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Braun C, Bschor T, Franklin J, Baethge C. Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:171-9. [PMID: 27043848 DOI: 10.1159/000442293] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use. METHODS We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs). RESULTS Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01). CONCLUSIONS Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.
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Affiliation(s)
- Cora Braun
- Department of Psychiatry and Psychotherapy, University of Cologne Medical School, Cologne, Germany
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Berwian IM, Walter H, Seifritz E, Huys QJM. Predicting relapse after antidepressant withdrawal - a systematic review. Psychol Med 2017; 47:426-437. [PMID: 27786144 PMCID: PMC5244448 DOI: 10.1017/s0033291716002580] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 09/07/2016] [Accepted: 09/08/2016] [Indexed: 12/28/2022]
Abstract
A substantial proportion of the burden of depression arises from its recurrent nature. The risk of relapse after antidepressant medication (ADM) discontinuation is high but not uniform. Predictors of individual relapse risk after antidepressant discontinuation could help to guide treatment and mitigate the long-term course of depression. We conducted a systematic literature search in PubMed to identify relapse predictors using the search terms '(depress* OR MDD*) AND (relapse* OR recurren*) AND (predict* OR risk) AND (discontinu* OR withdraw* OR maintenance OR maintain or continu*) AND (antidepress* OR medication OR drug)' for published studies until November 2014. Studies investigating predictors of relapse in patients aged between 18 and 65 years with a main diagnosis of major depressive disorder (MDD), who remitted from a depressive episode while treated with ADM and were followed up for at least 6 months to assess relapse after part of the sample discontinued their ADM, were included in the review. Although relevant information is present in many studies, only 13 studies based on nine separate samples investigated predictors for relapse after ADM discontinuation. There are multiple promising predictors, including markers of true treatment response and the number of prior episodes. However, the existing evidence is weak and there are no established, validated markers of individual relapse risk after antidepressant cessation. There is little evidence to guide discontinuation decisions in an individualized manner beyond overall recurrence risk. Thus, there is a pressing need to investigate neurobiological markers of individual relapse risk, focusing on treatment discontinuation.
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Affiliation(s)
- I. M. Berwian
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Wilfriedstrasse 6, 8032 Zürich, Switzerland
| | - H. Walter
- Mind and Brain, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - E. Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
| | - Q. J. M. Huys
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Wilfriedstrasse 6, 8032 Zürich, Switzerland
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53
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Chiu WC, Su YP, Su KP, Chen PC. Recurrence of depressive disorders after interferon-induced depression. Transl Psychiatry 2017; 7:e1026. [PMID: 28170005 PMCID: PMC5438022 DOI: 10.1038/tp.2016.274] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/31/2016] [Accepted: 11/28/2016] [Indexed: 01/14/2023] Open
Abstract
Interferon alpha (IFN-α)-treated patients commonly develop depression during the therapy period. Although most IFN-α-induced depressive disorders achieve remission after IFN-α therapy, no studies have examined the long-term mood effects of IFN-α treatment. We conducted a 12-year population-based cohort study of hepatitis C virus (HCV)-infected patients who were older than 20 years and had received IFN-α therapy. The sample was obtained from the Taiwan National Health Insurance Research Database. The cohort included patients with and without IFN-α-induced depression, matched randomly by age, sex and depression history, at a ratio of 1:10. The follow-up started after the last administration of IFN-α and was designed to determine the incidence of recurrent depressive disorder after IFN-α therapy. A total of 156 subjects were identified as having IFN-α-induced depression and achieving full remission after IFN-α therapy. The overall incidence of recurrent depressive disorders among patients with and without IFN-α-induced depression was 56.8 (95% confidence interval (CI), 42.4-76.1) and 4.1 (95% CI, 2.9-5.8) cases, respectively, per 100 000 person-years, P<0.001. The adjusted hazard ratios for recurrent depressive disorder were 13.5 (95% CI, 9.9-18.3) in the IFN-α-treated cohort and 22.2 (95% CI, 11.2-44.2) in the matched cohort for IFN-α-induced depression patients after adjusting for age, sex, income, urbanization and comorbid diseases. IFN-α-induced depression was associated with a high risk of recurrent depression. It was not a transient disease and might be considered an episode of depressive disorder. Continuation therapy might be considered, and further research is needed.
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Affiliation(s)
- W-C Chiu
- Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan,School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Y-P Su
- Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan,School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - K-P Su
- Graduate Institute of Neural and Cognitive Sciences, China Medical University, Taichung, Taiwan,Department of Psychiatry and Mind-Body Interface Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - P-C Chen
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan,Department of Environmental and Occupational Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan,Department of Public Health, National Taiwan University College of Public Health, Taipei, Taiwan,Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, 17 Syujhou Road, Taipei 10055, Taiwan. E-mail:
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54
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Dunlop BW. Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:156-173. [PMID: 31975799 PMCID: PMC6519650 DOI: 10.1176/appi.focus.20150042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.
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Affiliation(s)
- Boadie W Dunlop
- Dr. Dunlop is with the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia (e-mail: )
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Leucht S, Helfer B, Gartlehner G, Davis JM. How effective are common medications: a perspective based on meta-analyses of major drugs. BMC Med 2015; 13:253. [PMID: 26431961 PMCID: PMC4592565 DOI: 10.1186/s12916-015-0494-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/18/2015] [Indexed: 12/15/2022] Open
Abstract
The vastness of clinical data and the progressing specialization of medical knowledge may lead to misinterpretation of medication efficacy. To show a realistic perspective on drug efficacy we present meta-analyses on some of the most commonly used pharmacological interventions. For each pharmacological intervention we present statistical indexes (absolute risk or response difference, percentage response ratio, mean difference, standardized mean difference) that are often used to represent efficacy. We found that some of the medications have relatively low effect sizes with only 11 out of 17 of them showing a minimal clinically important difference. Efficacy was often established based on surrogate outcomes and not the more relevant patient-oriented outcomes. As the interpretation of the efficacy of medication is complex, more training for physicians might be needed to get a more realistic view of drug efficacy. That could help prevent harmful overtreatment and reinforce an evidence-based, but personalized medicine.
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Bartosz Helfer
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Gerald Gartlehner
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems an der Donau, Austria. .,RTI-International, Research Triangle Park, NC, USA.
| | - John M Davis
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA.
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Enduring effects of Preventive Cognitive Therapy in adults remitted from recurrent depression: A 10 year follow-up of a randomized controlled trial. J Affect Disord 2015; 185:188-94. [PMID: 26188380 DOI: 10.1016/j.jad.2015.06.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prevention of recurrence is a challenge in the management of major depressive disorder (MDD). The long-term effects of Preventive Cognitive Therapy (PCT) in preventing recurrence in MDD are not known. METHODS A RCT comparing the addition of PCT to Treatment As Usual (TAU), versus TAU including patients with recurrent depression who were in remission at entry (N=172). PCT consisted of eight weekly group sessions. TAU involved standard treatment. Primary outcome is time to first recurrence of a depressive episode as assessed by blinded interviewers over 10 years based on DSM-IV-TR criteria. RESULTS Also over 10 years, the protective effect of PCT was dependent on the number of previous episodes a patient experienced. The protective effect intensified with the number of previous depressive episodes (Cox regression; p=.004, Hazard ratio=.576, 95% CI=.396-.837) and is mainly established within the first half of the 10 year follow-up period. For patients with more than three previous episodes (52% of the sample), PCT significantly increased the median survival time (713.0 days) versus patients that received TAU (205.0 days). No enduring effects were found on secondary outcomes. LIMITATIONS Dropout rates were relatively high for secondary outcomes, but relatively low for the primary outcome. Results were comparable after multiple imputation. CONCLUSIONS PCT in remitted patients with multiple prior episodes has long-term preventive effects on time to recurrence. To reduce recurrence rates, booster sessions might be necessary. A personalized medicine approach might be necessary to reduce recurrence rates even further.
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Sim K, Lau WK, Sim J, Sum MY, Baldessarini RJ. Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials. Int J Neuropsychopharmacol 2015; 19:pyv076. [PMID: 26152228 PMCID: PMC4772815 DOI: 10.1093/ijnp/pyv076] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/02/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Findings of substantial remaining morbidity in treated major depressive disorder (MDD) led us to review controlled trials of treatments aimed at preventing early relapses or later recurrences in adults diagnosed with MDD to summarize available data and to guide further research. METHODS Reports (n = 97) were identified through systematic, computerized literature searching up to February 2015. Treatment versus control outcomes were summarized by random-effects meta-analyses. RESULTS In 45 reports of 72 trials (n = 14 450 subjects) lasting 33.4 weeks, antidepressants were more effective than placebos in preventing relapses (response rates [RR] = 1.90, confidence interval [CI]: 1.73-2.08; NNT = 4.4; p < 0.0001). In 35 reports of 37 trials (n = 7253) lasting 27.0 months, antidepressants were effective in preventing recurrences (RR = 2.03, CI 1.80-2.28; NNT = 3.8; p < 0.0001), with minor differences among drug types. In 17 reports of 22 trials (n = 1 969) lasting 23.7 months, psychosocial interventions yielded inconsistent or inconclusive results. CONCLUSIONS Despite evidence of the efficacy of drug treatment compared to placebos or other controls, the findings further underscore the substantial, unresolved morbidity in treated MDD patients and strongly encourage further evaluations of specific, improved individual and combination therapies (pharmacological and psychological) conducted over longer times, as well as identifying clinical predictors of positive or unfavorable responses and of intolerability of long-term treatments in MDD.
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Affiliation(s)
- Kang Sim
- Yong Loo Lin School of Medicine, National University of Singapore (Drs K Sim, Lau, and J Sim); Research Department, Institute of Mental Health, Singapore (Dr K Sim and Ms Sum); Department of General Psychiatry, Institute of Mental Health, Singapore (Dr K Sim); Department of Psychiatry, Harvard Medical School, Boston, MA (Dr Baldessarini); International Consortium for Psychotic and Mood Disorders Research, McLean Hospital, Belmont, MA (Dr Baldessarini).
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Interventions for preventing relapse or recurrence of depression in primary health care settings: A systematic review. Prev Med 2015; 76 Suppl:S16-21. [PMID: 25192769 DOI: 10.1016/j.ypmed.2014.07.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/04/2014] [Accepted: 07/23/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A systematic review was conducted to assess the efficacy of pharmacological and psychological interventions for preventing relapse or recurrence of depression in adults with depression in primary care. METHOD Papers published from inception to January 28th 2014 were identified searching the electronic databases MEDLINE, EMBASE, PsycINFO, and CENTRAL. Randomized controlled trials of any pharmacological, psychological or psychosocial intervention or combination of interventions delivered in primary care settings were included, with relapse or recurrence of a depressive disorder as a main outcome. The Cochrane Collaboration risk of bias tool was used to assess study quality. RESULTS Only three studies with a small number of patients fulfilled the inclusion criteria. None of the three randomized controlled trials included in our review showed a statistically significant superiority of an intervention for the prevention of depression relapse or recurrence. CONCLUSIONS There is limited evidence to inform relapse or recurrence prevention strategies specifically in primary care.
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59
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Bockting CL, Hollon SD, Jarrett RB, Kuyken W, Dobson K. A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence. Clin Psychol Rev 2015; 41:16-26. [PMID: 25754289 DOI: 10.1016/j.cpr.2015.02.003] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 12/14/2014] [Accepted: 02/10/2015] [Indexed: 11/26/2022]
Abstract
Major depressive disorder (MDD) is highly disabling and typically runs a recurrent course. Knowledge about prevention of relapse and recurrence is crucial to the long-term welfare of people who suffer from this disorder. This article provides an overview of the current evidence for the prevention of relapse and recurrence using psychological interventions. We first describe a conceptual framework to preventive interventions based on: acute treatment; continuation treatment, or; prevention strategies for patients in remission. In brief, cognitive-behavioral interventions, delivered during the acute phase, appear to have an enduring effect that protects patients against relapse and perhaps others from recurrence following treatment termination. Similarly, continuation treatment with either cognitive therapy or perhaps interpersonal psychotherapy appears to reduce risk for relapse and maintenance treatment appears to reduce risk for recurrence. Preventive relapse strategies like preventive cognitive therapy or mindfulness based cognitive therapy (MBCT) applied to patients in remission protects against subsequent relapse and perhaps recurrence. There is some preliminary evidence of specific mediation via changing the content or the process of cognition. Continuation CT and preventive interventions started after remission (CBT, MBCT) seem to have the largest differential effects for individuals that need them the most. Those who have the greatest risk for relapse and recurrence including patients with unstable remission, more previous episodes, potentially childhood trauma, early age of onset. These prescriptive indications, if confirmed in future research, may point the way to personalizing prevention strategies. Doing so, may maximize the efficiency with which they are applied and have the potential to target the mechanisms that appear to underlie these effects. This may help make this prevention strategies more efficacious.
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Affiliation(s)
- Claudi L Bockting
- Department of Clinical Psychology, University of Groningen, Groningen, The Netherlands; Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands.
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Robin B Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Willem Kuyken
- Department of Psychiatry, University of Oxford, Oxford OX1 2JD, UK
| | - Keith Dobson
- Department of Psychology, University of Calgary, Alberta, Canada
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Eisendrath SJ, Gillung E, Delucchi K, Mathalon DH, Yang TT, Satre DD, Rosser R, Sipe WEB, Wolkowitz OM. A Preliminary Study: Efficacy of Mindfulness-Based Cognitive Therapy versus Sertraline as First-line Treatments for Major Depressive Disorder. Mindfulness (N Y) 2014; 6:475-482. [PMID: 26085853 DOI: 10.1007/s12671-014-0280-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Major depressive disorder (MDD) is the leading cause of disability in the developed world, yet broadly effective treatments remain elusive. The primary aim of this pilot study was to investigate the efficacy of Mindfulness-Based Cognitive Therapy (MBCT) monotherapy, compared to sertraline monotherapy, for patients with acute MDD. This open-label, nonrandomized controlled trial examined a MBCT cohort (N=23) recruited to match the gender, age, and depression severity of a depressed control group (N=20) that completed 8 weeks of monotherapy with the antidepressant sertraline. The 17-item clinician-rated Hamilton Depression Severity Rating Scale (HAMD-17) was the primary outcome measure of depression to assess overall change after 8 weeks and rates of response and remission. The 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) was the secondary outcome measure to further assess depression severity. Both cohorts were demographically similar and showed significant improvement in depression ratings. No difference was found in the degree of change in HAMD-17 scores (t(34) = 1.42, p = .165) between groups. Secondary analysis showed statistically significant differences in mean scores of the QIDS-SR16 (t (32) = 4.39, p < 0.0001), with the MCBT group showing greater mean improvement. This study was limited by the small sample size and non-randomized, non-blinded design. Preliminary findings suggest that an 8-week course of MBCT monotherapy may be effective in treating MDD and a viable alternative to antidepressant medication. Greater changes in the self-rated QIDS-SR16 for the MBCT cohort raise the possibility that patients derive additional subjective benefit from enhanced self-efficacy skills.
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Affiliation(s)
- Stuart J Eisendrath
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143. phone: (415) 476-7868; fax: (415) 476-7449
| | - Erin Gillung
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
| | - Kevin Delucchi
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
| | - Daniel H Mathalon
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121
| | - Tony T Yang
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
| | - Derek D Satre
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143. Division of Research, Kaiser Permanente, 200 Broadway Blvd, Oakland, CA 94612
| | - Rebecca Rosser
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
| | - Walter E B Sipe
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
| | - Owen M Wolkowitz
- Department of Psychiatry, University of California-San Francisco, Box 0984-AIP, San Francisco, CA 94143
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Grott Zanicotti C, Perez D, Glue P. Case report: long-term mood response to repeat dose intramuscular ketamine in a depressed patient with advanced cancer. J Palliat Med 2013; 16:719-20. [PMID: 23676095 DOI: 10.1089/jpm.2013.0057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kennedy SH. A review of antidepressant therapy in primary care: current practices and future directions. Prim Care Companion CNS Disord 2013; 15:12r01420. [PMID: 23930234 PMCID: PMC3733527 DOI: 10.4088/pcc.12r01420] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 12/10/2012] [Indexed: 12/25/2022] Open
Abstract
Objective: To provide general practitioners with a comparison of major depressive disorder treatments received in primary care and psychiatric clinic settings, a focus on treatment outcomes related to currently prescribed antidepressants, and a review of new and emerging therapeutic strategies. Data Sources: English-language evidence-based guidelines and peer-reviewed literature published between January 1, 2005, and December 31, 2011, were identified using PubMed, MEDLINE, and EMBASE. All searches contained the terms major depressive disorder and unipolar depression, and excluded the terms bipolar disorder/manic depressive disorder. The following search terms were also included: naturalistic study, antidepressant, relapse, recurrence, residual symptoms, response, remission, sequential medication trials, and treatment-resistant depression. Study Selection: Meta-analyses, systematic reviews, and practice guidelines were included. Bibliographies were used to identify additional articles of interest. Data Extraction: Abstracts and articles were screened for relevance to primary care practice. Population-based studies and those involving patients treated in primary care were used whenever possible. Data Synthesis: Achieving remission from a major depressive episode is important to improve functional outcomes and to reduce relapse and recurrence. Despite the availability of numerous antidepressants, as many as 50% of patients require treatment modifications beyond first-line therapy. Among remitters, 90% report residual symptoms that may interfere with function. Patients treated in primary care often have chronic depression (symptom duration ≥ 24 months at presentation) and medical comorbidities. These are clinical predictors of worse outcomes and require individualized attention when treatment is initiated. Antidepressants differ in efficacy, tolerability, and side effects—factors that may affect adherence to treatment. Conclusions: Major depressive disorder is highly prevalent in primary care and is among the most common causes of loss of disability-adjusted life-years worldwide. There are few differences in clinical profiles between depressed patients in primary care and those in specialist clinics, although differences in symptoms and comorbid conditions among individual depressed patients present a challenge for the physician providing individualized treatment. The goal of treatment is remission with good functional and psychosocial outcomes. Physicians in primary care should have expertise in working with a number of current antidepressant approaches and an awareness of new and emerging treatments.
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Affiliation(s)
- Sidney H Kennedy
- University Health Network, University of Toronto, Ontario, Canada
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63
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Peñaranda APB, Valencia JG, Guarín MR, Borrero ÁEA, Díaz SMC, de la Hoz Bradford AM, Riveros PM, Jaramillo LE, Brito E, Acosta CAP, Pedraza RS, González-Pacheco J, Gómez-Restrepo C. [Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part II: General Aspects of Treatment, Management of the Acute Phase, Continuation and Maintenance of Patients with a Depression Diagnosis]. ACTA ACUST UNITED AC 2012; 41:740-73. [PMID: 26572264 DOI: 10.1016/s0034-7450(14)60045-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/06/2012] [Indexed: 12/28/2022]
Abstract
INTRODUCTION This article presents recommendations based on evidence gathered to answer a series of clinical questions concerning the depressive episode and the recurrent depressive disorder, with emphasis on general treatment aspects, treatment in the acute phase and management of the continuation/maintenance, all intended to grant health care parameters based on the best and more updated available evidence for achieving minimum quality standards with adult patients thus diagnosed. METHODOLOGY A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from NICE90 and CANMAT guides were adopted and updated so as to answer the questions posed while de novo questions were developed. RESULTS Recommendations 5-22 corresponding to management of depression are presented.
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Affiliation(s)
- Adriana Patricia Bohórquez Peñaranda
- Médica psiquiatra, MSc Epidemiología Clínica, profesora Departamento de Psiquiatría y Salud Mental, Pontificia Universidad Javeriana, Coordinadora GAI Depresión, Bogotá, Colombia.
| | - Jenny García Valencia
- Médica psiquiatra, MSc PhD Epidemiología, profesora Departamento de Psiquiatría, Universidad de Antioquia, Medellín, Colombia
| | - Maritza Rodríguez Guarín
- Médica psiquiatra, MSc Epidemiología Clínica, profesora Departamento de Psiquiatría y Salud Mental, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Álvaro Enrique Arenas Borrero
- Médico psiquiatra, Maestrando Epidemiología Clínica, Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Sergio Mario Castro Díaz
- Médico residente psiquiatría, asistente de investigación, Departamento de Psiquiatría y Salud Mental, Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ana María de la Hoz Bradford
- Médica MSc Epidemiología Clínica, Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Patricia Maldonado Riveros
- Médica rural, asistente de investigación, Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Luis Eduardo Jaramillo
- Médico psiquiatra, MSc Farmacología, profesor titular Departamento de Psiquiatría, Universidad Nacional de Colombia, delegado Asociación Colombiana de Psiquiatría, Bogotá, Colombia
| | - Enrique Brito
- Médico psiquiatra, delegado Asociación Colombiana de Psiquiatría, Bogotá, Colombia
| | - Carlos Alberto Palacio Acosta
- Médico psiquiatra, MSc Epidemiología Clínica, profesor titular Departamento de Psiquiatría, Universidad de Antioquia, Medellín, Colombia
| | - Ricardo Sánchez Pedraza
- Médico psiquiatra, MSc Epidemiología Clínica, profesor titular Departamento de Psiquiatría, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan González-Pacheco
- Médico psiquiatra, profesor y director Departamento de Psiquiatría y Salud Mental, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Carlos Gómez-Restrepo
- Médico psiquiatra, MSc Epidemiología Clínica, Psiquiatra de Enlace, Psicoanalista, profesor titular Departamento de Psiquiatría y Salud Mental, director Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Director GAI Depresión, codirector CINETS, Bogotá, Colombia
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El-Mallakh RS, Briscoe B. Studies of long-term use of antidepressants: how should the data from them be interpreted? CNS Drugs 2012; 26:97-109. [PMID: 22296314 DOI: 10.2165/11599450-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Depression is a recurrent illness in which afflicted individuals have an increased risk for recurrence as a function of a greater number of previous episodes. Consequently, prevention of future episodes is central to improving the prognosis. The current recommendation is to use antidepressants over prolonged periods of time to prevent further episodes of depression. However, the database for this practice is limited and can be interpreted in multiple ways. Review of the relevant literature was performed. MEDLINE and PubMed databases were searched from inception to 5 September 2011 for randomized, placebo-controlled trials of at least 18 months duration. After treatment of an acute depressive episode, antidepressants clearly prevent relapse back into the same depressive episode. This is demonstrated by an adequate number of randomized, blinded, placebo-controlled, 1-year continuation trials. The ability of antidepressants to prevent recurrence of future episodes is less clear. Randomized, blinded, placebo-controlled trials of 18 months or longer are infrequent - 18 studies were identified. While nearly all show that antidepressant continuation is superior to placebo in preventing resurgence of depressive symptoms, nearly all of the difference occurs in the first 6 months after randomization. This pattern strongly suggests that the apparent superiority of antidepressants may be due to (i) their ability to prevent recurrence, (ii) antidepressant withdrawal (characterized by depressive symptoms) in patients switched to placebo or (iii) a combination of these phenomena.
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Affiliation(s)
- Rif S El-Mallakh
- Mood Disorders Research Program, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
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Abstract
INTRODUCTION OR BACKGROUND Depressive disorder is a long term, relapsing condition associated with high levels of disability and mortality. It has a neurobiological basis and is associated with functional and structural brain abnormalities. SOURCES OF DATA The data discussed have been obtained mainly from meta-analyses, randomized controlled clinical trials and key review papers as well as animal studies. AREAS OF AGREEMENT Genetic vulnerability and stress are key factors in its aetiopathogenesis. Dysregulation of the hypothalamo-pituitary-adrenal (HPA) axis reduces hippocampal volumes and prefrontal cortex (PFC) activity in depressed patients and disrupts homeostasis within the neurocircuit of depression. Antidepressant drugs increase brain-derived neurotrophin, restoring neuronal growth and activity and modulate interactions between the neurocircuit anatomical structures. AREAS OF CONTROVERSY It remains to be confirmed whether structural changes in the brain are purely abnormalities in neuroplasticity and are fully reversible, whether they predate depression and whether they increase in the long term. GROWING POINTS Investigation of the molecular mechanisms mediating gene and environment interaction is a growing and potentially fruitful area of research in the neurobiology of depression. Further elucidation of the neuroanatomical and physiological connections between the limbic structures and PFC may help identify key areas to target in treatment. The role of the dysregulation of the HPA axis and identifiable stressors in the recent or remote past which are not always present in depression need further study. AREAS TIMELY FOR DEVELOPING RESEARCH Prospective studies examining the interaction between changes in brain function and structure in relation to stress and identified relevant genes and how these may be influenced by antidepressant drug treatment and the long-term course of depression would help clarify their role in the pathophysiology of this disorder.
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Affiliation(s)
- Eleni Palazidou
- East London Foundation Trust, Tower Hamlets Centre for Mental Health, Mile End Hospital, London, UK.
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66
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Llorca PM, Charpeaud T, Nourry A, Samalin L. [The contributions of the evidence-based medicine or how to optimize the management of major depressive disorder]. L'ENCEPHALE 2011; 37:457-65. [PMID: 22137218 DOI: 10.1016/j.encep.2011.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 10/06/2011] [Indexed: 11/19/2022]
Abstract
In the early 1980s, Evidence-Based Medicine (EBM) has been developed in the Department of Clinical Epidemiology at McMaster Medical School in Canada to meet the ever-increasing need to integrate publications in clinical practice. In this approach, we cannot ever consider that the evidence will replace clinical experience. The quality of scientific data is prioritized taking into account the methodological characteristics of studies. It takes time to learn and practice the method, which is often difficult in daily practice. The concept of "management recommendations" covers multiple realities. It can rely on the results of clinical trials (randomized, controlled or not…), the trends from the meta-analysis that attempt to "simplify" the field of literature or the Clinical Practice Guidelines. Meta-analysis should be used with caution. They do not preclude the need to use the data "sources", but they help the comparability of results and synthesis work. However it should be aware that this is a work of interpretation. The controversy over the action of antidepressants compared to placebo in depression according to the severity of the episode shows that a result depends on the included studies, the statistical technique used, but also how the results are reported. The international literature produced many recommendations in the management of depression. It is useful to refer to it as the meta-analysis because they provide an overall view of the current state of knowledge. We can regret the lack of recent French recommendations that could articulate the specifics of the French practice and data from the literature. The use of guidelines in clinical practice remains low in all fields of medicine. However improving the consideration of the recommendations is an important issue because it is associated with improved patient care. It remains to develop a collective strategy to implement them. The Evidence-Based Medicine is a major change in the everyday clinical practice. It may be insufficiently known and understood, seems too complex, time-consuming and therefore inapplicable. We have to mobilize our efforts to improve our practices.
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Affiliation(s)
- P-M Llorca
- CMP B, université d'Auvergne, CHU de Clermont-Ferrand, France.
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67
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Abstract
OBJECTIVE The aim of this study was to review the current state of development and application of a wide range of brain stimulation approaches in the treatment of psychiatric disorders. METHOD The approaches reviewed include forms of minimally invasive magnetic and electrical stimulation, seizure induction, implanted devices and several highly novel approaches in early development. RESULTS An extensive range of brain stimulation approaches are now being widely used in the treatment of patients with psychiatric disorders, or actively investigated for this use. Both vagal nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS) have been introduced into clinical practice in some countries. A small body of research suggests that VNS has some potentially long-lasting antidepressant effects in a minority of patients treated. rTMS has now been extensively investigated for over 15 years, with a large body of research now supporting its antidepressant effects. Further rTMS research needs to focus on defining the most appropriate stimulation methods and exploring its longer term use in maintenance protocols. Very early data suggest that magnetic seizure therapy (MST) has promise in the treatment of patients referred for electroconvulsive therapy: MST appears to have fewer side effects and may have similar efficacy. A number of other approaches including surgical and alternative forms of electrical stimulation appear to alter brain activity in a promising manner, but are in need of evaluation in more substantive patient samples. CONCLUSIONS It appears likely that the range of psychiatric treatments available for patients will grow over the coming years to progressively include a number of novel brain stimulation techniques.
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Affiliation(s)
- Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, The Alfred and Monash University School of Psychology and Psychiatry, Melbourne, Victoria, Australia. paul.fi
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68
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Andrews PW, Kornstein SG, Halberstadt LJ, Gardner CO, Neale MC. Blue again: perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression. Front Psychol 2011; 2:159. [PMID: 21779273 PMCID: PMC3133866 DOI: 10.3389/fpsyg.2011.00159] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 06/23/2011] [Indexed: 12/15/2022] Open
Abstract
Some evolutionary researchers have argued that current diagnostic criteria for major depressive disorder (MDD) may not accurately distinguish true instances of disorder from a normal, adaptive stress response. According to disorder advocates, neurochemicals like the monoamine neurotransmitters (serotonin, norepinephrine, and dopamine) are dysregulated in major depression. Monoamines are normally under homeostatic control, so the monoamine disorder hypothesis implies a breakdown in homeostatic mechanisms. In contrast, adaptationist hypotheses propose that homeostatic mechanisms are properly functioning in most patients meeting current criteria for MDD. If the homeostatic mechanisms regulating monoamines are functioning properly in these patients, then oppositional tolerance should develop with prolonged antidepressant medication (ADM) therapy. Oppositional tolerance refers to the forces that develop when a homeostatic mechanism has been subject to prolonged pharmacological perturbation that attempt to bring the system back to equilibrium. When pharmacological intervention is discontinued, the oppositional forces cause monoamine levels to overshoot their equilibrium levels. Since depressive symptoms are under monoaminergic control, this overshoot should cause a resurgence of depressive symptoms that is proportional to the perturbational effect of the ADM. We test this prediction by conducting a meta-analysis of ADM discontinuation studies. We find that the risk of relapse after ADM discontinuation is positively associated with the degree to which ADMs enhance serotonin and norepinephrine in prefrontal cortex, after controlling for covariates. The results are consistent with oppositional tolerance, and provide no evidence of malfunction in the monoaminergic regulatory mechanisms in patients meeting current diagnostic criteria for MDD. We discuss the evolutionary and clinical implications of our findings.
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Affiliation(s)
- Paul W. Andrews
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth UniversityRichmond, VA, USA
- Department of Psychology, Neuroscience and Behaviour, McMaster UniversityHamilton, ON, Canada
| | - Susan G. Kornstein
- Department of Psychiatry, Virginia Commonwealth UniversityRichmond, VA, USA
| | - Lisa J. Halberstadt
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth UniversityRichmond, VA, USA
| | - Charles O. Gardner
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth UniversityRichmond, VA, USA
| | - Michael C. Neale
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth UniversityRichmond, VA, USA
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