and Applied Clinical Research Department, Division of Psychiatry, University College London (UCL), UK
| | - Joseph F. Hayes
- Epidemiology and Applied Clinical Research Department, Division of Psychiatry, University College London (UCL), UK
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12
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Kishi T, Ikuta T, Sakuma K, Okuya M, Hatano M, Matsuda Y, Iwata N. Antidepressants for the treatment of adults with major depressive disorder in the maintenance phase: a systematic review and network meta-analysis. Mol Psychiatry 2023; 28:402-409. [PMID: 36253442 PMCID: PMC9812779 DOI: 10.1038/s41380-022-01824-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 01/09/2023]
Abstract
A systematic review and random-effects model network meta-analysis were conducted to compare the efficacy, acceptability, tolerability, and safety of antidepressants to treat adults with major depressive disorder (MDD) in the maintenance phase. This study searched the PubMed, Cochrane Library, and Embase databases and included only double-blind, randomized, placebo-controlled trials with an enrichment design: patients were stabilized on the antidepressant of interest during the open-label study and then randomized to receive the same antidepressant or placebo. The outcomes were the 6-month relapse rate (primary outcome, efficacy), all-cause discontinuation (acceptability), discontinuation due to adverse events (tolerability), and the incidence of individual adverse events. The risk ratio with a 95% credible interval was calculated. The meta-analysis comprised 34 studies (n = 9384, mean age = 43.80 years, and %females = 68.10%) on 20 antidepressants (agomelatine, amitriptyline, bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, tianeptine, venlafaxine, vilazodone, and vortioxetine) and a placebo. In terms of the 6-month relapse rate, amitriptyline, citalopram, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, tianeptine, venlafaxine, and vortioxetine outperformed placebo. Compared to placebo, desvenlafaxine, paroxetine, sertraline, venlafaxine, and vortioxetine had lower all-cause discontinuation; however, sertraline had a higher discontinuation rate due to adverse events. Compared to placebo, venlafaxine was associated with a lower incidence of dizziness, while desvenlafaxine, sertraline, and vortioxetine were associated with a higher incidence of nausea/vomiting. In conclusion, desvenlafaxine, paroxetine, venlafaxine, and vortioxetine had reasonable efficacy, acceptability, and tolerability in the treatment of adults with stable MDD.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, 470-1192, Japan.
| | - Toshikazu Ikuta
- grid.251313.70000 0001 2169 2489Department of Communication Sciences and Disorders, School of Applied Sciences, University of Mississippi, University, Oxford, MS 38677 USA
| | - Kenji Sakuma
- grid.256115.40000 0004 1761 798XDepartment of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470–1192 Japan
| | - Makoto Okuya
- grid.256115.40000 0004 1761 798XDepartment of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470–1192 Japan
| | - Masakazu Hatano
- grid.256115.40000 0004 1761 798XDepartment of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470–1192 Japan ,grid.256115.40000 0004 1761 798XDepartment of Clinical Pharmacy, Fujita Health University School of Medicine, Toyoake, Aichi 470–1192 Japan
| | - Yuki Matsuda
- grid.411898.d0000 0001 0661 2073Department of Psychiatry, The Jikei University School of Medicine, Minato-ku, Tokyo 105–8461 Japan
| | - Nakao Iwata
- grid.256115.40000 0004 1761 798XDepartment of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470–1192 Japan
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13
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Robberegt SJ, Kooiman BEAM, Albers CJ, Nauta MH, Bockting C, Stikkelbroek Y. Personalised app-based relapse prevention of depressive and anxiety disorders in remitted adolescents and young adults: a protocol of the StayFine RCT. BMJ Open 2022; 12:e058560. [PMID: 36521888 PMCID: PMC9756181 DOI: 10.1136/bmjopen-2021-058560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Youth in remission of depression or anxiety have high risks of relapse. Relapse prevention interventions may prevent chronicity. Aim of the study is therefore to (1) examine efficacy of the personalised StayFine app for remitted youth and (2) identify high-risk groups for relapse and resilience. METHOD AND ANALYSIS In this Dutch single-blind parallel-group randomised controlled trial, efficacy of app-based monitoring combined with guided app-based personalised StayFine intervention modules is assessed compared with monitoring only. In both conditions, care as usual is allowed. StayFine modules plus monitoring is hypothesised to be superior to monitoring only in preventing relapse over 36 months. Participants (N=254) are 13-21 years and in remission of depression or anxiety for >2 months. Randomisation (1:1) is stratified by previous treatment (no treatment vs treatment) and previous episodes (1, 2 or >3 episodes). Assessments include diagnostic interviews, online questionnaires and monitoring (ecological momentary assessment with optional wearable) after 0, 4, 12, 24 and 36 months. The StayFine modules are guided by certified experts by experience and based on preventive cognitive therapy and ingredients of cognitive behavioural therapy. Personalisation is based on shared decision-making informed by baseline assessments and individual symptom networks. Time to relapse (primary outcome) is assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia-lifetime version diagnostic interview. Intention-to-treat survival analyses will be used to examine the data. Secondary outcomes are symptoms of depression and anxiety, number and duration of relapses, global functioning, and quality of life. Mediators and moderators will be explored. Exploratory endpoints are monitoring and wearable outcomes. ETHICS, FUNDING AND DISSEMINATION The study was approved by METC Utrecht and is funded by the Netherlands Organisation for Health Research and Development (636310007). Results will be submitted to peer-reviewed scientific journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER NCT05551468; NL8237.
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Affiliation(s)
- Suzanne J Robberegt
- Department of Psychiatry, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Depression Expertise Centre-Youth, GGZ Oost Brabant, Boekel, The Netherlands
| | - Bas E A M Kooiman
- Depression Expertise Centre-Youth, GGZ Oost Brabant, Boekel, The Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Casper J Albers
- Department of Psychometrics and Statistics, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Maaike H Nauta
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
- Child Study Centre, Accare, Groningen, The Netherlands
| | - Claudi Bockting
- Department of Psychiatry, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Centre for Urban Mental Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvonne Stikkelbroek
- Depression Expertise Centre-Youth, GGZ Oost Brabant, Boekel, The Netherlands
- Department of Clinical Child and Family Studies, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
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14
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Transitions in depression: if, how, and when depressive symptoms return during and after discontinuing antidepressants. Qual Life Res 2022; 32:1295-1306. [PMID: 36418524 PMCID: PMC10123048 DOI: 10.1007/s11136-022-03301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2022] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose
The aim of the current study is to provide insight into if, how, and when meaningful changes occur in individual patients who discontinue antidepressant medication. Agreement between macro-level quantitative symptom data, qualitative ratings, and micro-level Ecological Momentary Assessments is examined.
Methods
During and shortly after antidepressant discontinuation, depressive symptoms and ‘feeling down’ were measured in 56 participants, using the SCL-90 depression subscale weekly (macro-level) for 6 months, and 5 Ecological Momentary Assessments daily (micro-level) for 4 months (30.404 quantitative measurements in total). Qualitative information was also obtained, providing additional information to verify that changes were clinically meaningful.
Results
At the macro-level, an increase in depressive symptoms was found in 58.9% of participants that (a) was statistically reliable, (b) persisted for 3 weeks and/or required intervention, and (c) was clinically meaningful to patients. Of these increases, 30.3% happened suddenly, 42.4% gradually, and for 27.3% criteria were inconclusive. Quantitative and qualitative criteria showed a very high agreement (Cohen’s κ = 0.85) regarding if a participant experienced a recurrence of depression, but a moderate agreement (Cohen’s κ = 0.49) regarding how that change occurred. At the micro-level, 41.1% of participants experienced only sudden increases in depressed mood, 12.5% only gradual, 30.4% experienced both types of increase, and 16.1% neither.
Conclusion
Meaningful change is common in patients discontinuing antidepressants, and there is substantial heterogeneity in how and when these changes occur. Depressive symptom change at the macro-level is not the same as depressive symptom change at the micro-level.
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15
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Low predictive power of clinical features for relapse prediction after antidepressant discontinuation in a naturalistic setting. Sci Rep 2022; 12:11171. [PMID: 35778458 PMCID: PMC9249776 DOI: 10.1038/s41598-022-13893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022] Open
Abstract
The risk of relapse after antidepressant medication (ADM) discontinuation is high. Predictors of relapse could guide clinical decision-making, but are yet to be established. We assessed demographic and clinical variables in a longitudinal observational study before antidepressant discontinuation. State-dependent variables were re-assessed either after discontinuation or before discontinuation after a waiting period. Relapse was assessed during 6 months after discontinuation. We applied logistic general linear models in combination with least absolute shrinkage and selection operator and elastic nets to avoid overfitting in order to identify predictors of relapse and estimated their generalisability using cross-validation. The final sample included 104 patients (age: 34.86 (11.1), 77% female) and 57 healthy controls (age: 34.12 (10.6), 70% female). 36% of the patients experienced a relapse. Treatment by a general practitioner increased the risk of relapse. Although within-sample statistical analyses suggested reasonable sensitivity and specificity, out-of-sample prediction of relapse was at chance level. Residual symptoms increased with discontinuation, but did not relate to relapse. Demographic and standard clinical variables appear to carry little predictive power and therefore are of limited use for patients and clinicians in guiding clinical decision-making.
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16
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Horowitz MA, Taylor D. Distinguishing relapse from antidepressant withdrawal: clinical practice and antidepressant discontinuation studies. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2021.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
We now recognise that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting in some people. Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse. We describe how their onset soon after dose reduction, the association of psychological with physical symptoms, their prompt response to reinstatement, and their typical ‘wave’ pattern of onset, peak and resolution can help distinguish withdrawal symptoms from relapse. We also examine evidence that suggests that antidepressant withdrawal symptoms are misdiagnosed as relapse in discontinuation studies aimed at demonstrating the ability of antidepressants to prevent future relapse (relapse prevention properties). In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.
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17
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Nogami W, Nakagawa A, Katayama N, Kudo Y, Amano M, Ihara S, Kurata C, Kobayashi Y, Sasaki Y, Ishikawa N, Sato Y, Mimura M. Effect of Personality Traits on Sustained Remission Among Patients with Major Depression: A 12-Month Prospective Study. Neuropsychiatr Dis Treat 2022; 18:2771-2781. [PMID: 36465145 PMCID: PMC9717585 DOI: 10.2147/ndt.s384705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Major depression is a heterogeneous disorder. Therefore, careful evaluation and comprehensive assessment are crucial elements for achieving remission. Personality traits influence prognosis and treatment outcomes, but there is not enough evidence on the association between personality traits and sustained remission (SR). Hence, the present study aimed to evaluate the relationship between personality traits and SR among patients with major depression. PATIENTS AND METHODS The 12-month prospective study evaluated 77 patients diagnosed with major depressive disorder. All patients underwent a comprehensive assessment, including the Temperament and Personality Questionnaire (T&P) at baseline, and depression severity was measured at baseline as well as six and 12 months. SR was defined as remission (the GRID-Hamilton Depression Rating Scale [GRID-HAMD17] score ≦ 7) at both the 6- and 12-month follow-up. We compared eight T&P construct scores at baseline between the SR and non-SR groups. Multivariable logistic regression analyses were performed to determine the T&P personality traits related to SR. RESULTS Patients who achieved SR had a lower T&P personal reserve and lower T&P rejection sensitivity. Further, lower scores on the T&P personal reserve trait were independently associated with higher rates of SR among patients with major depression. Patients who achieved SR had a shorter duration of the current depressive episode and milder severity of depression at baseline. CONCLUSION A lower level of personal reserve predicted a higher probability of SR in the treatment of depression. Extended observations in naturalistic follow-up settings with larger sample sizes are required to better understand the personality traits affecting SR in patients with depression.
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Affiliation(s)
- Waka Nogami
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Atsuo Nakagawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Neuropsychiatry, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Nariko Katayama
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yuka Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Psychiatry, Gunma Hospital, Gunma, Japan.,Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Mizuki Amano
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Psychiatry, Toyosato Hospital, Ibaraki, Japan
| | - Sakae Ihara
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Chika Kurata
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yuki Kobayashi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Sasaki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Natsumi Ishikawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Child Psychiatry, the University of Tokyo Hospital, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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18
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More treatment but no less depression: The treatment-prevalence paradox. Clin Psychol Rev 2021; 91:102111. [PMID: 34959153 DOI: 10.1016/j.cpr.2021.102111] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/28/2021] [Accepted: 12/06/2021] [Indexed: 12/28/2022]
Abstract
Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This "treatment-prevalence paradox" (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more "false positive" diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in "real world" settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these a-c explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical.
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19
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Duffy L, Clarke CS, Lewis G, Marston L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, King M, Lanham P, Mangin D, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Donkor Y, Hunt A, Pervin J, Lewis G. Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT. Health Technol Assess 2021; 25:1-62. [PMID: 34842135 DOI: 10.3310/hta25690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been a steady increase in the number of primary care patients receiving long-term maintenance antidepressant treatment, despite limited evidence of a benefit of this treatment beyond 8 months. OBJECTIVE The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial investigated the clinical effectiveness and cost-effectiveness of antidepressant medication in preventing relapse in UK primary care. DESIGN This was a Phase IV, double-blind, pragmatic, multisite, individually randomised parallel-group controlled trial, with follow-up at 6, 12, 26, 39 and 52 weeks. Participants were randomised using minimisation on centre, type of antidepressant and baseline depressive symptom score above or below the median using Clinical Interview Schedule - Revised (two categories). Statisticians were blind to allocation for the outcome analyses. SETTING General practices in London, Bristol, Southampton and York. PARTICIPANTS Individuals aged 18-74 years who had experienced at least two episodes of depression and had been taking antidepressants for ≥ 9 months but felt well enough to consider stopping their medication. Those who met an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of depression or with other psychiatric conditions were excluded. INTERVENTION At baseline, participants were taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg. They were randomised to either remain on their current medication or discontinue medication after a tapering period. MAIN OUTCOME MEASURES The primary outcome was the time, in weeks, to the beginning of the first depressive episode after randomisation. This was measured by a retrospective Clinical Interview Schedule - Revised that assessed the onset of a depressive episode in the previous 12 weeks, and was conducted at 12, 26, 39 and 52 weeks. The depression-related resource use was collected over 12 months from medical records and patient-completed questionnaires. Quality-adjusted life-years were calculated using the EuroQol-5 Dimensions, five-level version. RESULTS Between 9 March 2017 and 1 March 2019, we randomised 238 participants to antidepressant continuation (the maintenance group) and 240 participants to antidepressant discontinuation (the discontinuation group). The time to relapse of depression was shorter in the discontinuation group, with a hazard ratio of 2.06 (95% confidence interval 1.56 to 2.70; p < 0.0001). By 52 weeks, relapse was experienced by 39% of those who continued antidepressants and 56% of those who discontinued antidepressants. The secondary analysis revealed that people who discontinued experienced more withdrawal symptoms than those who remained on medication, with the largest difference at 12 weeks. In the discontinuation group, 37% (95% confidence interval 28% to 45%) of participants remained on their randomised medication until the end of the trial. In total, 39% (95% confidence interval 32% to 45%) of participants in the discontinuation group returned to their original antidepressant compared with 20% (95% confidence interval 15% to 25%) of participants in maintenance group. The health economic evaluation demonstrated that participants randomised to discontinuation had worse utility scores at 3 months (-0.037, 95% confidence interval -0.059 to -0.015) and fewer quality-adjusted life-years over 12 months (-0.019, 95% confidence interval -0.035 to -0.003) than those randomised to continuation. The discontinuation pathway, besides giving worse outcomes, also cost more [extra £2.71 per patient over 12 months (95% confidence interval -£36.10 to £37.07)] than the continuation pathway, although the cost difference was not significant. CONCLUSIONS Patients who discontinue long-term maintenance antidepressants in primary care are at increased risk of relapse and withdrawal symptoms. However, a substantial proportion of patients can discontinue antidepressants without relapse. Our findings will give patients and clinicians an estimate of the likely benefits and harms of stopping long-term maintenance antidepressants and improve shared decision-making. The participants may not have been representative of all people on long-term maintenance treatment and we could study only a restricted range of antidepressants and doses. Identifying patients who will not relapse if they discontinued antidepressants would be clinically important. TRIAL REGISTRATION Current Controlled Trials ISRCTN15969819 and EudraCT 2015-004210-26. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 69. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- PRIMENT Clinical Trials Unit, University College London, London, UK.,Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon Gilbody
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Tony Kendrick
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael King
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Paul Lanham
- Division of Psychiatry, University College London, London, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Faye Bacon
- Division of Psychiatry, University College London, London, UK
| | - Molly Bird
- Division of Psychiatry, University College London, London, UK
| | - Sally Brabyn
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Alison Burns
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Yvonne Donkor
- Division of Psychiatry, University College London, London, UK
| | - Anna Hunt
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jodi Pervin
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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20
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Paulus MP, Kuplicki R, Victor TA, Yeh HW, Khalsa SS. Methylphenidate augmentation of escitalopram to enhance adherence to antidepressant treatment: a pilot randomized controlled trial. BMC Psychiatry 2021; 21:582. [PMID: 34798853 PMCID: PMC8603485 DOI: 10.1186/s12888-021-03583-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Adherence to treatment, i.e. the extent to which a patient's therapeutic engagement coincides with the prescribed treatment, is among the most important problems in mental health care. The current study investigated the influence of pairing an acute positive reinforcing dopaminergic/noradrenergic effect (methylphenidate, MPH) with a standard antidepressant on the rates of adherence to medication treatment. The primary objective of this study was to determine whether MPH + escitalopram resulted in higher rates of medication adherence relative to placebo + escitalopram. METHODS Twenty participants with moderate to severe depression were 1-1 randomized to either (1) 5 mg MPH + 10 mg escitalopram or (2) placebo + 10 mg escitalopram with the possibility for a dose increase at 4 weeks. A Bayesian analysis was conducted to evaluate the outcomes. RESULTS First, neither percent Pill count nor Medication Electronic Monitoring System adherence showed that MPH was superior to placebo. In fact, placebo showed slightly higher adherence rates on the primary (7.82% better than MPH) and secondary (7.07% better than MPH) outcomes. There was a less than 25% chance of MPH augmentation showing at least as good or better adherence than placebo. Second, both groups showed a significant effect of treatment on the QIDS-SR with a median effect of an 8.6-point score reduction. Third, neither subjective measures of adherence attitudes nor socio-demographic covariates had a significant influence on the primary or secondary outcome variables. CONCLUSIONS These data do not support the use of MPH to increase adherence to antidepressant medication in individuals with moderate to severe depression. CLINICALTRIALS. GOV IDENTIFIER NCT03388164 , registered on 01/02/2018.
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Affiliation(s)
- Martin P. Paulus
- grid.417423.70000 0004 0512 8863Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK 74136-3326 USA ,grid.267360.60000 0001 2160 264XOxley College of Health Sciences, The University of Tulsa, Tulsa, OK USA
| | - Rayus Kuplicki
- grid.417423.70000 0004 0512 8863Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK 74136-3326 USA
| | - Teresa A. Victor
- grid.417423.70000 0004 0512 8863Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK 74136-3326 USA
| | - Hung-Wen Yeh
- grid.417423.70000 0004 0512 8863Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK 74136-3326 USA ,grid.239559.10000 0004 0415 5050Health Services & Outcomes Research, Children’s Mercy Hospital, Kansas City, MO USA
| | - Sahib S. Khalsa
- grid.417423.70000 0004 0512 8863Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa, OK 74136-3326 USA ,grid.267360.60000 0001 2160 264XOxley College of Health Sciences, The University of Tulsa, Tulsa, OK USA
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Moriarty AS, Robertson L, Mughal F, Cook N, Gilbody S, McMillan D, Chew-Graham CA, Ali S, Hetrick SE, Churchill R, Meader N. Interventions for preventing relapse or recurrence of major depressive disorder in adults in a primary care setting: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Andrew S Moriarty
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
- Hull York Medical School; University of York; York UK
| | - Lindsay Robertson
- Cochrane Common Mental Disorders; University of York; York UK
- Centre for Reviews and Dissemination; University of York; York UK
| | - Faraz Mughal
- School of Medicine; Keele University; Keele UK
- Unit of Academic Primary Care; Warwick Medical School, University of Warwick; Coventry UK
| | - Natalie Cook
- Tees, Esk and Wear Valleys NHS Foundation Trust; York UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
- Hull York Medical School; University of York; York UK
| | - Dean McMillan
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | | | - Shehzad Ali
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
- Children and Young People Satellite, Cochrane Common Mental Disorders; The University of Auckland; Auckland New Zealand
| | - Rachel Churchill
- Cochrane Common Mental Disorders; University of York; York UK
- Centre for Reviews and Dissemination; University of York; York UK
| | - Nicholas Meader
- Cochrane Common Mental Disorders; University of York; York UK
- Centre for Reviews and Dissemination; University of York; York UK
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22
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Lewis G, Marston L, Duffy L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, Mangin D, King M, Lanham P, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Clarke CS, Hunt A, Pervin J, Lewis G. Maintenance or Discontinuation of Antidepressants in Primary Care. N Engl J Med 2021; 385:1257-1267. [PMID: 34587384 DOI: 10.1056/nejmoa2106356] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with depression who are treated in primary care practices may receive antidepressants for prolonged periods. Data are limited on the effects of maintaining or discontinuing antidepressant therapy in this setting. METHODS We conducted a randomized, double-blind trial involving adults who were being treated in 150 general practices in the United Kingdom. All the patients had a history of at least two depressive episodes or had been taking antidepressants for 2 years or longer and felt well enough to consider stopping antidepressants. Patients who had received citalopram, fluoxetine, sertraline, or mirtazapine were randomly assigned in a 1:1 ratio to maintain their current antidepressant therapy (maintenance group) or to taper and discontinue such therapy with the use of matching placebo (discontinuation group). The primary outcome was the first relapse of depression during the 52-week trial period, as evaluated in a time-to-event analysis. Secondary outcomes were depressive and anxiety symptoms, physical and withdrawal symptoms, quality of life, time to stopping an antidepressant or placebo, and global mood ratings. RESULTS A total of 1466 patients underwent screening. Of these patients, 478 were enrolled in the trial (238 in the maintenance group and 240 in the discontinuation group). The average age of the patients was 54 years; 73% were women. Adherence to the trial assignment was 70% in the maintenance group and 52% in the discontinuation group. By 52 weeks, relapse occurred in 92 of 238 patients (39%) in the maintenance group and in 135 of 240 (56%) in the discontinuation group (hazard ratio, 2.06; 95% confidence interval, 1.56 to 2.70; P<0.001). Secondary outcomes were generally in the same direction as the primary outcome. Patients in the discontinuation group had more symptoms of depression, anxiety, and withdrawal than those in the maintenance group. CONCLUSIONS Among patients in primary care practices who felt well enough to discontinue antidepressant therapy, those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy. (Funded by the National Institute for Health Research; ANTLER ISRCTN number, ISRCTN15969819.).
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Affiliation(s)
- Gemma Lewis
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Louise Marston
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Larisa Duffy
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Nick Freemantle
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Simon Gilbody
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Rachael Hunter
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Tony Kendrick
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - David Kessler
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Dee Mangin
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Michael King
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Paul Lanham
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Michael Moore
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Irwin Nazareth
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Nicola Wiles
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Faye Bacon
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Molly Bird
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Sally Brabyn
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Alison Burns
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Caroline S Clarke
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Anna Hunt
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Jodi Pervin
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Glyn Lewis
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
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Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AI, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; 4:CD013495. [PMID: 33886130 PMCID: PMC8092632 DOI: 10.1002/14651858.cd013495.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants. OBJECTIVES To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. SEARCH METHODS We searched all databases for randomised controlled trials (RCTs) until January 2020. SELECTION CRITERIA We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety. AUTHORS' CONCLUSIONS Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression. There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mieke L van Driel
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An Im De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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Zisook S, Johnson GR, Hicks P, Chen P, Beresford T, Michalets JP, Rao S, Thase ME, Wilcox J, Sevilimedu V, Mohamed S. Continuation phase treatment outcomes for switching, combining, or augmenting strategies for treatment-resistant major depressive disorder: A VAST-D report. Depress Anxiety 2021; 38:185-195. [PMID: 33225492 DOI: 10.1002/da.23114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 09/18/2020] [Accepted: 10/18/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This secondary analysis of the VA Augmentation and Switching Treatments for Depression study compared the continuation phase treatment outcomes of three commonly used second-step treatment strategies following at least one prior failed medication treatment attempt. METHODS In total, 1522 outpatients with MDD were randomized to switching to bupropion-SR (S-BUP), combining with bupropion-SR (C-BUP), or augmenting with aripiprazole (A-ARI). Following 12 weeks of acute phase treatment, 725 entered the 24-week continuation treatment phase. Depressive symptom severity, relapse, "emergent" remission, anxiety, suicidal ideation, quality of life, health status, and side effects were compared. RESULTS We did not find clinically significant differential treatment effects with the exception that A-ARI was associated with less anxiety than S-BUP or C-BUP. Participants who entered continuation treatment as remitters had milder depressive symptom severity and lower relapse rates than those not in remission; they also experienced more improvement on most other outcomes. A-ARI was associated with less anxiety, insomnia, and dry mouth but more somnolence, extrapyramidal effects, akathisia, abnormal laboratory values, and appetite and weight gain. CONCLUSIONS Continuation treatment is a dynamic period. Regardless of the treatment, participants who entered continuation treatment at Week 12 in full remission continued to have better outcomes over the subsequent 24 weeks than those who were not in remission at the start of the continuation phase.
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Affiliation(s)
- Sidney Zisook
- Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,The Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Gary R Johnson
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Paul Hicks
- The Department of Psychiatry, Texas A&M College of Medicine, Temple, Texas, USA
| | - Peijun Chen
- The Department of Psychiatry, School of Medicine, Louis Stokes VA Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas Beresford
- Mental Health, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | | | - Sanjai Rao
- Mental Health, VA San Diego Healthcare System, San Diego, California, USA
| | - Michael E Thase
- Mental Health, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| | - James Wilcox
- Mental Health, Southern Arizona VA Healthcare System, Tucson, Arizona, USA
| | - Varadan Sevilimedu
- Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Somaia Mohamed
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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25
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Kato M, Hori H, Inoue T, Iga J, Iwata M, Inagaki T, Shinohara K, Imai H, Murata A, Mishima K, Tajika A. Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis. Mol Psychiatry 2021; 26:118-133. [PMID: 32704061 PMCID: PMC7815511 DOI: 10.1038/s41380-020-0843-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022]
Abstract
A significant clinical issue encountered after a successful acute major depressive disorder (MDD) treatment is the relapse of depressive symptoms. Although continuing maintenance therapy with antidepressants is generally recommended, there is no established protocol on whether or not it is necessary to prescribe the antidepressant used to achieve remission. In this meta-analysis, the risk of relapse and treatment failure when either continuing with the same drug used to achieved remission or switching to a placebo was assessed in several clinically significant subgroups. The pooled odds ratio (OR) (±95% confidence intervals (CI)) was calculated using a random effects model. Across 40 studies (n = 8890), the relapse rate was significantly lower in the antidepressant group than the placebo group by about 20% (OR = 0.38, CI: 0.33-0.43, p < 0.00001; 20.9% vs 39.7%). The difference in the relapse rate between the antidepressant and placebo groups was greater for tricyclics (25.3%; OR = 0.30, CI: 0.17-0.50, p < 0.00001), SSRIs (21.8%; OR = 0.33, CI: 0.28-0.38, p < 0.00001), and other newer agents (16.0%; OR = 0.44, CI: 0.36-0.54, p < 0.00001) in that order, while the effect size of acceptability was greater for SSRIs than for other antidepressants. A flexible dose schedule (OR = 0.30, CI: 0.23-0.48, p < 0.00001) had a greater effect size than a fixed dose (OR = 0.41, CI: 0.36-0.48, p < 0.00001) in comparison to placebo. Even in studies assigned after continuous treatment for more than 6 months after remission, the continued use of antidepressants had a lower relapse rate than the use of a placebo (OR = 0.40, CI: 0.29-0.55, p < 0.00001; 20.2% vs 37.2%). The difference in relapse rate was similar from a maintenance period of 6 months (OR = 0.41, CI: 0.35-0.48, p < 0.00001; 19.6% vs 37.6%) to over 1 year (OR = 0.35, CI: 0.29-0.41, p < 0.00001; 19.9% vs 39.8%). The all-cause dropout of antidepressant and placebo groups was 43% and 58%, respectively, (OR = 0.47, CI: 0.40-0.55, p < 0.00001). The tolerability rate was ~4% for both groups. The rate of relapse (OR = 0.32, CI: 0.18-0.64, p = 0.0010, 41.0% vs 66.7%) and all-cause dropout among adolescents was higher than in adults. To prevent relapse and treatment failure, maintenance therapy, and careful attention for at least 6 months after remission is recommended. SSRIs are well-balanced agents, and flexible dose adjustments are more effective for relapse prevention.
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Affiliation(s)
- Masaki Kato
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan.
| | - Hikaru Hori
- Department of Psychiatry, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Junichi Iga
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Masaaki Iwata
- Department of Neuropsychiatry, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takahiko Inagaki
- Adolescent Mental Health Service, Biwako Hospital, Otsu, Japan.,Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan
| | - Kiyomi Shinohara
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - Hissei Imai
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - Atsunobu Murata
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Aran Tajika
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
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26
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Cosci F, Mansueto G, Fava GA. Relapse prevention in recurrent major depressive disorder. A comparison of different treatment options based on clinical experience and a critical review of the literature. Int J Psychiatry Clin Pract 2020; 24:341-348. [PMID: 32716222 DOI: 10.1080/13651501.2020.1779308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reducing the risk of relapses is a critical component of major depressive disorders treatment. Guidelines suggest maintenance with antidepressant drugs in recurrent depression, but this solution has recently been questioned. OBJECTIVE The aim of this article is to provide a critical review of the literature of the main treatment options currently available to prevent relapse and recurrence in depression. METHODS We compared long-term antidepressant therapy (i.e., indefinite maintenance of antidepressant), intermittent antidepressant therapy (i.e., use of antidepressants mainly limited to the acute phases), use of psychotherapy in the sequential model (i.e., pharmacotherapy in the acute phase and psychotherapy in the residual phase). RESULTS We argue that the same solution may not apply to all patients and question the feasibility of a single course of treatment in the setting of complex disorders that are encountered in practice. The clinician should weigh advantages and disadvantages in the individual case. CONCLUSIONS The sequential model appears to be particularly indicated in recurrent depression. KEY POINTS Relapse is a major challenge of depressive disorders treatment Treatment options currently available include long-term antidepressants, intermittent antidepressants, addition of psychotherapy to pharmacotherapy in the sequential model Maintenance with antidepressants in recurrent depression has recently been questioned The sequential model appears to be particularly indicated in recurrent depression.
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Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Department of Psychiatry & Neuropsychology, Maastricht University, Maastricht, the Netherlands
| | - Giovanni Mansueto
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Giovanni Andrea Fava
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
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27
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Blues in the Brain and Beyond: Molecular Bases of Major Depressive Disorder and Relative Pharmacological and Non-Pharmacological Treatments. Genes (Basel) 2020; 11:genes11091089. [PMID: 32961910 PMCID: PMC7564223 DOI: 10.3390/genes11091089] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Despite the extensive research conducted in recent decades, the molecular mechanisms underlying major depressive disorder (MDD) and relative evidence-based treatments remain unclear. Various hypotheses have been successively proposed, involving different biological systems. This narrative review aims to critically illustrate the main pathogenic hypotheses of MDD, ranging from the historical ones based on the monoaminergic and neurotrophic theories, through the subsequent neurodevelopmental, glutamatergic, GABAergic, inflammatory/immune and endocrine explanations, until the most recent evidence postulating a role for fatty acids and the gut microbiota. Moreover, the molecular effects of established both pharmacological and non-pharmacological approaches for MDD are also reviewed. Overall, the existing literature indicates that the molecular mechanisms described in the context of these different hypotheses, rather than representing alternative ones to each other, are likely to contribute together, often with reciprocal interactions, to the development of MDD and to the effectiveness of treatments, and points at the need for further research efforts in this field.
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28
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Predicting treatment effects in unipolar depression: A meta-review. Pharmacol Ther 2020; 212:107557. [PMID: 32437828 DOI: 10.1016/j.pharmthera.2020.107557] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/23/2020] [Indexed: 12/23/2022]
Abstract
There is increasing interest in clinical prediction models in psychiatry, which focus on developing multivariate algorithms to guide personalized diagnostic or management decisions. The main target of these models is the prediction of treatment response to different antidepressant therapies. This is because the ability to predict response based on patients' personal data may allow clinicians to make improved treatment decisions, and to provide more efficacious or more tolerable medications to the right patient. We searched the literature for systematic reviews about treatment prediction in the context of existing treatment modalities for adult unipolar depression, until July 2019. Treatment effect is defined broadly to include efficacy, safety, tolerability and acceptability outcomes. We first focused on the identification of individual predictor variables that might predict treatment response, and second, we considered multivariate clinical prediction models. Our meta-review included a total of 10 systematic reviews; seven (from 2014 to 2018) focusing on individual predictor variables and three focusing on clinical prediction models. These identified a number of sociodemographic, phenomenological, clinical, neuroimaging, remote monitoring, genetic and serum marker variables as possible predictor variables for treatment response, alongside statistical and machine-learning approaches to clinical prediction model development. Effect sizes for individual predictor variables were generally small and clinical prediction models had generally not been validated in external populations. There is a need for rigorous model validation in large external data-sets to prove the clinical utility of models. We also discuss potential future avenues in the field of personalized psychiatry, particularly the combination of multiple sources of data and the emerging field of artificial intelligence and digital mental health to identify new individual predictor variables.
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29
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Smit AC, Snippe E, Wichers M. Increasing Restlessness Signals Impending Increase in Depressive Symptoms More than 2 Months before It Happens in Individual Patients. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:249-251. [PMID: 31256155 DOI: 10.1159/000500594] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/24/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Arnout C Smit
- ICPE, Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,
| | - Evelien Snippe
- ICPE, Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marieke Wichers
- ICPE, Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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30
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DeRubeis RJ, Zajecka J, Shelton RC, Amsterdam JD, Fawcett J, Xu C, Young PR, Gallop R, Hollon SD. Prevention of Recurrence After Recovery From a Major Depressive Episode With Antidepressant Medication Alone or in Combination With Cognitive Behavioral Therapy: Phase 2 of a 2-Phase Randomized Clinical Trial. JAMA Psychiatry 2020; 77:237-245. [PMID: 31799993 PMCID: PMC6902236 DOI: 10.1001/jamapsychiatry.2019.3900] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/12/2019] [Indexed: 01/12/2023]
Abstract
Importance Antidepressant medication (ADM) maintenance treatment is associated with the prevention of depressive recurrence in patients with major depressive disorder (MDD), but whether cognitive behavioral therapy (CBT) treatment is associated with recurrence prevention remains unclear. Objective To determine the effects of combining CBT with ADM on the prevention of depressive recurrence when ADMs are withdrawn or maintained after recovery in patients with MDD. Design, Setting, and Participants A total of 292 adult outpatients with chronic or recurrent MDD who participated in the second phase of a 2-phase trial. Participants had recovered in the first phase of the trial receiving ADM, either alone or in combination with CBT. The trial was conducted in research clinics in 3 university medical centers in the United States. Patients in phase 2 were randomized to receive maintenance of or withdrawal from ADM and were followed up for 3 years. The first and last patients entered phase 2 in August 2003 and October 2009, respectively. The last patient completed phase 2 in August 2012. Data were analyzed from December 2013 to December 2018. Interventions Maintenance of or withdrawal from treatment with ADM. Main Outcomes and Measures Recurrence of an MDD episode using longitudinal interval follow-up evaluations; sustained recovery across both phases. Results A total of 292 participants (171 women, 121 men; mean [SD] age 45.1 [12.9] years) were included in analyses of depressive recurrence. Maintenance ADM yielded lower rates of recurrence compared with ADM withdrawal regardless of whether patients had achieved recovery in phase 1 with ADM alone (48.5% vs 74.8%; z = -3.16; P = .002; number needed to treat [NNT], 2.8; 95% CI, 1.8-7.0) or ADM plus CBT (48.5% vs 76.7%; z = -3.49; P < .001; NNT, 2.7; 95% CI, 1.9-5.9). Sustained recovery rates differed as a function of phase 2 condition, with maintenance ADM superior to ADM withdrawal (z = 2.90; P = .004; OR, 2.54; 95% CI, 1.37-4.84; NNT, 2.3; 95% CI, 1.5-6.4). Phase 1 condition was not associated with differential rates of sustained recovery (ADM alone vs ADM plus CBT; z = 0.22; P = .83; OR, 1.08; 95% CI, 0.52-2.11; NNT, 26.0; 95% CI, number needed to harm 3.2 to NNT 2.8), nor was there a significant interaction of phase 1 condition and phase 2 condition (z = 0.30; P = .77; OR, 1.14; 95% CI, 0.49-2.88). Conclusions and Relevance Maintenance ADM treatment, but not previous exposure to CBT, was associated with reduced rates of depressive recurrence. In previous studies, when CBT has been provided without ADM, CBT has shown a preventive effect on depressive relapse. Whether CBT also has a preventive effect on depressive recurrence, or if adding ADM interferes with any such preventive effect, remains unclear. Trial Registration ClinicalTrial.gov identifier: NCT00057577.
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Affiliation(s)
| | - John Zajecka
- Department of Psychiatry, Rush University, Chicago, Illinois
| | - Richard C. Shelton
- Department of Psychiatry, Vanderbilt University, Nashville, Tennessee
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham
| | - Jay D. Amsterdam
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Jan Fawcett
- Department of Psychiatry, University of New Mexico, Albuquerque
| | - Colin Xu
- Department of Psychology, University of Pennsylvania, Philadelphia
| | - Paula R. Young
- Department of Psychiatry, Rush University, Chicago, Illinois
| | - Robert Gallop
- Department of Mathematics and Applied Statistics, West Chester University, West Chester, Pennsylvania
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
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31
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Van Leeuwen E, van Driel ML, De Sutter AIM, Anderson K, Robertson L, Christiaens T. Discontinuation of long-term antidepressant use for depressive and anxiety disorders in adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Ellen Van Leeuwen
- Ghent University; Clinical Pharmacology Unit of the Department of Pharmacology; Ghent Belgium 9000
- Ghent University; Department of Family Medicine and Primary Health Care; Ghent Belgium
| | - Mieke L van Driel
- The University of Queensland; Primary Care Clinical Unit, Faculty of Medicine; Brisbane Queensland Australia 4029
| | - An IM De Sutter
- Ghent University; Department of Family Medicine and Primary Health Care; Ghent Belgium
| | - Kristen Anderson
- The University of Queensland; School of Pharmacy; Brisbane Australia
| | - Lindsay Robertson
- University of York; Cochrane Common Mental Disorders; Heslington York UK YO10 5DD
| | - Thierry Christiaens
- Ghent University; Clinical Pharmacology Unit of the Department of Pharmacology; Ghent Belgium 9000
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32
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Ormel J, Spinhoven P, de Vries YA, Cramer AOJ, Siegle GJ, Bockting CLH, Hollon SD. The antidepressant standoff: why it continues and how to resolve it. Psychol Med 2020; 50:177-186. [PMID: 31779735 DOI: 10.1017/s0033291719003295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antidepressant medications (ADMs) are widely used and long-term use is increasing. Given this extensive use and recommendation of ADMs in guidelines, one would expect ADMs to be universally considered effective. Surprisingly, that is not the case; fierce debate on their benefits and harms continues. This editorial seeks to understand why the controversy continues and how consensus can be achieved. METHODS 'Position' paper. Critical analysis and synthesis of relevant literature. RESULTS Advocates point at ADMs impressive effect size (number needed to treat, NNT = 6-8) in acute phase treatment and continuation/maintenance ADM treatment prevention relapse/recurrence in acute phase ADM responders (NNT = 3-4). Critics point at the limited clinically significant surplus value of ADMs relative to placebo and argue that effectiveness is overstated. We identified multiple factors that fuel the controversy: certainty of evidence is low to moderate; modest efficacy on top of strong placebo effects allows critics to focus on small net efficacy and advocates on large gross efficacy; ADM withdrawal symptoms masquerade as relapse/recurrence; lack of association between ADM treatment and long-term outcome in observational databases. Similar problems affect psychological treatments as well, but less so. We recommend four approaches to resolve the controversy: (1) placebo-controlled trials with relevant long-term outcome assessments, (2) inventive analyses of observational databases, (3) patient cohort studies including effect moderators to improve personalized treatment, and (4) psychological treatments as universal first-line treatment step. CONCLUSIONS Given the public health significance of depression and increased long-term ADM usage, new approaches are needed to resolve the controversy.
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Affiliation(s)
- Johan Ormel
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
| | - Philip Spinhoven
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Psychiatry, Leiden University, Institute of Psychology, Leiden, The Netherlands
| | - Ymkje Anna de Vries
- Department of Developmental Psychology, University of Groningen, Groningen, The Netherlands
| | - Angélique O J Cramer
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Methodology and Statistics, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Greg J Siegle
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Claudi L H Bockting
- Netherlands Institute for Advanced Study KNAW, Amsterdam, The Netherlands
- Department of Psychiatry, University of Amsterdam, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
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33
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Wang G, Han C, Liu CY, Chan S, Kato T, Tan W, Zhang L, Feng Y, Ng CH. Management of Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia. Neuropsychiatr Dis Treat 2020; 16:2943-2959. [PMID: 33299316 PMCID: PMC7721287 DOI: 10.2147/ndt.s264813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Consensus is lacking on the management of treatment-resistant depression (TRD), resulting in significant variations on how TRD patients are being managed in real-world practice. A survey explored how clinicians managed TRD across Asia, followed by an expert panel that interpreted the survey results and provided recommendations on how TRD could be managed in real-world clinical settings. METHODS Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan completed a survey related to their treatment approaches for TRD. RESULTS The survey showed physicians using more polytherapy (71%) compared to maintaining patients on monotherapy (29%). The most commonly (23%) administered polytherapy involved antidepressant augmentation with antipsychotics that 19% of physicians also indicated as their most important approach for managing TRD. The highest number of physicians (34%) ranked switching to another class of antidepressants as their most important approach, while 16% and 9% chose antidepressant combinations and electroconvulsive therapy (ECT), respectively. CONCLUSION Taking into account the survey results, the expert panel made general recommendations on the management of TRD. TRD partial-responders to antidepressants should be considered for augmentation with second-generation antipsychotics. For non-responders, switching to another class of antidepressants ought to be considered. TRD patients achieving remission with acute treatment should consider continuing their antidepressants for at least another 6 months to prevent relapse. ECT is a treatment consideration for patients with severe depression or persistent symptoms despite multiple adequate trials of antidepressants. Physicians should also consider the response, tolerability and adherence to the current and previous antidepressants, the severity of symptoms, comorbidities, concomitant medications, preferences, and cost when choosing a TRD treatment approach for each individual patient.
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Affiliation(s)
- Gang Wang
- The National Clinical Research Center for Mental Disorder & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, People's Republic of China
| | - Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, South Korea
| | - Chia-Yih Liu
- Department of Psychiatry, Chang Gung Medical Center, and Chang Gung University School of Medicine, Taoyuan City, Taiwan
| | - Sandra Chan
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Tadafumi Kato
- RIKEN Center for Brain Science, Wako, Saitama, Japan.,Department of Psychiatry and Behavioral Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Wilson Tan
- Regional Medical Affairs, Janssen Pharmaceutical Companies of Johnson and Johnson, Singapore, Singapore
| | - Lili Zhang
- Medical Affairs, Xian Janssen Pharmaceutical Ltd, Beijing, People's Republic of China
| | - Yu Feng
- Medical Affairs, Xian Janssen Pharmaceutical Ltd, Beijing, People's Republic of China
| | - Chee H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
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34
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Duffy L, Bacon F, Clarke CS, Donkor Y, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, King M, Lanham P, Lewis G, Mangin D, Marston L, Moore M, Nazareth I, Wiles N, Lewis G. A randomised controlled trial assessing the use of citalopram, sertraline, fluoxetine and mirtazapine in preventing relapse in primary care patients who are taking long-term maintenance antidepressants (ANTLER: ANTidepressants to prevent reLapse in dEpRession): study protocol for a randomised controlled trial. Trials 2019; 20:319. [PMID: 31159856 PMCID: PMC6547591 DOI: 10.1186/s13063-019-3390-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/02/2019] [Indexed: 01/08/2023] Open
Abstract
Background Antidepressants are used both for treating acute episodes and for prophylaxis to prevent future episodes of depression, also called maintenance treatment. This article describes the protocol for a randomised controlled trial (ANTLER: ANTidepressants to prevent reLapse in dEpRession) to investigate the clinical effectiveness and cost-effectiveness in UK primary care of continuing on long-term maintenance antidepressants compared with a placebo in preventing relapse of depression in those who have taken antidepressants for more than 9 months and who are currently well enough to consider stopping maintenance treatment. Methods/design The ANTLER trial is an individually randomised, double-blind, placebo-controlled trial in which participants are randomised to remain on active medication or to take an identical placebo after a tapering period of 2 months. Eligible participants are those who: are between the ages of 18 and 74 years; have had at least two episodes of depression; and have been taking antidepressants for 9 months or more and are currently taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg but are well enough to consider stopping their medication. The participants will be followed up at 6, 12, 26, 39 and 52 weeks. The primary outcome will be the time in weeks to the beginning of the first episode of depression after randomisation. This will be measured using a retrospective version of the Clinical Interview Schedule—Revised administered at 12, 26, 39 and 52 weeks. Secondary outcomes will include depressive and anxiety symptoms, adverse effects, withdrawal symptoms, emotional processing tasks, quality of life and the resources and costs used. We will also perform a cost-effectiveness analysis based on results of the trial. Discussion The ANTLER trial findings will inform primary care prescribing practice by providing a valid and generalisable estimate of the clinical effectiveness and cost-effectiveness of long-term maintenance treatment with antidepressants in UK primary care. Trial registration Controlled Trials ISRCTN Registry, ISRCTN15969819. Registered on 21 September 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3390-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Faye Bacon
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Yvonne Donkor
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nick Freemantle
- Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Comprehensive Clinical Trials Unit, University College London, 90 High Holborn 2nd Floor, London, WC1V 6LJ, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tony Kendrick
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Michael King
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Paul Lanham
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.,Department of General Practice, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Michael Moore
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
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Machmutow K, Meister R, Jansen A, Kriston L, Watzke B, Härter MC, Liebherz S. Comparative effectiveness of continuation and maintenance treatments for persistent depressive disorder in adults. Cochrane Database Syst Rev 2019; 5:CD012855. [PMID: 31106850 PMCID: PMC6526465 DOI: 10.1002/14651858.cd012855.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Persistent depressive disorder (PDD) is defined as a depressive disorder with a minimum illness duration of two years, including four diagnostic subgroups (dysthymia, chronic major depression, recurrent major depression with incomplete remission between episodes, and double depression). Persistent forms of depression represent a substantial proportion of depressive disorders, with a lifetime prevalence ranging from 3% to 6% in the Western world. Growing evidence indicates that PDD responds well to several acute interventions, such as combined psychological and pharmacological treatments. Yet, given the high rates of relapse and recurrences of depression following response to acute treatment, long-term continuation and maintenance therapy are of great importance. To date, there has been no evidence synthesis available on continuation and maintenance treatments of PDDs. OBJECTIVES To assess the effects of pharmacological and psychological (either alone or combined) continuation and maintenance treatments for persistent depressive disorder, in comparison with each other, placebo (drug/attention placebo/non-specific treatment control), and treatment as usual (TAU). Continuation treatments are defined as treatments given to currently remitted people (remission is defined as depressive symptoms dropping below case level) or to people who previously responded to an antidepressant treatment. Maintenance therapy is given during recovery (which is defined as remission lasting longer than six months). SEARCH METHODS We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 28 September 2018. An earlier search of these databases was also conducted for RCTs via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 Dec 2015). In addition we searched grey literature resources as well as the international trial registers ClinicalTrials.gov and ICTRP to 28 September 2018. We screened reference lists of included studies and contacted the first author of all included studies. SELECTION CRITERIA We included randomized (RCTs) and non-randomized controlled trials (NRCTs) in adults with formally diagnosed PDD, receiving pharmacological, psychological, or combined continuation and maintenance interventions. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted and analyzed data. The primary efficacy outcome was relapse/recurrence rate of depression. The primary acceptance outcome was dropout due to any reason other than relapse/recurrence. We performed random-effects meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 10 studies (seven RCTs, three NRCTs) involving 840 participants in this review, from which five studies investigated continuation treatments and five studies investigated maintenance treatments. Overall, the included studies were at low-to-moderate risk of bias. For the three NRCTs, the most common source of risk of bias was selection of reported results. For the seven RCTs, the most common sources of risk of bias was non-blinding of outcome assessment and other bias (especially conflict of interest due to pharmaceutical sponsoring).Pharmacological continuation and maintenance therapiesThe most common comparison was antidepressant medication versus tablet placebo (five studies). Participants taking antidepressant medication were probably less likely to relapse or to experience a recurrent episode compared to participants in the placebo group at the end of the intervention (13.9% versus 33.8%, RR 0.41, 95% CI 0.21 to 0.79; participants = 383; studies = 4; I² = 54%, moderate quality evidence). Overall dropout rates may be similar between participants in the medication and placebo group (23.0% versus 25.5%, RR 0.90, 95% CI 0.39 to 2.11; RCTs = 4; participants = 386; I² = 64%, low quality evidence). However, sensitivity analyses showed that the primary outcome (rate of relapse/recurrence) showed no evidence of a difference between groups when only including studies with low risk of bias.None of the studies compared pharmacological or psychological treatments versus TAU.Psychological continuation and maintenance therapiesOne study compared psychological therapies versus attention placebo/non-specific control. One study compared psychotherapy with medication. The results of the studies including psychotherapy might indicate that continued or maintained psychotherapy could be a useful intervention compared to no treatment or antidepressant medication. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusions.Combined psychological and pharmacological continuation and maintenance therapiesThree studies compared combined psychological and pharmacological therapies with pharmacological therapies alone. One study compared combined psychological and pharmacological therapies with psychotherapeutic therapies alone. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusionsComparison of different antidepressant medications Two studies reported data on the direct comparison of two antidepressants. However, the body of evidence for this comparison was too small and uncertain to draw any high quality conclusions. AUTHORS' CONCLUSIONS Currently, it is uncertain whether continued or maintained pharmacotherapy (or both) with the reviewed antidepressant agents is a robust treatment for preventing relapse and recurrence in people with PDD, due to moderate or high risk of bias as well as clinical heterogeneity in the analyzed studies.For all other comparisons, the body of evidence was too small to draw any final conclusions, although continued or maintained psychotherapy might be effective compared to no treatment. There is need for more high quality trials of psychological interventions. Further studies should address health-related quality of life and adverse events more precisely, as well as assessing follow-up data.
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Affiliation(s)
- Katja Machmutow
- University of ZurichDepartment of Clinical Psychology and PsychotherapyZurichSwitzerland
- Psychiatrische Dienste Aargau AGWindischSwitzerland
| | - Ramona Meister
- University Medical Center Hamburg‐EppendorfDepartment of Medical PsychologyMartinistr. 52HamburgHamburgGermanyD‐20246
| | - Alessa Jansen
- University Medical Center Hamburg‐EppendorfDepartment of Medical PsychologyMartinistr. 52HamburgHamburgGermanyD‐20246
| | - Levente Kriston
- University Medical Center Hamburg‐EppendorfDepartment of Medical PsychologyMartinistr. 52HamburgHamburgGermanyD‐20246
| | - Birgit Watzke
- University of ZurichDepartment of Clinical Psychology and PsychotherapyZurichSwitzerland
| | - Martin Christian Härter
- University Medical Center Hamburg‐EppendorfDepartment of Medical PsychologyMartinistr. 52HamburgHamburgGermanyD‐20246
| | - Sarah Liebherz
- University Medical Center Hamburg‐EppendorfDepartment of Medical PsychologyMartinistr. 52HamburgHamburgGermanyD‐20246
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Shinohara K, Efthimiou O, Ostinelli EG, Tomlinson A, Geddes JR, Nierenberg AA, Ruhe HG, Furukawa TA, Cipriani A. Comparative efficacy and acceptability of antidepressants in the long-term treatment of major depression: protocol for a systematic review and networkmeta-analysis. BMJ Open 2019; 9:e027574. [PMID: 31110100 PMCID: PMC6530313 DOI: 10.1136/bmjopen-2018-027574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/22/2019] [Accepted: 03/27/2019] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Pharmacotherapy plays an important role in the treatment of major depression. At the initiation of antidepressant treatment, both improvement of symptoms in the short term and relapse prevention in the long term should be taken into account. However, there is insufficient evidence regarding the efficacy and the acceptability of continuation/maintenance treatments and the relative efficacy/acceptability of antidepressants. OBJECTIVE We will conduct a pairwise meta-analysis and a network meta-analysis (NMA) to examine the relative efficacy, tolerability and acceptability of antidepressants in the long-term treatment of major depression. METHODS AND ANALYSIS We will include double-blind randomised controlled trials comparing any of the following antidepressants, which we included in our previous NMA of the acute treatment for major depression, with placebo or with another active drug for long-term treatment of major depression: agomelatine, amitriptyline, bupropion, citalopram, clomipramine, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, trazodone, venlafaxine, vilazodone and vortioxetine. Our primary outcomes will be sustained response and all-cause dropouts. We will include four types of designs that are used to investigate long-term treatment. We will conduct two main analyses. First, we will conduct a pairwise meta-analysis comparing all antidepressants versus placebo to investigate whether continuing antidepressants after achieving a positive response in the acute-phase treatment is beneficial and/or safe. Second, we will conduct an NMA to examine the comparative efficacy and acceptability of the drugs. We will use a novel approach that will combine the results of acute-phase treatment NMA with long-term treatment studies to include all related designs in the NMA. We will ensure the validity of combining different designs and our new approach by checking the distribution of important effect modifiers and consistency of network. ETHICS AND DISSEMINATION This study did not require ethical approval. We will disseminate our findings by publishing results in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018114561; Pre-results.
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Affiliation(s)
- Kiyomi Shinohara
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - John R Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Henricus G Ruhe
- Department of Psychiatry, Radboud University, Nijmegen, the Netherlands
| | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Abstract
Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. The first review outlined an approach to screening and diagnosing depression in primary care. This second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.
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Affiliation(s)
- Parashar Ramanuj
- Center for Family and Community Medicine, Columbia University Medical Center, New York, NY, USA
- Royal National Orthopaedic Hospital
| | | | - Harold Alan Pincus
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY, USA
- Irving Institute for Clinical and Translational Research, Columbia University, New York, NY, USA
- RAND Corporation, Pittsburgh, PA, USA
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Durgam S, Chen C, Migliore R, Prakash C, Thase ME. Relapse prevention with levomilnacipran ER in adults with major depressive disorder: A multicenter, randomized, double-blind, placebo-controlled study. Depress Anxiety 2019; 36:225-234. [PMID: 30675739 PMCID: PMC6590342 DOI: 10.1002/da.22872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 09/27/2018] [Accepted: 11/30/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Levomilnacipran extended release (ER) is a serotonin and norepinephrine reuptake inhibitor approved for major depressive disorder (MDD) in adults. This study was designed to evaluate relapse prevention with levomilnacipran ER in patients with MDD. METHODS Patients (≥18 years) with MDD (N = 644) received 20 weeks of open-label treatment with levomilnacipran ER 40, 80, or 120 mg/d (8 weeks flexible dosing; 12 weeks fixed dosing). Patients with a Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≤12 from the end of week 8 to week 20 were randomized to 26 weeks of double-blind treatment with levomilnacipran ER (same dosage; n = 165) or placebo (n = 159). The primary efficacy endpoint was time to relapse, defined as insufficient therapeutic response (≥2-point increase from randomization in Clinical Global Impression of Severity score, risk of suicide, need for hospitalization due to worsening of depression, or need for alternative antidepressant treatment as determined by the investigator) or an MADRS total score ≥18 at 2 consecutive visits. RESULTS In the double-blind intent-to-treat population, levomilnacipran ER-treated patients had a significantly longer time to relapse compared with placebo (hazard ratio = 0.56; 95% CI, 0.33-0.92; P = 0.0212). Crude relapse rates were 14.5% (levomilnacipran ER) and 24.5% (placebo). Double-blind treatment-emergent adverse events (AEs) were reported for 58.8% and 56.0% of levomilnacipran ER and placebo patients, respectively; 3.0% and 1.3% discontinued due to AEs, and 1.2% and 0.6% had serious AEs, respectively. CONCLUSION Levomilnacipran ER (40-120 mg/d) was effective in preventing relapse in patients with MDD. Safety and tolerability results were consistent with levomilnacipran ER acute studies.
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Affiliation(s)
| | | | | | | | - Michael E. Thase
- University of Pennsylvania Health SystemPhiladelphiaPennsylvania
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Klein NS, Wijnen BFM, Lokkerbol J, Buskens E, Elgersma HJ, van Rijsbergen GD, Slofstra C, Ormel J, Dekker J, de Jong PJ, Nolen WA, Schene AH, Hollon SD, Burger H, Bockting CLH. Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants. BJPsych Open 2019; 5:e12. [PMID: 30762507 PMCID: PMC6381417 DOI: 10.1192/bjo.2018.81] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/-AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact. METHOD Data were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model. RESULTS Mean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/-AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/-AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/-AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/-AD. CONCLUSIONS Adding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/-AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor of PLOS One and receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.
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Affiliation(s)
- Nicola S Klein
- PhD Candidate,Department of Clinical Psychology and Experimental Psychopathology,University of Groningen;and Psychologist, Top Referent Traumacentrum,GGZ Drenthe,the Netherlands
| | - Ben F M Wijnen
- Health Economist,Center of Economic Evaluation,Trimbos Institute (Netherlands Institute of Mental Health and Addiction);and Postdoctoral Researcher,Department of Health Services Research,Maastricht University,Care and Public Health Research Institute CAPHRI,the Netherlands
| | - Joran Lokkerbol
- Director, Center of Economic Evaluation,Trimbos Institute (Netherlands Institute of Mental Health and Addiction),the Netherlands;and Harkness Fellow in Health Care Policy and Practice,Department of Health Care Policy,Harvard Medical School,USA
| | - Erik Buskens
- Professor of Health Technology Assessment,Faculty of Economics and Business,University Medical Center Groningen, University of Groningen,the Netherlands
| | - Hermien J Elgersma
- PhD Candidate,Department of Clinical Psychology and Experimental Psychopathology,University of Groningen;and Clinical Psychologist,Accare,the Netherlands
| | - Gerard D van Rijsbergen
- Health Care Psychologist,Department of Early Detection and Intervention in Psychosis,GGZ Drenthe,the Netherlands
| | - Christien Slofstra
- Senior Researcher,Lentis Psychiatric Institute,Lentis Research,the Netherlands
| | - Johan Ormel
- Professor of Psychiatric Epidemiology,University Center for Psychiatry and Interdisciplinary Center Psychiatric Epidemiology,University of Groningen, University Medical Center Groningen,the Netherlands
| | - Jack Dekker
- Professor, Department of Clinical, Neuro and Developmental Psychology,Vrije Universiteit;and Head of Research Department,Arkin Mental Health Institute,the Netherlands
| | - Peter J de Jong
- Professor of Experimental Psychopathology,Chair of Department of Clinical Psychology and Experimental Psychopathology,University of Groningen,the Netherlands
| | - Willem A Nolen
- Emeritus Professor,Department of Psychiatry,University of Groningen, University Medical Center Groningen,the Netherlands
| | - Aart H Schene
- Professor of Psychiatry,Head of the Department of Psychiatry,Radboud University Medical Center;and Principal Investigator,Donders Institute for Brain,Cognition and Behavior,Radboud University,the Netherlands
| | - Steven D Hollon
- Professor of Psychology, Department of Psychology,Vanderbilt University,USA
| | - Huibert Burger
- Associate Professor of Clinical Epidemiology,Department of General Practice,University of Groningen, University Medical Center Groningen;and Associate Professor of Clinical Epidemiology,Amsterdam UMC, location AMC,Department of Psychiatry,University of Amsterdam,the Netherlands
| | - Claudi L H Bockting
- Professor of Clinical Psychology in Psychiatry,Amsterdam UMC, location AMC,Department of Psychiatry,University of Amsterdam,the Netherlands
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Pope CJ, Sharma V, Sommerdyk C, Mazmanian D. Antidepressants and recurrence of depression in the postpartum period. Arch Womens Ment Health 2018; 21:821-828. [PMID: 29943237 DOI: 10.1007/s00737-018-0877-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/15/2018] [Indexed: 11/24/2022]
Abstract
To examine postpartum recurrence rates of depression comparing women receiving antidepressant treatment to women not being treated with psychotropic medication. This was a prospective study of 130 women with major depressive disorder (MDD) who attended a tertiary care perinatal clinic during and after pregnancy. Depression recurrence was defined as a score of 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) or a score of greater than 13 on the Hamilton Depression Rating Scale (HDRS). Over half of women (56.9%) were not receiving medication during pregnancy to treat their mood disorder, with the rate of medication use increasing over the 1-year postpartum period. When comparing women being treated with antidepressant medication (monotherapy or combination therapy) to women receiving no psychotropic medication, no significant differences in recurrence rates were observed during the postpartum period. However, we did observe that the occurrence of depression in our sample fluctuated between rates comparable to general population estimates to rates that were at times more than twofold higher, regardless of treatment with antidepressant medication. The findings of this study align with research which suggests that the postpartum period is a particularly vulnerable time for recurrence of depression. Moreover, our results suggest that this remains the case regardless of antidepressant treatment.
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Affiliation(s)
- C J Pope
- Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Verinder Sharma
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada. .,St. Joseph's Health Care London, Parkwood Institute Mental Health Care Building, 550 Wellington Road, London, Ontario, N6C 0A7, Canada.
| | - C Sommerdyk
- St. Joseph's Health Care London, Parkwood Institute Mental Health Care Building, 550 Wellington Road, London, Ontario, N6C 0A7, Canada
| | - D Mazmanian
- Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
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Slofstra C, Nauta MH, Bringmann LF, Klein NS, Albers CJ, Batalas N, Wichers M, Bockting CL. Individual Negative Affective Trajectories Can Be Detected during Different Depressive Relapse Prevention Strategies. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:243-245. [PMID: 29758551 PMCID: PMC6159830 DOI: 10.1159/000489044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 04/04/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Christien Slofstra
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Maaike H. Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Laura F. Bringmann
- Department of Psychometrics and Statistics, University of Groningen, Groningen, the Netherlands,Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry (UCP), University Medical Center Groningen (UMCG), University of Groningen, Groningen, the Netherlands
| | - Nicola S. Klein
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Casper J. Albers
- Department of Psychometrics and Statistics, University of Groningen, Groningen, the Netherlands
| | - Nikolaos Batalas
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Marieke Wichers
- Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry (UCP), University Medical Center Groningen (UMCG), University of Groningen, Groningen, the Netherlands
| | - Claudi L.H. Bockting
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands,Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands,*Claudi L.H. Bockting, Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Meibergdreef 5, NL–1105 AZ Amsterdam (The Netherlands), E-Mail
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Bockting CLH, Klein NS, Elgersma HJ, van Rijsbergen GD, Slofstra C, Ormel J, Buskens E, Dekker J, de Jong PJ, Nolen WA, Schene AH, Hollon SD, Burger H. Effectiveness of preventive cognitive therapy while tapering antidepressants versus maintenance antidepressant treatment versus their combination in prevention of depressive relapse or recurrence (DRD study): a three-group, multicentre, randomised controlled trial. Lancet Psychiatry 2018; 5:401-410. [PMID: 29625762 DOI: 10.1016/s2215-0366(18)30100-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Keeping individuals on antidepressants after remission or recovery of major depressive disorder is a common strategy to prevent relapse or recurrence. Preventive cognitive therapy (PCT) has been proposed as an alternative to maintenance antidepressant treatment, but whether its addition would allow tapering of antidepressants or enhance the efficacy of maintenance antidepressant treatment is unclear. We aimed to compare the effectiveness of antidepressants alone, with PCT while tapering off antidepressants, or PCT added to antidepressants in the prevention of relapse and recurrence. METHODS In this single-blind, multicentre, parallel, three-group, randomised controlled trial, individuals recruited by general practitioners, pharmacists, secondary mental health care, or media were randomly assigned (10:10:8) to PCT and antidepressants, antidepressants alone, or PCT with tapering of antidepressants, using computer-generated randomised allocation stratified for number of previous depressive episodes and type of care. Eligible participants had previously experienced at least two depressive episodes and were in remission or recovery on antidepressants, which they had been receiving for at least the past 6 months. Exclusion criteria were current mania or hypomania, a history of bipolar disorder, any history of psychosis, current alcohol or drug abuse, an anxiety disorder that requires treatment, psychological treatment more than twice a month, and a diagnosis of organic brain damage. The primary outcome was time-related proportion of individuals with depressive relapse or recurrence in the intention-to-treat population, assessed four times in 24 months. Assessors were masked to treatment allocation, whereas physicians and participants could not be masked. This trial is registered with the Netherlands Trial Register, number NTR1907. FINDINGS Between July 14, 2009, and April 30, 2015, 2486 participants were assessed for eligibility and 289 were randomly assigned to PCT and antidepressant (n=104), antidepressant alone (n=100), or PCT with tapering of antidepressant (n=85). The overall log-rank test was significant (p=0·014). Antidepressants alone were not superior to PCT while tapering off antidepressants in terms of the risk of relapse or recurrence (hazard ratio [HR] 0·86, 95% CI 0·56-1·32; p=0·502). Adding PCT to antidepressant treatment resulted in a 41% relative risk reduction compared with antidepressants alone (0·59, 0·38-0·94; p=0·026). There were two suicide attempts (one in the antidepressants alone group and one in the PCT with tapering of antidepressants group) and one death (in the PCT and antidepressants group) not related to the interventions during the 24 months' follow-up. INTERPRETATION Maintenance antidepressant treatment is not superior to PCT after recovery, whereas adding PCT to antidepressant treatment after recovery is superior to antidepressants alone. PCT should be offered to recurrently depressed individuals on antidepressants and to individuals who wish to stop antidepressants after recovery. FUNDING The Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Claudi L H Bockting
- Academic Medical Centre, Department of Psychiatry, University of Amsterdam, Amsterdam, Netherlands; Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands.
| | - Nicola S Klein
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - Hermien J Elgersma
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - Gerard D van Rijsbergen
- Department of Early Detection and Intervention in Psychosis, GGZ Drenthe, Assen, Netherlands
| | | | - Johan Ormel
- University Medical Centre Groningen, Department of Psychiatry, University of Groningen, Groningen, Netherlands
| | - Erik Buskens
- Health Technology Assessment, University of Groningen, Groningen, Netherlands
| | - Jack Dekker
- Department of Clinical, Neuro and Developmental Psychology, VU University Amsterdam, Amsterdam, Netherlands; Arkin Institute for Mental Health, Amsterdam, Netherlands
| | - Peter J de Jong
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - Willem A Nolen
- University Medical Centre Groningen, Department of Psychiatry, University of Groningen, Groningen, Netherlands
| | - Aart H Schene
- Department of Psychiatry, Radboud University Medical Centre, and Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Huibert Burger
- Department of General Practice, University of Groningen, Groningen, Netherlands
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Kennedy JC, Dunlop BW, Craighead LW, Nemeroff CB, Mayberg HS, Craighead WE. Follow-up of monotherapy remitters in the PReDICT study: Maintenance treatment outcomes and clinical predictors of recurrence. J Consult Clin Psychol 2018; 86:189-199. [PMID: 29369664 PMCID: PMC6892631 DOI: 10.1037/ccp0000279] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study followed remitted patients from a randomized controlled trial of adults with major depressive disorder (MDD). The aims were to describe rates of recurrence and to evaluate 3 clinical predictor domains. METHOD Ninety-four treatment-naïve patients (50% female; Mage = 38.1 years; 48.9% White; 30.9% Hispanic) with MDD who had remitted to 12-week monotherapy (escitalopram, duloxetine, or cognitive behavior therapy [CBT]) participated in a 21-month maintenance phase (i.e., continued medication or 3 possible CBT booster sessions per year). Recurrence was assessed quarterly, and the clinical predictors were the following: 2 measures of residual depressive symptoms, 1 measure of lifetime depressive episodes, and 2 measures of baseline anxiety. Survival analysis models evaluated recurrence rates, and regression models evaluated the predictors. RESULTS Among all patients, 15.5% experienced a recurrence, and the survival distributions did not statistically differ among treatments. Residual depressive symptoms on the Hamilton Depression Rating Scale at the end of monotherapy were associated with increased risk for recurrence (hazard ratio = 1.31, 95% confidence interval [CI: 1.02, 1.67], Wald χ2 = 4.41, p = .036), and not having a comorbid anxiety disorder diagnosis at study baseline reduced the risk of recurrence (hazard ratio = .31, 95% CI [.10, .94], Wald χ2 = 4.28, p = .039). CONCLUSIONS The study supported the benefits of maintenance treatment for treatment-naïve patients who remitted to initial monotherapy; nevertheless, remitted patients with a comorbid anxiety disorder diagnosis at the beginning of treatment or residual depressive symptoms after initial treatment were at risk for poorer long-term outcomes. (PsycINFO Database Record
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Affiliation(s)
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University
| | | | | | - Helen S Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University
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Li K, Tao J, Li Y, Chen M, Wu X, Liao Y, Lin X, Gan Z. Patterns of persistence with pharmacological treatment among patients with current depressive episode and their impact on long-term outcome: a naturalistic study with 5-year follow-up. Patient Prefer Adherence 2018; 12:681-693. [PMID: 29765205 PMCID: PMC5939908 DOI: 10.2147/ppa.s160767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The aim of the study was to describe and compare the patterns of medication persistence among patients with unipolar depression (UD) or bipolar depression in a 5-year follow-up, and explore their impact on long-term outcome. PATIENTS AND METHODS A total of 333 eligible patients with current major depressive episode were observed and followed up from the first index prescription for 5 years. Lack of persistence or treatment interruption was defined as a gap of at least 2 consecutive months without taking any medication. Time to lack of persistence in the first (TLP1) and the second (TLP2) episode of treatment, number of visits before the first treatment interruption (NV) and number of treatment interruptions (NTI) were measured. RESULTS During the 5-year follow-up, nearly 50% of patients experienced at least two times of treatment interruption. Pattern of medication persistence did not significantly differ between UD and bipolar disorder (BD) patients. TLP1 was positively associated with TLP2. Shorter TLP1 predicted a higher possibility of subsequent visits because of recurrence or relapse and more NTI meant a lower likelihood of achieving full remission in the fifth year for both UD and BD patients. For UD patients, shorter TLP1 or less NV predicted a lower chance of achieving remission, while for BD patients, shorter TLP1 meant an earlier subsequent visit and more NTI predicted a lower possibility of achieving remission. CONCLUSION Pattern of medication persistence was similar but its impact on the long-term outcome was quite different between UD and BD.
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Affiliation(s)
- Kanglai Li
- Department of Very Important Patient, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Jiong Tao
- Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yuemei Li
- Department of Obstetrics, Wuzhou Gongren Hospital, Wuzhou, People’s Republic of China
| | - Minhua Chen
- Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Xiuhua Wu
- Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yingtao Liao
- Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Xiaolan Lin
- Department of Infectious Diseases, the 3rd Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
- Correspondence: Xiaolan Lin, Department of Infectious Diseases, the 3rd Affiliated Hospital of Sun Yat-Sen University, No 600, Tianhe Road, Tianhe District, Guangzhou 510630, Guangdong, People’s Republic of China, Tel +86 20 8525 3333, Fax +86 20 8525 3336, Email
| | - Zhaoyu Gan
- Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Zhaoyu Gan, Department of Psychiatry, the 3rd Affiliated Hospital of Sun Yat-Sen University, No 600, Tianhe Road, Tianhe District, Guangzhou, Guangdong 510630, People’s Republic of China, Tel +86 20 8525 3423, Fax +86 20 8525 2479, Email
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Differing antidepressant maintenance methodologies. Contemp Clin Trials 2017; 61:87-95. [DOI: 10.1016/j.cct.2017.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022]
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Oluboka OJ, Katzman MA, Habert J, McIntosh D, MacQueen GM, Milev RV, McIntyre RS, Blier P. Functional Recovery in Major Depressive Disorder: Providing Early Optimal Treatment for the Individual Patient. Int J Neuropsychopharmacol 2017; 21:128-144. [PMID: 29024974 PMCID: PMC5793729 DOI: 10.1093/ijnp/pyx081] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Major depressive disorder is an often chronic and recurring illness. Left untreated, major depressive disorder may result in progressive alterations in brain morphometry and circuit function. Recent findings, however, suggest that pharmacotherapy may halt and possibly reverse those effects. These findings, together with evidence that a delay in treatment is associated with poorer clinical outcomes, underscore the urgency of rapidly treating depression to full recovery. Early optimized treatment, using measurement-based care and customizing treatment to the individual patient, may afford the best possible outcomes for each patient. The aim of this article is to present recommendations for using a patient-centered approach to rapidly provide optimal pharmacological treatment to patients with major depressive disorder. Offering major depressive disorder treatment determined by individual patient characteristics (e.g., predominant symptoms, medical history, comorbidities), patient preferences and expectations, and, critically, their own definition of wellness provides the best opportunity for full functional recovery.
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Affiliation(s)
- Oloruntoba J Oluboka
- Department of Psychiatry, University of Calgary, Alberta, Canada,Correspondence: Oloruntoba J. Oluboka, MD, Director, PES/PORT, Consultant Psychiatrist, Addiction and Mental Health, South Health Campus, Alberta Health Services, Assistant Clinical Professor of Psychiatry, University of Calgary, Calgary, Canada ()
| | - Martin A Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, Ontario, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Diane McIntosh
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Glenda M MacQueen
- Mathison Centre for Mental Health Research and Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Roumen V Milev
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
| | - Roger S McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Ontario, Canada
| | - Pierre Blier
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario
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Slofstra C, Klein NS, Nauta MH, Wichers M, Batalas N, Bockting CL. Imagine your mood: Study design and protocol of a randomized controlled micro-trial using app-based experience sampling methodology to explore processes of change during relapse prevention interventions for recurrent depression. Contemp Clin Trials Commun 2017; 7:172-178. [PMID: 29696182 PMCID: PMC5898558 DOI: 10.1016/j.conctc.2017.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/03/2017] [Accepted: 07/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background Relapse prevention strategies include continuation of antidepressant medication and preventive psychological interventions. This study aims to gain understanding that may inform tailoring of relapse prevention to individual differences, to improve their effects. Such treatment personalization may be based on repeated assessments within one individual, using experience sampling methodology. As a first step towards informing decisions based on this methodology, insight is needed in individual differences in risk of relapse and response to treatment, and how relapse prevention strategies may differentially target vulnerability for relapse. Methods The smartphone application ‘Imagine your mood’ has been developed specifically for this study to assess emotions, imagery, cognitions, and behaviors in daily life. Parallel to the randomized controlled trial ‘Disrupting the rhythm of depression’, 45 remitted recurrently depressed individuals taking continuation antidepressant medication will be randomly assigned to either continuing antidepressant medication (n = 15), continuing antidepressant medication combined with an eight-session preventive cognitive therapy (n = 15), or tapering of antidepressant medication in combination with preventive cognitive therapy (n = 15). Relapse and return of depressive symptomatology over a 24-month follow-up will be assessed. Additionally, matched never depressed individuals (n = 15) will be recruited as controls. Discussion This innovative study combines the strengths of a randomized controlled trial and experience sampling methodology in a micro-trial to explore individual differences in risk of relapse and what works for whom to prevent relapse. Results may ultimately pave the way for therapists to tailor relapse prevention strategies to individual (affective) vulnerability. Trial registration ISRCTN15472145, retrospectively registered.
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Affiliation(s)
- Christien Slofstra
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Nicola S. Klein
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Maaike H. Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
| | - Marieke Wichers
- University of Groningen, University Medical Center Groningen (UMCG), Department of Psychiatry (UCP), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), 9700 RB, Groningen, The Netherlands
| | - Nikolaos Batalas
- Department of Industrial Design, Eindhoven University of Technology, 5612 AZ, Eindhoven, The Netherlands
| | - Claudi L.H. Bockting
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 TS, Groningen, The Netherlands
- Department of Clinical Psychology, Utrecht University, 3508 TC, Utrecht, The Netherlands
- Corresponding author. Department of Clinical & Health Psychology, Utrecht University, 3508 TC, Utrecht, The Netherlands.
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Tiihonen J, Tanskanen A, Hoti F, Vattulainen P, Taipale H, Mehtälä J, Lähteenvuo M. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry 2017; 4:547-553. [PMID: 28578901 DOI: 10.1016/s2215-0366(17)30134-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/09/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Little is known about the comparative effectiveness of long-term pharmacological treatments for severe unipolar depression. We aimed to study the effectiveness of pharmacological treatments in relapse prevention in a nationwide cohort of patients who had been admitted to hospital at least once as a result of unipolar depression. METHODS Our nationwide cohort study investigated the risk of readmission to hospital in 1996-2012 in all patients in Finland who had been admitted to hospital at least once for unipolar depression (without a diagnosis of schizophrenia or bipolar disorder) in Finland between Jan 1, 1987, and Dec 31, 2012. We used nationwide databases to obtain data for hospital admission, mortality, and dispensed medications. Exposure and non-exposure periods for medications were established using the PRE2DUP method. The primary analysis was within-individual analysis of readmission to hospital in the total cohort, in which each individual was used as his or her own control to eliminate selection bias. Putative survival and protopathic biases were controlled in sensitivity analyses. Since 33 independent statistical comparisons were done for specific medications, the level of statistical significance was set at p<0·0015. FINDINGS Data from 123 712 patients were included in the total cohort, with a mean follow-up time of 7·9 years (SD 5·3). Lithium use was associated with a lower risk of re-admission to hospital for mental illness than was no lithium use (hazard ratio [HR] 0·47 [95% CI 0·40-0·55]; p<0·0001), whereas the groups of antidepressants (HR 1·10 [1·06-1·13]; p<0·0001) and antipsychotics (HR 1·16 [1·12-1·20]; p<0·0001) were not associated with a reduced risk of readmission to hospital. Risk of hospital readmission was lower during lithium therapy alone (HR 0·31 [0·21-0·47]; p<0·0001) than during use of lithium with antidepressants (HR 0·50 [0·43-0·59]; p<0·0001). After lithium, clozapine (HR 0·65 [0·46-0·90]; p=0·010) and amitriptyline (HR 0·75 [0·70-0·81]; p<0·0001) were the specific agents associated with the next lowest risk of readmission. In the sensitivity analyses controlling for survival and protopathic biases, all drugs were associated with lower rates of readmission to hospital than they were in the primary analysis, showing the same rank order in comparative effectiveness. The lowest mortality was observed during antidepressant use (HR 0·56 [0·54-0·58]; p<0·0001). INTERPRETATION Our results indicate that lithium, especially without concomitant antidepressant use, is the pharmacological treatment associated with the lowest risk of hospital readmission for mental illness in patients with severe unipolar depression, and the outcomes for this measure related to antidepressants and antipsychotics are poorer than lithium. Lithium treatment should be considered for a wider population of severely depressed patients than those currently considered, taking into account its potential risks and side-effects. FUNDING The Finnish Ministry of Health.
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Affiliation(s)
- Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; National Institute for Health and Welfare, Impact Assessment Unit, Helsinki, Finland
| | | | | | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland; School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
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