The costs of depression

Intersection of Sex and Depression: Pathogenesis, Presentation, and Treatments

Major Depressive Disorder (MDD) is a highly prevalent, debilitating disorder. According to the World Health Organization, approximately 5% of adults suffer from depression worldwide and more women than men are affected. Yet, we have a very limited understanding of the pathogenesis of the disease, how sex and genetics influence the pathophenotype of MDD, and how they contribute to the responses to pharmacological treatment. This chapter addresses key theories about the etiology of depression, the variations in epidemiology and presentation, and the treatment options with respect to sex and gender. Additionally, we discuss the emerging wave of treatment modalities, diagnosis, and research focusing on MDD.

Neuromodulatory effects of transcranial electrical stimulation on emotion regulation in internalizing psychopathologies

OBJECTIVE

We hypothesize offset theta-tACS (transcranial alternating current stimulation) improves emotion regulation (ER) and psychopathology more than transcranial direct current stimulation (tDCS) in participants with internalizing psychopathologies (IPs).

METHODS

This pilot study utilized a double-blind, pseudo-counterbalanced, sham-controlled design with participants with IPs. Participants were assigned to receive tDCS or tACS, underwent four stimulation sessions (two sham), and completed an emotion regulation task (ERT) during or after stimulation. Participants completed the Beck Depression Inventory before/after the study, the Spielberger State and Trait Anxiety Index after each ERT, and rated their arousal, valence, and perceived reappraisal ability during the ERT.

RESULTS

Participants receiving either stimulation type showed a reduction in anxiety, depression, and valence and arousal ratings. We additionally discovered an effect demonstrating those who received sham stimulation first displayed little-to-no change in any score across the study, but tACS participants who received verum stimulation first showed significant improvements in each metric.

CONCLUSIONS

Improving ER capabilities via theta tACS has the potential to yield beneficial clinical effects.

SIGNIFICANCE

This study adds validity to the use of non-invasive neuromodulatory methods, especially tACS, to alleviate IPs. Additional research is needed to better understand the effects of sham stimulation. Careful consideration of sham incorporation should be made in future studies.

Therapist-guided and self-guided internet-delivered behavioural activation for adolescents with depression: a randomised feasibility trial

OBJECTIVE

Access to effective treatments for adolescents with depression needs to improve. Few studies have evaluated behavioural activation (BA) for adolescent depression, and none remotely delivered BA. This study explored the feasibility and acceptability of therapist-guided and self-guided internet-delivered BA (I-BA) in preparation for a future randomised controlled trial (RCT).

DESIGN

A single-blinded randomised controlled feasibility trial.

SETTING

A specialist outpatient clinic in Sweden.

PARTICIPANTS

Thirty-two adolescents with mild-to-moderate major depression, aged 13-17 years.

INTERVENTIONS

Ten weeks of therapist-guided I-BA or self-guided I-BA, or treatment as usual (TAU). Both versions of I-BA included parental support. TAU included referral to usual care within child and youth psychiatry or primary care.

OUTCOMES

Feasibility measures included study take-up, participant retention, acceptability, safety and satisfaction. The primary outcome measure was the blinded assessor-rated Children's Depression Rating Scale, Revised. The primary endpoint was the 3-month follow-up.

RESULTS

154 adolescents were screened and 32 were randomised to therapist-guided I-BA (n=11), self-guided I-BA (n=10) or TAU (n=11). Participant retention was acceptable, with two drop-outs in TAU. Most participants in TAU had been offered interventions by the primary endpoint. The mean number of completed chapters (total of 8) for adolescents was 7.5 in therapist-guided I-BA and 5.4 in self-guided I-BA. No serious adverse events were recorded. Satisfaction was acceptable in both I-BA groups. Following an intent-to-treat approach, the linear mixed-effects model revealed that both therapist-guided and self-guided I-BA (Cohen's d=2.43 and 2.23, respectively), but not TAU (Cohen's d=0.95), showed statistically significant changes on the primary outcome measure with large within-group effect sizes.

CONCLUSIONS

Both therapist-guided and self-guided I-BA are acceptable and potentially efficacious treatments for adolescents with depression. It is feasible to conduct a large-scale RCT to establish the efficacy and cost-effectiveness of I-BA versus TAU.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04117789).

Deficits in ascending pain modulation pathways in breast cancer survivors with chronic neuropathic pain: A resting-state fMRI study

Purpose

Breast cancer (BC) is the highest frequent malignancy in women globally. Approximately 25-60% of BC patients with chronic neuropathic pain (CNP) result from advances in treating BC. Since the CNP mechanism is unclear, the various treatment methods for CNP are limited. We aimed to explore the brain alternations in BC patients with CNP and the relationship between depression and CNP utilizing resting-state functional magnetic resonance imaging (rs-fMRI).

Methods

To collect the data, the female BC survivors with CNP (n = 20) and healthy controls (n = 20) underwent rs-fMRI. We calculated and compared the functional connectivity (FC) between the two groups using the thalamus and periaqueductal gray (PAG) as seed regions.

Results

Patients with BC showed increased depression and FC between the thalamus and primary somatosensory cortices (SI). Moreover, the Hospital Anxiety and Depression Scale-Depression (HADS-D) and pain duration were linked positively to the strength of FC from the thalamus to the SI. Furthermore, the thalamus-SI FC mediated the impact of pain duration on HADS-D.

Conclusion

In BC patients with CNP, the ascending pain regulation mechanism is impaired and strongly associated with chronic pain and accompanying depression. This research increased our knowledge of the pathophysiology of CNP in patients with BC, which will aid in determining the optimal therapeutic strategy for those patients.

Comparative effectiveness of exercise, antidepressants and their combination in treating non-severe depression: a systematic review and network meta-analysis of randomised controlled trials

OBJECTIVE

To assess the comparative effectiveness of exercise, antidepressants and their combination for alleviating depressive symptoms in adults with non-severe depression.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Cochrane Library, Web of Science, Scopus and SportDiscus.

ELIGIBILITY CRITERIA

Randomised controlled trials (1990-present) that examined the effectiveness of an exercise, antidepressant or combination intervention against either treatment alone or a control/placebo condition in adults with non-severe depression.

STUDY SELECTION AND ANALYSIS

Risk of bias, indirectness and the overall confidence in the network were assessed by two independent investigators. A frequentist network meta-analysis was performed to examine postintervention differences in depressive symptom severity between groups. Intervention drop-out was assessed as a measure of treatment acceptability.

RESULTS

Twenty-one randomised controlled trials (n=2551) with 25 comparisons were included in the network. There were no differences in treatment effectiveness among the three main interventions (exercise vs antidepressants: standardised mean differences, SMD, -0.12; 95% CI -0.33 to 0.10, combination versus exercise: SMD, 0.00; 95% CI -0.33 to 0.33, combination vs antidepressants: SMD, -0.12; 95% CI -0.40 to 0.16), although all treatments were more beneficial than controls. Exercise interventions had higher drop-out rates than antidepressant interventions (risk ratio 1.31; 95% CI 1.09 to 1.57). Heterogeneity in the network was moderate (τ2=0.03; I2=46%).

CONCLUSIONS

The results suggest no difference between exercise and pharmacological interventions in reducing depressive symptoms in adults with non-severe depression. These findings support the adoption of exercise as an alternative or adjuvant treatment for non-severe depression in adults.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD4202122656.

Identifying high-risk population of depression: association between metabolic syndrome and depression using a health checkup and claims database

Depression and metabolic syndrome (MetS) are correlated, leading to an increased healthcare burden and decreased productivity. We aimed to investigate the association between MetS-related factors and depression using a health checkup and claims database. Individuals aged 18-75 years who underwent health examinations between 2014 and 2019 were enrolled in the study. Among 76,277 participants, "ever" and "incident" antidepressant users exhibited worse metabolic profiles and were more likely to be prescribed hypnotics and anxiolytics than "never" users. In a nested case-control study with a 1:10 ratio of incident users to controls, MetS was associated with incident antidepressant use (odds ratio, 1.53 [95% confidence interval 1.24-1.88]) adjusted for lifestyle information obtained from a self-administered questionnaire, medical history, and medications. Other metabolic traits also showed significant associations: body mass index (1.04 [1.02-1.06]), abdominal circumference per 10 cm (1.17 [1.08-1.27]), high blood pressure (1.17 [1.00-1.37]), glucose intolerance (1.29 [1.05-1.58]), and dyslipidemia (1.27 [1.08-1.51]). A bodyweight increase > 10 kg from age 20 years (1.46 [1.25-1.70]) was also significantly associated with incident antidepressant use. In conclusion, metabolic abnormalities were associated with incident antidepressant use and can be useful in identifying populations at high risk of depression.

Health-oriented leadership: Antecedents of leaders’ awareness regarding warning signals of emerging depression and burnout

Due to growing demands, there is an increase in depression and burnout causing sickness absence and early retirement. Detecting depression and burnout at an early stage is a crucial task for leaders to allow for early support and prevent more severe illnesses. Within the health-oriented leadership concept, awareness is the ability to recognize followers’ warning signals as a potential health risk. Although it is widely accepted that awareness is a precondition to taking appropriate action, it is yet unclear to what extent leaders recognize the warning signals of followers and which factors facilitate or impede awareness. In an experimental study ( N = 54) and a survey study ( N = 215) we examined antecedents of awareness in followers and leaders: (a) clarity of displayed warning signals in followers, (b) leaders’ stressors, (c) leaders’ autonomy. Even under favorable conditions, only about half of the leaders recognized warning signals as a health risk. Leaders showed lower awareness during times of high stress and low autonomy and when followers displayed less clear warning signals. Autonomy moderated the effect of stress (workload) on awareness, but there was no buffering effect as expected. The findings deepen the theoretical understanding of awareness and suggest that leaders need to know how their awareness may be impeded. We provide practical recommendations for human resource management on how leaders’ awareness can be fostered.

Family History of Depression and Neural Reward Sensitivity: Findings From the Adolescent Brain Cognitive Development Study

BACKGROUND

Previous studies have found that offspring of depressed parents exhibit reduced striatal reward response to anticipating and receiving rewards, suggesting that this may constitute a neurobiological risk marker for depression. The present study aimed to assess whether maternal and paternal depression history have independent effects on offspring reward processing and whether greater family history density of depression is associated with increased blunting of striatal reward responses.

METHODS

Data from the baseline visit of the ABCD (Adolescent Brain Cognitive Development) Study were used. After exclusion criteria, 7233 9- and 10-year-old children (49% female) were included in analyses. Neural responses to reward anticipation and receipt in the monetary incentive delay task were examined in 6 striatal regions of interest. Using mixed-effects models, we evaluated the effect of maternal or paternal depression history on striatal reward response. We also evaluated the effect of family history density on reward response.

RESULTS

Across all 6 striatal regions of interest, neither maternal nor paternal depression significantly predicted blunted response to reward anticipation or feedback. Contrary to hypotheses, paternal depression history was associated with increased response in the left caudate during anticipation, and maternal depression history was associated with increased response in the left putamen during feedback. Family history density was not associated with striatal reward response.

CONCLUSIONS

Our findings suggest that family history of depression is not strongly associated with blunted striatal reward response in 9- and 10-year-old children. Factors contributing to heterogeneity across studies need to be examined in future research to reconcile these results with past findings.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Efficacy and Safety of Subcutaneous Esketamine in the Treatment of Suicidality in Major Depressive Disorder and Bipolar Depression

BACKGROUND AND OBJECTIVE

Affective disorders account for most cases of suicide. The pharmacological arsenal to treat suicidality is limited and available agents take too long to take effect. A large body of evidence shows optimal results of ketamine for treating depression, but the evidence concerning suicidality has not been fully described. We report the first real-world study of severely depressed patients presenting with suicide ideation who were treated with repeated administration of subcutaneous esketamine.

METHODS

We analyzed data from 70 acutely depressed subjects diagnosed with resistant major depressive disorder or bipolar depression. Subjects were administered subcutaneous esketamine once a week for 6 weeks. The primary efficacy endpoint, the change from baseline to 24-h post-administration 6 in the item 10 Montgomery-Åsberg Depression Rating Scale score, was analyzed using a mixed-effects repeated-measures model.

RESULTS

There were significant effects for time on item 10 Montgomery-Åsberg Depression Rating Scale scores (p < 0.0001) but not for a time × diagnosis interaction (p = 0.164) from baseline to the end of the study. Efficacy of esketamine did not differ between groups (major depressive disorder vs bipolar depression) at any timepoint. Statistical significance on suicidality scores was observed from 24 h after the first administration (p < 0.001), and a further reduction was observed with repeated administrations. Esketamine was safe and well tolerated. Mean heart rate remained stable during the administrations and the blood pressure increase was self-limited.

CONCLUSIONS

Repeated subcutaneous esketamine administration had significant anti-suicidality effects in both major depressive disorder and bipolar groups, with a rapid onset of action and a good tolerability profile. Large randomized controlled trials are warranted to confirm these preliminary findings.

The association between dietary insulin index and load with mental health

Background

Depression, anxiety, and stress are common mental problems. The aim of this cross-sectional study was to investigate the association between two indexes that measure postprandial insulin response to different food, dietary insulin index (DII) and insulin load (DIL), with psychological disorders.

Method

Participants (n = 10,000) aged 20–69 were randomly selected from 200 clusters in Yazd from the recruitment phase of the Yazd Health Study. The dietary intake of participants was collected by a reliable and validated food frequency questionnaire (FFQ) consisting of 178 food items. DII and DIL were calculated from the FFQ data using previously published reference values. To assess psychological disorders an Iranian validated short version of a self-reported questionnaire (Depression Anxiety Stress Scales 21 [DASS21]) was used.

Results

No significant association was observed between DIL and DII with odds of depression or anxiety using crude or adjusted models. However, individuals in the highest quartiles of DIL had the lowest odds of stress (OR: 0.69; 95% CI 0.48–1.01, P-trend = 0.047). This association remained significant after adjustment for potential confounders in model II including marital status, smoking, education, job status, salt intake, and multi-vitamin supplement use (OR: 0.38; 95% CI 0.16–0.91, P-trend = 0.039) and the third and final model which is further adjusted for BMI (OR: 0.39; 95% CI 0.16–0.91, P-trend = 0.041).

Conclusion

Overall, consumption of foods with higher DII as well as DIL were associated with lower stress scores; however, no significant relationship was observed between DII or DIL with respective depression or anxiety scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00925-2.

Associations of depression and regional brain structure across the adult lifespan: Pooled analyses of six population-based and two clinical cohort studies in the European Lifebrain consortium

OBJECTIVE

Major depressive disorder has been associated with lower prefrontal thickness and hippocampal volume, but it is unknown whether this association also holds for depressive symptoms in the general population. We investigated associations of depressive symptoms and depression status with brain structures across population-based and patient-control cohorts, and explored whether these associations are similar over the lifespan and across sexes.

METHODS

We included 3,447 participants aged 18-89 years from six population-based and two clinical patient-control cohorts of the European Lifebrain consortium. Cross-sectional meta-analyses using individual person data were performed for associations of depressive symptoms and depression status with FreeSurfer-derived thickness of bilateral rostral anterior cingulate cortex (rACC) and medial orbitofrontal cortex (mOFC), and hippocampal and total grey matter volume (GMV), separately for population-based and clinical cohorts.

RESULTS

Across patient-control cohorts, depressive symptoms and presence of mild-to-severe depression were associated with lower mOFC thickness (r_symptoms = -0.15/ r_status = -0.22), rACC thickness (r_symptoms = -0.20/ r_status = -0.25), hippocampal volume (r_symptoms = -0.13/ r_status = 0.13) and total GMV (r_symptoms = -0.21/ r_status = -0.25). Effect sizes were slightly larger for presence of moderate-to-severe depression. Associations were similar across age groups and sex. Across population-based cohorts, no associations between depression and brain structures were observed.

CONCLUSIONS

Fitting with previous meta-analyses, depressive symptoms and depression status were associated with lower mOFC, rACC thickness, and hippocampal and total grey matter volume in clinical patient-control cohorts, although effect sizes were small. The absence of consistent associations in population-based cohorts with mostly mild depressive symptoms, suggests that significantly lower thickness and volume of the studied brain structures are only detectable in clinical populations with more severe depressive symptoms.

Social cognition and depression in adolescent girls

BACKGROUND AND OBJECTIVES

Depression has been associated with alterations in social functioning. Decoding and understanding others' mental states and adaptive reasoning are important for social functioning. This study examined theory of mind (ToM) and socio-moral reasoning (SMR) in adolescent girls with and without depression. Within the depression group, we examined associations between relevant clinical features (depression severity, anxiety symptoms and borderline personality traits) and ToM and SMR.

METHODS

A cross-sectional study was conducted, whereby 43 adolescent girls (mean age = 16.19, SD = 1.24) meeting full or subthreshold criteria for depression and 40 adolescent girls (mean age = 15.44, SD = 1.24) with no psychiatric diagnosis were recruited. ToM was assessed using the Movie for the Assessment of Social Cognition; SMR was evaluated via the Socio-Moral Reasoning Aptitude Level task.

RESULTS

Analyses of covariance indicated that adolescents with depression did not differ from controls in ToM abilities but showed lower socio-maturity scores on the SMR task. This difference disappeared after controlling for the number of words used to justify responses. Amongst adolescents with depression, multiple linear regression analyses revealed that higher levels of borderline personality traits were associated with lower levels of mentalization (ToM task), and more severe depressive symptoms were associated with lower socio-moral maturity stages (SMR task) LIMITATIONS: Directional associations were not studied, and the sample included only girls.

CONCLUSIONS

Findings may help to explain clinical heterogeneity in social cognitive functioning observed in individuals with depression.

Treatment-resistant depression and major depression with suicide risk-The cost of illness and burden of disease

Introduction

Treatment-Resistant Depression (TRD) and Major Depression with Suicide Risk (MDSR) are types of depression with relevant effects on the health of the population and a potentially significant economic impact. This study estimates the burden of disease and the costs of illness attributed to Treatment-Resistant Depression and Major Depression with Suicide Risk in Portugal.

Methods

The disease burden for adults was quantified in 2017 using the Disability-Adjusted Life Years (DALYs) lost. Direct costs related to the health care system and indirect costs were estimated for 2017, with indirect costs resulting from the reduction in productivity. Estimates were based on multiple sources of information, including the National Epidemiological Study on Mental Health, the Hospital Morbidity Database, data from the Portuguese National Statistics Institute on population and causes of death, official data on wages, statistics on the pharmaceutical market, and qualified opinions of experts.

Results

The estimated prevalence of TRD, MDSR, and both types of depression combined was 79.4 thousand, 52.5 thousand, and 11.3 thousand patients, respectively. The disease burden (DALY) due to the disability generated by TRD alone, MDSR alone, and the joint prevalence was 25.2 thousand, 21 thousand, and 4.5 thousand, respectively, totaling 50.7 thousand DALYs. The disease burden due to premature death by suicide was 15.6 thousand DALYs. The estimated total disease burden was 66.3 thousand DALYs. In 2017, the annual direct costs with TRD and MDSR were estimated at € 30.8 million, with the most important components being medical appointments and medication. The estimated indirect costs were much higher than the direct costs. Adding work productivity losses due to reduced employment, absenteeism, presenteeism, and premature death, a total cost of € 1.1 billion was obtained.

Conclusions

Although TRD and MDSR represent relatively small direct costs for the health system, they have a relevant disease burden and extremely substantial productivity costs for the Portuguese economy and society, making TRD and MDSR priority areas for achieving health gains.

Cost-Utility Analysis of Pharmacogenetic Testing Based on CYP2C19 or CYP2D6 in Major Depressive Disorder: Assessing the Drivers of Different Cost-Effectiveness Levels from an Italian Societal Perspective

Background and Objectives

Major depressive disorder (MDD) is a common and severe psychiatric disorder that has enormous economical and societal costs. As pharmacogenetics is one of the key tools of precision psychiatry, we analyze the cost–utility of test screening of CYP2C19 and CYP2D6 for patients suffering from major depressive disorder (MDD) and try to understand the main drivers that influence the cost–utility.

Methods

We developed two pharmacoeconomic nonhomogeneous Markov models to test the cost–utility, from an Italian societal perspective, of pharmacogenetic testing genetic to characterize the metabolizing profiles of cytochrome P450 (CYP) 2C19 and CYP2D6 in a hypothetical case study of patients suffering from major depressive disorder (MDD). The model considers different scenarios of adjustment of antidepressant treatment according to the patient’s metabolizing profile or treatment over a period of 18 weeks. The uncertainty of model parameters is tested through both a probabilistic sensitivity analysis and a one-way deterministic sensitivity analysis, and these results are used in a post-hoc analysis to understand the main drivers of three alternative cost-effectiveness levels (“poor,” “standard,” and “high”). These drivers are first evaluated from an exploratory multidimensional perspective and next from a predictive perspective as the probability that a patient belongs to a specific cost-effectiveness level is estimated on the basis of a restricted set of parameters used in the original pharmacoeconomic model.

Results

The models for CYP2C19 and CYP2D6 indicate that screening has an incremental cost-effectiveness ratio of 60,000€ and 47,000€ per quality-adjusted life year (QALY), respectively. The probabilistic sensitivity analysis shows that the treatments are cost-effective for a 75,000€ willingness to pay (WTP) threshold in 58% and 63% of the Monte Carlo replications, respectively. The post-hoc analysis highlights the factors that allow us to clearly discriminates poor cost-effectiveness from high cost-effectiveness scenarios and demonstrates that it is possible to predict with reasonable accuracy the cost-effectiveness of a genetic test and the associated therapeutic pattern.

Conclusions

Our findings suggest that screenings for both CYP2C19 and CYP2D6 enzymes for patients with MDD are cost-effective for a WTP threshold of 75,000€ per QALY, and provide relevant suggestions about the most important aspects to be further explored in clinical studies aimed at addressing the cost-effectiveness of genetic testing for patients diagnosed with MDD.

Psychosocial functionality in depressive workers: A study on associated factors

BACKGROUND

Major Depressive Disorder (MDD) has been shown a high prevalence and debilitating mental health. Most of the burden comes from reduced work functioning and frequent or long-term absenteeism.

AIMS

Describe psychosocial functionality in sample of workers with MDD and observe associated factors with sick-leave.

METHODS

Cross-sectional study. Participants were 172 formal workers with MDD according to Mini International Neuropsychiatric Interview. They were classified as active (n = 76) or in sick leave (n = 96). Functionality Assessment Short Test (FAST) was used and the variables were: personal, clinical, and occupational characteristics. Descriptive, bivariate and hierarchical multivariate analyses were conducted; significant with p < .05.

RESULTS

Most of the sample was female and <50. Workers in sick leave were older, less physically active, and presented worse scores in global and in each domain of functionality (FAST). High autonomy at working process, perceived stressing work, do not enjoy the work and low resilience to work adversities were significantly associated with sick leave (p < .05). Regarding clinical characteristics of MDD, severity, clinical comorbidity and recidivate subtype were associated with sick leave outcome (p < .05).

CONCLUSION

Sick leave is an important indicator of global functionality. Effective strategies to reduce MDD burden ought to involve some perspectives: (1) Diagnosis and efficient treatment; (2) Promotion and monitoring of functionality and rehabilitation programs; (3) Subject-centered actions that help workers cope with adversities, mitigate stress, and increase satisfaction at work.

Association between fasting blood glucose and thyroid stimulating hormones and suicidal tendency and disease severity in patients with major depressive disorder

Thyroid dysfunction and diabetes are reported to be associated with depression. However, their role in the suicide risk in patients with major depressive disorder (MDD) is unclear. The purpose of this study was to investigate and compare thyroid dysfunction and diabetes between suicide attempters and non-suicide attempters in a large sample of first-episode drug-naïve (FEND) MDD patients. A descriptive study was conducted on 1279 Chinese outpatients with a diagnosis of first-episode MDD. Their sociodemographic information, blood levels of thyroid hormones, glucose, lipids and body mass index (BMI) parameters were collected. The positive subscales of the positive and negative syndrome scale (PANSS), Hamilton Anxiety Rating Scale (HAMA), Hamilton Depression Rating Scale (HAMD) were measured for psychotic, anxiety and depressive symptoms. Our results showed that compared with non-suicide attempters (P<0.01), suicide attempters had statistically higher scores on HAMD, HAMA and PANSS psychotic symptoms, as well as higher thyroid stimulating hormone (TSH) serum levels, glucose, anti-thyroglobulin (A-TG), anti-thyroid peroxidase (A-TPO), total cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL-C), systolic blood pressure and diastolic blood pressure (all with P<0.001). These results revealed that TSH, A-TG, A-TPO, TC, TG and LDL-C may be promising biomarkers of suicide risk in MDD, implying the importance of regular assessment of blood glucose level and thyroid function parameters for suicide prevention, along with possible treatment for impaired thyroid function and diabetes for the suicide intervention in MDD patients. Such patients with abnormal blood sugar and TSH must undergo thorough screening for suicidal ideation.

Online micro intervention for mood improvement: The role of confidence, motivation, and activity type

BACKGROUND

Internet interventions provide a unique opportunity to increase widespread accessibility of treatment at reduced and scalable costs (Muñoz, 2010). Previous research has explored the impact of specific types of activities on participant's main depressive symptoms i.e., anhedonia, or enjoyment levels, and mood (Bunge et al., 2017).The aim of the current study is to improve the understanding of the effects of online micro interventions targeting motivation, enjoyment levels, and mood.

METHODS

A total of 838 participants recruited from Amazon Mechanical Turk participated in an online calendar activity to improve mood.

RESULTS

A regression analysis showed that confidence and motivation were significantly associated with mood (R² = 0.467, p < .001). The total number of activities reported in the last two days was associated with participants' current mood (R² = 0.203, p < .001) and enjoyment (R² = 0.156, p < .001). Interestingly, only mastery and meaningful activities improved mood but not pleasant activities. Regarding enjoyment, pleasant and meaningful activities impacted current enjoyment of the day but not mastery activities. Lastly, only individuals who engaged with the calendar showed a significant increase in motivation and confidence.

LIMITATIONS

Depression may moderate engagement and was not analyzed in the present study. Additionally, there were no follow-up analyses that looked at the long-term effects of the intervention or changes in actual activity engagement.

CONCLUSIONS

Online micro interventions have a promising future as an intervention that can impact the mood and motivation for change. Future studies should examine increasing engagement to facilitate confidence and motivation to enact change.

Improvements in Depression Outcomes Following a Digital Cognitive Behavioral Therapy Intervention in a Polychronic Population: Retrospective Study

Background

Digital mental health interventions have shown promise in reducing barriers to effective care for depression. Depression and related mental disorders are known to be highly comorbid with common chronic physical conditions, such as obesity and type 2 diabetes. While some research has explored the interaction dynamics of treating populations living with both mental and physical disorders, very little is known about such dynamics in digital care.

Objective

We aimed to examine the effectiveness of a 12-week, therapist-supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety. The studied population included adults with a heavy burden of chronic physical disease, including obesity and type 2 diabetes.

Methods

A total of 1512 participants with at least moderate depression were enrolled. The treatment cohort consisted of 831 (54.96%) participants who completed a follow-up assessment. The program included structured lessons and tools (ie, exercises and practices) and offered one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly sessions thereafter. The clinically validated 8-item Patient Health Questionnaire (PHQ-8) and the 7-item Generalized Anxiety Disorder scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Given correlation among various measures of program usage, a composite variable for depth of usage was used to analyze the correlation between usage and changes in depressive symptoms. Body weight changes from baseline were assessed primarily with digitally connected scales.

Results

Out of 831 participants in the treatment cohort, 74.5% (n=619) showed a clinically significant reduction in depressive symptom severity after 12 weeks, where follow-up PHQ-8 scores had shifted downward by at least one diagnostic category. In total, 67.5% (n=561) of the participants showed a reliable improvement in PHQ-8 scores as measured by the reliable change index. There was an average reduction of 5.9 (SD 5.2) points (P<.001) between baseline and follow-up. Greater program usage was correlated with greater likelihood of reliable improvement in depressive symptoms (odds ratio 1.3, 95% CI 1.1-1.5; P=.002). An exploratory analysis of body weight changes with a multilevel, mixed-effect model suggested that reliable improvement in depressive symptoms at follow-up was associated with significantly greater weight loss at 9 months (β=–1.11, P=.002).

Conclusions

The results provide further support that digital interventions can support clinically meaningful improvements in depression. Some form of synergy in treatment of comorbid depression and obesity or diabetes could be studied in future research. The study was limited by postintervention participant attrition as well as the retrospective observational study design.

Determinants of effective treatment coverage for major depressive disorder in the WHO World Mental Health Surveys

Background

Most individuals with major depressive disorder (MDD) receive either no care or inadequate care. The aims of this study is to investigate potential determinants of effective treatment coverage.

Methods

In order to examine obstacles to providing or receiving care, the type of care received, and the quality and use of that care in a representative sample of individuals with MDD, we analyzed data from 17 WHO World Mental Health Surveys conducted in 15 countries (9 high-income and 6 low/middle-income). Of 35,012 respondents, 3341 had 12-month MDD. We explored the association of socio-economic and demographic characteristics, insurance, and severity with effective treatment coverage and its components, including type of treatment, adequacy of treatment, dose, and adherence.

Results

High level of education (OR = 1.63; 1.19, 2.24), private insurance (OR = 1.62; 1.06, 2.48), and age (30–59yrs; OR = 1.58; 1.21, 2.07) predicted effective treatment coverage for depression in a multivariable logistic regression model. Exploratory bivariate models further indicate that education may follow a dose—response relation; that people with severe depression are more likely to receive any services, but less likely to receive adequate services; and that in low and middle-income countries, private insurance (the only significant predictor) increased the likelihood of receiving effective treatment coverage four times.

Conclusions

In the regression models, specific social determinants predicted effective coverage for major depression. Knowing the factors that determine who does and does not receive treatment contributes to improve our understanding of unmet needs and our ability to develop targeted interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00539-6.

The Effects of School Climate, Parent-Child Closeness, and Peer Relations on the Problematic Internet Use of Chinese Adolescents: Testing the Mediating Role of Self-Esteem and Depression

Although previous research has investigated the associations among family factors, school factors, peer factors, and problematic Internet use, its causal direction has not been verified, particularly in the Chinese context. Using school-based data, this study aims to explore the possible causal direction among school climate, parent-child closeness, peer relations, and the problematic Internet use of Chinese adolescents. Nine hundred and sixty students in junior and senior high schools participated in a questionnaire survey. The results showed that parent-child closeness, school climate, and peer relations had a significantly direct effect on the problematic Internet use of Chinese adolescents. Meanwhile, the effects of parent-child closeness, school climate, and peer relations on problematic Internet use were mediated by self-esteem and depression. Implications are also discussed to prevent the problematic Internet use of adolescents.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

A Concise Occupational Mental Health Screening Tool for South African Workplaces

Mental health in the workplace is becoming of ever greater importance. General occupational health surveillance programmes are already in widespread use, with established referral systems for treatment and rehabilitation, and the same mechanisms could be expanded to include mental health screening and intervention. This study aimed to develop a concise composite mental health screening tool, based on analysis of existing data, for application in routine occupational health surveillance in South Africa. Data from workplace occupational health surveillance programs from 2,303 participants were analysed. Participants completed a number of questions/scaled items collated into a survey format, and partook in an interview with a psychologist. The data was analysed using frequency of positive self-reports, Chi square to calculate associations with outcomes, Receiver Operator Characteristic curve analysis to explore predictive ability, and binomial logistic regression to calculate the relative contribution of markers to outcomes. An exploratory factor analysis was further conducted on identified items. A general workplace model with 14 markers (and a maritime workplace model with 17 markers) were identified. The factor analysis suggested their organisation into five domains (similar for both models), namely neurocognitive health, common mental disorders, history of adaptation in occupational specific contexts, family-work interface, and stress overload. The study’s data-driven approach proposed a concise composite screener with less than 50 items, comprising five domains. This tool appears useful in identifying employees at risk for workplace injuries or poor mental health outcomes, and could be applied to related workplace settings in South Africa.

Depression in Diabetic Patients: What Is the Link With Eating Disorders? Results of a Study in a Representative Sample of Patients With Type 1 Diabetes

Background and Purpose

Comorbidity between diabetes and depression, and diabetes and eating disorders (ED) conveys significant diagnostic, clinical and therapeutic implications. The present study was conducted on a sample of adult outpatients affected by Type 1 Diabetes (T1DM) to assess lifetime prevalence of ED; current prevalence of depression and Disturbed Eating Behaviors (DEB) and their impact on glycemic control. We hypothesized that patients with depression would have higher rates of lifetime ED and current DEB. We hypothesized a significant and independent association between DEB and the prevalence of depression.

Materials and Methods

The study was carried out using a cross-sectional design in a sample of 172 diabetic patients with T1DM aged from 17 to 55 years. Lifetime prevalence of ED according to DSM-5 criteria was assessed by means of the Module H modified of the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). The following questionnaires were used: Beck Depression Inventory-IA version (BDI-IA) and Diabetes Eating Problems Survey-Revised (DEPS-R), to assess respectively the current presence of depression and DEB. Socio-demographic, clinical, and laboratory data were also collected.

Results

High rates of depression (35.5%) and DEB (19.2%) were observed in our sample of 172 adult outpatients with T1DM. Lifetime history of ED was present in 20.9% of the sample and was more frequently diagnosed in patients with current depression (34.4% vs. 13.9%, p = 0.002). Higher levels of DEB at DEPS-R significantly increased the odds of depression (adjOR: 1.09; 95% CI: 1.03-1.15; p = 0.003). The presence of DEB was associated with poor glycemic control. On the other hand, no association was found between depression and metabolic compensation.

Conclusion

Adult patients with T1DM and depression should be screened for ED and DEB. Treating DEB could positively impact both mood and glycemic control in this population. Further studies should be carried out on a larger patient population using a longitudinal design and an accurate method of evaluation to explore the complex relationship between diabetes, depression, ED, and DEB. Future research should investigate treatment strategies for DEB in T1DM patients and their impact on both psychopathological and metabolic outcomes.

Eyes Fixed on Heaven's Gate: An Empirical Examination of Blink Rate and Suicide

Anecdotal and theoretical work suggests blink rate as an indicator of imminent suicide risk. We sought to empirically examine whether suicide decedents displayed a reduced blink rate in goodbye videos filmed before death, compared to several control groups. Independent raters coded blink rates from videos of 34 suicide decedents and four comparison groups: "mundane" product review, non-suicidal arousal, non-suicidal depression, and non-imminent risk of suicidal ideation. Mean blink rate was lower in the suicide decedent group relative to all comparison groups (ps < .001), except the depressed (p = .976) and suicidal ideation (p = .393) groups. Findings indicate blink rate may be reduced among individuals at imminent risk for suicide, exhibiting clinically-significant depressive symptoms, or experiencing suicidal ideation.

Associations between neighborhood socioeconomic deprivation and severity of depression: Data from the National Health and Nutrition Examination Survey, 2011-2014

Neighborhood socioeconomic disadvantage may contribute to depression. This study examined associations between neighborhood socioeconomic disadvantage, measured as deprivation, and depression severity within a broadly representative sample of the U.S. adult population. The sample (n = 6308 U.S. adults) was from the 2011-2014 National Health and Nutrition Examination Survey. Neighborhood deprivation was calculated using the 2010 U.S. Census and shown in tertile form. Depression severity was calculated from responses to the Patient Health Questionnaire-9 (PHQ-9) as a continuous depression severity score and binary Clinically Relevant Depression (CRD). Multilevel modeling estimated the relationship between deprivation and depression (reference = low deprivation). Models were additionally stratified by gender and race/ethnicity. U.S. adults living in high deprivation neighborhoods were more likely to have a higher PHQ-9 score (p < 0.0001). In unadjusted models, living in high deprivation neighborhoods associated with higher PHQ-9 (β = 0.89, SE = 0.15, p < 0.0001) and higher odds of CRD (OR = 1.35, 95% CI = 1.20-1.51). Living in medium deprivation neighborhoods associated with higher PHQ-9 (β = 0.49, SE = 0.16, p = 0.0019). Associations between deprivation and depression severity lost significance after adjusting for individual-level SES. The results suggest that, for U.S. adults, the relationship between neighborhood-level disadvantage and depression may be attenuated by individual-level SES.

Adeno-Associated Viruses for Modeling Neurological Diseases in Animals: Achievements and Prospects

Adeno-associated virus (AAV) vectors have become an attractive tool for efficient gene transfer into animal tissues. Extensively studied as the vehicles for therapeutic constructs in gene therapy, AAVs are also applied for creating animal models of human genetic disorders. Neurological disorders are challenging to model in laboratory animals by transgenesis or genome editing, at least partially due to the embryonic lethality and the timing of the disease onset. Therefore, gene transfer with AAV vectors provides a more flexible option for simulating genetic neurological disorders. Indeed, the design of the AAV expression construct allows the reproduction of various disease-causing mutations, and also drives neuron-specific expression. The natural and newly created AAV serotypes combined with various delivery routes enable differentially targeting neuronal cell types and brain areas in vivo. Moreover, the same viral vector can be used to reproduce the main features of the disorder in mice, rats, and large laboratory animals such as non-human primates. The current review demonstrates the general principles for the development and use of AAVs in modeling neurological diseases. The latest achievements in AAV-mediated modeling of the common (e.g., Alzheimer’s disease, Parkinson’s disease, ataxias, etc.) and ultra-rare disorders affecting the central nervous system are described. The use of AAVs to create multiple animal models of neurological disorders opens opportunities for studying their mechanisms, understanding the main pathological features, and testing therapeutic approaches.

Examining Economic Risks in Adolescents' Families, Neighborhoods, and Schools: Implications for Mental and Behavioral Health in Early Adulthood

PURPOSE

This study assessed long-term links among adolescent family, neighborhood, and school economic contexts and mental and behavioral health in early adulthood, irrespective of adult economic contexts.

METHODS

Data were drawn from Add Health, following 10,180 participants from adolescence through early adulthood in the United States. Early adults self-reported on their depressive symptoms, perceived psychological stress, and alcohol use disorder. Income at family and school levels was drawn from youth and parent report; neighborhood income was derived from US Census Data. Multilevel models assessed associations between income in adolescence and early adult outcomes 13 years later while accounting for adolescent outcomes and income in early adulthood. Links with depressive symptoms and stress were assessed utilizing ordinary least squares regression; alcohol use disorder was assessed using ordered logistic regression. Nonlinearities in income effects were assessed with quadratic income variables in adolescence and early adulthood.

RESULTS

Family income emerged as the most consistent predictor of depressive symptoms (p < .01) and stress (p < .01), showing negative curvilinear associations. In contrast, exposure to higher income schools (p < .01) and neighborhoods (p < .01) during adolescence was associated with heightened risks for alcohol use disorder in early adulthood. These links emerged over and above concurrent negative connections between early adult family and neighborhood economic contexts and depressive symptoms and stress.

DISCUSSION

Findings call attention to persistent health-related risks across the income spectrum-not only at the lower end-and also highlight the long-term importance of broader economic contexts beyond the family context.

The COVID-19 Lockdown and Mental Wellbeing of Females in China

Most studies consider that COVID-19 lockdowns lead to mental health problems for females, while the effect of role change on female mental health has been overlooked. This study aimed to explore multiple facets of the risk of mental distress in a sample of Chinese married females aged 21-50 during the COVID-19 lockdowns. A cross-sectional study was carried out with 613 valid responses from married females in the Guangdong province. Our primary tool was a questionnaire using a Kessler-10 scale to detect the probability of mental distress based on the level of nervousness, tiredness, restlessness, and depression. Eighty-eight point three percent of married females possessed a high risk of psychological distress because they frequently felt tired out, hopeless, and restless. The evidence suggests that the lockdown has caused a conflict in the female role to maintain a balance between family and career. Increasing family care responsibilities are positively associated with nervousness, tiredness, and mental disorder. The heterogeneity of the social role in mental wellbeing is explored. Married females whose income was worse off during the lockdown are negatively associated with mental wellbeing. Married females who are employed are found to be less mentally healthy than the self-employed.

ICU bereaved surrogates' comorbid psychological-distress states and their associations with prolonged grief disorder

Background/objective

Bereaved ICU family surrogates’ psychological distress, e.g., anxiety, depression, and post-traumatic stress disorder (PTSD), is usually examined independently, despite the well-recognized comorbidity of these symptoms. Furthermore, the few studies exploring impact of psychological distress on development of prolonged grief disorder (PGD) did not consider the dynamic impact of symptom evolution. We identified surrogates’ distinct patterns/states of comorbid psychological distress and their evolution over the first 3 months of bereavement and evaluated their associations with PGD at 6-month postloss.

Methods

A longitudinal observational study was conducted on 319 bereaved surrogates. Symptoms of anxiety, depression, PTSD, and PGD were measured by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised scale, and the PGD-13, respectively. Distinct psychological-distress states and their evolution were examined by latent transition analysis. Association between psychological-distress states and PGD symptoms was examined by logistic regression.

Results

Three distinct comorbid psychological-distress states (prevalence) were initially identified: no distress (56.3%), severe-depressive/borderline-anxiety distress (30.5%), and severe-anxiety/depressive/PTSD distress (13.3%). Except for those in the stable no-distress state, surrogates tended to regress to states of less psychological distress at the subsequent assessment. The proportion of participants in each psychological-distress state changed to no distress (76.8%), severe-depressive/borderline-anxiety distress (18.6%), and severe-anxiety/depressive/PTSD distress (4.6%) at 3-month postloss. Surrogates in the severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD-distress state at 3-month postloss were more likely to develop PGD at 6-month postloss (OR [95%] = 14.58 [1.48, 143.54] and 104.50 [10.45, 1044.66], respectively).

Conclusions

A minority of family surrogates of ICU decedents suffered comorbid severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD symptoms during early bereavement, but they were more likely to progress into PGD at 6-month postloss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03981-7.

Flavonoids for depression and anxiety: a systematic review and meta-analysis

Natural flavonoids are the most plentiful form of polyphenols. Given the anti-inflammatory and antioxidant properties of flavonoids, researchers discovered that it might be effective in treating depression and anxiety. The effect of flavonoids on depression and anxiety was investigated by a meta-analysis and systematic review. We searched PubMed, Embase, and Medline databases up to October 15, 2021. We selected 11 studies, among them, 10 studies were chosen to evaluate the depression effects of flavonoids and 7 studies were used to assess anxiety disorder. The meta-analysis showed that flavonoids have an overall significant effect on depression (p = 0.004, Hedge's g = -0.487, 95% CI -0.814 to -0.160) and anxiety (p = 0.006, Hedge's g = -0.741, 95% CI -1.266 to -0.217). Subgroup analysis indicated that the symptoms of depression were significantly improved in the studies when the dose of flavonoids was 50-100mg/day or the treatment duration was ≥8weeks. Anxiety symptoms were improved in the studies with the dose of flavonoids was ≥50mg/day. There was no evidence of publication bias. Our findings suggest that flavonoids might improve symptoms of depression and anxiety. However, a small number of participants and studies were included in this meta-analysis. Therefore, the results should be interpreted with caution.

Desmosterol and 7-dehydrocholesterol concentrations in post mortem brains of depressed people: The role of trazodone

Major depressive disorder (MDD) is a common, disabling, and heterogeneous condition that responds unpredictably to current treatments. We previously showed an association between depressive symptoms and plasma concentrations of two cholesterol precursors, desmosterol and 7-dehydrocholesterol (7DHC). Here, we measured total cholesterol and sterol concentrations with mass spectrometry in postmortem brain samples from depressed and control subjects. Mean (±SEM) desmosterol concentration was 8.9 ± 0.97 ng/mg in the depressed versus 10.7 ± 0.72 ng/mg in the control group. The mean of the posterior probability distribution for the difference in desmosterol concentration between the two groups was 2.36 (95% highest density interval [HDI] 0.59-4.17). Mean 7DHC concentrations, 12.5 ± 4.1 ng/mg in the depressed versus 5.4 ± 0.74 ng/mg in the control group, were unlikely to be different (95% HDI, [-1.37-0.34]). We found that presence of trazodone in the peri-mortem toxicology screen accounted for the observed difference in desmosterol concentrations. We also observed extremely high 7DHC levels in all 4 subjects who had taken trazodone. Trazodone has been recently found to inhibit 7-dehydrocholesterol reductase and alter sterol concentrations in rodents, cell culture, human fibroblasts, and blood. In this study, we demonstrate for the first time that trazodone alters human brain sterol composition. Given congenital deficiency of 7-dehydrocholesterol reductase results in Smith-Lemli-Opitz syndrome, our findings support the hypothesis that this commonly used medication may have previously unappreciated risks.

P2X7 Receptor-Related Genetic Mouse Models – Tools for Translational Research in Psychiatry

Depression is a common psychiatric disorder and the leading cause of disability worldwide. Although treatments are available, only about 60% of treated patients experience a significant improvement in disease symptoms. Numerous clinical and rodent studies have identified the purinergic P2X7 receptor (P2X7R) as one of the genetic factors potentially contributing to the disease risk. In this respect, genetically engineered mouse models targeting the P2X7R have become increasingly important in studying designated immunological features and subtypes of depression in vivo. This review provides an overview of the P2X7R -related mouse lines currently available for translational psychiatric research and discusses their strengths, weaknesses, and potentials.

The Potential for Outdoor Nature-Based Interventions in the Treatment and Prevention of Depression

There is growing interest in nature-based interventions (NBI) to improve human health and wellbeing. An important nascent area is exploring the potential of outdoor therapies to treat and prevent common mental health problems like depression. In this conceptual analysis on the nature-depression nexus, we distil some of the main issues for consideration when NBIs for depression are being developed. We argue that understanding the mechanisms, or 'active ingredients' in NBIs is crucial to understand what works and for whom. Successfully identifying modifiable mediating intervention targets will pave the way for interventions with increased efficacy. We highlight a non-exhaustive list of five clinically relevant putative, candidate mechanisms which may underly the beneficial effects of NBIs on depression: stress, rumination, mindfulness, sleep and exercise. We also make the case that when developing NBIs it is important to not neglect young people, explore personalised approaches and focus on both treatment and prevention approaches. To achieve these aims methodologically rigorous programmes of clinical research are needed that include well-powered and controlled experimental designs including randomised controlled trials, qualitative research, longitudinal studies and large prospective cohorts.

A Systematic Review and Meta-Analysis of Nature Walk as an Intervention for Anxiety and Depression

Scientific research has widely examined the therapeutic and health benefits of being in contact with natural environments. Nature walk have been proposed as a cost-effective and inclusive method for successfully exploiting nature for the promotion of health and well-being. Depression and anxiety symptoms have been shown to benefit from nature walk. Despite recent empirical findings published in the scientific literature, a summary quantitative work on the effect of nature walk on depression and anxiety does not yet exist. The present systematic review and meta-analysis quantitatively analyze and qualitatively discuss the studies published on the effect of nature walk on depression and anxiety published during the past decade. A database search as well as snowballing methods were used to retrieve eligible articles. The research question and literature search were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Based on screening and retrieval processes, seven studies met the eligibility criteria and were then included in the quantitative meta-analysis. Risk of bias (RoB) analysis was used to evaluate the quality of the included studies using the Newcastle-Ottawa Scale. After a qualitative evaluation of the studies, data from six experiments were included in the meta-analysis. The meta-analysis show that nature walk effectively improve mental health. The findings were confirmed for the experiments reporting the quantitative data within groups (pre- and post-test) and between groups (experimental vs. control group).

"My life disappeared in illness": bipolar disorder and themes in narrative identity

Bipolar Disorder (BD) has substantial consequences for the course of life and the formation of self and identity. In the present study, we extended the existing literature by examining narrative identity. Fifteen female outpatients with remitted BD and fifteen non-clinical control participants described past and future chapters in their life stories. The chapters were coded for agency, communion, redemption and contamination. Patients diagnosed with BD described their past chapters with lower agency, lower communion and more contamination compared to the control group. Contrary to our expectations, the future chapters described by the BD patients did not differ significantly from the control group. A focus on narrative identity may contribute to understanding the disorder and inspire interventions targeting personal recovery.

Association of residential greenness and incident depression: Investigating the mediation and interaction effects of particulate matter

BACKGROUND

Growing evidence has linked residential greenness to depression, the results from prospective cohort study are still limited. And it remains unclear whether particulate matter (PM) modify, mediate, or interact the greenness-depression relationship.

METHODS

We collected data from Yinzhou Cohort(N = 47,516) which was recruited between June 2015 and December 2017. Depression cases before April 2020 were ascertained from local Health Information System covered all residents' health care records. Residential greenness (the Normalized Difference Vegetation Index, NDVI, and the Enhanced Vegetation Index, EVI) and PM (particulate matters with diameters≤2.5 μm, PM_2.5 and particulate matters with diameters≤10 μm, PM₁₀) were estimated based on participants' residential coordinates. We conducted Cox models employing age as timescale to estimate the association between residential greenness within different buffers and incident depression. Furthermore, we explored the potential confounding, mediation and interaction relationship between greenness and PM.

RESULTS

During the 99,556 person-years of follow-up, 1043 incident depression cases occurred. In single exposure models, residential greenness was inversely associated with depression incidence (e.g. Hazard Ratio (HR) = 0.86, 95% confidence interval (CI): 0.79, 0.94 for per interquartile range (IQR) increase NDVI 250 m). The protective association between greenness was attenuated after introducing PM_2.5 and PM₁₀ into the models. We identified multiplicative interactions between greenness and PM exposure for depression (e.g. HR _interaction = 0.91, 95%CI: 0.85, 0.98 for per IQR decrease NDVI 250 m and per IQR increase PM_2.5). Besides, we found the protective association of greenness was partly mediated by PM (e.g. mediation proportion = 52.9% between NDVI 250 m and PM_2.5).

CONCLUSIONS

In this longitudinal cohort study, residents living in greener neighborhoods had a lower risk of depression incidence and the benefits were interacted and partly mediated by PM. Improvement in residential greenness could be an actionable and planning intervention to prevent depression.

The Duration of Stress Determines Sex Specificities in the Vulnerability to Depression and in the Morphologic Remodeling of Neurons and Microglia

Stress exposure has been shown to induce a variety of molecular and functional alterations associated with anxiety and depression. Some studies suggest that microglia, the immune cells of the brain, play a significant role in determining neuronal and behavioral responses to chronic stress and also contribute to the development of stress-related psychopathologies. However, little is known about the impact of the duration of stress exposure upon microglia and neurons morphology, particularly considering sex differences. This issue deserves particular investigation, considering that the process of morphologic remodeling of neurons and microglia is usually accompanied by functional changes with behavioral expression. Here, we examine the effects of short and long unpredictable chronic mild stress (uCMS) protocols on behavior, evaluating in parallel microglia and neurons morphology in the dorsal hippocampus (dHIP) and in the nucleus accumbens (NAc), two brain regions involved in the etiology of depression. We report that long-term uCMS induced more behavioral alterations in males, which present anxiety and depression-like phenotypes (anhedonia and helplessness behavior), while females only display anxiety-like behavior. After short-term uCMS, both sexes presented anxiety-like behavior. Microglia cells undergo a process of morphologic adaptation to short-term uCMS, dependent on sex, in the NAc: we observed a hypertrophy in males and an atrophy in females, transient effects that do not persist after long-term uCMS. In the dHIP, the morphologic adaptation of microglia is only observed in females (hypertrophy) and after the protocol of long uCMS. Interestingly, males are more vulnerable to neuronal morphological alterations in a region-specific manner: dendritic atrophy in granule neurons of the dHIP and hypertrophy in the medium spiny neurons of the NAc, both after short- or long-term uCMS. The morphology of neurons in these brain regions were not affected in females. These findings raise the possibility that, by differentially affecting neurons and microglia in dHIP and NAc, chronic stress may contribute for differences in the clinical presentation of stress-related disorders under the control of sex-specific mechanisms.

Assets, stressors, and symptoms of persistent depression over the first year of the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by an increase in depression in U.S. adults. Previous literature suggests that having assets may protect against depression. Using a nationally representative longitudinal panel survey of U.S. adults studied in March and April 2020 and in March and April 2021, we found that (i) 20.3% of U.S. adults reported symptoms of persistent depression in Spring 2020 and Spring 2021, (ii) having more assets was associated with lower symptoms of persistent depression, with financial assets-household income and savings-most strongly associated, and (iii) while having assets appeared to protect persons-in particular those without stressors-from symptoms of persistent depression over the COVID-19 pandemic, having assets did not appear to reduce the effects of job loss, financial difficulties, or relationship stress on symptoms of persistent depression. Efforts to reduce population depression should consider the role played by assets in shaping risk of symptoms of persistent depression.

Wealth and depression: A scoping review

INTRODUCTION

The inverse relation between income and depression is well established. Less is understood about the relation between wealth and depression. We therefore conducted a scoping review to answer the question: What is known from the existing literature about the relation between wealth and depression?

METHODS

We searched for studies and articles in Medline (via PubMed), Embase, PsycINFO, PsycArticles, EconLit, and SocINDEX from inception through July 19, 2020. Ninety-six articles were included in our review. Key article characteristics were year of publication, sample size, country, study design, definition of depression, definition of wealth, and association between wealth and depression. Thirty-two longitudinal articles were included in a detailed charted review.

RESULTS

Depression was defined in a relatively standard manner across articles. In contrast, definitions and measurements of wealth varied greatly. The majority of studies in the full review (n = 56, 58%) and half of the studies in the longitudinal charted review (n = 16, 50%) reported an inverse relation between wealth and depression. The longitudinal charted review showed that (1) macro-economic events influenced depression, (2) wealth status influenced depression across the lifecourse, (3) wealth protected against depression in the face of stressors such as job loss, (4) subjective or psychosocial factors such as perception of wealth, relative comparison, and social status modified the relation between wealth and depression, and (5) savings interventions were successful in reducing depression and varied by context.

CONCLUSION

These findings suggest that wealth should be included in our consideration of the forces that shape mental health.

Meta-Analysis of Positive Psychology Interventions on the Treatment of Depression

This meta-analysis examined the efficacy of positive psychology interventions (PPIs) in treating depression in 11 articles. PubMed, Web of Science, and Clinical Key were used to identify papers published from 2010 to 2020 that utilized PPIs. Key terms were “positive psychology” and “treatment of depression.” Studies on adults with (a) depressive symptoms or (b) diagnosed clinical depression were included. A random-effects model was used to compare PPIs and control groups on post- vs. pre-intervention differences in depression scores. Data analysis examined Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), and Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) scores. Findings show PPIs are effective in treating depressive symptoms, with significant improvements in depression scores when compared to control groups in all but one study. This was true for both post- vs. pre-intervention (pooled Cohen’s d = −0.44 (−0.77, −0.11)) and follow-up- vs. pre-intervention analyses (pooled Cohen’s d = −0.46 (−1.02, 0.09)). PPIs can improve the accessibility and affordability of depression treatments.

Cost-Effectiveness of a Web-Based Program for Residual Depressive Symptoms: Mindful Mood Balance

OBJECTIVE

Mindful Mood Balance (MMB) is an effective Web-based program for residual depressive symptoms that prevents relapse among patients with partial recovery from major depressive episodes. This cost-effectiveness analysis was conducted from the health plan perspective alongside a pragmatic randomized controlled trial of MMB.

METHODS

Adults were recruited from behavioral health and primary care settings in a large integrated health system and randomly assigned to MMB plus usual depression care (MMB+UDC) or UDC. Patients had at least one prior major depressive episode; a current score of 5-9 on the Patient Health Questionnaire-9, indicating residual depressive symptoms; and Internet access. Program costs included recruitment, coaching, and MMB licensing. Center for Medicare and Medicaid fee schedules were applied to electronic health record utilization data for psychotropic medications and psychiatric and psychotherapy visits. Effectiveness was measured as depression-free days (DFDs), converted from PHQ-9 scores collected monthly for 1 year. Incremental cost-effectiveness ratios were calculated with various sets of cost inputs.

RESULTS

A total of 389 patients (UDC, N=210; MMB+UDC, N=179) had adequate follow-up PHQ-9 measures for inclusion. MMB+UDC patients had 29 more DFDs during follow-up. Overall, the incremental cost of MMB+UDC was $431.54 over 12 months. Incremental costs per DFD gained ranged from $9.63 for program costs only to $15.04 when psychiatric visits, psychotherapy visits, and psychotropic medications were included.

CONCLUSIONS

MMB offers a cost-effective Web-based program for reducing residual depressive symptoms and preventing relapse. Health systems should consider adopting MMB as adjunctive to traditional mental health care services.

Lesional psychiatric neurosurgery: meta-analysis of clinical outcomes using a transdiagnostic approach

BACKGROUND

Four ablative neurosurgical procedures are used in the treatment of refractory psychiatric illness. The long-term effects of these procedures on psychiatric symptoms across disorders has never been synthesised and meta-analysed.

METHODS

A preregistered systematic review was performed on studies reporting clinical results following ablative psychiatric neurosurgery. Four possible outcome measures were extracted for each study: depression, obsessive-compulsive symptoms, anxiety and clinical global impression. Effect sizes were calculated using Hedge's g. Equipercentile linking was used to convert symptom scores to a common metric. The main outcome measures were the magnitude of improvement in depression, obsessive compulsive symptoms, anxiety and clinical global impression. The secondary outcome was a subgroup analysis comparing the magnitude of symptom changes between the four procedures.

RESULTS

Of 943 articles, 43 studies reporting data from 1414 unique patients, were included for pooled effects estimates with a random-effects meta-analysis. Results showed that there was a large effect size for improvements in depression (g=1.27; p<0.0001), obsessive-compulsive symptoms (g=2.25; p<0.0001) and anxiety (g=1.76; p<0.0001). The pooled clinical global impression improvement score was 2.36 (p<0.0001). On subgroup analysis, there was only a significant degree of heterogeneity in effect sizes between procedure types for anxiety symptoms, with capsulotomy resulting in a greater reduction in anxiety than cingulotomy.

CONCLUSIONS

Contemporary ablative neurosurgical procedures were significantly associated with improvements in depression, obsessive-compulsive symptoms, anxiety and clinical global impression.

PROSPERO REGISTRATION NUMBER

CRD42020164784.

Mental Health and Wellbeing in Young People in the UK during Lockdown (COVID-19)

This study aimed to assess the levels of mental wellbeing and potential for clinical need in a sample of UK university students aged 18-25 during the COVID-19 pandemic. We also tested the dose-response relationship between the severity of lockdown restrictions and mental wellbeing. We carried out a prospective shortitudinal study (one month between baseline and follow up) during the pandemic to do this and included 389 young people. We measured a range of facets of mental wellbeing, including depression, depressogenic cognition (rumination), wellbeing, stress and sleep disturbance. Our primary outcome was 'probable depression' as indexed by a score of ≥10 on the patient health questionnaire (PHQ-8). The prevalence of probable depression was significantly higher than pre-pandemic levels (55%) and did not decrease significantly over time (52%). Higher levels of lockdown severity were prospectively associated with higher levels of depressive symptoms. Nearly all students had at least one mental wellbeing concern at either time point (97%). The evidence suggests that lockdown has caused a wellbeing crisis in young people. The associated long-term mental, social, educational, personal and societal costs are as yet unknown but should be tracked using further longitudinal studies.